Colorado Health OP Formulary

Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
1 ML SYRIMGE MIS 18GX1"
1 ML SYRINGE MIS 22X1-1/2
1.5 ML SYRNG MIS 22X1-1/2
1/2ML ALLERG KIT 27GX1/2"
1/2ML ALLERG KIT 27GX3/8"
1/2ML TB SYR MIS 27GX1/2"
10 SERIES BP MIS MONITOR
100ML SYRING MIS LUER-LOK
10-12ML SYRN MIS LUER LCK
10-12ML SYRN MIS LUER SLP
10BURN DRESS MIS 12"X12"
10ML CARTRID MIS PLASTIC
10ML CONTRO MIS LUER-LOK
10ML CONTROL MIS SANA-LOK
10ML LL SYRG MIS CONTROL
10ML LL SYRN MIS 20GX1"
10ML LL SYRN MIS 20GX1.5"
10ML LL SYRN MIS 21GX1"
10ML LL SYRN MIS 21GX1.5"
10ML LL SYRN MIS 22GX1"
10ML LL SYRN MIS 22GX1.5"
10ML LL SYRN MIS 23GX1.25
10ML SYRINGE MIS
10ML SYRINGE MIS 20GX1"
10ML SYRINGE MIS 20GX1.5"
10ML SYRINGE MIS 21GX1"
10ML SYRINGE MIS 21GX1.5"
10ML SYRINGE MIS 22GX1"
10ML SYRINGE MIS 22GX1.5"
2
3
3
3
2
2
2
2
2
3
3
3
2
3
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
1
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
10ML SYRINGE MIS 25GX1.5"
10ML SYRINGE MIS 27GX1.5"
10PEH/380GFN TAB
10PEH/380GFN TAB /15DM
10PEH/400GFN TAB /20DM
10PEH/4CPM/ TAB 20DM
12 HOUR COLD TAB 120MG CR
12 HR NASAL SPR 0.05%
12.5CPD/100G LIQ FN/30PSE
12.5CPD/1DCP LIQ M/30PSE
12ML LL SYRN MIS 20GX1"
12ML LL SYRN MIS 22GX1"
12ML SYRINGE MIS 18GX1"
12ML SYRINGE MIS 20GX1.5"
12ML SYRINGE MIS 21GX1"
12ML SYRINGE MIS 21GX1.5"
12ML SYRINGE MIS 22GX1.5"
140ML SYRING MIS CATH TIP
140ML SYRING MIS LUER-LOC
14-COUNT MIS WARMER
18G SHIELDED MIS NEEDLE
1-DAY 6.5% OIN MONISTAT
1-LEG LEOTAR MIS CUSTOM
1ML ALLERGIS KIT TRAY SYR
1ML ALLERGIS KIT TRAY SYR
1ML ALLERGIS KIT TRAY SYR
1ML ALLR SYR MIS 27GX1/2"
1ML SYR/NEED MIS 26GX5/8"
1ML SYRINGE MIS 23GX1"
3
3
1
1
1
1
1
1
1
1
3
3
2
2
2
2
3
2
3
3
3
1
3
2
2
2
2
2
3
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
2
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
1ML SYRINGE MIS 25GX1"
1ML SYRINGE MIS 25GX5/8"
1ML SYRINGE MIS 26GX3/8"
1ML SYRINGE MIS 26GX3/8"
1ML SYRINGE MIS 27GX1/2"
1ML SYRINGE MIS 27GX3/8"
1ML SYRINGE MIS 28GX1/2"
1ML SYRINGE MIS SLIP TIP
1ML TB SYRNG MIS 21GX1"
1ML TB SYRNG MIS 22GX1"
1ML TB SYRNG MIS 25GX1"
1ML TB SYRNG MIS 25GX5/8"
1ML TB SYRNG MIS 26GX5/8"
1ML TB SYRNG MIS LUER SLP
1ST CHOICE MIS LANCETS
1ST CHOICE MIS LANCETS
1ST TIER UNI MIS 29GX12MM
1ST TIER UNI MIS 31GX5MM
1ST TIER UNI MIS 31GX6MM
1ST TIER UNI MIS 31GX8MM
1ST TIER UNI MIS 32GX4MM
1-STEP TES PREGNAN
2.5ML SYRING MIS
20-25ML SYRN MIS LS EC
20-25ML SYRN MIS LUER LCK
20ML CONTROL MIS SANA-LOK
20ML SYRINGE MIS GLASLUER
2-3ML SYRING MIS LUER LCK
2-3ML SYRING MIS LUER SLP
2
2
2
2
2
3
2
2
2
2
2
2
2
2
2
0
2
2
3
2
3
2
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
3
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2-DEOXY-D POW -GLUCOSE
2-IN-1 LIQ CLEANSER
2-METHOXYEST POW
2ML CONTROL MIS LUER-LOK
2ML TB SYRNG MIS LL ZONE1
2ND SKIN CUT MIS CLOSURE
2ND SKIN GEL PAD MOIST 1"
2ND SKIN GEL QUICK HL
2ND SKIN GEL SCAR
2OZ CATH SYR MIS GLASS
2-PC BARRIER MIS 1"
2-PC BARRIER WAF FLANGE
3 DAY VAGINL CRE 2%
3 DAY VAGNAL CRE 4%
3 ML SYRINGE MIS 22X1-1/2
30-35ML SYRN MIS CATH TIP
30-35ML SYRN MIS LUER LCK
30ML SYRINGE MIS ECC LUER
30ML SYRINGE MIS GL ZONE1
30ML SYRINGE MIS GLASLUER
3-IN-1 CONT MIS TRAN SET
2
3
2
2
3
3
3
3
3
3
2
3
1
1
3
3
2
2
3
2
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
3ML CARTRIDG MIS PLASTIC
-
-
3ML CTRL SYR MIS LL ZONE1
3ML GLAS SYR KIT NA HEPAR
3ML LL SYRNG MIS 18GX1.5"
3ML LL SYRNG MIS 20GX1"
3ML LL SYRNG MIS 20GX1.5"
3ML LL SYRNG MIS 20GX3/4"
3
3
2
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
4
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3ML LL SYRNG MIS 21GX1"
3ML LL SYRNG MIS 21GX1.25
3ML LL SYRNG MIS 21GX1.5"
3ML LL SYRNG MIS 22GX1"
3ML LL SYRNG MIS 22GX1.25
3ML LL SYRNG MIS 22GX1.5"
3ML LL SYRNG MIS 22GX3/4"
3ML LL SYRNG MIS 23GX1"
3ML LL SYRNG MIS 23GX1.25
3ML LL SYRNG MIS 23GX1.5"
3ML LL SYRNG MIS 23GX3/4"
3ML LL SYRNG MIS 24GX1"
3ML LL SYRNG MIS 25GX1"
3ML LL SYRNG MIS 25GX1.5"
3ML LL SYRNG MIS 25GX5/8"
3ML LL SYRNG MIS 26GX3/8"
3ML LL SYRNG MIS 26GX5/8"
3ML LL SYRNG MIS 27GX1.25
3ML SYRINGE MIS 18GX1"
3ML SYRINGE MIS 20GX1.5"
3ML SYRINGE MIS 21GX1.5"
3ML SYRINGE MIS 23GX1.5"
3ML SYRINGE MIS 25GX1"
3ML SYRINGE MIS 25GX1.25
3ML SYRINGE MIS 27GX1.5"
3ML SYRINGE MIS GLASLUER
3ML SYRINGE MIS LUER-LOK
3-WAY CATH MIS 18FR-30
4 AMINOPYRID POW
2
2
2
2
2
2
2
2
2
2
3
2
2
2
2
3
2
2
2
3
3
3
3
2
3
2
3
3
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
5
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
40PSE/4BRM/ TAB 20DM
45PSE/400GFN TAB
45PSE/400GFN TAB /15DM
4-AMINOBUTYR CRY ACID
4-CHLORO-M- POW CRESOL
4-N-1 CRE
4-WAY FAST SPR 1%
4-WAY SALINE SPR
4X PROBIOTIC TAB
5 DAY FRESH PAD
5 DAY LIQ
50-60ML SYRN MIS CT EC
50-60ML SYRN MIS LUER LCK
50ML SYRINGE MIS GLASLUER
50ML SYRINGE MIS LL ZONE1
5-6ML SYRING MIS LUER LCK
5-6ML SYRING MIS LUER SLP
5-AMINOSALIC POW ACID
5-HTP CAP
5-HTP CAP 100MG
5-HTP CAP 50MG
5-HTP MAX ST CAP 200MG
1
3
2
2
3
2
1
3
3
3
3
3
2
2
3
2
3
2
3
1
1
3
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
-
-
2
2
2
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
5-HTP TRYPTO TAB 50MG
5-HYDROXY-L- POW TRYPTOPH
5-METHYLTETR POW
5-METHYLTETR POW DISODIUM
5ML CONTROL MIS LUER-LOK
5ML CONTROL MIS SANA-LOK
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
6
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
5ML LL SYRNG MIS 20GX1"
5ML LL SYRNG MIS 20GX1.5"
5ML LL SYRNG MIS 21GX1"
5ML LL SYRNG MIS 21GX1.5"
5ML LL SYRNG MIS 22GX1"
5ML LL SYRNG MIS 22GX1.5"
5ML LL SYRNG MIS 23GX1"
5ML LL SYRNG MIS 23GX1.25
5ML SYRINGE MIS
5ML SYRINGE MIS 20GX1"
5ML SYRINGE MIS 20GX1.5"
5ML SYRINGE MIS 21GX1.5"
5ML SYRINGE MIS 22GX1"
5ML SYRINGE MIS 25GX1.5"
5ML SYRINGE MIS 27GX1.5"
5ML SYRINGE MIS CANNULA
60PSE/400GFN TAB /20DM
60PSE/4CPM/ TAB 20DM
666 COLD LIQ PREPARTN
666 COLD TAB 5-325MG
6-AMINOCAPRO POW ACID
6ML LL SYRNG MIS 20GX1.5"
6ML LL SYRNG MIS 21GX1"
6ML LL SYRNG MIS 21GX1.5"
6ML LL SYRNG MIS 22GX1.5"
6ML LUER LOK MIS 20GX1"
6ML LUER LOK MIS 21GX1.25
6ML LUER LOK MIS 22GX1"
6ML LUER LOK MIS 22GX1.25
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
1
1
1
2
2
2
2
3
3
3
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
7
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
6ML LUER LOK MIS 23GX1"
6ML SYRINGE MIS 18GX1"
6ML SYRINGE MIS 22GX1.5"
7-KETO DHEA POW
7-KETO LEAN CAP
8 HOUR PAIN TAB 650MG
80ML SYRINGE MIS ANGIO
8-MOP CAP 10MG
9-AMINOACRID POW HCL
3
2
2
2
3
1
3
2
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
-
-
3
3
Non-Preferred Brand
Non-Preferred Brand
-
-
A THRU Z SEL TAB 50+ ADVA
-
-
A THRU Z TAB ADVANTAG
-
-
A.E.R. PAD TRAVELER
A.H.A FACIAL CRE SPF15
A/B SOL OTIC
1
3
1
Generic
Non-Preferred Brand
Generic
A/BETA CAROT CAP 25000UNT
-
-
A/BETA CAROT TAB 25000UNT
-
-
2
Preferred Brand
-
-
3
3
Non-Preferred Brand
Non-Preferred Brand
A & D CAP
A + D PERSON LOT
A + D PERSON MIS CARE WIP
A THRU Z CHW SELECT
A/D ZINC OXI CRE
A/G PRO TAB
A+D CRACKED CRE SKIN REL
A+D DIAPER CRE RASH
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
8
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
1
Preferred Brand
Generic
-
-
1
3
Generic
Non-Preferred Brand
3
Non-Preferred Brand
A-200 MAX ST LIQ
1
Generic
A-25 CAP 25000UNT
-
-
3
3
3
3
3
1
1
1
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
ABILIFY DISC TAB 10MG
2
Preferred Brand
ABILIFY DISC TAB 15MG
2
Preferred Brand
2
Preferred Brand
2
Preferred Brand
A+D FIRST OIN AID
A+D PREVENT OIN
A-10000 CAP
A-200 AER 0.5%
A-200 GEL 0.33-4%
A-200 KIT
A-ACETYLMAND POW ACID
ABACAV/LAMIV TAB /ZIDOVUD
ABACAVIR TAB 300MG
ABATRACE CAP
ABATREX TAB
ABATRON AF TAB
ABATRON LIQ
ABATUSS DMX LIQ 30-1-15
ABELCET INJ 5MG/ML
ABILIFY INJ 9.75MG
ABILIFY MAIN INJ 300MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
PA Required
-
-
YES, Specialty Drug
YES, Specialty Drug
Maximum of 30
per 30 days
Maximum of 30per
30 days
May be subject to
Quantity Level
Limits
9
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Formulary Status
Special Plan Edits
2
Preferred Brand
May be subject to
Quantity Level
Limits
ABILIFY SOL 1MG/ML
2
Preferred Brand
ABILIFY TAB 10MG
2
Preferred Brand
ABILIFY TAB 15MG
2
Preferred Brand
ABILIFY TAB 20MG
2
Preferred Brand
ABILIFY TAB 2MG
2
Preferred Brand
ABILIFY TAB 30MG
2
Preferred Brand
ABILIFY TAB 5MG
2
Preferred Brand
3
3
2
3
3
1
2
3
3
3
1
2
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
ABILIFY MAIN INJ 400MG
ABLAVAR INJ 244MG/ML
ABRAXANE INJ 100MG
ABREVA CRE 10%
ABROPERNOL SUB
ABSINTHIUM OIL
ABSORBINE GEL PAIN 10%
ABSORBINE JR LIQ
ABSORBINE JR LIQ EX-STR
ABSORBINE JR PAD 1.27%
ABSORBINE JR PAD 6.5%
ABSORBINE JR PAD BACK
ABSORICA CAP 10MG
ABSORICA CAP 20MG
ABSORICA CAP 25MG
ABSORICA CAP 30MG
WDRx 2/23/15
Tier
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
YES, Specialty Drug
PA Required
PA Required
PA Required
PA Required
10
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
2
2
3
3
3
3
3
3
3
2
3
1
1
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
ACAI WEIGHT CAP CONTROL
-
-
ACAI+SUPERFR TAB GREENTEA
ACAMPRO CAL TAB 333MG
ACANYA GEL 1.2-2.5%
ACAPELLA MIS DEVICE
ACARBOSE TAB 100MG
ACARBOSE TAB 25MG
ACARBOSE TAB 50MG
ACCESS PORT MIS CATHETER
3
1
2
2
1
1
1
3
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
ACCOLATE TAB 10MG
3
Non-Preferred Brand
ACCOLATE TAB 20MG
3
Non-Preferred Brand
3
Non-Preferred Brand
ABSORICA CAP 35MG
ABSORICA CAP 40MG
ABSTRAL SUB 100MCG
ABSTRAL SUB 200MCG
ABSTRAL SUB 300MCG
ABSTRAL SUB 400MCG
ABSTRAL SUB 600MCG
ABSTRAL SUB 800MCG
AC DERMAPEPT LIQ
ACACIA POW
ACACIA POW MILLED
ACAI BERRY CAP 500MG
ACAI CAP 25MG
ACCU-CHEK IN LIQ CONTROL
WDRx 2/23/15
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
11
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
-
Not a covered
benefit
-
-
ACCU-CHEK KIT COMPACT
ACCU-CHEK KIT FASTCLIX
3
-
Non-Preferred Brand
$0 Preventative Drug
ACCU-CHEK KIT SPIRIT
-
-
Not a covered
benefit
-
-
ACCU-CHEK LIQ COMPACT
2
Preferred Brand
ACCU-CHEK MIS ADAPTER
-
-
Not a covered
benefit
-
-
ACCU-CHEK MIS AVIVA
ACCU-CHEK TES ACTIVE
ACCU-CLEAR TES PREGNANC
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ACCUNEB NEB 0.63MG/3
3
Non-Preferred Brand
ACCUNEB NEB 1.25MG/3
3
Non-Preferred Brand
ACCUPRIL TAB 10MG
3
Non-Preferred Brand
ACCUPRIL TAB 20MG
3
Non-Preferred Brand
ACCUPRIL TAB 40MG
3
Non-Preferred Brand
ACCUPRIL TAB 5MG
3
Non-Preferred Brand
3
Non-Preferred Brand
Drug Name
ACCU-CHEK KIT COMBO
ACCURETIC TAB 10-12.5
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
12
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ACCURETIC TAB 20-12.5
3
Non-Preferred Brand
ACCURETIC TAB 20-25MG
3
Non-Preferred Brand
ACCUTREND MIS PLUS
ACCUTREND SOL CHOLEST
ACCUTREND TES CHOLEST
ACD FORMULA SOL A
ACD FORMULA SOL B
3
3
2
2
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
ACD/FLUORIDE DRO 0.25MG
-
-
ACD-A SOL
ACE ACD/ALUM SOL 2% OTIC
ACE AERO CLD MIS ENHANCER
ACE BACK MIS STABILZR
ACEBUTOLOL CAP 200MG
ACEBUTOLOL CAP 400MG
ACEBUTOLOL POW
3
2
2
2
1
1
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
ACEON TAB 4MG
3
Non-Preferred Brand
ACEON TAB 8MG
3
Non-Preferred Brand
1
1
1
2
Generic
Generic
Generic
Preferred Brand
ACEPHEN SUP 120MG
ACEPHEN SUP 325MG
ACEPHEN SUP 650MG
ACEPROMAZINE POW MALEATE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
13
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
-
-
ACEROLA C CHW 500MG
-
-
ACEROLA C WAF 500MG
-
-
ACESULFAME POW POTASSIU
2
Preferred Brand
ACETADOTE INJ 200MG/ML
3
Non-Preferred Brand
ACETADRYL TAB
ACETA-GESIC TAB 12.5-325
ACETAM MELTS TAB 80MG
ACETAMIN CAP 500MG
ACETAMIN CHW 80MG
ACETAMIN DRO 100MG/ML
ACETAMIN DRO 80/0.8ML
ACETAMIN ELX 160/5ML
ACETAMIN GRA
ACETAMIN JR TAB 160MG RT
ACETAMIN LIQ 160/5ML
ACETAMIN LIQ 500/15ML
ACETAMIN PM TAB 25-500MG
ACETAMIN POW
ACETAMIN SOL 160/5ML
ACETAMIN TAB 325MG
ACETAMIN TAB 500MG
ACETAMINOPHE TAB 650MG
ACETAMINOPHN SUS 160/5ML
ACETANILIDE POW
1
1
1
1
1
1
1
1
3
1
1
1
1
2
1
1
1
2
1
3
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Non-Preferred Brand
ACERFLEX POW
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
14
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ACETARSONE POW
ACETASOL HC SOL OTIC
ACETAZOLAMID CAP 500MG ER
ACETAZOLAMID CRY
ACETAZOLAMID INJ 500MG
ACETAZOLAMID POW
ACETAZOLAMID TAB 125MG
ACETAZOLAMID TAB 250MG
ACETEST TAB TABLETS
ACETIC ACID SOL 0.25%IRR
ACETIC ACID SOL 2% OTIC
ACETIC ACID SOL 3%
ACETIC ACID SOL 50%
ACETIC ACID SOL GLACIAL
ACETOHYDROXA POW ACID
ACETOL ACETA LIQ ESTER
ACETONE SOL
ACETYL DIPEP SOL CETYL ES
ACETYL L-CAR CAP 500MG
ACETYL/ALA CAP 400-200
ACETYLCHOLIN POW CHLORIDE
ACETYLCYST INJ 200MG/ML
ACETYLCYST POW
ACETYLCYST SOL 10%
ACETYLCYST SOL 20%
ACETYL-L-CAR POW HCL
ACETYLSALICY POW ACID USP
ACHES/PAINS TAB MEDICINE
3
1
1
2
1
2
2
1
2
1
1
2
2
3
3
3
2
3
3
3
2
1
2
1
1
2
2
3
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
15
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
ACID BLOCKER PAK DEPLETIO
-
-
Not a covered
benefit
-
ACID CONTROL CHW COMPLETE
ACID CONTROL TAB 10MG
ACID CONTROL TAB 150MG
ACID CONTROL TAB 20MG
ACID CONTROL TAB 75MG
ACID GONE CHW
ACID GONE SUS
ACID RED 52 POW
ACID REDUCER TAB 200MG
ACIDO LACTOB POW 10BU/GM
ACIDO LACTOB POW 1BU/GM
ACIDOLL CAP
ACIDOPH/PROB TAB FORMULA
ACIDOPHILUS CAP /PECTIN
ACIDOPHILUS CAP GOATMILK
ACIDOPHILUS CHW
ACIDOPHILUS TAB
ACIDOPHILUS WAF
ACIDOPHILUS/ TAB CIT PECT
ACIDOPHILUS/ WAF BIFIDUS
ACIGEST II TAB
ACIGEST TAB
1
1
1
1
1
1
1
3
1
2
3
1
2
1
3
3
1
3
2
3
1
3
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
ACIPHEX SPR CAP 10MG
3
Non-Preferred Brand
ACIPHEX SPR CAP 5MG
3
Non-Preferred Brand
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
-
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
16
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ACIPHEX TAB 20MG
ACITRETIN CAP 10MG
ACITRETIN CAP 17.5MG
ACITRETIN CAP 25MG
ACLARO EMU
ACLOVATE CRE 0.05%
ACNE CLEANSI BAR 10%
ACNE CLEANSR LIQ OIL-FREE
ACNE CONTROL CRE CLNS 10%
ACNE MEDICAT GEL 10%
ACNE MEDICAT GEL 5%
ACNE MEDICAT LOT 10%
ACNE MEDICAT LOT 5%
ACNE PAD MAX ST
ACNE SPOT GEL TREAT 2%
ACNE-AID BAR
ACNOMEL CRE ADULT
ACNOTEX LOT
ACONITE EXT
ACONITE TIN
ACONITUM DRO HOMACCOR
ACRIFLAVINE POW HCL
ACRIFLAVINE POW NEUTRAL
ACRYLINE 2 KIT
ACT DRY LOZ MOUTH
WDRx 2/23/15
Tier
Formulary Status
Special Plan Edits
3
Non-Preferred Brand
Maximum of 30
per 30 days
1
1
1
Generic
Generic
Generic
-
-
3
Non-Preferred Brand
1
1
1
1
1
2
2
1
1
3
2
3
3
3
3
3
2
3
1
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
17
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ACT FLUORIDE SOL 0.05%
ACT TOTAL SOL DRY MOUT
ACTEMRA INJ 162/0.9
ACTEMRA INJ 200/10ML
ACTEMRA INJ 400/20ML
ACTEMRA INJ 80MG/4ML
ACTHAR HP INJ 80UNIT
ACTHIB INJ
ACTHREL INJ 100MCG
ACTICAL CAP
ACTICIN CRE 5%
ACTICLATE TAB 150MG
ACTICLATE TAB 75MG
ACTICOAT 3 MIS 16"X16"
ACTICOAT 3 MIS 2"X2"
ACTICOAT 3 MIS 4"X48"
ACTICOAT 3 MIS 4"X8"
ACTICOAT 3 MIS 8"X16"
ACTICOAT 7 MIS 1"X24"
ACTICOAT 7 MIS 4"X5"
ACTICOAT 7 MIS 6"X6"
ACTICOAT 7 PAD 4"X5"
ACTICOAT ABS MIS 3/4"X12"
ACTICOAT MIS 4"X4"
ACTICOAT MIS 5"X5"
ACTICOAT MIS SITE
ACTICOAT MOI PAD 2"X2"
ACTICOAT MOI PAD 4"X4"
WDRx 2/23/15
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
1
3
3
3
3
3
3
2
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Preferred Brand
PA Required
PA Required
PA Required
PA Required
PA Required
YES, Specialty Drug
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
-
-
Not a covered
benefit
-
1
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Penalty applied if Brand Selected
over Generic
-
18
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ACTICOAT MOI PAD 4"X8"
ACTICOAT SUR PAD 4"X10"
ACTICOAT SUR PAD 4X13.75"
ACTICOAT SUR PAD 4X4-3/4"
ACTIDOSE/SOR LIQ 25/120ML
ACTIDOSE-AQ LIQ 15/72ML
ACTIFIED CLD TAB /ALLERGY
ACTIFOAM MIS 12.7X8.9
3
3
3
3
1
1
1
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
3
Non-Preferred Brand
3
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ACTIQ LOZ 1200MCG
3
Non-Preferred Brand
PA Required
ACTIQ LOZ 1600MCG
3
Non-Preferred Brand
PA Required
ACTIQ LOZ 200MCG
3
Non-Preferred Brand
PA Required
ACTIQ LOZ 400MCG
3
Non-Preferred Brand
PA Required
ACTIGALL CAP 300MG
ACTIMMUNE INJ 2MU/0.5
ACTIPHYTE OF LIQ ALGAE
ACTIPHYTE OF LIQ CUCUMBER
ACTIPHYTE OF LIQ IVY
ACTIPHYTE OF LIQ LEMONGRA
ACTIPREP KIT PREP KIT
ACTIPREP LIQ 73%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
19
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
ACTIQ LOZ 600MCG
3
Non-Preferred Brand
PA Required
ACTIQ LOZ 800MCG
3
Non-Preferred Brand
PA Required
ACTIVASE INJ 100MG
ACTIVASE INJ 50MG
2
2
Preferred Brand
Preferred Brand
ACTIVE 55 LIQ PLUS
-
-
3
2
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
$0 Preventative Drug
ACTIVE Q MAX CAP 300MG
ACTIVE Q SYP 100/5ML
3
3
Non-Preferred Brand
Non-Preferred Brand
ACTIVELLA TAB 0.5-0.1
3
Non-Preferred Brand
ACTIVELLA TAB 1-0.5MG
3
Non-Preferred Brand
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
ACTIVE FE TAB 75-1.25
ACTIVE LIFE MIS 1"
ACTIVE LIFE MIS 19-64MM
ACTIVE MEDIC KIT SPECIMEN
ACTIVE OB CAP
ACTIVE-PAC/ MIS GABA 300
ACTIVE-Q CAP
ACTIVE-Q CAP EXT STR
ACTIVITY PCH MIS
ACTONEL TAB 150MG
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 1per
30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
20
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ACTONEL TAB 30MG
3
Non-Preferred Brand
ACTONEL TAB 35MG
3
Non-Preferred Brand
ACTOPLUS MET TAB 15-500MG
3
Non-Preferred Brand
Maximum of 90
per 30 days
ACTOPLUS MET TAB 15-850MG
3
Non-Preferred Brand
Maximum of 90
per 30 days
ACTOPLUS MET TAB XR
2
Preferred Brand
ACTOPLUS MET TAB XR
2
Preferred Brand
ACTOS TAB 15MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
ACTOS TAB 30MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
ACTOS TAB 45MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
ACULAR LS SOL 0.4%
3
Non-Preferred Brand
ACULAR SOL 0.5% OP
3
Non-Preferred Brand
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ACURA CONTRL SOL HIGH
ACURA CONTRL SOL LOW
ACURA CONTRL SOL NORMAL
ACUVAIL SOL 0.45%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of30per
30 days
Maximum of 4 per
30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
21
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ACUWASH LIQ
ACYCLOVIR CAP 200MG
ACYCLOVIR NA INJ 1000MG
ACYCLOVIR NA INJ 500MG
ACYCLOVIR NA INJ 50MG/ML
ACYCLOVIR OIN 5%
ACYCLOVIR POW
ACYCLOVIR SUS 200/5ML
ACYCLOVIR TAB 400MG
ACYCLOVIR TAB 800MG
ACZONE GEL 5%
AFLURIA INJ 2012-13
ADAGEN INJ 250/ML
3
1
2
1
1
1
2
1
1
1
2
3
Non-Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
$ACA Drug
Non-Preferred Brand
ADALAT CC TAB 30MG ER
3
Non-Preferred Brand
ADALAT CC TAB 60MG ER
3
Non-Preferred Brand
ADALAT CC TAB 90MG ER
3
Non-Preferred Brand
1
1
1
2
2
2
2
2
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
ADAPALENE CRE 0.1%
ADAPALENE GEL 0.1%
ADAPALENE GEL 0.3%
ADAPT CONVEX MIS RING
ADAPT LUBRIC LIQ DEODORNT
ADAPT MIS BARRIER
ADAPT PST
ADAPT STOMA POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
PA after 25
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA after 25
PA after 25
PA after 25
22
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ADAPTADERM CRE
ADAPTADERM GEL
ADAPTOR MIS LG TOP
ADASUVE INH 10MG
ADCETRIS INJ 50MG
ADCIRCA TAB 20MG
ADD-A-FOLEY KIT 2000ML
ADDAMEL N INJ
ADDAPRIN TAB 200MG
3
2
3
3
3
3
2
2
1
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
ADDERALL TAB 10MG
3
Non-Preferred Brand
PA after 25
ADDERALL TAB 12.5MG
3
Non-Preferred Brand
PA after 25
ADDERALL TAB 15MG
3
Non-Preferred Brand
PA after 25
ADDERALL TAB 20MG
3
Non-Preferred Brand
PA after 25
ADDERALL TAB 30MG
3
Non-Preferred Brand
PA after 25
ADDERALL TAB 5MG
3
Non-Preferred Brand
PA after 25
ADDERALL TAB 7.5MG
3
Non-Preferred Brand
PA after 25
WDRx 2/23/15
Special Plan Edits
PA Required
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
23
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
ADDERALL XR CAP 10MG
3
Non-Preferred Brand
PA after 25
ADDERALL XR CAP 15MG
3
Non-Preferred Brand
PA after 25
ADDERALL XR CAP 20MG
3
Non-Preferred Brand
PA after 25
ADDERALL XR CAP 25MG
3
Non-Preferred Brand
PA after 25
ADDERALL XR CAP 30MG
3
Non-Preferred Brand
PA after 25
ADDERALL XR CAP 5MG
3
Non-Preferred Brand
PA after 25
2
2
3
3
3
3
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ADENOCARD INJ 12MG/4ML
3
Non-Preferred Brand
ADENOCARD INJ 3MG/ML
3
Non-Preferred Brand
ADD-INS PAK COMPLETE
ADDITIONS FO POW ENHANCER
ADEFOV DIPIV TAB 10MG
ADEMPAS TAB 0.5MG
ADEMPAS TAB 1.5MG
ADEMPAS TAB 1MG
ADEMPAS TAB 2.5MG
ADEMPAS TAB 2MG
WDRx 2/23/15
PA Required
PA Required
PA Required
PA Required
PA Required
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
24
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ADENOSCAN INJ 3MG/ML
Tier
Formulary Status
3
Non-Preferred Brand
1
1
1
2
2
3
2
3
3
3
2
3
2
3
2
3
3
3
3
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ADIPEX-P CAP 37.5MG
-
-
ADIPEX-P TAB 37.5MG
-
-
ADJ LANCING MIS DEVICE
ADLT BARRIER AER 10%
3
$0 Preventative Drug
Non-Preferred Brand
ADLT ONE DLY CHW GUMMIES
-
-
ADENOSINE INJ 12MG/4ML
ADENOSINE INJ 3MG/ML
ADENOSINE INJ 3MG/ML
ADENOSINE POW
ADENOSINE-5 POW MONOPHOS
ADENOSYLCOBA POW
ADH BANDAGE MIS CLEAR
ADH REMOVER LIQ
ADH REMOVER MIS WIPE
ADHES STRIP MIS 2-SIDED
ADHESIVE PAD 2"X3"
ADHESIVE PAD 3"X4"
ADHESIVE TAP 1"X5YD
ADHESIVE TAP 1"X6YD
ADHESV GAUZE PAD 2-3/8X4"
ADHESV GAUZE PAD 3-1/2"X6
ADHESV GAUZE PAD 3-1/2"X8
ADHESV GAUZE PAD 6"X6"
ADHSV GAUZE PAD 4"X8"
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
25
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ADMIN SET MIS 1.2MICR
ADMIX NEEDLE MIS 16GX1"
ADMIX NEEDLE MIS 18GX1.5"
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
ADOXA PAK 1/ TAB 100MG
3
Non-Preferred Brand
ADOXA PAK 1/ TAB 150MG
3
Non-Preferred Brand
ADOXA TAB 50MG
3
Non-Preferred Brand
ADOXA TAB 75MG
3
Non-Preferred Brand
ADRENACLICK INJ 0.15MG
3
Non-Preferred Brand
ADRENACLICK INJ 0.3MG
3
Non-Preferred Brand
ADRENAL C TAB FORMULA
-
-
ADRENAL CAP 200MG
1
Generic
ADRENAL TAB CALM
-
-
ADRENALIN INJ 1MG/ML
ADRENALIN INJ 1MG/ML
ADRENALIN INJ 30/30ML
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
ADOXA CAP 150MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Not a covered
benefit
Not a covered
benefit
4 per 12 months
4 per 12 months
-
-
-
-
26
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ADRENALIN SOL 1:1000
ADRENOCHROME POW SEMICARB
3
2
Non-Preferred Brand
Preferred Brand
-
-
ADREVIEW INJ
ADRIAMYC INJ 50MG
ADRIAMYCIN INJ 10MG
ADRIAMYCIN INJ 20MG
ADRIAMYCIN INJ 2MG/ML
ADRUCIL INJ 2.5G/50M
ADRUCIL INJ 500/10ML
ADRUCIL INJ 5GM/100M
3
1
1
2
1
1
1
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ADULT 50+ CAP OCUVITE
-
-
ADULT ASA TAB 81MG QM
ADULT BRIEF MIS X-LARGE
ADULT DISPOS MIS MOUTHPIE
ADULT MASK MIS
ADULT WASH MIS CLOTHS
ADULT-LOCK MIS WKLY PIL
3
2
2
3
2
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
ADV DIABETIC TAB MULTIVIT
-
-
ADV FORMULA DRO EYE
1
Generic
ADVAIR DISKU AER 100/50
2
Preferred Brand
ADVAIR DISKU AER 250/50
2
Preferred Brand
ADRENOID CAP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
-
-
Not a covered
benefit
-
-
Maximum of 60
DISP PACK per 30
days
Maximum of60
DISP PACKper 30
days
27
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Not a covered
benefit
-
-
Not a covered
benefit
-
-
Formulary Status
Special Plan Edits
ADVAIR DISKU AER 500/50
2
Preferred Brand
Maximum of 60
DISP PACK per 30
days
ADVAIR HFA AER 115/21
2
Preferred Brand
Maximum of 24gm
per 30 days
ADVAIR HFA AER 230/21
2
Preferred Brand
Maximum of 24gm
per 30 days
ADVAIR HFA AER 45/21
2
Preferred Brand
Maximum of 24gm
per 30 days
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
2
Preferred Brand
-
-
ADVANCED SOL LUBRICAN
ADVANCED SUS ANTACID
1
1
Generic
Generic
ADVANTAGE POW FORMULA
-
-
ADVATE INJ 1000UNIT
ADVATE INJ 1500UNIT
ADVATE INJ 2000UNIT
ADVATE INJ 250UNIT
ADVATE INJ 3000UNIT
ADVATE INJ 4000UNIT
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ADVANC FIBER CAP COMPLEX
ADVANCD ORAL SPR
ADVANCED CA/ TAB D/MAGNES
ADVANCED DNA KIT COLLECTI
ADVANCED E CAP
ADVANCED EYE CAP HEALTH
ADVANCED MIS AM/PM
WDRx 2/23/15
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
28
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ADVATE INJ 500UNIT
Tier
Formulary Status
3
Non-Preferred Brand
ADVERA LIQ CHOCOLAT
-
-
ADVICOR TAB 1000-20
3
Non-Preferred Brand
ADVICOR TAB 1000-40
3
Non-Preferred Brand
ADVICOR TAB 500-20MG
3
Non-Preferred Brand
ADVICOR TAB 750-20MG
3
Non-Preferred Brand
3
3
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
ADVIL CHILD SUS 100/5ML
ADVIL COLD/ CAP SINUS
ADVIL COLD/ TAB SINUS
ADVIL CONGST TAB RELIEF
ADVIL JR ST TAB 100MG
ADVIL JR STR CHW 100MG
2
2
2
3
1
1
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
ADVIL PM CAP 200-25MG
3
Non-Preferred Brand
2
2
3
2
3
1
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
ADVIL ALLERG TAB CONGEST
ADVIL ALLERG TAB SINUS
ADVIL CAP 200MG
ADVIL PM TAB 200-38MG
ADVIL TAB 200MG
ADVOCATE DUO KIT TALKING
AERCHMBR PLS MIS FLOW-VU
AERCHMBR PLS MIS MASK
AERO OTIC HC SOL
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Not a covered
benefit
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
29
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
3
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
1
1
1
3
3
3
3
3
3
3
3
3
2
1
3
$0 Preventative Drug
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
AFRIN NODRIP SPR 0.05%
3
Non-Preferred Brand
AFRIN SALINE SPR 0.65%
AFTERSUN GEL 0.5%
AFTERSUN GEL SOOTHING
1
2
1
Generic
Preferred Brand
Generic
AEROCHAMBER KIT ACTION
AEROECLIPSE MIS II NEB
AEROSPAN AER 80MCG
AF LANCETS MIS THIN
AF SPRY POWD AER 1%
AFEDITAB TAB 30MG CR
AFEDITAB TAB 60MG CR
AFINITOR DIS TAB 2MG
AFINITOR DIS TAB 3MG
AFINITOR DIS TAB 5MG
AFINITOR TAB 10MG
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AFIRM 1X CRE
AFLURIA INJ 2012-13
AFLURIA INJ 2013-14
AFLURIA INJ PF 12-13
AFRICAN MANG CAP 1200-200
AFRIN 12 HR SPR 0.05%
AFRIN CHILD SPR 0.25%
AFRIN MENTHL SPR 0.05%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
May be subject to
Quantity Level
Limits
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
30
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
AG SHAMPOO & LIQ BODY CL
AGAR POW
AGGRASTAT INJ 25MG/500
2
3
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
AGGRENOX CAP 25-200MG
2
Preferred Brand
AGORAL LIQ MAX ST
3
Non-Preferred Brand
AGRYLIN CAP 0.5MG
3
Non-Preferred Brand
3
2
3
3
3
3
3
2
1
2
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
-
-
2
1
3
3
1
1
3
1
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
AHIST TAB 25MG
A-HYDROCORT INJ 100MG
AIF #2 DRUG CRE PREP KIT
ATROVENT HFA AER 17MCG
AIR CLEANER MIS HEPA
AIR FILTER MIS
AIR FILTER MIS HEPA
AIR FOAM MIS INSOLES
AIR SALONPAS SPR
AIRAVITE TAB
AIRS DISPOSA KIT NEBULIZE
AIRSHIELD TAB
AIRZONE PEAK MIS FLOW MTR
AK-FLUOR INJ 10% OP
AK-FLUOR INJ 25% OP
AKNE-MYCIN OIN 2%
AKORN BALANC SOL SALT OP
AK-POLY-BAC OIN OP
AKTEN GEL 3.5%
AKWA TEARS OIN OP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 60
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
31
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
1
1
1
3
Generic
Generic
Generic
Non-Preferred Brand
ALA SCALP LOT 2%
3
Non-Preferred Brand
ALA SEB SHA 2-2%
ALA SEB T SHA 1-2-2%
ALA-BATH OIL
ALAGESIC LQ SOL
ALAHIST AC LIQ 7.5-10
ALAHIST DHC LIQ 7.5-3
1
2
3
2
3
3
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ALAHIST DM LIQ 7.5-4-15
3
Non-Preferred Brand
ALA-HIST IR TAB 2MG
ALA-HIST PE TAB 2-10MG
ALAMAG CHW 300-150
ALAMAG-PLUS CHW
ALANINE PAK 1000MG
ALANINE POW
ALASKAN RED POW ALGAE
ALAVERT ALRG TAB /SINUS
ALAVERT TAB 10MG
ALAVERT TAB 10MG
ALAWAY CHILD DRO 0.025%OP
ALBA-DERM CRE
ALBAFORT CAP
ALBA-LYBE NR LIQ
2
2
3
1
3
2
3
1
1
1
1
2
3
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
AKWA TEARS SOL RENEWED
AL12 LOT 12%
ALA CORT CRE 1%
ALA QUIN CRE 3-0.5%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
32
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ALBATUSSIN CAP
ALBATUSSIN LIQ NN
ALBENDAZOLE POW
ALBENZA TAB 200MG
ALBOLENE CRE SCENTED
ALBUKED 25 INJ 25%
ALBUKED 5 INJ 5%
ALBUSTIX TES
ALBUTEROL NEB 0.083%
ALBUTEROL NEB 0.5%
ALBUTEROL NEB 0.63MG/3
ALBUTEROL NEB 1.25MG/3
ALBUTEROL POW
ALBUTEROL POW SULFATE
ALBUTEROL SYP 2MG/5ML
ALBUTEROL TAB 2MG
ALBUTEROL TAB 4MG
ALBUTEROL TAB 4MG ER
ALBUTEROL TAB 8MG ER
ALCAINE SOL 0.5% OP
ALCALAK CHW 420MG
ALC-FREE AER 0.1%
ALCLOMETASON CRE 0.05%
ALCLOMETASON OIN 0.05%
ALCO-GEL GEL 60%
ALCOH-GLOVE PAD CONTOURE
ALCOHOL GEL GEL
WDRx 2/23/15
Tier
Formulary Status
3
3
2
2
3
1
1
2
1
1
1
1
3
2
1
1
1
1
1
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
3
Non-Preferred Brand
1
3
1
1
3
2
Generic
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
$0 Preventative Drug
Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
33
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ALCOHOL INJ 98%
ALCOHOL ISOP SOL 50% WINT
ALCOHOL MIS WIPES
ALCOHOL PAD
ALCOHOL PREP PAD 6-70%
ALCOHOL SOL REGENT
ALCORTIN A GEL
1
2
2
1
3
3
Generic
Preferred Brand
Preferred Brand
$0 Preventative Drug
Generic
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
-
$0 Preventative Drug
ALDACTONE TAB 100MG
3
Non-Preferred Brand
ALDACTONE TAB 25MG
3
Non-Preferred Brand
ALDACTONE TAB 50MG
3
Non-Preferred Brand
3
Non-Preferred Brand
ALDEX AN CHW 5MG
3
Non-Preferred Brand
ALDEX D SUS 16-5MG/5
3
Non-Preferred Brand
ALDEX GS DM TAB
ALDEX GS TAB 30-190MG
ALDEX-CT CHW 12.5-5MG
ALDOSTERONE POW
3
2
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ALDACTAZIDE TAB 25/25
CAPTOPR/HCTZ TAB 25-15MG
ALDARA CRE 5%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
34
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ALDURAZYME INJ 2.9MG/5M
ALENDRONATE SOL 70/75ML
ALENDRONATE TAB 10MG
ALENDRONATE TAB 35MG
ALENDRONATE TAB 40MG
ALENDRONATE TAB 5MG
ALENDRONATE TAB 70MG
ALER-CAP CAP 25MG
ALER-DRYL TAB 50MG
ALERTAB TAB 25MG
ALERTNESS AI TAB 200MG
ALEVAZOL OIN 1%
3
2
1
1
2
1
1
1
3
1
1
3
Non-Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
ALEVE CAP 220MG
3
Non-Preferred Brand
ALEVE TAB 220MG
3
Non-Preferred Brand
ALEVE-D TAB 120-220
3
Non-Preferred Brand
ALEVEER DIS 0.0375-5
ALFALFA POW
ALFALFA POW FLAVOR
ALFALFA TAB 250MG
ALFALFA TAB 500MG
ALFALFA TAB 600MG
ALFALFA TAB 650MG
ALFALFA TAB 8GR
ALFAMIN TAB
3
3
2
2
3
3
1
1
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
35
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ALFENTA INJ 500/ML
Tier
Formulary Status
3
Non-Preferred Brand
1
3
1
3
1
2
3
2
2
1
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
ALIMENTUM LIQ RTF
-
-
ALIMENTUM POW
-
-
ALIMTA INJ 100MG
ALIMTA INJ 500MG
ALINIA SUS 100/5ML
ALINIA TAB 500MG
A-LIPOIC POW ACID
3
3
2
2
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
ALITRAQ POW VANILLA
-
-
3
3
3
2
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ALFENTANIL INJ 500/ML
ALFERON N INJ 5MU/ML
ALFUZOSIN TAB 10MG
ALGA CAP
ALGAL-900DHA CAP 300MG
ALGAL-900DHA CAP 450MG
ALGICELL DRS MIS 2"X2"
ALGINIC ACID POW
ALGISITE M MIS 4"X4"
ALI-FLEX TAB 50-500MG
ALKA SELTZER TAB HEARTBRN
ALKA-AID TAB 360-180
ALKALOL SOL
ALKA-SELT PL CAP COLD/CGH
ALKA-SELT PL MIS DAY/NGHT
ALKA-SELT PL TAB CLD/FLU
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Not a covered
benefit
Not a covered
benefit
-
-
-
-
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
-
-
36
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ALKA-SELT PL TAB COLD/CGH
ALKA-SELT PL TAB NGHT CLD
ALKA-SELTZER CAP PLUS-D
ALKA-SELTZER TAB 325MG
ALKA-SELTZER TAB 500MG
ALKA-SELTZER TAB GOLD
3
3
1
2
3
3
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ALKA-SELTZER TAB PLS COLD
3
Non-Preferred Brand
3
Non-Preferred Brand
YES, Specialty Drug
3
2
2
1
1
1
1
1
1
2
2
3
2
2
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
YES, Specialty Drug
ALKERAN INJ 50MG
ALKERAN TAB 2MG
ALKYL ACRYL POW CROSSPOL
ALKYL BENZOA LIQ C12-15
ALL DAY ALLG CAP 10MG
ALL DAY ALLG CHW 10MG
ALL DAY ALLG SOL 1MG/ML
ALL DAY ALLG TAB 10MG
ALL DAY ALRG TAB 5-120MG
ALL DAY PAIN TAB 220MG
ALL GEL TOE MIS SPREADER
ALL PURPOSE MIS MASK
ALL PURPOSE PAD 4"X4"
ALLANTOIN POW
ALLCLENZ LIQ
ALL-DRY MIS SIZE 3
ALLEGRA ALRG SUS 30MG/5ML
ALLEGRA ALRG TAB 180MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
37
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ALLEGRA ALRG TAB 30MG
2
Preferred Brand
ALLEGRA ALRG TAB 30MG
2
Preferred Brand
ALLEGRA ALRG TAB 60MG
3
Non-Preferred Brand
3
2
2
1
1
1
1
1
1
3
2
2
2
3
1
1
1
3
1
1
1
1
1
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
ALLEGRA RELF CRE 2-0.5%
ALLEGRA-D TAB 12 HOUR
ALLEGRA-D TAB 24 HOUR
ALLEGRY RELF LIQ MAX ST
ALLER/CONGES TAB 10-240MG
ALLER-CHLOR SYP 2MG/5ML
ALLER-CHLOR TAB 4MG
ALLER-EASE TAB 180MG
ALLER-EASE TAB 60MG
ALLERGARD MIS GLOV 5.5
ALLERGIST KIT 0.5/28G
ALLERGIST KIT 1MLX27G
ALLERGIST KIT 1MLX28G
ALLERGIST KIT 27GX1/2"
ALLERGY CHLD LIQ 12.5/5ML
ALLERGY CRE 2-0.1%
ALLERGY EYE DRO OP
ALLERGY EYE DRO RELF PF
ALLERGY MULT PAK DAY/NGHT
ALLERGY MULT TAB DAYTIME
ALLERGY MULT TAB NIGHTTIM
ALLERGY PLUS TAB SINUS
ALLERGY REL ELX 12.5/5ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
38
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ALLERGY RELF GEL 2%
ALLERGY RELF SYP 5MG/5ML
ALLERGY RELF TAB 1.34MG
ALLERGY RELF TAB 12MG CR
ALLERGY SPR BUSTER
ALLERGY/SINU TAB HEADACHE
ALLERGY/SINU TAB HEADACHE
ALLERGY-D TAB 12 HOUR
ALLERGY-D TAB 25-10MG
ALLER-TIME TAB 2.5-60MG
ALLEVYN NON- PAD ADH 8"X8
ALLEVYN PLUS PAD 6"X8"CAV
ALLFEN CD TAB 400-10MG
ALLFEN CDX LIQ
ALLFEN CDX TAB 400-20MG
ALLFEN DM TAB 400-20MG
ALLFEN TAB 400MG
1
1
1
1
3
1
1
1
1
1
2
3
3
3
3
1
2
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
-
-
1
1
2
1
1
1
2
1
2
2
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Preferred Brand
ALLI CAP 60MG
ALL-NITE LIQ COLD/FLU
ALL-NITE LIQ COLD/FLU
ALLOPURINOL POW
ALLOPURINOL TAB 100MG
ALLOPURINOL TAB 300MG
ALLRGY MELTS TAB 12.5MG
ALMACONE CHW
ALMACONE SUS
ALMOND OIL LIQ BITTER
ALMOND OIL SWEET
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
39
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ALOCRIL SOL 2%
ALODOX KIT 20MG
ALOE 99 GEL
ALOE GRANDE CRE
ALOE GRANDE LOT
ALOE VERA CAP 25MG
ALOE VERA CAP 470MG
ALOE VERA CAP 500MG
ALOE VERA CRE 72%
ALOE VERA GEL 0.5-0.1%
ALOE VERA GEL 99.5%
ALOE VERA LIQ JUICE
ALOE VERA LIQ JUICE DR
ALOE VERA OIL
ALOE VERA POW
ALOE VERA/ GEL LIDOCAIN
ALOE VESTA AER MULTI PR
ALOE VESTA AER SKIN PRO
ALOE VESTA LIQ BODY WSH
ALOE VESTA LIQ FOAM
ALOE VESTA LOT SKN COND
ALOE VESTA OIN 2%
3
3
3
2
3
1
1
3
3
3
3
3
2
2
2
1
2
3
1
1
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
ALOE VESTA OIN PROTECTV
3
Non-Preferred Brand
3
3
1
2
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
ALOIN POW
ALOMIDE SOL 0.1% OP
ALOPHEN TAB 5MG EC
ALOPRIM INJ 500MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
40
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ALOQUIN GEL 1.25-1%
3
Non-Preferred Brand
ALORA DIS 0.025MG
3
Non-Preferred Brand
ALORA DIS 0.05MG
3
Non-Preferred Brand
ALORA DIS 0.075MG
3
Non-Preferred Brand
ALORA DIS 0.1MG
3
Non-Preferred Brand
2
1
3
3
2
1
1
2
2
1
2
1
1
1
1
2
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
ALPHAGAN P SOL 0.15%
3
Non-Preferred Brand
ALPHA-LIPOIC CAP 50MG
ALPHA-LIPOIC TAB 300MG
3
3
Non-Preferred Brand
Non-Preferred Brand
ALOXI INJ 0.25MG/5
ALP HIGH3 CAP 600MG
ALPAIN TAB
ALPHA AMYLAS POW
ALPHA KERI OIL SHWR/BTH
ALPHA LIPOIC CAP 100MG
ALPHA LIPOIC CAP 200MG
ALPHA LIPOIC CAP 300MG
ALPHA LIPOIC CAP 50MG
ALPHA LIPOIC CAP 600MG
ALPHA LIPOIC POW ACID
ALPHA LIPOIC TAB 100MG
ALPHA LIPOIC TAB 50MG
ALPHA LIPOIC TAB ACID
ALPHABATH OIL
ALPHAGAN P SOL 0.1%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 8 per
30 days
Maximum of 8 per
30 days
Maximum of 8 per
30 days
Maximum of 8 per
30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
41
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ALPHANATE INJ VWF/HUM
ALPHANATE INJ VWF/HUM
ALPHANATE INJ VWF/HUM
ALPHANATE INJ VWF/HUM
ALPHANATE INJ VWF/HUM
ALPHANINE SD INJ 1000UNIT
ALPHANINE SD INJ 1500UNIT
ALPHANINE SD INJ 500UNIT
3
3
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ALPHAQUIN HP CRE 4%
-
-
ALPHASOFT OIL
ALPHATREX GEL 0.05%
1
1
Generic
Generic
ALPH-E CAP 400UNIT
-
-
ALPH-E-CREAM CRE
1
Generic
ALPH-E-MIXED CAP 1000UNIT
-
-
ALPH-E-MIXED CAP 200UNIT
-
-
ALPRAZOLAM CON 1 MG/ML
ALPRAZOLAM POW
ALPRAZOLAM TAB 0.25 ODT
ALPRAZOLAM TAB 0.25MG
ALPRAZOLAM TAB 0.5MG
ALPRAZOLAM TAB 0.5MG ER
ALPRAZOLAM TAB 0.5MG OD
ALPRAZOLAM TAB 1MG
ALPRAZOLAM TAB 1MG ER
ALPRAZOLAM TAB 1MG ODT
ALPRAZOLAM TAB 2MG
2
2
1
1
1
1
1
1
1
1
1
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
-
-
Not a covered
benefit
-
-
-
-
-
-
Not a covered
benefit
Not a covered
benefit
42
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ALPRAZOLAM TAB 2MG ER
ALPRAZOLAM TAB 2MG ODT
ALPRAZOLAM TAB 3MG ER
ALPROLIX INJ 1000UNIT
ALPROLIX INJ 2000UNIT
ALPROLIX INJ 3000UNIT
ALPROLIX INJ 500UNIT
ALPROSTADIL INJ 500MCG
ALPROSTADIL POW
ALREX SUS 0.2%
ALRGY RELEAF PAK SYSTEM
ALRGY RELF D TAB 180-240
1
1
1
3
3
3
3
1
2
2
3
1
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
ALSOY SOY CON
-
-
ALSUMA INJ 6MG/0.5
3
Non-Preferred Brand
3
1
Non-Preferred Brand
Generic
ALTACE CAP 1.25MG
3
Non-Preferred Brand
ALTACE CAP 10MG
3
Non-Preferred Brand
ALTACE CAP 2.5MG
3
Non-Preferred Brand
ALTACE CAP 5MG
3
Non-Preferred Brand
ALTABAX OIN 1%
ALTACAINE SOL 0.5% OP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
May be subject to
Quantity Level
Limits
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
43
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ALTACHLORE OIN 5% OP
ALTACHLORE SOL 5% OP
ALTAFLUOR SOL 0.25-0.4
ALTAFRIN SOL 10% OP
ALTAFRIN SOL 2.5% OP
ALTARUSSIN SYP 100/5ML
ALTARUSSIN SYP -PE
ALTARUSSN DM SYP 100-10/5
ALTARYL SYP 12.5/5ML
ALTAVERA TAB
ALTAZINE SOL 0.05% OP
1
1
1
1
1
1
1
1
1
1
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
$0 Preventative Drug
Generic
ALTOPREV TAB 20MG ER
3
Non-Preferred Brand
ALTOPREV TAB 40MG ER
3
Non-Preferred Brand
ALTOPREV TAB 60MG ER
3
Non-Preferred Brand
3
2
3
2
1
3
2
2
1
2
2
2
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
ALTRENOGEST POW
ALUM AMMONIU POW
ALUM POTASS POW
ALUMINUM ACE POW
ALUMINUM ACE POW ASTRINGN
ALUMINUM BTL MIS SEAL
ALUMINUM CHL POW ANHYDROU
ALUMINUM CL CRY
ALUMINUM CL SOL 20%
ALUMINUM GRA SULFATE
ALUMINUM POT GRA SULFATE
ALUMINUM POT POW SULFATE
ALUMINUM POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
44
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
2
2
3
3
2
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
ALVESCO AER 160MCG
3
Non-Preferred Brand
ALVESCO AER 80MCG
3
Non-Preferred Brand
3
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
-
-
3
1
2
1
2
2
Non-Preferred Brand
Generic
Preferred Brand
Generic
Preferred Brand
Preferred Brand
AMARYL TAB 1MG
3
Non-Preferred Brand
AMARYL TAB 2MG
3
Non-Preferred Brand
ALUMINUM POW ACETATE
ALUMINUM POW CHLOROHY
ALUMINUM POW HYDROXID
ALUMINUM POW MONOSTEA
ALUMINUM POW OXIDE
ALUMINUM SOL ACETATE
ALUVEA CRE 39%
ALWAYS MAXI PAD JUMBO
ALYACEN TAB 1/35
ALYACEN TAB 7/7/7
ALZ-NAC TAB
AMALAKI TAB 500MG
AMANTADINE CAP 100MG
AMANTADINE POW HCL
AMANTADINE SYP 50MG/5ML
AMANTADINE TAB 100MG
A-MANTLE CRE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 12.2
gm per 30 days
Maximum of 12.2
gm per 30 days
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
45
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
AMARYL TAB 4MG
Tier
Formulary Status
3
Non-Preferred Brand
1
1
1
1
1
1
3
3
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
AMBIEN CR TAB 12.5MG
3
Non-Preferred Brand
AMBIEN CR TAB 6.25MG
3
Non-Preferred Brand
AMBIEN TAB 10MG
3
Non-Preferred Brand
AMBIEN TAB 5MG
3
Non-Preferred Brand
3
3
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
AMBERDERM AER
AMBI 10PEH/ TAB 400GFN
AMBI 20DM/ TAB 4CPM
AMBI 40PSE/ TAB 400GFN
AMBI 60PSE/ TAB 400GFN
AMBI 60PSE/ TAB 4CPM
AMBI ESSNTLS CRE CLEANSR
AMBI EVEN & LIQ CLEAR
AMBIFED CD TAB
AMBIFED CDX TAB
AMBIFED DM TAB
AMBIFED TAB
AMBIFED-G CD TAB
AMBIFED-G DM TAB
AMBIFED-G TAB 20-400MG
AMBIFED-G TAB CDX
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
46
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
AMBISOME INJ 50MG
AMCINONIDE CRE 0.1%
AMCINONIDE LOT 0.1%
AMCINONIDE OIN 0.1%
AMD FOAM PAD 3.5"X3"
AMEDA NOSHOW PAD NURSING
2
1
2
2
3
3
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
AMERGE TAB 1MG
3
Non-Preferred Brand
Maximum of 12
per 30 days
AMERGE TAB 2.5MG
3
Non-Preferred Brand
Maximum of 12
per 30 days
1
2
3
2
3
3
1
1
3
1
1
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Generic
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
3
Non-Preferred Brand
3
Non-Preferred Brand
AMERICERIN CRE
AMERIGEL GEL DRESSING
AMERIGEL KIT POST-OP
AMERIGEL LOT BARRIER
AMERIGEL LOT CARE
AMERIGEL SOL WOUND
AMERIPHOR OIN
AMERISTORE LOT
AMERIWASH LOT
A-METHAPRED INJ 125MG
A-METHAPRED INJ 40MG
AMETHIA LO TAB
AMETHIA TAB
AMETHYST TAB 90-20MCG
AMICAR SYP 25%
AMICAR TAB 1000MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
47
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
AMICAR TAB 500MG
3
Non-Preferred Brand
AMIDATE INJ 2MG/ML
3
Non-Preferred Brand
AMIFOSTINE INJ 500MG
AMIKACIN INJ 1GM/4ML
AMIKACIN INJ 500/2ML
AMIKACIN POW
AMIKACIN POW SULFATE
AMILOR/HCTZ TAB 5-50
AMILORIDE TAB 5MG
AMINA-21 CAP
AMINO 4800 TAB CR
AMINO ACIDS INJ 15%
AMINO ACIDS TAB COMPLEX
AMINOAC ACID SOL 1.5% IRR
3
1
1
2
2
1
1
1
3
1
1
1
Non-Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
AMINOBENZOIC POW ACID
-
-
AMINOBEZ POT POW
-
-
AMINOBRAIN CAP
-
-
3
1
1
1
3
3
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
AMINOBUT ACD POW
AMINOCAPR AC INJ 250MG/ML
AMINOCAPR AC SYP 25%
AMINOCAPR AC TAB 500MG
AMINOGUANIDI POW HYDROGEN
AMINOHIPPURA INJ 20%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
48
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
AMINOLEVULIN CRY ACID HCL
AMINOLEVULIN POW ACID HCL
AMINOPHYLLIN INJ 25MG/ML
AMINOPHYLLIN POW ANHYDROU
AMINOSAL ACD POW -4
AMINOSALICYL POW SODIUM
AMINOSYN 7% INJ /LYTES
AMINOSYN II INJ 10%
AMINOSYN II INJ 15%
AMINOSYN II INJ 7%
AMINOSYN II INJ 8.5%
AMINOSYN II INJ 8.5/LYTE
AMINOSYN INJ 10%
AMINOSYN INJ 3.5%
AMINOSYN INJ 8.5%
AMINOSYN M INJ 3.5%
AMINOSYN-HF INJ 8%
AMINOSYN-RF INJ 5.2%
AMIODARONE INJ 150MG/3M
AMIODARONE POW HCL
AMIODARONE TAB 100MG
AMIODARONE TAB 200MG
AMIODARONE TAB 400MG
AMITIZA CAP 24MCG
AMITIZA CAP 8MCG
AMITRAZ POW
AMITRIPTYLIN KIT 2%
AMITRIPTYLIN POW HCL
AMITRIPTYLIN TAB 100MG
3
3
1
2
2
2
2
2
2
2
2
1
3
2
3
2
1
2
1
3
1
1
1
2
2
3
3
2
-
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
49
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
AMITRIPTYLIN TAB 10MG
AMITRIPTYLIN TAB 150MG
AMITRIPTYLIN TAB 25MG
AMITRIPTYLIN TAB 50MG
AMITRIPTYLIN TAB 75MG
AMLACTIN CRE FOOT
AMLACTIN CRE ULTRA
AMLOD/ATORVA TAB 10-10MG
AMLOD/ATORVA TAB 10-20MG
AMLOD/ATORVA TAB 10-40MG
AMLOD/ATORVA TAB 10-80MG
AMLOD/ATORVA TAB 2.5-10MG
AMLOD/ATORVA TAB 2.5-20MG
AMLOD/ATORVA TAB 2.5-40MG
AMLOD/ATORVA TAB 5-10MG
AMLOD/ATORVA TAB 5-20MG
AMLOD/ATORVA TAB 5-40MG
AMLOD/ATORVA TAB 5-80MG
AMLOD/BENAZP CAP 10-20MG
AMLOD/BENAZP CAP 10-40MG
AMLOD/BENAZP CAP 2.5-10MG
AMLOD/BENAZP CAP 5-10MG
AMLOD/BENAZP CAP 5-20MG
AMLOD/BENAZP CAP 5-40MG
AMLODIPINE POW BESYLATE
AMLODIPINE TAB 10MG
AMLODIPINE TAB 2.5MG
AMLODIPINE TAB 5MG
AMMON CARBON MIS CHIPS
2
2
1
1
1
1
1
1
1
1
1
1
1
2
2
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
50
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
AMMON MOLYBD INJ 25MCG/ML
AMMONIA AROM INH
AMMONIA AROM INH SPIRITS
AMMONIUM BRO GRA
AMMONIUM CAR POW
AMMONIUM CHL INJ 5MEQ/ML
AMMONIUM GRA BICARBON
AMMONIUM GRA CHLORIDE
AMMONIUM GRA SULFATE
AMMONIUM LAC CRE 12%
AMMONIUM LAC SOL 70%
AMMONIUM LIQ LAURYL
AMMONIUM POW ACETATE
AMMONIUM POW BICARBON
AMMONIUM POW DICHROMA
AMMONIUM POW GLYCYRRH
AMMONIUM POW MOLYBDAT
AMMONIUM POW NITRATE
AMMONIUM SOL HYDROXID
AMMONUL INJ 10%
AMNESTEEM CAP 10MG
AMNESTEEM CAP 20MG
AMNESTEEM CAP 40MG
AMODIAQUINE POW HCL DIHY
AMORPH WOUND GEL DRESSING
AMOSAN POW
AMOX/K CLAV CHW 200MG
AMOX/K CLAV CHW 400MG
AMOX/K CLAV SUS 200/5ML
2
1
2
2
2
2
2
2
2
1
2
2
3
2
3
3
2
3
2
2
1
1
1
3
3
3
1
1
1
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
PA Required
PA Required
PA Required
51
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
AMOX/K CLAV SUS 250/5ML
AMOX/K CLAV SUS 400/5ML
AMOX/K CLAV SUS 600/5ML
AMOX/K CLAV TAB 250MG
AMOX/K CLAV TAB 500MG
AMOX/K CLAV TAB 875MG
AMOXAPINE TAB 100MG
AMOXAPINE TAB 150MG
AMOXAPINE TAB 25MG
AMOXAPINE TAB 50MG
AMOXICILLIN CAP 250MG
AMOXICILLIN CAP 500MG
AMOXICILLIN CHW 125MG
AMOXICILLIN CHW 250MG
AMOXICILLIN- POW K CLAV
AMOXICILLIN POW TRIHYDRA
AMOXICILLIN SUS 125/5ML
AMOXICILLIN SUS 200/5ML
AMOXICILLIN SUS 250/5ML
AMOXICILLIN SUS 400/5ML
AMOXICILLIN TAB 500MG
AMOXICILLIN TAB 775MG
AMOXICILLIN TAB 875MG
AMOX-POT CLA TAB ER
AMPHADASE INJ 150/ML
AMPHETAMINE CAP 10MG ER
AMPHETAMINE CAP 15MG ER
AMPHETAMINE CAP 20MG ER
AMPHETAMINE CAP 25MG ER
1
1
1
1
1
1
2
2
2
2
1
1
2
2
3
2
1
1
1
1
1
3
1
1
3
1
1
1
1
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
PA after 25
PA after 25
PA after 25
PA after 25
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
52
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
AMPHETAMINE CAP 30MG ER
AMPHETAMINE CAP 5MG ER
AMPHETAMINE TAB 10MG
AMPHETAMINE TAB 12.5MG
AMPHETAMINE TAB 15MG
AMPHETAMINE TAB 20MG
AMPHETAMINE TAB 30MG
AMPHETAMINE TAB 5MG
AMPHETAMINE TAB 7.5MG
AMPHOTEC INJ 100MG
AMPHOTEC INJ 50MG
AMPHOTERICIN INJ 50MG
AMPHOTERICIN POW B
AMPICILLIN CAP 250MG
AMPICILLIN CAP 500MG
AMPICILLIN INJ 125MG
AMPICILLIN INJ 250MG
AMPICILLIN INJ 500MG
AMPICILLIN POW TRIHYDRA
AMPICILLIN SUS 125/5ML
AMPICILLIN SUS 250/5ML
AMP-SULBACTA INJ 1.5GM
AMP-SULBACTA INJ 1.5GM
AMP-SULBACTA INJ 10-5GM
AMP-SULBACTA INJ 10-5GM
AMP-SULBACTA INJ 2-1GM
AMP-SULBACTA INJ 3GM
AMPYRA TAB 10MG
AMRIX CAP 15MG
1
1
1
1
1
1
1
1
1
2
2
2
2
1
1
2
1
1
3
2
2
1
1
1
1
1
2
3
3
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
WDRx 2/23/15
PA Required
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
53
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
Non-Preferred Brand
AMTURNIDE150 TAB -5-12.5
2
Preferred Brand
AMTURNIDE300 TAB -10-12.5
2
Preferred Brand
AMTURNIDE300 TAB -10-25MG
2
Preferred Brand
AMTURNIDE300 TAB -5-12.5
2
Preferred Brand
AMTURNIDE300 TAB -5-25MG
2
Preferred Brand
AMVISC INJ 12MG/ML
AMVISC PLUS INJ 16MG/ML
AMYL ACETATE OIL
AMYTAL SOD INJ 500MG
AMYVID INJ
ANACAINE OIN
3
3
3
2
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ANADROL-50 TAB 50MG
-
-
ANAFRANIL CAP 25MG
3
Non-Preferred Brand
ANAFRANIL CAP 50MG
3
Non-Preferred Brand
ANAFRANIL CAP 75MG
3
Non-Preferred Brand
ANAGRELIDE CAP 0.5MG
ANAGRELIDE CAP 1MG
ANA-LEX KIT
ANALGESIC CRE /ALOE
1
1
1
1
Generic
Generic
Generic
Generic
AMRIX CAP 30MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
54
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ANALPRAM E KIT
Tier
Formulary Status
3
Non-Preferred Brand
ANALPRAM KIT ADVANCED
2
Preferred Brand
ANALPRAM-HC CRE 1-1%
3
Non-Preferred Brand
ANALPRAM-HC CRE 1-2.5%
3
Non-Preferred Brand
ANALPRAM-HC CRE SINGLES
3
Non-Preferred Brand
ANALPRAM-HC LOT 2.5%
ANAMU CAP 400MG
ANAMU CAP 450MG
ANANA FORTE TAB 133333
2
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ANAPROX DS TAB 550MG
3
Non-Preferred Brand
3
Non-Preferred Brand
3
2
2
1
1
2
2
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
ANAPROX TAB 275MG
ANASCORP INJ
ANASPAZ TAB 0.125MG
ANASTROZOLE POW
ANASTROZOLE TAB 1MG
ANBESOL COLD OIN SORE
ANBESOL GEL 10%
ANBESOL GEL 20%
ANBESOL LIQ 10%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
55
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ANBESOL LIQ 20%
2
Preferred Brand
ANCOBON CAP 250MG
3
Non-Preferred Brand
ANCOBON CAP 500MG
3
Non-Preferred Brand
2
3
3
2
2
2
2
2
2
3
3
2
3
2
1
1
1
2
3
2
2
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ANDRENOCORTI POW HORMONE
ANDRODERM DIS 2MG/24HR
ANDRODERM DIS 4MG/24HR
ANDROGEL GEL 1%(25MG)
ANDROGEL GEL 1%(50MG)
ANDROGEL GEL 1.62%
ANDROGEL GEL 1.62%
ANDROGEL GEL 1.62%
ANDROGEL GEL PUMP 1%
ANDROID CAP 10MG
ANDROSTENED POW
ANDROSTENEDI POW
ANDROSTERONE POW
ANDROXY TAB 10MG
ANECREAM CRE 4%
ANECREAM KIT 4%
ANECREAM5 CRE 5%
ANECTINE INJ 20MG/ML
ANESTH NEEDL MIS 20GX4"
ANESTH NEEDL MIS 20GX6"
ANESTH NEEDL MIS 22GX2"
ANESTH NEEDL MIS 22GX3"
ANESTH NEEDL MIS 22GX4"
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
56
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ANESTHETIC GEL 20%
ANESTHETIC LIQ ORAL
ANETHOLE LIQ
1
1
3
Generic
Generic
Non-Preferred Brand
ANGELIQ TAB 0.25-0.5
3
Non-Preferred Brand
ANGELIQ TAB 0.5-1MG
3
Non-Preferred Brand
2
2
3
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
-
-
-
-
ANIMAL SHAPE CHW COMPLETE
-
-
ANISE FLAVOR OIL
ANISE OIL
ANISINDIONE POW
ANKLE WRAP PAD ICE/HEAT
ANORO ELLIPT AER 62.5-25
ANSWER OVUL KIT
ANT&ANTI-GAS CHW 1000-60
2
2
2
3
2
3
1
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
3
Non-Preferred Brand
ANGIOMAX INJ 250MG
ANHYDROUS CRE BASE
ANHYDROUS GEL SILICONE
ANHYDROUS OIN BASE
ANIMAL CHEWS CHW
ANIMAL SHAPE CHW /IRON
ANTABUSE TAB 250MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
57
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ANTABUSE TAB 500MG
Tier
Formulary Status
3
Non-Preferred Brand
3
1
2
1
1
1
1
1
1
1
Non-Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
ANTARA CAP 130MG
3
Non-Preferred Brand
ANTARA CAP 30MG
-
$0 Preventative Drug
ANTARA CAP 43MG
3
Non-Preferred Brand
3
3
3
2
2
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
-
-
1
1
Generic
Generic
ANTACID CHW
ANTACID CHW 1000MG
ANTACID CHW 1177MG
ANTACID CHW 500MG
ANTACID CHW 550-110
ANTACID CHW 750MG
ANTACID CHW DBL ST
ANTACID EXTR CHW 675-135
ANTACID MULT CHW -SYMPTOM
ANTACID/PAIN TAB 325MG
ANTARA CAP 90MG
ANTHELIOS 30 SPR ULT LGHT
ANTHELIOS 45 LIQ ULT LGHT
ANTHELIOS 60 LOT MELT-IN
ANTHRALIN POW
ANTI MONKEY POW BUTT
ANTI-ALLERGY TAB
ANTIB + PAIN CRE RELIEF
ANTIBAC HAND LIQ SOAP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
58
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ANTI-BACTER MIS WIPES
ANTIBACTERIA LIQ LOTION
ANTIBACTERIA MIS WIPES
ANTI-BACTERL LOT HAND LOT
ANTIBIOT EAR SOL 1% OTIC
ANTIBIOTIC OIN
ANTIBIOTIC OIN PAIN RLF
ANTICOAG CPD SOL
ANTICOAGULNT SOL SOD CITR
ANTI-DANDRUF SHA 1%
ANTI-DANDRUF SHA COAL TAR
ANTI-DIARRHE CAP 2MG
ANTI-DIARRHE LIQ 1MG/5ML
ANTI-DIARRHE TAB 2MG
ANTI-DIARRHE TAB GAS RELF
ANTIFUNGAL AER 1%
ANTI-FUNGAL CRE 1%
ANTIFUNGAL CRE 1%
ANTIFUNGAL CRE 2%
ANTIFUNGAL CRE FOOT 1%
ANTI-FUNGAL LIQ 12.5%
ANTI-FUNGAL LIQ 25%
ANTIFUNGAL OIN MAX STR
ANTI-FUNGAL POW 1%
ANTI-FUNGAL POW 2%
ANTI-FUNGAL SOL 1%
ANTI-FUNGAL SPR 2%
ANTI-GAS CAP
ANTI-GAS CAP 180MG
3
1
1
3
1
1
1
2
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
59
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
ANTI-INFLAMM CAP FORMULA
-
-
Not a covered
benefit
-
-
ANTI-ITCH CRE 1-01%
ANTI-ITCH CRE 5-2%
ANTI-ITCH CRE MAX-STR
ANTI-ITCH CRE MEDICATD
ANTI-ITCH LOT
ANTI-ITCH LOT 1%
ANTI-ITCH LOT CLEAR
ANTI-ITCH LOT SENS 1%
ANTI-ITCH OIN 1%
ANTI-ITCH SPR 2%
ANTI-ITCH/ CRE ALOE
ANTIMICROBIA LIQ CLEANSER
ANTIMONY CRY TRICHLOR
ANTIMONY POT POW TARTRATE
ANTIMONY POW TRISULF
ANTI-NAUSEA GUM GINGER
ANTI-NAUSEA LIQ
1
1
1
1
1
1
1
2
1
1
1
1
2
2
2
3
1
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
-
-
-
-
-
-
-
-
-
-
-
-
3
1
2
2
3
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
ANTIOXIDANT CAP
ANTIOXIDANT CAP FORMULA
ANTI-OXIDANT TAB
ANTI-PERSPIR SOL 12%
ANTI-PLAQUE LIQ DNTL RNS
ANTIPY/BENZO SOL OTIC
ANTIPYRINE CRY
ANTIPYRINE POW PURIFIED
WDRx 2/23/15
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Penalty applied if Brand Selected
over Generic
60
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ANTISEP RINS LIQ 0.7%
ANTISEPTIC AER
ANTISEPTIC GEL
ANTISEPTIC GEL CLEANER
ANTISEPTIC LIQ FIRSTAID
ANTISEPTIC LIQ FRESH MN
ANTISEPTIC LIQ PAIN REL
ANTISEPTIC LIQ RINSE
ANTISEPTIC SOL 10%
ANTISEPTIC SOL CLNSR 4%
ANTISEPTIC SPR CLEANSER
ANTI-SNORE LIQ THROAT
ANTIVENIN KIT LAT MACT
ANTIVENIN MI INJ
ANTIVERT TAB 50MG
ANTI-WRINKLE LOT SPF 15
1
3
2
3
1
1
1
1
1
2
1
3
3
3
3
1
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
ANTIZOL INJ 1GM/ML
3
Non-Preferred Brand
ANUCORT-HC SUP 25MG
ANU-MED SUP
1
1
Generic
Generic
ANUSOL-HC CRE 2.5%
3
Non-Preferred Brand
ANUSOL-HC SUP 25MG
3
Non-Preferred Brand
ANZEMET INJ 20MG/ML
ANZEMET TAB 100MG
ANZEMET TAB 50MG
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
61
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
AO-DISC MIS CATALYST
AO-SEPT MIS
AO-SEPT MIS DIS PACK
AOSEPT SOL
APAP 500 LIQ 500/5ML
APAP CRYSTAL CRY 60 MESH
APAP/CAFF/DI TAB HYDROCOD
APAP/CODEINE SOL 120-12/5
APAP/CODEINE TAB 300-15MG
APAP/CODEINE TAB 300-30MG
APAP/CODEINE TAB 300-60MG
3
3
3
3
2
2
2
1
1
1
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
-
-
APATATE LIQ
-
-
APETEX ELX
-
-
APETIGEN TAB PLUS
-
-
APETIGEN-PLS SOL
-
-
APETIMAR SYP /IRON
-
-
APEXICON E CRE 0.05%
APEXICON OIN 0.05%
AP-HIST DM LIQ 7.5-4-15
APIDRA INJ SOLOSTAR
APIDRA INJ U-100
2
1
1
3
3
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
APLENZIN TAB 174MG
3
Non-Preferred Brand
APATATE FORT LIQ
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
-
-
Maximum of 30
per 30 days
62
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
APLENZIN TAB 348MG
3
Non-Preferred Brand
APLENZIN TAB 522MG
3
Non-Preferred Brand
APLIGRAF MIS
APLISOL INJ 5/0.1ML
APOKYN INJ 10MG/ML
APOMORPHINE POW HCL
APOP GEL 10%
APPBUTAMONE PAK
3
2
3
2
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
APPEAREX TAB 2.5MG
-
-
3
3
3
3
1
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
-
-
1
Generic
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
APPETITE TAB CONTROL
APPFORMIN PAK
APPLE CIDER CAP 188MG
APPLE CIDER CAP VINEGAR
APPLE CIDER TAB 300MG
APPLE FLAVOR LIQ
APPLE FLAVOR POW
APPLICATOR MIS COTTON
APPTRIM CAP
APRACLONIDIN SOL 0.5% OP
APRI TAB
APRISO CAP 0.375GM
APTIOM TAB 200MG
APTIOM TAB 400MG
APTIOM TAB 600MG
APTIOM TAB 800MG
APTIVUS CAP 250MG
WDRx 2/23/15
3
3
3
3
3
3
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Limited Distribution
Not a covered
benefit
-
-
Not a covered
benefit
-
-
YES, Specialty Drug
63
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
APTIVUS SOL
AP-ZEL TAB
Tier
Formulary Status
3
Non-Preferred Brand
-
-
3
1
1
2
1
2
3
2
3
3
3
2
3
3
2
2
2
3
2
2
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
AQUADEKS CHW
-
-
AQUADEKS DRO
-
-
AQUA-E LIQ
-
-
3
Non-Preferred Brand
AQ GLY TONER MIS TOWELETT
AQUA CARE CRE 10%
AQUA CARE LOT 10%
AQUA LACTEN LOT
AQUA LUBE GEL
AQUABASE OIN
AQUACEL AG MIS 0.39X18"
AQUACEL AG PAD 2"X2"
AQUACEL AG PAD 3.5"X10"
AQUACEL AG PAD 3.5"X12"
AQUACEL AG PAD 3.5"X14"
AQUACEL AG PAD 3.5"X4"
AQUACEL AG PAD 3.5"X6"
AQUACEL AG PAD 4"X5"
AQUACEL AG PAD 8" X 12"
AQUACEL AG PAD EX 4"X5"
AQUACEL AG PAD EX 6"X6"
AQUACEL ROPE MIS 0.39X18"
AQUACEL ROPE MIS 3/4"X18"
AQUACEL-AG PAD 4"X4.7"
AQUAFRESH GEL WHITENIN
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
-
-
64
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
AQUAFRESH MIS EXT SOFT
AQUAFRESH MIS WHT TRAY
AQUAFRESH PST
AQUANIL SKIN LOT CLEANSER
AQUAPHIL OIN BASE
AQUAPHILIC OIN
AQUAPHILIC OIN 10% CARB
AQUAPHILIC OIN 20% CARB
AQUAPHOR OIN
3
3
3
2
3
2
2
2
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
AQUASOL A INJ 50000/ML
-
-
AQUASOL E DRO 15/0.3ML
-
-
3
Non-Preferred Brand
AQUAVIT-E SOL 15/0.3ML
-
-
AQUEOUS DRO SELENIUM
AQUORAL AER
ARALAST NP INJ 1000MG
ARALAST NP INJ 400MG
ARALAST NP INJ 500MG
ARALAST NP INJ 800MG
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ARALEN TAB 500MG
3
Non-Preferred Brand
ARANELLE TAB
ARANESP INJ 100MCG
ARANESP INJ 100MCG
ARANESP INJ 150MCG
ARANESP INJ 150MCG
3
3
3
3
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
AQUASOL OIN
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
65
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
3
3
3
3
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ARAVA TAB 10MG
3
Non-Preferred Brand
ARAVA TAB 20MG
3
Non-Preferred Brand
ARBINOXA SOL 4MG/5ML
ARBINOXA TAB 4MG
ARBUTIN POW ALPHA
ARC OIN
ARCALYST INJ 220MG
1
1
3
3
3
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ARCAPTA CAP 75MCG
2
Preferred Brand
1
3
1
2
2
Generic
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
ARANESP INJ 200MCG
ARANESP INJ 200MCG
ARANESP INJ 25MCG
ARANESP INJ 25MCG
ARANESP INJ 300MCG
ARANESP INJ 300MCG
ARANESP INJ 40MCG
ARANESP INJ 40MCG
ARANESP INJ 500MCG
ARANESP INJ 60MCG
ARANESP INJ 60MCG
ARCTIC RELF GEL 0.2-3.5%
ARESTIN MIS 1MG
ARGATROBAN INJ 100MG/ML
ARGATROBAN INJ 125/125
ARGATROBAN INJ 50MG/50M
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Maximum of 30 (1
BOX) per 30 days
66
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ARGENTUM-D20 INJ
ARGIMENT AT PAK
3
3
Non-Preferred Brand
Non-Preferred Brand
ARGINAID LIQ EXTRA
-
-
2
2
1
3
3
3
1
1
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
ARICEPT ODT TAB 10MG
3
Non-Preferred Brand
ARICEPT ODT TAB 5MG
3
Non-Preferred Brand
ARICEPT TAB 10MG
3
Non-Preferred Brand
ARICEPT TAB 23MG
3
Non-Preferred Brand
ARICEPT TAB 5MG
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
2
Preferred Brand
ARGININE HCL POW
ARGININE PAK 500MG
ARGININE TAB 500MG
ARGININE2000 PAK 2000MG
ARGITEIN PAK
ARGLAES POW
ARGYL SALINE SOL 0.9%
ARGYL SALINE SOL 100ML
ARIDOL KIT
ARIMIDEX TAB 1MG
ARISTOSPAN INJ 20MG/ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Maximum of30per
30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
67
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
Preferred Brand
ARIXTRA SOL 10/0.8
3
Non-Preferred Brand
ARIXTRA SOL 2.5/0.5
3
Non-Preferred Brand
ARIXTRA SOL 5.0/0.4
3
Non-Preferred Brand
ARIXTRA SOL 7.5/0.6
3
Non-Preferred Brand
ARKALIOX CAP 200MG
-
-
2
2
2
2
2
2
2
2
2
3
3
2
2
3
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ARISTOSPAN INJ 5MG/ML
ARLACEL 165 POW
ARMOUR THYRO TAB 120MG
ARMOUR THYRO TAB 15MG
ARMOUR THYRO TAB 180MG
ARMOUR THYRO TAB 240MG
ARMOUR THYRO TAB 300MG
ARMOUR THYRO TAB 30MG
ARMOUR THYRO TAB 60MG
ARMOUR THYRO TAB 90MG
ARNICA GEL
ARNICA MIS MONTANA
ARNICA TIN 20%
ARNICA TIN FLOWER
ARNICARE CRE ARNICA
ARNICARE OIN ARNICA
ARNICARE TAB ARTHRITI
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
68
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
AROMASIN TAB 25MG
Tier
Formulary Status
Special Plan Edits
Non-Preferred Brand
3
2
3
3
3
3
1
3
3
1
1
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
ARTHROTEC 50 TAB
3
Non-Preferred Brand
Maximum of 120
per 30 days
ARTHROTEC 75 TAB
3
Non-Preferred Brand
Maximum of 120
per 30 days
1
1
1
1
1
1
3
3
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
ARTIFI TEARS DRO
ARTIFI TEARS DRO 1-0.3%
ARTIFI TEARS OIN OP
ARTIFICIAL DRO TEARS
ARTIFICIAL SOL TEARS
ARTIFICIAL SOL TEARS OP
ARTISS SOL 10ML
ARZERRA CON 100/5ML
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
3
ARRANON INJ 5MG/ML
ARSENIC POW TRIOXIDE
ARTERIAL NDL MIS 19GX1.5"
ARTERIAL NDL MIS 20GX1.5"
ARTERIAL TAB THERAPY
ARTH ARREST LOT
ARTHOGENIC CRE PLUS
ARTHRICARE GEL DBLE ICE
ARTHRITIS AER REL/ALOE
ARTHRITIS CRE 0.025%
ARTHRITIS CRE HOT
ARTHRITIS CRE PAIN REL
ARTHRO MUFF PAD
Medication must be filled
through US Specialty Care
Pharmacy
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
69
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ARZERRA CON 1000/50
ARZOL SILVER MIS NITR APP
A-S PL SINUS TAB 7.8-325
A-S PLS NGHT CAP CLD/FLU
ASA FREE CHW 160MG JR
ASACOL HD TAB 800MG
ASACOL TAB 400MG DR
ASAFETIDA TIN
ASAFOETIDA POW GUM
ASCENSIA MIS AUTODISC
ASCLERA INJ 0.5%
ASCLERA INJ 1%
3
2
3
3
1
2
2
2
3
3
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
-
-
ASCOCID-ISO- POW PH
-
-
ASCOMP/COD CAP 30MG
1
Generic
ASCOR L 500 INJ 500MG/ML
-
-
ASCORBIC ACD CHW 250MG
-
-
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
ASCORBIC ACD TAB 1000MG
-
-
ASCORBIC ACD TAB 250MG
-
-
ASCOCID POW
ASCOCID-1000 TAB
ASCORBIC ACD GRA
ASCORBIC ACD POW
ASCORBIC ACD POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
-
-
-
-
-
-
-
-
70
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ASCORBIC ACD TAB 500MG
ASCORBYL POW PALMITAT
ASCRBYL PHOS POW SOD DIHY
ASCRIPTIN TAB
ASCRIPTIN TAB MAX-STR
ASEPTO BULB MIS 1/2OZ
ASEPTO BULB MIS 1-1/2OZ
ASEPTO BULB MIS 1OZ CATH
ASEPTO BULB MIS 2OZ CATH
ASEPTO BULB MIS 3OZ CATH
ASEPTO BULB MIS 4OZ CATH
ASEPTO ORAL KIT CELSIUS
ASEPTO THERM MIS ORAL
ASEPTO THERM MIS RECTAL
ASHWAGANDHA POW EXT 2.5%
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
-
Not a covered
benefit
-
-
2
2
2
3
3
2
2
2
2
2
3
3
3
2
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
-
-
ASMANEX 120 AER 220MCG
2
Preferred Brand
ASMANEX 14 AER 220MCG
3
Non-Preferred Brand
ASMANEX 30 AER 110MCG
2
Preferred Brand
ASPARAGINE POW MONOHYDR
2
Preferred Brand
-
-
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
ASPARTAME POW
ASPARTATE CAP MG & K
ASPARTIC ACD POW MAG SALT
ASPERCREME CRE /ALOE
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Maximum of 2
INHALERS per 30
days
Maximum of 2
INHALERS per 30
days
Maximum of 2
INHALERS per 30
days
Not a covered
benefit
71
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ASPERCREME LIQ MAX ROLL
3
Non-Preferred Brand
ASPERCREME LOT 10%
ASPERGILLUS INJ 1:500
ASPIR-81 TAB 81MG EC
ASPIRATOR MIS NASAL
ASPIRIN ADLT TAB 81MG
ASPIRIN CHIL CHW 81MG
ASPIRIN POW
ASPIRIN SUP 120MG
ASPIRIN SUP 200MG
ASPIRIN SUP 300MG
ASPIRIN SUP 600MG
ASPIRIN TAB 325MG
ASPIRIN TAB 325MG EC
ASPIRIN TAB 81MG
ASPIRTAB M/S TAB 500MG
ASSURA DRAIN KIT POUCH
ASTAGRAF XL CAP 0.5MG
ASTAGRAF XL CAP 1MG
ASTAGRAF XL CAP 5MG
ASTAXANTHIN CAP 4MG
ASTAXANTHIN CAP 5MG
2
3
2
3
3
3
1
1
1
3
3
3
3
1
1
Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Preferred Brand
$0 ACA Drug
$0 ACA Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
ASTELIN NASA SPR 137MCG
3
Non-Preferred Brand
2
Preferred Brand
ASTEPRO SPR 0.15%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
mL (1 BOTTLE)
per 30 days
72
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
-
-
-
-
Drug Name
Tier
Formulary Status
ASTHMA RELF TAB 12.5-200
ASTHMANEFRIN NEB 2.25%
ASTHMAPACK I KIT
ASTRAGALUS POW EXTRACT
ASTRAGALUS POW ROOT
ASTRAMORPH INJ 1MG/2ML
ASTRAMORPH INJ 2MG/2ML
ASTRING-O-SO LIQ MTHWASH
ASTRINGYN SOL 259MG/GM
1
1
2
2
2
1
1
3
3
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
-
$0 Preventative Drug
2
Preferred Brand
-
$0 Preventative Drug
ATABEX TAB PRENATAL
-
$0 Preventative Drug
ATACAND HCT TAB 16-12.5
3
Non-Preferred Brand
Maximum of 30
per 30 days
ATACAND HCT TAB 32-12.5
3
Non-Preferred Brand
Maximum of 30
per 30 days
ATACAND HCT TAB 32-25MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
ATACAND TAB 16MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
ATACAND TAB 32MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
ATABEX CHW PRENATAL
ATABEX DHA CAP 250-100
ATABEX EC TAB
WDRx 2/23/15
Not a covered
benefit
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
73
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
ATACAND TAB 4MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
ATACAND TAB 8MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
2
Preferred Brand
Maximum of 4 per
30 days
2
1
1
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Generic
Generic
ATIVAN INJ 2MG/ML
3
Non-Preferred Brand
ATIVAN INJ 4MG/ML
3
Non-Preferred Brand
ATIVAN TAB 0.5MG
3
Non-Preferred Brand
ATIVAN TAB 1MG
3
Non-Preferred Brand
ATIVAN TAB 2MG
3
Non-Preferred Brand
ATELVIA TAB
ATENOL/CHLOR TAB 100-25MG
ATENOL/CHLOR TAB 50-25MG
ATENOLOL POW
ATENOLOL TAB 100MG
ATENOLOL TAB 25MG
ATENOLOL TAB 50MG
ATGAM INJ 250MG
ATHLETE FOOT AER 2%
ATHLETES FT OIN MAX ST
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
74
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
CAPTOPR/HCTZ TAB 25-25MG
CAPTOPR/HCTZ TAB 50-15MG
ATORVASTATIN TAB 10MG
ATORVASTATIN TAB 20MG
ATORVASTATIN TAB 40MG
ATORVASTATIN TAB 80MG
ATOVAQ/PROGU TAB 250-100
ATOVAQ/PROGU TAB 62.5-25
ATOVAQUONE POW
ATOVAQUONE SUS 750/5ML
ATRAC-TAIN CRE 10%
ATRAC-TAIN LOT 5%
ATRACURIUM INJ 10MG/ML
ATRACURIUM INJ 10MG/ML
ATRALIN GEL 0.05%
ATRAPRO DERM SPR
ATRIPLA TAB
ATROPEN INJ 0.25MG
ATROPEN INJ 0.5MG
ATROPEN INJ 1MG
ATROPEN INJ 2MG
ATROPIN-CARE SOL 1% OP
ATROPINE POW
ATROPINE POW SULFATE
ATROPINE SUL INJ 0.05MG/1
ATROPINE SUL INJ 0.1MG/ML
ATROPINE SUL INJ 0.4/0.5
ATROPINE SUL INJ 0.4MG/ML
ATROPINE SUL INJ 1MG/ML
1
1
3
1
2
2
1
1
2
3
3
3
3
3
3
1
2
2
2
1
2
1
1
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Generic
Generic
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
PA after 25
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
75
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ATROPINE SUL OIN 1% OP
ATROPINE SUL POW MONOHYDT
CAPTOPR/HCTZ TAB 50-25MG
2
2
-
Preferred Brand
Preferred Brand
$0 Preventative Drug
ATROVENT NAS SOL 0.03%
3
Non-Preferred Brand
ATROVENT NAS SOL 0.06%
3
Non-Preferred Brand
ATTAPULGITE POW
AUBAGIO TAB 14MG
AUBAGIO TAB 7MG
AUBRA TAB 0.1-0.02
AUG BETAMET CRE 0.05%
AUG BETAMET LOT 0.05%
AUG BETAMET OIN 0.05%
2
3
3
1
1
1
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Generic
Generic
Generic
AUGMENTIN CHW 200MG
3
Non-Preferred Brand
AUGMENTIN SUS 125/5ML
2
Preferred Brand
AUGMENTIN SUS 250/5ML
3
Non-Preferred Brand
AUGMENTIN SUS ES-600
3
Non-Preferred Brand
AUGMENTIN TAB 500MG
3
Non-Preferred Brand
AUGMENTIN TAB 875MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
76
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
AUGMENTIN XR TAB 12HR
3
Non-Preferred Brand
AURALGAN SOL 5.5-1.4%
3
Non-Preferred Brand
AURAPHENE-B SOL 6.5% OT
AURAX SOL 5.5-1.4%
AURO-DRI LIQ 95% OTIC
AURSTAT ANTI GEL -ITCH
AURSTAT KIT
AURSTAT KIT HYDROGEL
AURUM LIQ 12X
AUTOJECT 2 MIS
AUTO-LANCET MIS
AUTOLET LITE KIT
AUTOLET PLAT MIS 1.8MM
AUTOPEN MIS 1 UNIT
AUTOSHIELD MIS 29GX1/2"
AUTOSHIELD MIS 29X3/16"
AUTOSHIELD MIS 29X5/16"
AUTOSHIELD MIS 30GX3/16
AUXIPRO OIN PLASTICI
1
1
1
3
3
3
3
2
2
3
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
-
-
AVAILNEX CHW 750MG
-
-
AVALIDE TAB 150-12.5
3
Non-Preferred Brand
AVAGE CRE 0.1%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
Maximum of 30
per 30 days
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
77
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Maximum of 30
per 30 days
AVALIDE TAB 300-12.5
3
Non-Preferred Brand
AVANDAMET TAB 2-1000MG
3
Non-Preferred Brand
AVANDAMET TAB 2-500MG
3
Non-Preferred Brand
AVANDAMET TAB 4-1000MG
3
Non-Preferred Brand
AVANDAMET TAB 4-500MG
3
Non-Preferred Brand
AVANDARYL TAB 4-1MG
3
Non-Preferred Brand
AVANDARYL TAB 4-2MG
3
Non-Preferred Brand
AVANDARYL TAB 4-4MG
3
Non-Preferred Brand
AVANDARYL TAB 8-2MG
3
Non-Preferred Brand
AVANDARYL TAB 8-4MG
3
Non-Preferred Brand
AVANDIA TAB 2MG
3
Non-Preferred Brand
AVANDIA TAB 4MG
3
Non-Preferred Brand
AVANDIA TAB 8MG
3
Non-Preferred Brand
AVAPRO TAB 150MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
AVAPRO TAB 300MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
78
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
AVAPRO TAB 75MG
AVAR CLEANSE EMU 10-5%
AVAR LS LIQ 10-2%
AVAR LS PAD 10-2%
AVAR PAD 9.5-5%
AVAR-E EMOLL CRE 10-5%
AVAR-E LS CRE 10-2%
Tier
Formulary Status
Special Plan Edits
3
Non-Preferred Brand
Maximum of 30
per 30 days
1
Generic
3
Non-Preferred Brand
3
3
1
Non-Preferred Brand
Non-Preferred Brand
Generic
3
Non-Preferred Brand
AVASTIN INJ
AVASTIN INJ
AVC CRE 15%
AVEED INJ 750/3ML
AVEENO ACTIV PAD ULT-CALM
AVEENO ANTI- CRE ITCH
AVEENO ANTI- LOT ITCH
AVEENO BABY CRE DIAPER
AVEENO BABY CRE ECZEMA
AVEENO BABY CRE SOOTHING
AVEENO BABY KIT BATHTIME
AVEENO BABY KIT CARE
AVEENO BABY LIQ WASH
3
3
3
3
3
2
2
2
2
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
AVEENO BABY LOT CALMING
3
Non-Preferred Brand
AVEENO BABY LOT MOISTURE
3
Non-Preferred Brand
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
79
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
AVEENO BABY MIS SPF50+
AVEENO BABY SHA CONDITIO
AVEENO BATH PAK TREATMNT
AVEENO BODY LIQ WASH
AVEENO CLEAR BAR COMPLEX
AVEENO CLEAR CRE COMPLEX
AVEENO CLEAR LOT COMPLEXI
AVEENO CLEAR PAD COMPLEX
3
3
2
3
3
3
1
1
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
AVEENO DAILY LOT MOISTURE
3
Non-Preferred Brand
AVEENO DAILY LOT MOISTURE
3
Non-Preferred Brand
AVEENO DANDR LIQ CONDITIO
AVEENO EYE LIQ TREATMEN
AVEENO GEL THERAPEU
AVEENO INTEN CRE RELIEF
AVEENO NOURI SHA +DANDRUF
AVEENO NOURI SHA DANDRUFF
AVEENO POSIT KIT AGELESS
AVEENO PURE AER RENEWAL
AVEENO PURE SHA RENEWAL
AVEENO SKIN OIL RELIEF
AVEENO ULTRA AER CALMING
AVELOX ABC TAB 400MG
AVELOX INJ
AVICEL PH105 POW MICROCRY
AVIDOXY DK KIT
AVIDOXY TAB 100MG
3
3
3
2
1
3
3
3
3
3
3
2
2
2
3
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
80
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
AVINZA CAP 120MG
3
Non-Preferred Brand
AVINZA CAP 30MG
3
Non-Preferred Brand
AVINZA CAP 45MG
3
Non-Preferred Brand
AVINZA CAP 60MG
3
Non-Preferred Brand
AVINZA CAP 75MG
3
Non-Preferred Brand
AVINZA CAP 90MG
3
Non-Preferred Brand
1
1
3
3
2
2
3
3
3
3
3
2
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
AVITA CRE 0.025%
AVITA GEL 0.025%
AVITENE PAD 35X35MM
AVITENE POW FLOUR
AVO CREAM EMU
AVOCADO OIL
AVODART CAP 0.5MG
AVONEX KIT 30MCG
AVONEX PEN KIT 30MCG
AVORIA CAL+D POW
AVORIA GC+ POW
AVOSIL OIN
AXERT TAB 12.5MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA after 25
PA after 25
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
Maximum of 12
per 30 days
81
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
AXERT TAB 6.25MG
3
Non-Preferred Brand
Maximum of 12
per 30 days
AXID AR TAB 75MG
3
Non-Preferred Brand
AXID CAP 300MG
3
Non-Preferred Brand
AXID SOL 15MG/ML
3
Non-Preferred Brand
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
-
-
AXSAIN CRE 0.25%
3
Non-Preferred Brand
AYGESTIN TAB 5MG
3
Non-Preferred Brand
3
2
2
3
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
AZACTAM INJ 1GM
3
Non-Preferred Brand
AZACTAM INJ 2GM
3
Non-Preferred Brand
2
Preferred Brand
AXILLARY NDL MIS 22GX1"
AXILLARY NDL MIS 25GX1"
AXIRON SOL 30MG/ACT
AXONA POW
AYR ALLERGY SPR & SINUS
AYR NASAL DRO 0.65%
AYR SALINE KIT NETI RNS
AYR SALINE MIS NASAL
AZACITIDINE INJ 100MG
AZACTAM/DEX INJ 1GM
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
82
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
2
2
3
3
2
1
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
-
-
AZELAIC ACID MIS
AZELASTINE DRO 0.05%
AZELASTINE POW HCL
AZELASTINE SPR 0.1%
2
1
3
1
Preferred Brand
Generic
Non-Preferred Brand
Generic
AZELASTINE SPR 0.15%
1
Generic
AZELEX CRE 20%
3
Non-Preferred Brand
AZILECT TAB 0.5MG
2
Preferred Brand
AZILECT TAB 1MG
2
Preferred Brand
3
1
2
2
1
1
1
1
1
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
AZACTAM/DEX INJ 2GM
AZASAN TAB 100MG
AZASAN TAB 75 MG
AZASITE SOL 1%
AZATADINE POW MALEATE
AZATHIOPRINE POW
AZATHIOPRINE TAB 50MG
AZEC CAP
AZITHROMYCIN INJ 2.5GM
AZITHROMYCIN INJ 500MG
AZITHROMYCIN POW
AZITHROMYCIN POW 1GM PAK
AZITHROMYCIN SUS 100/5ML
AZITHROMYCIN SUS 200/5ML
AZITHROMYCIN TAB 250MG
AZITHROMYCIN TAB 500MG
AZITHROMYCIN TAB 600MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Maximum of 30
mL (1 BOTTLE)
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
83
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
1
1
Preferred Brand
Generic
Generic
3
Non-Preferred Brand
AZO TES STRIPS
AZOLEN TINC SOL 2%
AZOPT SUS 1% OP
2
2
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
AZOR TAB 10-20MG
2
Preferred Brand
AZOR TAB 10-40MG
2
Preferred Brand
AZOR TAB 5-20MG
2
Preferred Brand
AZOR TAB 5-40MG
2
Preferred Brand
AZOSTIX TES
AZTREONAM INJ 1GM
AZTREONAM INJ 2GM
3
1
1
Non-Preferred Brand
Generic
Generic
AZULFIDINE TAB 500MG
3
Non-Preferred Brand
3
Non-Preferred Brand
AZO CRNBERRY TAB
AZO DINE TAB 95MG
AZO DINE TAB MAX ST
AZO STANDARD TAB MAX ST
AZULFIDINE TAB 500MG EN
AZURETTE TAB 28 DAY
B COMP/IRON/ TAB VIT C/E
B COMPLETE TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
$0 Preventative Drug
-
-
-
-
Not a covered
benefit
Not a covered
benefit
-
-
-
-
84
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
-
-
-
-
-
-
B COMPLEX TAB
-
-
B COMPLEX TAB
-
-
B COMPLEX TAB PLUS C
-
-
B COMPLEX/ CAP VIT C
-
-
3
3
2
2
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
B-1 HI POTCY TAB 100MG
-
-
B1 NATURAL TAB 250MG
-
-
B-1 TAB 250MG
-
-
B-1 TAB 500MG
-
-
B-100 COMP TAB TR
-
-
B-100 COMPLX TAB
-
-
B-100 COMPLX TAB
-
-
B COMPLEX +C TAB TR
B COMPLEX CAP
B COMPLEX CAP MAXI
B COMPLEX/FO TAB
B&L ACCESSOR MIS LEN CASE
B&L RENU SOL DISINFEC
B&L RENU SOL REWET DR
B+DRIER LIQ
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
85
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
B-12 CAP 1000MCG
B-12 CAP 3000MCG
B-12 COMP KIT 1000MCG
B-12 DOTS TAB 500MCG
B-12 LIQ 5000/ML
B-12 LOZ 1000MCG
B-12 LOZ 3000MCG
B-12 MICRLOZ SUB 500MCG
B-12 SUB 2500MCG
B-12 SUB 3000MCG
B-12 SUB 5000MCG
B-12 TAB 1000 CR
B-12 TAB 100MCG
B-12 TAB 2000MCG
B-12 TAB 2000MCG
B-12 TAB 2500MCG
B-12 TAB 250MCG
B-12 TAB 5000MCG
B-12 TAB 500MCG
B-12 TAB 50MCG
3
3
3
2
3
3
3
1
1
1
1
1
1
1
1
3
1
3
1
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
B12/LMTHF/B6 TAB
-
-
B12-ACTIVE CHW 1MG
3
Non-Preferred Brand
B-2 TAB 100MG
-
-
B-2 TAB 50MG
-
-
B-2-400 CAP
-
-
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
-
-
-
-
-
-
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
86
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
-
Not a covered
benefit
-
-
3
Non-Preferred Brand
-
-
-
-
B-6 TAB 250MG
-
-
-
-
B-6 TAB 500MG
-
-
-
-
B-6 TAB 50MG
-
-
-
-
2
2
3
3
2
3
1
1
3
1
1
3
3
3
3
3
3
1
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
$0 ACA Drug
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
-
-
Drug Name
B-50 TR TAB
B6 FOLIC ACD CAP
B6 NATURAL TAB 100MG
BABY ANBESOL GEL 7.5%
BABY BASICS MIS SZ 6/XXL
BABY BEDTIME MIS WSHCLTH
BABY CHEST OIN RUB
BABY DARLING MIS WIPES
BABY DARLING OIL BABY
BABY DARLING POW BABY
BABY DARLING POW BATH
BABY DARLNG POW PED ELEC
BABY DARLNG SOL PED ELEC
BABY DDROPS LIQ 400UNIT
BABY EASE OIN 30%
BABY EYELID PAD CLEANSER
BABY LOT
BABY MONKEY CRE 2-12%
BABY MONKEY POW BUTT
BABY ORAJEL GEL CLEANSER
BABY ORAJEL LIQ 7.5%
BABY POW
WDRx 2/23/15
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Penalty applied if Brand Selected
over Generic
87
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
2
1
2
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
-
-
BABY WASH LIQ
BAC/NEO/POLY OIN OP
BACID TAB
2
1
2
Preferred Brand
Generic
Preferred Brand
BACIGUENT OIN 500/GM
3
Non-Preferred Brand
1
1
1
2
3
1
2
2
3
2
2
3
1
2
3
1
3
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
BABY SAFETY MIS SWABS
BABY SHAMPOO SHA
BABY TEETHNG GEL 7.5%
BABY THERMOM MIS
BABY VITAMIN DRO
BACIIM INJ 50000UNT
BACIT/POLYMY OIN
BACITR ZINC OIN 500/GM
BACITRACIN INJ 50000UNT
BACITRACIN OIN 40-500
BACITRACIN OIN 500/GM
BACITRACIN OIN OP
BACITRACIN POW
BACITRACIN POW MD
BACITRACIN POW MICRONIZ
BACITRACIN POW ZINC USP
BACITRAYCIN OIN 500-10
BACK & BODY TAB 500-32.5
BACK PAD MIS COLD PAC
BACK PAINOFF TAB
BACKACHE REL TAB 500MG
BACLOFEN CRE 1%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
88
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BACLOFEN POW
BACLOFEN TAB 10MG
BACLOFEN TAB 20MG
BACTER WATER INJ BENZ ALC
BACTER WATER INJ PARABENS
BACTERIASTAT LIQ
2
1
1
2
2
3
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
BACTOCILL INJ DEX 1GM
BACTOCILL INJ DEX 2GM
2
2
Preferred Brand
Preferred Brand
BACTRIM DS TAB 800-160
3
Non-Preferred Brand
BACTRIM TAB 400-80MG
3
Non-Preferred Brand
BACTROBAN CRE 2%
3
Non-Preferred Brand
BACTROBAN OIN 2%
3
Non-Preferred Brand
BACTROBAN OIN NASAL 2%
BAL IN OIL INJ 100MG/ML
BALAMINE DM SYP
3
2
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
BALANCE B-50 CAP COMPLEX
-
-
BALANCED B TAB COMPLEX
-
-
BAL-CARE DHA MIS ESSNTIAL
-
$0 Preventative Drug
BACTINE SPR
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
89
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
$0 Preventative Drug
Not a covered
benefit
-
2
3
2
2
1
3
1
2
2
2
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
$0 Preventative Drug
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
3
3
3
3
3
3
1
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
BANZEL TAB 200MG
2
Preferred Brand
BANZEL TAB 400MG
2
Preferred Brand
Drug Name
BAL-CARE MIS DHA
BALMEX CRE 11.3%
BALMEX MIS 11.3%
BALNEOL LOT
BALNETAR EMU 2.5%
BALSALAZIDE CAP 750MG
BALZIVA TAB
BANATROL PAK
BANDAGE LIQ
BANDAGE NEW PAD LARGE
BANDAGE ROLL MIS 2.25X3YD
BANDAGE ROLL MIS 4.5"X4YD
BAND-AID AER CALAMINE
BAND-AID GEL ANTI-ITC
BAND-AID MIS FRICTION
BAND-AID PAD 4" X 10"
BAND-AID PAD 4" X 14"
BAND-AID PAD 4" X 7"
BAND-AID PAD MOLESKIN
BAND-AID PLS PAD ANTIBIOT
BAND-AID WSH LIQ HURTFREE
BANOPHEN CAP 50MG
BANZEL SUS 40MG/ML
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 240
per 30 days
Maximum of 240
per 30 days
90
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
Non-Preferred Brand
YES, Specialty Drug
BARACLUDE TAB 0.5MG
3
Non-Preferred Brand
YES, Specialty Drug
BARACLUDE TAB 1MG
3
Non-Preferred Brand
YES, Specialty Drug
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
BARACLUDE SOL .05MG/ML
BARC LIQ
BARD PROTECT MIS FILM
BARD URETHRA MIS CATHETER
BARIDIUM TAB 97.2MG
BARIUM CHLOR CRY DIHYDRAT
BARIUM POW SULFATE
BAR-TEST TAB 650MG
BASAL THERM MIS
BASE A PEG POW 1450
BASE B PEG POW 3350
BASE C LIQ PEG 300
BASE C PEG LIQ 300
BASE CRE LIPOSOME
BASE D PEG POW 4500
BASE FOR GEL SALTS
BASE G ALMON OIL SWEET
BASE X MIS
BASIC FUCHSI POW HCL
BASIS FACIAL CRE MOIST
BAY OIL
BAY RUM LIQ
WDRx 2/23/15
3
Non-Preferred Brand
3
2
3
2
2
3
3
2
2
3
3
3
2
2
3
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
91
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BAYCADRON ELX 0.5/5ML
BAYER PLUS TAB 500MG
BAYER PM TAB 38.3-500
BAYER TAB MIGRAINE
BAYER WOMENS TAB 81-300MG
BAZA CLEANSE LOT 2%
BAZA CLEANSE MIS 2%
BAZA CLEAR OIN
BAZA CREAM KIT HOSP PAK
BC HEADACHE TAB
1
2
3
1
2
3
3
1
3
3
Generic
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
-
-
B-CARO-T CAP 15MG
-
-
BCG VACCINE INJ
2
Preferred Brand
B-COMP/B-12 TAB
-
-
B-COMPLEX CAP
-
-
B-COMPLEX INJ
-
-
B-COMPLEX TAB
-
-
B-COMPLEX TAB /IRON
-
-
B-COMPLEX TAB /VIT C
-
-
B-COMPLEX TAB C/FA/BIO
-
-
-
-
3
Non-Preferred Brand
BCAD 1 POW
B-COMPLEX/ SUB B-12
BD ANGIOCATH MIS 18GX1.16
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
92
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BD ASSURE MIS BPM/AUTO
BD ECLIPSE MIS 1ML/30G
BD ECLIPSE MIS 22GX1"
BD ECLIPSE MIS 22GX1.5"
BD ECLIPSE MIS 23GX1"
BD ECLIPSE MIS 25GX5/8"
BD GLUCOSE CHW 5GM
BD L-CATH KIT 16G/5FR
BD MAGNIGUID MIS MAGNIFIR
BD NEEDLE MIS 18GX1"TW
BD NEEDLE MIS 22GX3/4"
BD NEEDLE MIS 23GX1"
BD NEEDLE MIS 23GX1.25
BD NEEDLE MIS 27GX1.25
BD NEEDLE MIS 30G X 1"
BD NEEDLES MIS 16GX1.5"
BD NEEDLES MIS 19GX1"
BD NEEDLES MIS 20GX1"
BD NEEDLES MIS 20GX1.5"
BD NEEDLES MIS 21GX1.5"
BD NEEDLES MIS 22GX1.5"
BD NEEDLES MIS 25GX5/8"
BD NEEDLES MIS 25GX7/8"
BD NEEDLES MIS 27GX1/2"
BD NEEDLES MIS 30GX1/2"
BD NEXIVA MIS 20GX1"
BD PEN MINI MIS
BD PEN NEEDL MIS 29GX1/2"
BD POSIFLUSH INJ 0.9%
3
2
2
3
3
3
3
3
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
1
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
93
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BD SHARPS MIS 1.4QT
BD THERMTRS MIS BABY
BD THERMTRS MIS ORAL SHT
BD YALE LNR MIS 26GX1/2"
BD YALE LNR MIS 30GX1/2"
2
3
3
2
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
BE WELL PAK ROUNDED
-
$0 Preventative Drug
BEANO LIQ DROPS
BEANO TAB
BEANO TAB MELTAWAY
BEAUTY LOT LOTION
BEBULIN INJ 200-1200
3
2
3
1
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
BEC/ZINC TAB
-
-
2
Preferred Brand
BECONASE AQ SUS 0.042%
3
Non-Preferred Brand
BEDSIDE DRAI KIT COLL SYS
BEDSIDE-CARE LIQ PERINEAL
BEDSIDE-CARE SOL
BEE POLLEN CAP 550MG
BEE POLLEN CAP 580MG
BEE POLLEN CAP GINSENG
BEE POLLEN CHW 500MG
2
3
2
3
3
3
1
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
BEE POLLEN CHW R JELLY
-
-
BEE POLLEN TAB
BEE POLLEN TAB 1000MG
BEE VENOM INJ 1300MCG
BEE VENOM INJ 550MCG
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
BECLOMETHASO POW DIPROPIO
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
YES, Specialty Drug
Not a covered
benefit
-
-
-
-
Maximum of 25
gm per 30 days
Not a covered
benefit
94
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
2
2
3
2
3
2
2
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
-
-
2
Preferred Brand
BENADRYL ALG CHW CHILD
3
Non-Preferred Brand
BENADRYL ALG TAB 25MG
3
Non-Preferred Brand
BENADRYL ALL LIQ 12.5/5ML
3
Non-Preferred Brand
BENADRYL ALL TAB SINUS
3
Non-Preferred Brand
3
Non-Preferred Brand
2
2
1
Preferred Brand
Preferred Brand
Generic
BEEF LIVER POW DESICCAT
BEELITH TAB
BEES WAX MIS WHITE
BEESWAX LIP MIS BALM
BEESWAX MIS YELLOW
BELEODAQ INJ 500MG
BELLA/OPIUM SUP 16.2-30
BELLA/OPIUM SUP 16.2-60
BELLADONNA POW EXTRACT
BELLADONNA TIN
BELVIQ TAB 10MG
BENACTYZINE POW HCL
BENADRYL CAP 25MG
BENADRYL CRE 1-0.1%
BENADRYL CRE 2% EX ST
BENADRYL GEL ANTI-ITC
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Not a covered
benefit
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
95
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BENADRYL ITC MIS STICK
2
Preferred Brand
BENADRYL M-S SPR 2%
3
Non-Preferred Brand
BENADRYL SPR 2-0.1%
3
Non-Preferred Brand
BENADRYL-D SOL CHILD
1
Generic
BENADRYL-D TAB ALGY/SIN
3
Non-Preferred Brand
BENAZEP/HCTZ TAB 10-12.5
BENAZEP/HCTZ TAB 20-12.5
BENAZEP/HCTZ TAB 20-25MG
BENAZEP/HCTZ TAB 5-6.25
BENAZEPRIL POW HCL
BENAZEPRIL TAB 10MG
BENAZEPRIL TAB 20MG
BENAZEPRIL TAB 40MG
BENAZEPRIL TAB 5MG
BENDROFLUMET POW
BENECELA E4M POW PH CR
BENEFIBER CHW
BENEFIBER CHW /CALCIUM
BENEFIBER POW
BENEFIBER POW CALCIUM
BENEFIBER POW DRINK MX
BENEFIBER POW HEART
2
3
3
2
2
2
3
2
3
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
96
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BENEFIBER POW ORANGE
3
Non-Preferred Brand
BENEFIBER TAB
BENEFIBER TAB PLS B/FA
BENEFIX INJ 1000UNIT
BENEFIX INJ 2000UNIT
BENEFIX INJ 250UNIT
BENEFIX INJ 3000UNIT
BENEFIX INJ 500UNIT
2
3
3
3
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
BENFOTIAMINE CAP 150MG
-
-
BENFOTIAMINE POW
BENGAY ARTHR CRE FORMULA
BENGAY COLD GEL THERAPY
3
2
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
BENGAY CRE GREASLES
3
Non-Preferred Brand
BENGAY CRE ULTRA ST
3
Non-Preferred Brand
BENGAY DIS 1.4% LRG
BENGAY HEAT MIS LARGE
BENGAY PAIN GEL RELIEF
3
3
1
Non-Preferred Brand
Non-Preferred Brand
Generic
BENICAR HCT TAB 20-12.5
2
Preferred Brand
BENICAR HCT TAB 40-12.5
2
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
97
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
BENICAR HCT TAB 40-25MG
Tier
Formulary Status
2
Preferred Brand
BENICAR TAB 20MG
2
Preferred Brand
BENICAR TAB 40MG
2
Preferred Brand
BENICAR TAB 5MG
2
Preferred Brand
3
3
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
BENTYL CAP 10MG
3
Non-Preferred Brand
BENTYL INJ 10MG/ML
3
Non-Preferred Brand
BENLYSTA INJ 120MG
BENLYSTA INJ 400MG
BENOXINATE POW HCL
BENSAL HP OIN
BENSULFOID CRE
BENTONITE POW
BENTYL TAB 20MG
BENZAC AC LIQ 5% WASH
WDRx 2/23/15
3
Non-Preferred Brand
3
Non-Preferred Brand
Special Plan Edits
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 60
per 30 days
PA Required
PA Required
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
98
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
2
2
2
3
2
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
BENZAMYCIN GEL PAK
BENZEDREX INH
3
2
Non-Preferred Brand
Preferred Brand
BENZEFOAM AER 5.3%
3
Non-Preferred Brand
BENZEFOAM AER 9.8%
3
Non-Preferred Brand
3
1
1
2
3
3
1
2
1
Non-Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Generic
BENZACLIN GEL 1-5%
BENZACLIN GEL 1-5%PUMP
BENZALDEHYDE ELX
BENZALKONIUM CON 50%
BENZALKONIUM POW
BENZALKONIUM SOL 17%
BENZALKONIUM SOL 50%
BENZALKONIUM SOL NF
BENZAMYCIN GEL
BENZENE LIQ
BENZEPRO AER 5.3%
BENZEPRO SC AER 9.8%
BENZETHONIUM POW CHLORIDE
BENZIQ GEL 5.25%
BENZIQ LS GEL 2.75%
BENZIQ WASH LIQ 5.25%
BENZOCAINE POW
BENZOCAINE SOL 20%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
99
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
BENZODENT CRE
BENZODENT OIN 20%
BENZOIC ACID CRY
BENZOIC ACID POW
BENZOIN CMPD TIN
BENZOIN GUM POW
BENZOIN TIN
BENZONATATE CAP 100MG
BENZONATATE CAP 200MG
BENZOQUINONE CRY PARA
BENZ-O-STHET MIS 20%
BENZOYL PER GEL 2.5%
BENZOYL PER LIQ 10% WASH
BENZOYL PER LIQ 5% WASH
BENZOYL PER LOT 6%
BENZOYL PER POW 70%
BENZOYL PERO KIT ACNE PCK
BENZOYL PERO KIT ACNE PCK
BENZPHETAMIN TAB 50MG
BENZ-PROTECT MIS
BENZTROPINE INJ 1MG/ML
BENZTROPINE POW MESYLATE
BENZTROPINE TAB 0.5MG
BENZTROPINE TAB 1MG
BENZTROPINE TAB 2MG
BENZYL ALC LIQ
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
3
2
2
2
2
2
1
1
2
1
2
1
1
1
2
1
1
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
-
-
3
1
2
1
1
1
2
Non-Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
100
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BENZYL BENZO LIQ
BEPREVE DRO 1.5%
BERBERINE CAP COMPLEX
BERBERINE POW CHLORIDE
BERGAMOT OIL FRAGRANC
BERINERT INJ 500UNIT
BERRI-FREEZ GEL 3.5%
BERRI-FREEZ GEL 4.5%
BERRI-FREEZ SPR 10%
BESIVANCE SUS 0.6%
BEST FIBER POW
BETA CAROTEN BEA 10%
2
2
3
3
3
3
1
3
1
2
1
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Generic
Preferred Brand
BETA CAROTEN CAP 10000UNT
-
-
BETA CAROTEN POW
BETA GLUCAN POW
BETA MED SHA 2%
BETA-ALANINE POW
BETA-AMYLASE POW
BETADINE AER 5% SPRAY
BETADINE MIS SWAB AID
BETADINE SKN SOL 7.5% CLR
BETADINE SOL 10%
BETADINE SOL 5% OP
3
2
1
3
3
2
2
2
2
3
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
BETAGAN SOL 0.5% OP
3
Non-Preferred Brand
BETAHISTINE POW DIHCL
BETAINE HCL POW
2
2
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
101
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BETAINE HCL TAB 300MG
BETAINE POW ANHYDROU
BETAINE POW MONOHYDR
BETAMETH ACE POW
BETAMETH ACE POW MICRONIZ
BETAMETH DIP CRE 0.05%
BETAMETH DIP LOT 0.05%
BETAMETH DIP OIN 0.05%
BETAMETH DIP POW
BETAMETH VAL AER 0.12%
BETAMETH VAL CRE 0.1%
BETAMETH VAL LOT 0.1%
BETAMETHASON POW
BETAMETHASON POW SOD PHOS
BETAMETHASON POW VALERATE
BETAMIDE LOT 25%
BETANAPHTHOL POW 99%
3
2
3
2
3
1
1
1
2
1
1
1
2
2
2
1
2
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
BETAPACE AF TAB 120MG
3
Non-Preferred Brand
BETAPACE AF TAB 160MG
3
Non-Preferred Brand
BETAPACE AF TAB 80MG
3
Non-Preferred Brand
BETAPACE TAB 120MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
102
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BETAPACE TAB 160MG
3
Non-Preferred Brand
BETAPACE TAB 80MG
3
Non-Preferred Brand
1
3
2
1
3
1
1
1
1
2
1
1
1
1
3
3
3
3
3
3
2
Generic
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Preferred Brand
BETA-PHOS/AC INJ 3-3MG/ML
BETAQUIK EMU
BETASAL SHA 3%
BETASEPT LIQ 4%
BETASERON INJ 0.3MG
BETATAR GEL SHA 2.5%
BETAXOLOL SOL 0.5% OP
BETAXOLOL TAB 10MG
BETAXOLOL TAB 20MG
BETHANECHOL POW CHLORIDE
BETHANECHOL TAB 10MG
BETHANECHOL TAB 25MG
BETHANECHOL TAB 50MG
BETHANECHOL TAB 5MG
BETHKIS NEB 300/4ML
BETIMOL SOL 0.25%
BETIMOL SOL 0.5%
BETOPTIC-S SUS 0.25% OP
BEXXAR 131 I INJ 0.61/ML
BEXXAR 131 I INJ 5.6MCI/M
BEXXAR CON 14MG/ML
BEYAZ TAB
BHA POW
BHRT BASE CRE
WDRx 2/23/15
3
2
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Limited Distribution
103
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BHT GRA
BHT POW
BIAFINE EMU
BIATAIN FOAM PAD DRESSING
BIATAIN PAD ADHESIVE
BIATAIN PAD HEEL
BIATAIN PAD SACRAL
2
2
3
2
2
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
BIAXIN SUS 250/5ML
3
Non-Preferred Brand
BIAXIN TAB 250MG
3
Non-Preferred Brand
BIAXIN TAB 500MG
3
Non-Preferred Brand
3
Non-Preferred Brand
1
2
2
2
2
2
2
2
2
2
2
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
BIAXIN XL TAB 500MG
BICALUTAMIDE TAB 50MG
BICARSIM TAB 125MG
BICARSIM TAB 80MG
BICILLIN C-R INJ 1200000
BICILLIN C-R INJ 900/300
BICILLIN L-A INJ 1200000
BICILLIN L-A INJ 2400000
BICILLIN L-A INJ 600000
BICLORA LIQ
BICLORA TAB 25-25MG
BICLORA-D LIQ
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
104
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BICLORA-D TAB
BICNU INJ 100MG
BIDEX TAB 400MG
BIDIL TAB
BIFERA TAB 28MG
BIFERARX TAB
BIFIDOBACTER POW BIFIDUM
BIFIDOBACTER POW BIFIDUS
BILBERRY CAP /LUTEIN
BILBERRY CAP 1000MG
BILBERRY CAP 100MG
BILBERRY CAP 150MG
BILBERRY CAP 40MG
BILBERRY CAP 500MG
BILBERRY CAP 60MG
2
3
1
3
2
3
3
3
3
3
3
3
1
3
3
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
3
1
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
1
1
1
Generic
Generic
Generic
BILBERRY CAP 80MG
BILBERRY EXT CAP 30MG
BILBERRY EXT CAP 40MG
BILBERRY EXT CAP 80MG
BILE SALTS POW
BILTRICIDE TAB 600MG
BIMATOPROST POW
BINOSTO TAB 70MG
BIO GLO TES 1MG OP
BIO T PRES LIQ
BIO T PRES LIQ PEDIATRC
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
105
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BIOBRON SF SYP
BIOCLUSIVE PAD 2"X3"
BIOCOTRON LIQ 100-10/5
BIODESP DM SYP
BIO-D-MULSIO LIQ 2000UNIT
BIO-D-MULSIO LIQ 400UNIT
BIOFLAVINOID POW LEMON
BIOFLAVONOID POW CITRUS
2
3
1
3
2
2
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
Preferred Brand
Preferred Brand
BIOFLAVONOID TAB 1000MG
-
-
BIO-FLAX CAP 1000MG
3
Non-Preferred Brand
BIOFLONEX TAB 250-650
-
-
BIOFREEZE GEL 4%
BIOFREEZE SPR 10%
BIOGAIA CHW 100M CEL
BIOGAIA DRO PROBIOTI
BIOGAIA MIS PROBIOTI
BIOGESIC TAB 30-500MG
BIOGINKGO TAB 24/6
BIOGTUSS LIQ
BIONATUSS LIQ DXP
BIONECT CRE 0.2%
BIONECT GEL 0.2%
BIONECT SPR 0.2%
BIONEL LIQ
BIONEL LIQ PEDIATRC
BIOPATCH MIS 1"/4MM
1
3
2
2
3
1
1
1
2
3
3
3
2
3
3
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
106
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BIOPSY TRAY KIT MARROW
BIORE HYDRAT LIQ MOISTURZ
BIOREGESIC TAB 50-650MG
BIOSPEC DMX LIQ
BIO-STATIN CAP 1000000
BIO-STATIN CAP 500000
BIO-STATIN POW
BIOSTEP AG MIS 2"X2"
BIOSTEP AG MIS 4"X4"
BIOSTEP MIS 2"X2"
BIOSTEP MIS 4"X4"
3
3
3
3
3
3
1
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
2
2
3
2
1
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
BIOTIN 5000 CAP
-
-
BIOTIN CAP 1MG
-
-
BIOTIN CAP 2500MCG
-
-
BIOTIN FORTE TAB
-
-
BIOTIN FORTE TAB /ZINC
-
-
BIOTIN FORTE TAB 3MG
-
-
BIOTALAN LIQ CLEAR
BIOTENE DRY GUM MOUTH
BIOTENE LIQ DRY MTH
BIOTENE PBF GUM DRY MTH
BIOTENE SPR MOUTH
BIO-THERM LOT
BIOTHRAX INJ
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
107
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
-
-
-
-
-
-
BIOTIN TAB 10MG
-
-
BIOTIN TAB 300MCG
-
-
BIOTIN TAB 7500MCG
-
-
BIOTIN TAB 800MCG
-
-
-
-
1
3
3
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
3
2
1
2
1
1
1
2
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
BIOTIN FORTE TAB 5MG
BIOTIN POW
BIOTIN TAB 1000MCG
BIOTIN ULTRA CAP 10000MCG
BIOTUSS LIQ PEDIATRC
BIOVANCE MIS 1CMX2CM
BIOVANCE MIS 2CMX3CM
BIOVANCE MIS 4CMX4CM
BIOVANCE MIS 6CMX6CM
BIOVOL SYP
BIPHENOX TAB 30-325MG
BISABOLOL LIQ ALPHA-L
BISAC-EVAC SUP 10MG
BISACODYL POW
BISMATROL CHW 262MG
BISMATROL SUS 262/15ML
BISMATROL SUS 525/15ML
BISMUTH POW CITRATE
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
108
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BISMUTH POW SUBGALLA
BISMUTH POW SUBNITRA
BISMUTH POW SUBSALIC
BISMUTH POW TRIBROMP
BISMUTH SUBC POW
BISMUTH SUBG TAB 324MG
BISOPRL/HCTZ TAB 10/6.25
BISOPRL/HCTZ TAB 2.5/6.25
BISOPRL/HCTZ TAB 5-6.25MG
BISOPROL FUM TAB 10MG
BISOPROL FUM TAB 5MG
BITE/ITCH LOT
BITTER DRUG POW
BITTER MELON POW
BITTER MELON POW EXTRACT
BI-ZETS LOZ
BLACK COHOSH CAP 160MG
BLACK COHOSH CAP 175MG
BLACK COHOSH CAP 200MG
BLACK COHOSH CAP 40MG
BLACK COHOSH CAP 450MG
BLACK COHOSH CAP 540MG
BLACK COHOSH CAP EXTRACT
BLACK COHOSH POW ROOT
BLACK COHOSH TAB 20MG
BLADE HANDLE MIS 3
BLEOMYCIN INJ 15UNIT
BLEOMYCIN INJ 30UNIT
2
2
2
3
2
3
1
1
1
1
1
3
2
3
2
1
3
3
2
1
3
1
3
2
1
3
1
1
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
109
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
BLEPH-10 SOL 10% OP
BLEPHAMIDE OIN S.O.P.
BLEPHAMIDE SUS LIQUIFLM
BLISTEX COMP MIS MOIST
BLISTEX OIN MEDICATE
BLIS-TO-SOL POW 12%
BLK DRAUGHT CHW 10MG
BLK DRAUGHT SYP 90/15ML
BLOOD CLOTTI AER SPRAY
BLOOD PRESS KIT #100-019
BLOOD PRESS KIT LAR CUFF
BLOOD PRESSU KIT CUFF/LG
BLOODROOT POW
BLOXIVERZ INJ 1MG/ML
BLOXIVERZ INJ 5MG/10ML
BLUE AGAVE LIQ ORGANIC
BLUE GEL 2%
BLUE-EMU CRE
BLUE-EMU SPR 2.5%
BLUESTAR MIS
BLUNT CANNUL MIS 15GX1.5"
BLUNT CANNUL MIS 17GX1.5"
BLUNT CANNUL MIS 18GX1"
BLUNT CANNUL MIS 19GX1.5"
BLUNT CANNUL MIS 21GX1"
BLUNT NEEDLE MIS 18GX2"
BODY POWDER POW MEDICATE
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
3
3
1
3
3
3
3
3
3
2
2
2
2
2
2
1
3
3
3
2
2
2
2
2
3
1
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
110
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
1
3
3
3
3
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
-
-
-
-
1
3
$0 ACA Drug
Generic
Non-Preferred Brand
BORAGE OIL CAP 1000MG
3
Non-Preferred Brand
BORAGE OIL CAP 500MG
BORAX GRA
BORIC ACID CRY
BORIC ACID GRA
BORIC ACID POW
BORIC ACID SOL 4%
BORON AMORPH POW FINE
BORON CAP 3MG
BORON CITRAT POW 5%
BORON TAB 6MG
1
3
2
2
2
3
3
3
2
3
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
BOIL PAIN OIN 20%
BOIL-EASE MIS
BOIL-EASE OIN
BOLUS FEEDIN MIS SET
BONE DENSITY TAB
BONE MEAL TAB
BONIVA INJ 3MG/3ML
BONIVA TAB 150MG
BONTRIL PDM TAB 35MG
BOOST PUDDIN MIS BUTTSCTH
CERVARIX INJ
BORAGE 1000 CAP
BORAGE CAP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
111
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BOSTON DRO REWETTIN
BOSULIF TAB 100MG
BOSULIF TAB 500MG
BOSWELLIA POW SERRATA
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
BOTOX COSMET INJ 100UNIT
-
-
BOTOX COSMET INJ 50UNIT
-
-
BOTOX INJ 100UNIT
BOTOX INJ 200UNIT
BOTTLE ADAPT MIS ORAL SYR
BOUDREAUXS OIN 16%
BOUDREAUXS OIN 40%
BOUDREAUXS OIN BABY KIS
BOUDREAUXS SPR 10%
BOVINE SERUM POW ALBUMIN
BP 10-1 EMU
BP 8 COUGH LIQ
BP ARM CUFF MIS LARGE
BP CLEANSER LIQ 4.25%
BP CLEANSING EMU 10-4%
BP CLEANSING LOT 4%
3
3
3
2
1
3
3
2
1
2
3
1
1
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
BP FOLINATAL TAB PLUS B
-
$0 Preventative Drug
BP MULTINATL CHW PLUS
-
$0 Preventative Drug
BP MULTINATL TAB PLUS
-
$0 Preventative Drug
2
1
Preferred Brand
Generic
BP VIT 3 CAP
BP WASH LIQ 2.5%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
Not a covered
benefit
PA Required
PA Required
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
YES, Specialty Drug
YES, Specialty Drug
-
-
-
-
-
-
112
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BP WASH LIQ 7%
BPM-DM-PHEN SYP 5-2-10MG
BPM-PE-DM LIQ 4-10-20
BPM-PSE-DM LIQ 4-20-20
BPO CLOTHS MIS 3%
BPO CLOTHS MIS 6%
BPO CLOTHS MIS 9%
BPO CREAMY KIT 8% WASH
BPO GEL 4%
BPO GEL 8%
1
1
1
1
2
2
2
2
2
2
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
BPROTECTED LIQ MULTI-VI
-
-
BPROTECTED SOL TRI-VITE
-
-
BRAINSTRONG MIS PRENATAL
-
$0 Preventative Drug
BRAN FIBER TAB 500MG
BRASIVOL PST
1
3
Generic
Non-Preferred Brand
BRAVELLE INJ 75UNIT
-
-
3
2
3
3
2
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
BREVIBLOC INJ 10MG/ML
3
Non-Preferred Brand
BREVIBLOC SOL
BREVIBLOC SOL 10MG/ML
3
3
Non-Preferred Brand
Non-Preferred Brand
BREATH RX LIQ
BREATHE RIGH MIS ADVANCED
BREATHE RIGH MIS EXTRA
BREEZEE MIST AER FOOT PWD
BREO ELLIPTA INH 100-25
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
113
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
BREVICON TAB 0.5/35
Formulary Status
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
BREWERS YEAS POW
-
-
-
-
-
-
3
2
3
2
2
2
2
2
1
1
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
BRINTELLIX TAB 10MG
3
Non-Preferred Brand
BRINTELLIX TAB 20MG
3
Non-Preferred Brand
BRINTELLIX TAB 5MG
3
Non-Preferred Brand
BRIGHT BEGIN LIQ SOY
BRIJ 35 LIQ
BRIJ 35 MIS
BRIJ 700 LIQ
BRIJ 700 MIS
BRIJ 93 LIQ
BRILINTA TAB 90MG
BRILLIANT POW GREEN
BRIMONIDINE POW TARTRATE
BRIMONIDINE SOL 0.15%
BRIMONIDINE SOL 0.2% OP
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
$0 Preventative Drug
BREVITAL SOD INJ 2.5GM
BREVITAL SOD INJ 200MG
BREVITAL SOD INJ 500MG
BREWERS YEAS TAB 487.5MG
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
114
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
BRISDELLE CAP 7.5MG
BROCCOLI CAP EXTRACT
BROCCOLI TAB 500MG
BROHIST D TAB 4-10MG
BROM/PSE/DM SYP
BROM/PSEUD/ ELX DM
BROMDAY SOL 0.09%
BROMELAIN CAP 2400GDU
BROMELAIN POW
BROMELAIN TAB 100MG
BROMELAIN TAB 500MG
BROMHEXINE POW HCL
BROMI-LOTION LOT
BROMI-TALC POW
BROMOCRIPTIN CAP 5MG
BROMOCRIPTIN POW MESYLATE
BROMOCRIPTIN TAB 2.5MG
BROMOTHYMOL POW BLUE
BROMPHENIR POW MALEATE
BROMPHENIRAM CHW 12MG
BRONCHO SAL AER 0.9%
BRONCOMAR-1 ELX
BRONCOPECTOL SYP
BRONCOTRON DRO PED
BRONCOTRON LIQ PED
BRONCOTRON-D SUS
BRONCOTRON-S LIQ 20-400/5
WDRx 2/23/15
Tier
Formulary Status
Special Plan Edits
2
Preferred Brand
May be subject to
Quantity Level
Limits
3
3
2
1
1
3
3
2
3
3
2
2
3
1
2
1
3
2
3
1
3
3
3
1
2
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
115
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
3
2
3
2
1
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
3
Non-Preferred Brand
BROVEX PEB LIQ DM
3
Non-Preferred Brand
BROVEX PSB LIQ
BROVEX PSB LIQ DM
3
3
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
BROVEX PSE TAB DM
3
Non-Preferred Brand
BSS PLUS SOL OP
3
Non-Preferred Brand
3
2
3
3
1
2
1
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Generic
BRONDIL LIQ
BRONKAID TAB 25-400MG
BRONKIDS DRO
BRONKIDS LIQ 10-4-10
BRONTUSS DX LIQ
BROTAPP LIQ
BROVANA NEB 15MCG
BROVEX PEB LIQ
BROVEX PSE TAB 4-40MG
BTREX TAB
BUBBLE GUM SYP
BUCALSEP SOL
BUCALSEP SPR
BUCKLEYS LIQ CHEST
BUCKLEYS LIQ COUGH
BUDEPRION TAB 100MG SR
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
116
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BUDEPRION TAB 150MG SR
BUDESONIDE CAP 3MG/24HR
BUDESONIDE POW
BUDESONIDE SUS 0.25MG/2
BUDESONIDE SUS 0.5MG/2
1
1
2
-
Generic
Generic
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
BUDESONIDE SUS 32MCG
1
Generic
BUFFER CREAM POW
BUFFERED ASA TAB 325MG
3
1
Non-Preferred Brand
Generic
BUFFERED C TAB 500MG
-
-
1
Generic
-
-
2
3
2
2
3
3
3
1
3
1
1
1
2
3
3
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
BUFFERED TAB SALT
BUFFERED VIT CAP C 1000MG
BUFFERIN TAB 325MG
BUFFERIN TAB 500MG
BUFFERIN TAB 81MG
BUFLOMEDIL POW HCL
BUG ITCH SPR RELEAF
BULKEE II MIS 4.5"X4.1
BULL FROG GEL QUIK
BUMETANIDE INJ 0.25/ML
BUMETANIDE POW
BUMETANIDE TAB 0.5MG
BUMETANIDE TAB 1MG
BUMETANIDE TAB 2MG
BUMM BALM OIN 9.38%
BUNAVAIL MIS 2.1-0.3
BUNAVAIL MIS 4.2-0.7
BUNAVAIL MIS 6.3-1MG
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Not a covered
benefit
-
-
Special Plan Edits
Maximum of 8.6
gm per 30 days
117
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
BUNION GUARD PAD
BUPAP TAB 50-300MG
BUPAP TAB 50-650MG
BUPHENYL POW
BUPHENYL TAB 500MG
BUPIVACAINE INJ 0.25%
BUPIVACAINE INJ 0.25%
BUPIVACAINE INJ 0.5%
BUPIVACAINE INJ 0.5%
BUPIVACAINE INJ 0.75%
BUPIVACAINE INJ SPINAL
BUPIVACAINE POW HCL
BUPIVACAINE/ INJ EPI 0.25
BUPIVACAINE/ INJ EPI 0.25
BUPIVACAINE/ INJ EPI 0.5%
BUPIVACAINE/ INJ EPI 0.5%
BUPIVILOG KIT
BUPREN/NALOX SUB 2-0.5MG
BUPREN/NALOX SUB 8-2MG
BUPRENEX INJ 0.3MG/ML
BUPRENORPHIN INJ 0.3MG/ML
BUPRENORPHIN POW HCL
BUPRENORPHIN SUB 2MG
BUPRENORPHIN SUB 8MG
BUPROBAN TAB 150MG
BUPROPION POW HCL
WDRx 2/23/15
Tier
Formulary Status
2
3
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
2
1
1
1
1
1
1
2
1
1
1
1
3
1
1
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
3
Non-Preferred Brand
1
2
1
1
2
Generic
Preferred Brand
Generic
Generic
$0 ACA Drug
Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
118
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BUPROPION TAB 100MG
BUPROPION TAB 200MG ER
BUPROPION TAB 75MG
BUPROPN HCL TAB 150MG XL
BURN RELIEF AER 0.5%
BURN SPRAY AER
BUSPIRONE POW HCL
BUSPIRONE TAB 10MG
BUSPIRONE TAB 15MG
BUSPIRONE TAB 30MG
BUSPIRONE TAB 5MG
BUSPIRONE TAB 7.5MG
BUSULFEX INJ 6MG/ML
BUT/APAP/CAF CAP
BUT/APAP/CAF CAP
BUT/APAP/CAF CAP CODEINE
BUT/APAP/CAF CAP CODEINE
BUT/APAP/CAF TAB
BUT/APAP/CAF TAB
BUT/ASA/CAFF CAP
BUTAL/APAP TAB 50-325MG
BUTALBITAL POW
BUTANEDIOL LIQ
BUTISOL SOD ELX 30MG/5ML
BUTISOL SOD TAB 30MG
BUTISOL SOD TAB 50MG
BUTORPHANOL INJ 1MG/ML
BUTORPHANOL INJ 2MG/ML
BUTORPHANOL POW TARTRATE
1
1
1
1
1
3
2
1
1
1
1
1
3
1
1
1
1
1
1
1
1
2
3
3
3
3
1
1
2
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
119
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BUTORPHANOL SOL 10MG/ML
BUTRANS DIS 10MCG/HR
BUTRANS DIS 15MCG/HR
BUTRANS DIS 20MCG/HR
BUTRANS DIS 5MCG/HR
BUTYL ACETAT LIQ
BUTYL ALCOHO LIQ
BUTYLAT HYDR CRY
BUTYLENE LIQ GLYCOL
BUTYLPARABEN POW
BUTYRIC ACID LIQ
BV TREATMENT CAP
BV TREATMENT SUP
BXN MOUTHWSH SUS
BYDUREON INJ
BYDUREON INJ
BYETTA INJ 10MCG
BYETTA INJ 5MCG
1
2
2
2
2
3
2
2
2
2
3
3
3
2
2
2
2
2
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
BYSTOLIC TAB 10MG
2
Preferred Brand
BYSTOLIC TAB 2.5MG
2
Preferred Brand
BYSTOLIC TAB 20MG
2
Preferred Brand
BYSTOLIC TAB 5MG
2
Preferred Brand
C & E CAP 500-400
-
-
-
-
C 1000/BIOFL CAP /R HIPS
WDRx 2/23/15
Special Plan Edits
PA Required
PA Required
PA Required
PA Required
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 60
per 30 days
Maximum of 30
per 30 days
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
120
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
-
Not a covered
benefit
-
-
C INDICUM/C LIQ SINESIS
3
Non-Preferred Brand
C/ROSE HIPS TAB 500MG CR
-
-
-
-
C/ROSEHIP CR TAB 1000MG
-
-
-
-
C/ROSEHIP CR TAB 1500MG
-
-
-
-
-
-
-
-
-
-
-
-
CA ASCORBATE POW DIHYDRAT
-
-
-
-
CA CHLORIDE POW ANHYDR
CA CHLORIDE POW DIHYDRAT
CA CIT/VIT D TAB 315/200
CA CIT/VIT D TAB 315/250
CA CITRATE + TAB
CA CITRATE TAB 250MG
CA GLUCONATE TAB 50MG
CA GLYCEROPH POW
CA HI-CAL/D TAB 250MG
CA LACTATE TAB 100MG
CA LEVULINAT POW USP/NF
CA NITRATE POW TETRAHYD
2
2
1
1
1
2
3
2
3
3
3
3
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
-
-
-
-
-
-
Drug Name
C COMPLEX TAB 1000MG
C-500 SR CAP
CA ASCORBATE POW
CA PANTOTHEN POW
CA PANTOTHEN TAB 100MG
WDRx 2/23/15
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Penalty applied if Brand Selected
over Generic
121
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CA PANTOTHEN TAB 200MG
-
-
CA PANTOTHEN TAB 500MG
-
-
2
3
3
3
1
1
1
1
1
2
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
CADUET TAB 10-10MG
3
Non-Preferred Brand
CADUET TAB 10-20MG
3
Non-Preferred Brand
CADUET TAB 10-40MG
3
Non-Preferred Brand
CADUET TAB 10-80MG
3
Non-Preferred Brand
CADUET TAB 2.5-10MG
3
Non-Preferred Brand
CA PHOS DIHY POW DIBASIC
CA PHOSPHATE POW MONOBASC
CA PROPIONAT POW
CA UNDECYLEN POW
CA/D/MINERAL TAB
CA/MAG/ZN TAB
CA/MG/ZN TAB
CA/VIT/MIN CHW 600-400
CABERGOLINE TAB 0.5MG
CACODYLATE POW SODIUM
CA-DTPA SOL 1000MG
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
122
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CADUET TAB 2.5-20MG
3
Non-Preferred Brand
CADUET TAB 2.5-40MG
3
Non-Preferred Brand
CADUET TAB 5-10MG
3
Non-Preferred Brand
CADUET TAB 5-20MG
3
Non-Preferred Brand
CADUET TAB 5-40MG
3
Non-Preferred Brand
CADUET TAB 5-80MG
3
Non-Preferred Brand
CAFCIT INJ 60MG/3ML
3
Non-Preferred Brand
CAFCIT SOL 60MG/3ML
3
Non-Preferred Brand
3
1
1
2
2
2
3
3
Non-Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CAFERGOT TAB 1-100MG
CAFFEINE CIT INJ 60MG/3ML
CAFFEINE CIT SOL 20MG/ML
CAFFEINE POW ANHYDROU
CAFFEINE POW CITRATED
CAFFEINE/SOD INJ BENZOATE
CAJEPUT OIL
CAL CIT MAL/ TAB VITAMIND
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
123
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CAL SOFT CHW CHW CARAMEL
CAL/MAG TAB CHEW
CAL/MAG TAB CITRATE
CAL/MAG/VITD TAB
CALACLEAR LOT 1-0.1%
1
3
1
3
1
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
CALADRYL CLR LOT 1-0.1%
3
Non-Preferred Brand
3
Non-Preferred Brand
3
1
2
2
2
2
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
CALAN SR TAB 120MG
3
Non-Preferred Brand
CALAN SR TAB 180MG
3
Non-Preferred Brand
CALAN SR TAB 240MG
3
Non-Preferred Brand
CALAN TAB 120MG
3
Non-Preferred Brand
CALAN TAB 80MG
3
Non-Preferred Brand
CALADRYL LOT 1-8%
CALAGEL GEL MAX ST
CALAGESIC LOT 1-8%
CALAMINE LOT
CALAMINE LOT 8-8%
CALAMINE LOT PHENOLAT
CALAMINE POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
124
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CALAZIME SKN PST PROTECT
CALC + D + K TAB 750MG
CALC 1200+D3 TAB
CALC 600+D TAB 600-800
CALC 600+D+ TAB MINERALS
CALC ACETATE CAP 667MG
CALC ACETATE TAB 667MG
CALC ACETATE TAB 668MG
CALC CARBONA WAF 500MG
CALC CHEWABL CHW 600 PLUS
CALC CIT+D3 TAB 250-200
CALC CITR/D3 TAB 200-250
CALC CITRATE LIQ VIT D3
CALC CITRATE TAB 200MG
3
3
1
1
1
1
1
3
3
2
1
1
3
2
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
CALC COOKIE MIS PEANTBTR
-
-
CALC FOLINAT INJ 100/10ML
CALC FOLINAT INJ 300/30ML
CALC GUMMIES CHW CHILD
CALC SULFATE POW ANHYDR
CALC/MAGNES TAB 500-250
CALC/VIT D3 CHW 200-200
CALC/VIT D3 CHW DISNEY
CALCARB 600 TAB
CALCARB 600 TAB /VIT D
CALCARB/D TAB 600
CALCET BITES CHW 500-400
CALCET PETIT TAB 200-250
CALCI-CHEW CHW 1250MG
2
2
3
2
1
3
3
1
1
1
3
2
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
125
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
-
Not a covered
benefit
-
-
CALCIFEDIOL POW
CALCIFOL WAF
3
3
Non-Preferred Brand
Non-Preferred Brand
CALCI-MAX CAP
-
-
Not a covered
benefit
-
-
2
1
2
1
1
1
2
1
1
3
1
3
1
1
1
2
2
3
1
3
2
1
1
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Generic
Generic
Drug Name
CALCIDOL DRO 8000/ML
CALCI-MIX CAP 1250MG
CALCIO DEL TAB MAR
CALCIONATE SYP 1.8GM/5
CALCIPOTRIEN CRE 0.005%
CALCIPOTRIEN OIN 0.005%
CALCIPOTRIEN OIN BETAMETH
CALCIPOTRIEN POW
CALCIPOTRIEN SOL 0.005%
CALCITONIN SPR 200/ACT
CAL-CITRATE CAP 150MG
CALCITRATE TAB 950MG
CAL-CITRATE TAB PLUS D
CALCITRIOL CAP 0.25MCG
CALCITRIOL CAP 0.5MCG
CALCITRIOL INJ 1MCG/ML
CALCITRIOL OIL ALMOND
CALCITRIOL OIN 3MCG/GM
CALCITRIOL POW
CALCITRIOL SOL 1MCG/ML
CALCIUM & D3 LIQ BONE
CALCIUM &MAG TAB
CALCIUM + D CHW
CALCIUM + D TAB 600-200
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
126
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CALCIUM + D3 TAB 600MG
CALCIUM 1000 TAB + D
CALCIUM 1200 CHW
CALCIUM 500 TAB
CALCIUM 500 TAB /VIT D
CALCIUM 500 TAB /VIT D3
CALCIUM 500 TAB +D
CALCIUM 600 CHW W/VIT D
CALCIUM 600 TAB
CALCIUM 600 TAB +D/MNRLS
CALCIUM BUT CRY TRIHYDRA
CALCIUM CAP 250MG
CALCIUM CARB CHW 260MG
CALCIUM CARB POW
CALCIUM CARB POW 800/2GM
CALCIUM CARB POW EX-LIGHT
CALCIUM CARB SUS 1250/5ML
CALCIUM CARB TAB 648MG
CALCIUM CHW 500MG
CALCIUM CHW 600-400
CALCIUM CHW GUMMIES
CALCIUM CHW SFT CHEW
CALCIUM CIT TAB 1040MG
CALCIUM CIT TAB W/VIT D
CALCIUM CIT/ TAB VIT D
CALCIUM CL INJ 10%
CALCIUM DISO INJ 1GM/5ML
CALCIUM DISO INJ 500/2.5M
CALCIUM GLUC INJ 10%
1
2
1
2
1
1
1
1
1
1
3
3
3
2
3
3
1
2
1
3
3
1
3
3
2
1
2
3
1
Generic
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
127
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CALCIUM GLUC POW
CALCIUM GLUC POW ANHYDR
CALCIUM GLUC TAB 500MG
CALCIUM GLUC TAB 648MG
CALCIUM GLUC TAB 650MG
CALCIUM GRA CITRATE
CALCIUM LACT POW MONOHYDR
CALCIUM LACT POW PENTAHYD
CALCIUM LACT TAB 648MG
CALCIUM LACT TAB 750MG
CALCIUM LEV POW DIHYDRAT
CALCIUM PHOS POW DIBASIC
CALCIUM PHOS POW TRIBASIC
CALCIUM PLUS CAP D3
2
3
2
2
2
3
3
2
2
3
2
2
2
1
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
-
$0 Preventative Drug
2
2
3
2
3
3
2
2
2
3
3
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CALCIUM PNV CAP
CALCIUM POW ACETATE
CALCIUM POW ALGINATE
CALCIUM POW BROMIDE
CALCIUM POW CITRATE
CALCIUM POW CYANAMID
CALCIUM POW FLUORIDE
CALCIUM POW FOLINATE
CALCIUM POW GLUBIONA
CALCIUM POW HYDROXID
CALCIUM POW IODATE
CALCIUM POW MALATE
CALCIUM POW OXIDE
CALCIUM POW PEROXIDE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
128
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CALCIUM POW POLYCARB
CALCIUM POW PYRUVATE
CALCIUM POW SACCHARA
CALCIUM POW STEARATE
CALCIUM RICH SUS ANTACID
CALCIUM SOFT CHW CARAMEL
CALCIUM TAB
CALCIUM TAB 500/D
CALCIUM TAB 500MG
CALCIUM TAB 500MG
CALCIUM TAB 600MG
CALCIUM TAB 600MG
CALCIUM TAB 75MG
CALCIUM TAB FORMULA
CALCIUM TAB MAGNESIU
CALCIUM/C/D CHW 500MG
CALCIUM/D CAP 600MG
CALCIUM/D CHW 500-400
CALCIUM/D TAB 500-200
CALCIUM/D TAB 500MG
CALCIUM/D TAB 600-400
CALCIUM/D WAF
CALCIUM/D3 CHW GUMMIES
CALCIUM/D3 TAB
CALCIUM/MAG CAP VIT D
CALCIUM/MAGN TAB ZINC
CALCIUM/VITD CAP 600-400
CALCIUM-FA WAF PLUS D
CAL-CYUM WAF 500MG
3
2
2
3
1
1
3
1
1
1
1
1
3
3
3
2
1
1
1
1
1
3
3
1
3
1
2
2
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
129
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CALDOLOR INJ 400/4ML
CALDOLOR INJ 800/8ML
CALENDULA LOT
CAL-GLU CAP 500MG
CALGONATE GEL 2.5%
CAL-LAC CAP 500MG
CALLEX OIN
2
2
3
3
3
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CALLUS PAD REMOVERS
3
Non-Preferred Brand
1
1
3
3
3
3
3
2
1
2
2
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
-
$0 Preventative Drug
2
3
Preferred Brand
Non-Preferred Brand
CALLUS REMOV PAD 40%
CAL-MAG ASPA TAB 333-167
CAL-MAG CHEL CAP 70-83MG
CALMAG THINS TAB 200-50MG
CAL-MAG ZINC SUS II
CAL-MAG-D TAB SUPER
CAL-MAG-K CAP
CAL-MAG-ZINC TAB -D
CALMODROX OIN
CALMOL-4 SUP
CALMOSEPTINE OIN
CALNA TAB
CALPHRON TAB 667MG
CAL-QUICK LIQ 500-400
CALTRATE +D TAB 600-800
3
Non-Preferred Brand
CALTRATE 600 CHW 600-800
CALTRATE+D TAB 600-800
2
2
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
130
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Not a covered
benefit
-
-
Tier
Formulary Status
1
Generic
-
-
3
-
Non-Preferred Brand
$0 Preventative Drug
-
-
CAMPHENE POW
3
Non-Preferred Brand
CAMPHO-PHENI GEL
3
Non-Preferred Brand
CAMPHO-PHENI LIQ
3
Non-Preferred Brand
2
2
2
1
2
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
CAMPRAL TAB 333MG
3
Non-Preferred Brand
CAMPTOSAR INJ 100/5ML
3
Non-Preferred Brand
YES, Specialty Drug
CAMPTOSAR INJ 300/15ML
3
Non-Preferred Brand
YES, Specialty Drug
CAMPTOSAR INJ 40MG/2ML
3
Non-Preferred Brand
YES, Specialty Drug
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
CALVITE P&D TAB
CAM PRO COMP BAR GLYTACTI
CAMBIA POW 50MG
CAMILA TAB 0.35MG
CAMINO PRO POW BETTRMLK
CAMPHOR CRY
CAMPHOR GRA
CAMPHOR GUM GUM BLOCKS
CAMPHOR PHEN GEL 10.8-4.7
CAMPHOR SOL SPIRIT
CANADIAN LIQ BALSAM
CANASA SUP 1000MG
CANCIDAS INJ 50MG
WDRx 2/23/15
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
131
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
Preferred Brand
CANDESA/HCTZ TAB 16-12.5
1
Generic
CANDESA/HCTZ TAB 32-12.5
1
Generic
CANDESA/HCTZ TAB 32-25MG
1
Generic
CANDESARTAN TAB 16MG
1
Generic
CANDESARTAN TAB 32MG
1
Generic
CANDESARTAN TAB 4MG
1
Generic
CANDESARTAN TAB 8MG
1
Generic
2
1
3
2
3
2
2
3
3
3
3
2
3
3
3
2
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
CANCIDAS INJ 70MG
CANDIN INJ
CANKAID SOL 10%
CANRENONE POW
CANTHARIDIN POW
CANTIL TAB 25MG
CAP POSILOK CAP #0
CAPASTAT SUL INJ 1GM
CAPCOF SYP
CAPECITABINE TAB 150MG
CAPECITABINE TAB 500MG
CAPEX SHA 0.01%
CAPFILL PRO POW DPI
CAPFILL PRO POW FAGRON
CAPHOSOL SOL
CAPITAL/COD SUS 120-12/5
CAPMIST DM TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
YES, Specialty Drug
YES, Specialty Drug
132
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
CAPRON DM LIQ
CAPRYLIC CAP LIQ TRIGLYCE
CAPRYLIC LIQ ACID
CAPSAGEL GEL 0.025%
CAPSAGEL MS GEL 0.075%
CAPSAGEL XS GEL 0.05%
CAPSAICIN CRE 0.075%
CAPSAICIN CRE 0.1%
CAPSAICIN LIQ 0.15%
CAPSAICIN PAD HOT PTCH
CAPSAICIN POW
CAPSICUM LIQ OLEORESI
CAPSICUM OLE CRE 0.075%
CAPSICUM TIN
CAPSULE #0 CAP VEGGIE
CAPSULE 2 CAP VEGGIE
COMVAX INJ
CONCEPTROL GEL 4%
DAPTAEL INJ
FEMCAP MIS 22MM
CAPTOPRIL POW
CAPTOPRIL TAB 100MG
CAPTOPRIL TAB 12.5MG
CAPTOPRIL TAB 25MG
CAPTOPRIL TAB 50MG
CAPZASIN GEL RELIEF
CAPZASIN-HP CRE 0.1%
3
3
3
2
2
3
3
3
1
1
3
1
2
2
3
3
2
3
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
Limited Distribution
133
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
2
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
CARAMIPHEN POW EDISYLAT
CARAWAY OIL
3
3
Non-Preferred Brand
Non-Preferred Brand
CARB/LEVO 50 TAB /ENTACAP
2
Preferred Brand
CARB/LEVO 75 TAB /ENTACAP
2
Preferred Brand
CARB/LEVO ER TAB 25-100MG
CARB/LEVO ER TAB 50-200MG
CARB/LEVO TAB 10-100MG
CARB/LEVO TAB 10-100MG
CARB/LEVO TAB 25-100MG
CARB/LEVO TAB 25-100MG
CARB/LEVO TAB 25-250MG
CARB/LEVO TAB 25-250MG
1
1
1
1
1
1
1
1
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
CARB/LEVO100 TAB /ENTACAP
2
Preferred Brand
CARB/LEVO125 TAB /ENTACAP
2
Preferred Brand
CARB/LEVO150 TAB /ENTACAP
2
Preferred Brand
CARB/LEVO200 TAB /ENTACAP
2
Preferred Brand
CARBACHOL POW
CARBAGLU TAB 200MG
CARBAMAZEPIN CAP 100MG ER
CARBAMAZEPIN CAP 200MG ER
2
3
1
1
Preferred Brand
Non-Preferred Brand
Generic
Generic
CAPZASIN-P CRE 0.035%
CARAC CRE 0.5%
CARAFATE TAB 1GM
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 240
per 30 days
Maximum of 240
per 30 days
Maximum of 240
per 30 days
Maximum of 240
per 30 days
Maximum of 240
per 30 days
Maximum of 180
per 30 days
Limited Distribution
134
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CARBAMAZEPIN CAP 300MG ER
CARBAMAZEPIN CHW 100MG
CARBAMAZEPIN POW
CARBAMAZEPIN SUS 100/5ML
CARBAMAZEPIN TAB 200MG
CARBAMAZEPIN TAB 200MG ER
CARBAMAZEPIN TAB 400MG ER
CARBAMIDE POW PEROXIDE
CARBAPHEN 12 LIQ
CARBAPHEN 12 SUS PED
CARBAPHEN CH SUS
CARBAPHEN SUS PED CH
1
1
2
1
1
1
1
2
3
3
2
3
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
CARBATROL CAP 100MG
3
Non-Preferred Brand
CARBATROL CAP 200MG
3
Non-Preferred Brand
CARBATROL CAP 300MG
3
Non-Preferred Brand
3
2
1
2
3
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
CARBETAPENTA POW CITRATE
CARBIDOPA POW
CARBIDOPA TAB 25MG
CARBIMAZOLE POW
CARBINOXAMIN POW MALEATE
CARBOCAINE INJ 1%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
135
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
CARBOCAINE INJ 1% PF
Tier
Formulary Status
3
Non-Preferred Brand
CARBOCAINE INJ 1.5% PF
CARBOCAINE INJ 2%
CARBOCAINE INJ 2% PF
CARBOGEL GEL 940
CARB-O-LAC CRE HP
CARB-O-LAC5 CRE
CARBOMER POW 934P
CARBON LIQ TETRACHL
CARBOPLATIN INJ 150/15ML
CARBOPLATIN INJ 150MG
CARBOPLATIN INJ 450/45ML
CARBOPLATIN INJ 50MG/5ML
CARBOPLATIN INJ 600/60ML
CARBOPOL 934 POW RESIN
CARBOXYM SOD GRA MED VISC
CARBOXYMETHY POW CYSTEIN
CARBOXYMETHY POW SODIUM
CARBZERO EMU
CARDAMOM OIL
CARDEC DM DRO
CARDEC DRO
2
2
2
2
2
3
2
3
3
3
3
3
3
3
2
3
2
3
2
1
1
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
CARDENE I.V. INJ 2.5MG/ML
3
Non-Preferred Brand
CARDENE SR CAP 30MG
CARDENE SR CAP 60MG
3
3
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
136
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
-
Not a covered
benefit
-
-
3
3
3
3
1
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
-
-
Not a covered
benefit
-
-
CARDIOVID CAP PLUS
CARDIOWHEY POW CHOCOLAT
3
3
Non-Preferred Brand
Non-Preferred Brand
CARDIZEM CD CAP 120MG/24
3
Non-Preferred Brand
CARDIZEM CD CAP 180MG/24
3
Non-Preferred Brand
CARDIZEM CD CAP 240MG/24
3
Non-Preferred Brand
CARDIZEM CD CAP 300MG/24
3
Non-Preferred Brand
CARDIZEM CD CAP 360MG/24
3
Non-Preferred Brand
CARDIZEM LA TAB 120MG
-
$0 Preventative Drug
CARDIZEM LA TAB 180MG
3
Non-Preferred Brand
Drug Name
CARDENZ TAB
CARDIO CHEK KIT HDL
CARDIO CHEK KIT TRIGLYCE
CARDIO CHEK MIS KIT
CARDIO OMEGA CAP VIT D-3
CARDIOPLEGIC SOL
CARDIOSTEROL CAP
CARDIOTEK-RX TAB
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
137
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CARDIZEM LA TAB 240MG
3
Non-Preferred Brand
CARDIZEM LA TAB 300MG/24
3
Non-Preferred Brand
CARDIZEM LA TAB 360MG
3
Non-Preferred Brand
CARDIZEM LA TAB 420MG/24
3
Non-Preferred Brand
CARDIZEM TAB 120MG
3
Non-Preferred Brand
CARDIZEM TAB 30MG
3
Non-Preferred Brand
CARDIZEM TAB 60MG
3
Non-Preferred Brand
CARDIZEM TAB 90MG
3
Non-Preferred Brand
CARDURA TAB 1MG
3
Non-Preferred Brand
CARDURA TAB 2MG
3
Non-Preferred Brand
CARDURA TAB 4MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
138
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
CARDURA TAB 8MG
Tier
Formulary Status
3
Non-Preferred Brand
CARDURA XL TAB 4MG
3
Non-Preferred Brand
CARDURA XL TAB 8MG
3
Non-Preferred Brand
CA-REZZ CRE 0.3%
CA-REZZ GENT LIQ 0.2%
3
3
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
3
3
1
2
3
1
1
3
3
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
CARMOL-HC CRE 1%
3
Non-Preferred Brand
CARNAUBA WAX MIS
2
Preferred Brand
CA-REZZ LIQ 0.25%
CARIMUNE NF INJ 12GM
CARIMUNE NF INJ 3GM
CARIMUNE NF INJ 6GM
CARISOPR/ASA TAB 200-325
CARISOPRODOL POW
CARISOPRODOL TAB 250MG
CARISOPRODOL TAB 350MG
CARISOPRODOL TAB ASA/COD
CARLESTA OIN
CARMINE POW
CARMOL 10 LOT 10%
CARMOL 20 CRE 20%
CARMOL SHA 10%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
139
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
CARNI Q-GEL CAP 30-250MG
Tier
Formulary Status
3
Non-Preferred Brand
CARNITINE CAP 250MG
CARNITINE CAP 250MG
CARNITINE POW (L)
1
1
2
Generic
Generic
Preferred Brand
CARNITOR INJ 1GM/5ML
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
2
1
3
3
1
3
3
3
3
1
3
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
CARNITOR SF SOL 1GM/10ML
CARNITOR TAB 330MG
CARNOSINE L POW
CARRACOLLOID PAD 4"X4"
CARRAFOAM KIT SKN CARE
CARRAGEENAN POW
CARRAGINATE MIS 14" ROPE
CARRASMART PAD 2"X3"
CARRINGTON GEL DERM WND
CARRY ALL MIS TOTE BAG
CARRY CASE MIS PET PUMP
CARTEOLOL SOL 1% OP
CARTIA XT CAP 120/24HR
CARTIA XT CAP 180/24HR
CARTIA XT CAP 240/24HR
CARTIA XT CAP 300/24HR
CARTICEL IMP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
140
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
CARTILAGE POW BOVINE
CARTIVISC TAB
CARTRIDGE MIS 3.15ML
CARVEDILOL TAB 12.5MG
CARVEDILOL TAB 25MG
CARVEDILOL TAB 3.125MG
CARVEDILOL TAB 6.25MG
CASCARA AROM EXT 325/5ML
CASCARA EXT SAGRADA
CASCARA SAGR CAP 450MG
CASCARA SAGR POW EXTRACT
CASHEW NUT OIL
CASODEX TAB 50MG
CASTELLANI LIQ 1.5%
CASTILE SOAP ENE
CASTILE SOAP POW
CASTIVA COOL LOT
CASTIVA LOT
CASTOR LAXAT OIL 100%
CASTOR OIL
CASTOR OIL 100%
CASTOR OIL SULFATED
CAT HAIR INJ EXTRACT
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
3
Non-Preferred Brand
-
-
3
3
1
3
3
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
1
2
3
3
3
1
2
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
3
Non-Preferred Brand
3
3
Non-Preferred Brand
Non-Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
141
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CATAFLAM TAB 50MG
3
Non-Preferred Brand
CATAPRES TAB 0.1MG
3
Non-Preferred Brand
CATAPRES TAB 0.2MG
3
Non-Preferred Brand
CATAPRES TAB 0.3MG
3
Non-Preferred Brand
CATAPRES-TTS DIS 0.1/24HR
3
Non-Preferred Brand
CATAPRES-TTS DIS 0.2/24HR
3
Non-Preferred Brand
CATAPRES-TTS DIS 0.3/24HR
3
Non-Preferred Brand
CATECHIN POW
CATH TRAY KIT
CATHETER KIT IRRIGATI
CATHETER MIS SYRINGE
CATHFLO ACTI INJ VASE
CATNIP OIL
CATNIP POW
CATS CLAW CAP 1000MG
CATS CLAW CAP 350MG
CATS CLAW CAP 400MG
CATS CLAW CAP 500MG
3
3
3
2
2
3
2
3
1
2
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
142
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CATS CLAW POW
2
Preferred Brand
CAVAN-ALPHA KIT
-
$0 Preventative Drug
-
$0 Preventative Drug
1
2
2
2
2
3
2
3
3
2
1
3
3
1
3
3
3
3
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
-
-
3
2
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
CAVAN-EC SOD MIS DHA
CAVAREST GEL 1.1%
CAVERJECT INJ 20MCG
CAVERJECT INJ 40MCG
CAVERJECT KIT 10MCG
CAVERJECT KIT 20MCG
CAVILON CRE 1.3%
CAVILON DURA CRE BARRIER
CAVILON EMOL CRE
CAVILON FOOT CRE &DRY SKN
CAVILON NO MIS STN BARR
CAVILON NO SPR STN BARR
CAVILON ONE- LOT STEP SKN
CAVILON SKIN LIQ CLEANSER
CAVIRINSE SOL 0.2%
CAYENN/GARLC CAP 500MG
CAYENNE FRUI CAP 455MG
CAYENNE POW
CAYSTON INH 75MG
CAZIANT PAK
C-BUFF POW
CCP CAFFEINE TAB FREE
CDP/AMITRIP TAB 10-25MG
CDP/AMITRIP TAB 5-12.5MG
CEDAR LEAF OIL
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
10 per 30 days
10 per 30 days
10 per 30 days
10 per 30 days
Limited Distribution
Not a covered
benefit
-
-
143
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CEDARWOOD OIL
CEDAX CAP 400MG
CEDAX SUS 180/5ML
CEDAX SUS 90MG/5ML
CEENU CAP 100MG
CEENU CAP 10MG
CEENU CAP 40MG
CEFACLOR CAP 250MG
CEFACLOR CAP 500MG
CEFACLOR ER TAB 500MG
CEFACLOR SUS 125/5ML
CEFACLOR SUS 250/5ML
CEFACLOR SUS 375/5ML
CEFADROXIL CAP 500MG
CEFADROXIL POW MONOHYDR
CEFADROXIL SUS 250/5ML
CEFADROXIL SUS 500/5ML
CEFADROXIL TAB 1GM
CEFAZOL/DEX SOL 1GM
CEFAZOL/DEX SOL 2GM
CEFAZOLIN INJ 100GM
CEFAZOLIN INJ 10GM
CEFAZOLIN INJ 1GM/50ML
CEFAZOLIN INJ 20GM
CEFAZOLIN INJ 300GM
CEFAZOLIN INJ 500MG
CEFDINIR CAP 300MG
CEFDINIR SUS 125/5ML
CEFDINIR SUS 250/5ML
2
3
3
3
2
2
2
1
1
2
2
2
2
1
3
1
1
1
2
2
2
1
2
1
2
1
1
1
1
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
144
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CEFDITOREN TAB 200MG
CEFDITOREN TAB 400MG
CEFOTAXIME INJ 10GM
CEFOTAXIME INJ 1GM
CEFOTAXIME INJ 2GM
CEFOTAXIME INJ 500MG
CEFOTET/DEX INJ 1-3.58%
CEFOTET/DEX INJ 2-2.08%
CEFOTETAN INJ 10G
CEFOTETAN INJ 1GM/10ML
CEFOTETAN INJ 2GM/20ML
CEFOXITIN INJ 10GM
CEFPODO PROX SUS 100/5ML
CEFPODO PROX SUS 50MG/5ML
CEFPODOXIME TAB 100MG
CEFPODOXIME TAB 200MG
CEFPROZIL SUS 125/5ML
CEFPROZIL SUS 250/5ML
CEFPROZIL TAB 250MG
CEFPROZIL TAB 500MG
CEFTAZIDIME INJ 100GM
CEFTAZIDIME INJ 1GM
CEFTAZIDIME INJ 2GM
CEFTAZIDIME INJ 6GM
CEFTAZIDIME POW
CEFTAZIDIME POW SODIUM
CEFTAZIDIME/ SOL D5W 1GM
CEFTAZIDIME/ SOL D5W 2GM
CEFTIBUTEN CAP 400MG
2
2
1
1
1
1
3
3
2
2
2
1
1
1
1
1
1
1
1
1
3
1
1
1
3
2
2
2
2
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
145
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
Preferred Brand
CEFTIN SUS 125/5ML
3
Non-Preferred Brand
CEFTIN SUS 250/5ML
3
Non-Preferred Brand
CEFTIN TAB 250MG
3
Non-Preferred Brand
CEFTIN TAB 500MG
3
Non-Preferred Brand
2
2
1
1
1
1
1
1
1
2
2
2
2
2
1
1
3
1
2
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Preferred Brand
CEFTIBUTEN SUS 180/5ML
CEFTRIAX/DEX INJ 1GM
CEFTRIAX/DEX INJ 2GM
CEFTRIAXONE INJ 10GM
CEFTRIAXONE INJ 1GM
CEFTRIAXONE INJ 1GM
CEFTRIAXONE INJ 250MG
CEFTRIAXONE INJ 2GM
CEFTRIAXONE INJ 2GM
CEFTRIAXONE INJ 500MG
CEFTRIAXONE POW SODIUM
CEFTRIAXONE/ INJ DEX 1GM
CEFTRIAXONE/ INJ DEX 2GM
CEFUROX/DEXT INJ 1.5GM
CEFUROX/DEXT INJ 750MG
CEFUROXIME INJ 1.5GM
CEFUROXIME INJ 1.5GM
CEFUROXIME INJ 225GM
CEFUROXIME INJ 750MG
CEFUROXIME INJ 75GM
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
146
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
CEFUROXIME SUS 125/5ML
CEFUROXIME TAB 250MG
CEFUROXIME TAB 500MG
Tier
Formulary Status
1
1
1
Generic
Generic
Generic
Special Plan Edits
2
Preferred Brand
CELEBREX CAP 200MG
2
Preferred Brand
CELEBREX CAP 400MG
2
Preferred Brand
CELEBREX CAP 50MG
2
Preferred Brand
2
2
Preferred Brand
Preferred Brand
CELESTONE INJ SOLUSPAN
3
Non-Preferred Brand
CELESTONE SOL 0.6MG/5
3
Non-Preferred Brand
CELEXA TAB 10MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
CELEXA TAB 20MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Step Therapy
Required,
Maximum of 60
per 30 days
Step Therapy
Required,
Maximum of 60
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 60
per 30 days
CELEBREX CAP 100MG
CELECOXIB POW
CELERY SEED OIL
Medication must be filled
through US Specialty Care
Pharmacy
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
147
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Maximum of 30
per 30 days
CELEXA TAB 40MG
3
Non-Preferred Brand
CELLACEFATE POW
2
Preferred Brand
CELLCEPT CAP 250MG
3
Non-Preferred Brand
2
2
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
2
2
3
2
2
2
2
2
2
2
2
3
3
2
-
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
CELLCEPT IV INJ 500MG
CELLCEPT SUS 200MG/ML
CELLCEPT TAB 500MG
CELLUGEL SOL 2%
CELLULASE POW
CELLULOSE CRY MICROCRY
CELLULOSE POW MICROCRY
CELLULOSE/ POW CMC NA
CELONTIN CAP 300MG
CEM-UREA SOL 45%
CENESTIN TAB 0.3MG
CENESTIN TAB 0.45MG
CENESTIN TAB 0.625MG
CENESTIN TAB 0.9MG
CENESTIN TAB 1.25MG
CENFOL TAB
CENTANY AT KIT 2%
CENTRATEX CAP
CENTRUM SPEC PAK PRENATAL
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
148
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
-
Not a covered
benefit
-
3
Non-Preferred Brand
CEPACOL ANTI LIQ 0.05%
3
Non-Preferred Brand
CEPACOL CGH LOZ 5-7.5MG
CEPACOL COOL LOZ 4-9MG
CEPACOL DUAL SPR RELIEF
CEPACOL FIZZ TAB 6MG
CEPACOL HYDR LOZ 3MG
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
2
3
3
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
CEPACOL SORE LOZ 5.4MG
3
Non-Preferred Brand
CEPACOL SORE LOZ COATING
CEPACOL SORE SPR 0.1-33%
CEPACOL WARM LOZ 4MG
CEPASTAT LOZ CHERRY
CEPHALEXIN CAP 250MG
CEPHALEXIN CAP 500MG
CEPHALEXIN CAP 750MG
CEPHALEXIN SUS 125/5ML
CEPHALEXIN SUS 250/5ML
2
3
3
2
1
1
1
1
1
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Drug Name
CENTRUM TAB PERFORMA
CEO-TWO SUP
CEPACOL LOZ EXTRA ST
CEPACOL MAX LOZ NUMBING
CEPACOL REG LOZ 3MG
CEPACOL SORE LOZ 10-2.1MG
CEPACOL SORE LOZ 15-2.6MG
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
149
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CEPHALEXIN TAB 250MG
CEPHALEXIN TAB 500MG
CEPROTIN INJ 1000UNIT
CEPROTIN INJ 500 UNIT
CERALYTE 70 LIQ
CERALYTE 70 POW
CERAPHYL SLK LIQ
CERAXON SOL
CERAXON TAB 1000MG
CERAXON TAB 500MG
CERDELGA CAP 84MG
2
2
2
2
3
2
3
3
2
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CEREBYX INJ 100/2ML
3
Non-Preferred Brand
CEREBYX INJ 500/10ML
3
Non-Preferred Brand
-
-
2
3
3
3
1
1
3
2
3
3
-
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
CEREFOLIN TAB
CERESIN WAX MIS
CERETEC INJ
CEREZYME INJ 200UNIT
CEREZYME INJ 400UNIT
CEROVEL GEL 40%
CEROVEL LOT 40%
CERTAIN DRI MIS
CERTAIN DRI SOL
CERTAIN DRI SOL A.M.
CERTUSS-D TAB
FEMCAP MIS 26MM
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Limited Distribution
Limited Distribution
150
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CERVIDIL VAG MIS 10MG INS
CESAMET CAP 1MG
3
3
Non-Preferred Brand
Non-Preferred Brand
-
-
3
3
2
3
3
2
2
2
1
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CETROTIDE KIT 0.25MG
-
-
CETROTIDE KIT 3MG
-
-
2
2
2
2
2
2
2
3
3
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
CESINEX SUS
CESIUM 1000 CAP
CESIUM 500 CAP 500MG
CESIUM CHLOR POW
CESIUM POW CARBONAT
CESIUM TAB 100MG
CETAPHIL BAR ANTIBACT
CETAPHIL GTL BAR DRY/SENS
CETEARYL ALC POW /CET-20
CETIRIZINE TAB 5MG
CETOMACROGOL POW 1000
CETRAXAL SOL 0.2%
CETRIMONIUM POW BROMIDE
CETYL ALCOHO GRA
CETYL ALCOHO POW
CETYL ESTERS MIS
CETYL MYRIST MIS OLEATE
CETYL MYRIST OIL 40%
CETYL MYRIST POW 20%
CETYL MYRIST POW OLEATE
CETYLCIDE II CON
CETYLCIDE-G CON
CETYLPYRIDIN CRY CHLORIDE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
-
-
-
-
Not a covered
benefit
Not a covered
benefit
151
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CEVIMELINE CAP 30MG
CGH DM MAX LIQ 10-200
CGH RELIEF CAP 15MG
CGH/COLD DAY LIQ DELSYM
CGH/RUNNY NS SUS CHILDRNS
CGH/SORE THR LIQ 160-5ML
CGMS CABLE MIS
CGMS SYSTEM MIS GOLD
CHAMOMILE EXT FLOWER
CHAMOSYN OIN 0.45-20%
CHANTIX PAK 0.5& 1MG
CHANTIX PAK 1MG
CHANTIX TAB 0.5MG
CHAPARRAL POW
CHAPSTICK CRE RENEWAL
CHAPSTICK OIN MOISTURE
CHARCOAL CAP 200MG
CHARCOAL CAP 260MG
CHARCOAL POW
CHARCOAL TAB 250MG
CHAR-FLO SUS SORBITOL
CHASTEBERRY POW EXTRACT
CHEK-STIX TES CONTROL
CHELATE ZINC LOZ 23MG
CHELATED CA TAB 200MG
CHELATED MG TAB 100MG
CHELATED ZN TAB 50MG
CHEMET CAP 100MG
CHEMSIL K-12 PST
1
1
1
1
1
1
3
3
3
3
3
1
3
2
1
2
1
3
3
2
1
3
1
1
2
3
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
152
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
2
3
3
3
2
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
CHERACOL LIQ PLUS
3
Non-Preferred Brand
CHERACOL SPR 1.4%
2
Preferred Brand
CHERACOL-D LIQ 100-10/5
3
Non-Preferred Brand
CHERATUSSIN SOL DAC
CHERATUSSIN SYP 100-10/5
CHERRY CON
CHERRY MENTH LOZ DROPS
CHERRY SYP
CHEST CONGES TAB DAYTIME
CHEST RUB OIN MEDICATE
CHESTAL HONE SYP COUGH
CHEW Q CHW 100MG
CHEW Q CHW 30MG
CHEW Q CHW 600MG
1
1
3
1
2
1
1
3
2
2
2
Generic
Generic
Non-Preferred Brand
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
-
-
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CHEMSTRIP 10 TES MD
CHEMSTRIP 2 TES LN
CHEMSTRIP BG MIS LOG
CHEMSTRIP TES CALIBRAT
CHEMSTRIP TES UGK
CHENODAL TAB 250MG
CHENODEOXYCH POW ACID
CHEW-12 CHW
CHEWABLE CHW IRON
CHEW-HESIVE OIN
CHIA OIL CAP 1000MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
153
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CHILD ADVIL DRO 50/1.25
3
Non-Preferred Brand
CHILD ADVIL SUS COLD
1
Generic
CHILD CHEW/ CHW EXTRA C
-
-
CHILD COMPLE CHW ALLERGY
CHILD MOTRIN CHW 100MG
CHILD MOTRIN CHW 50MG
1
2
3
Generic
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
1
1
1
1
-
Generic
Generic
Generic
Generic
$0 ACA Drug
CHIA SEED POW
CHICKEN POW PROTEIN
CHIGG AWAY LOT 5-10%
CHIGGEREX OIN 2%
CHIGGERTOX LIQ
CHILD MOTRIN SUS COLD
CHILD PAIN LIQ REL COLD
CHILD PLUS SUS COLD
CHILD SILFED LIQ 15MG/5ML
CHILD SOOTHE CHW 400MG
CHILD VIT D CHW 400UNIT
CHILD-MULTI CHW VITAMINS
-
-
CHILDRENS CHW COMPLETE
-
-
CHILDRENS CHW GUMMIES
-
-
CHILDRENS LIQ 5-100MG
CHILDRENS SUS PLUS CLD
CHIRHOSTIM SOL 16MCG
1
1
3
Generic
Generic
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
-
-
154
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CHITOSAN POW
CHITOSAN TAB 500MG
CHLD IBUPRFN DRO 40MG/ML
3
3
1
Non-Preferred Brand
Non-Preferred Brand
Generic
3
Non-Preferred Brand
2
2
3
3
2
2
3
2
2
2
3
2
1
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
CHLD TYLENOL SUS PLUS
CHLO TUSS EX LIQ 12.5-100
CHLO TUSS LIQ
CHLOPHED LIQ
CHLOR GLUC LIQ 2%
CHLORAL CRY HYDRATE
CHLORAMBUCIL POW
CHLORAMINE-T POW
CHLORAMPHEN INJ 1GM
CHLORAMPHEN POW
CHLORAMPHENI POW PALMITAT
CHLORAPREP SOL ONE STEP
CHLORASEPTIC LIQ 0.5%
CHLORASEPTIC LIQ 1.4%
CHLORASEPTIC LOZ 6-10MG
CHLORASEPTIC LOZ CHERRY
3
Non-Preferred Brand
CHLORASEPTIC LOZ MAX
CHLORASEPTIC LOZ TOTAL
3
3
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
3
Non-Preferred Brand
Non-Preferred Brand
CHLORASEPTIC MIS
CHLORASEPTIC MIS KIDS
CHLORASEPTIC SPR 1.5-33%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
155
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CHLORAZOL POW BLACK E
CHLORD/CLIDI CAP 5-2.5MG
CHLORDIAZEP CAP 10MG
CHLORDIAZEP CAP 25MG
CHLORDIAZEP CAP 5MG
3
1
1
1
1
Non-Preferred Brand
Generic
Generic
Generic
Generic
-
-
2
3
3
1
2
2
2
2
3
2
2
3
2
1
3
3
2
2
1
1
2
1
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Generic
CHLORELLA CAP
CHLORELLA POW
CHLORHEX DIG SOL 20%
CHLORHEX GLU PAD 2%
CHLORHEX GLU SOL 0.12%
CHLORHEX GLU SOL 20%
CHLORHEXIDIN CON FLAVOR
CHLORHEXIDIN POW DIACETAT
CHLORHEXIDIN SOL GLUCONAT
CHLORMEZANON POW
CHLOROACETIC POW ACID
CHLOROBUTAN POW
CHLOROBUTAN POW HEMIHYDR
CHLOROFORM SOL
CHLOROMAG INJ 20%
CHLOROPHYLL POW
CHLOROPHYLL TAB 20MG
CHLOROPHYLL TAB 3MG
CHLOROPHYLLN POW COPPER
CHLOROPROC INJ 2%
CHLOROPROC INJ 3%
CHLOROQUINE POW PHOSPHAT
CHLOROQUINE TAB 250MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
156
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CHLOROQUINE TAB 500MG
CHLOROTHIAZ INJ 500MG
CHLOROTHIAZ TAB 500MG
CHLOROTHIAZI POW
CHLOROXINE POW
CHLOROXYGEN CAP 50MG
CHLOROXYGEN CON 50MG/18
CHLOROXYLEN POW
CHLORPHENIR POW MALEATE
CHLORPROMAZ INJ 25MG/ML
CHLORPROMAZ POW HCL
CHLORPROMAZ TAB 100MG
CHLORPROMAZ TAB 10MG
CHLORPROMAZ TAB 200MG
CHLORPROMAZ TAB 25MG
CHLORPROMAZ TAB 50MG
CHLORPROPAM TAB 100MG
CHLORPROPAM TAB 250MG
CHLORTHALID TAB 100MG
CHLORTHALID TAB 25MG
CHLORTHALID TAB 50MG
1
3
2
3
3
2
2
2
2
1
1
1
1
1
3
3
-
$0 Preventative Drug
$0 Preventative Drug
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
CHLOR-TRIMET SYP 2MG/5ML
3
Non-Preferred Brand
CHLOR-TRIMET TAB 12MG CR
3
Non-Preferred Brand
CHLOR-TRIMET TAB 4MG
CHLORZOXAZON POW
CHLORZOXAZON TAB 500MG
2
3
1
Preferred Brand
Non-Preferred Brand
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
157
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CHO MAG TRIS LIQ 500/5ML
CHO MAG TRIS TAB 1000MG
1
1
Generic
Generic
-
$0 Preventative Drug
2
3
3
3
2
2
2
3
3
3
3
2
2
3
3
2
3
3
3
2
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
CHOICE-OB+ PAK DHA
CHOLECALCIF POW
CHOLEST CARE CAP 500MG
CHOLEST OFF TAB
CHOLESTEROL CAP TRIO
CHOLESTEROL MIS FLAKES
CHOLESTEROL POW
CHOLESTEROL POW ACETATE
CHOLESTEROL TAB CONTROL
CHOLESTERYL POW ACETATE
CHOLESTIN CAP 600MG
CHOLESTOFF CAP 450MG
CHOLESTOFF TAB 450MG
CHOLESTYRAM POW 4GM
CHOLESTYRAM POW 4GM
CHOLESTYRAM POW 4GM LITE
CHOLESTYRAM POW 4GM LITE
CHOLESTYRAMI POW
CHOLETEC INJ
CHOLINE BIT CRY
CHOLINE BIT POW
CHOLINE CAP 648MG
CHOLINE CITR TAB 650MG
CHOLINE DIHY POW CITRATE
CHOLINE MAGN POW TRISALIC
CHOLINE POW CHLORIDE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
158
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CHOLOGRAFIN INJ 52%
CHON SULFATE CAP 150MG
CHONDROITIN CAP COMPLEX
CHONDROITIN POW SULFATE
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
CHOR GONADOT INJ 10000UNT
3
Non-Preferred Brand
CHORIONIC POW GONADOTR
CHROM PICOL TAB 1000MCG
CHROM PICOL TAB 400MCG
CHROM PICOLI CAP 500MCG
CHROMACAPS CAP
2
3
1
3
3
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
-
-
CHROMIC CRY CHLORIDE
3
Non-Preferred Brand
CHROMIUM ASP TAB 1 MG
3
Non-Preferred Brand
CHROMIUM CRY TRIOXIDE
CHROMIUM GTF TAB 200MCG
CHROMIUM K CRY SULF DOD
CHROMIUM PIC CAP 200MCG
CHROMIUM PIC TAB 200MCG
CHROMIUM PIC TAB 400MCG
CHROMIUM PIC TAB 500MCG
CHROMIUM PIC TAB 800MCG
CHROMIUM POW CHLORIDE
CHROMIUM POW PICOLINA
CHROMIUM POW POLYNICO
CHROMIUM POW SULFATE
CHROMIUM TAB 1MG
3
1
3
1
1
1
1
1
3
2
2
3
1
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
CHROMELIN SOL 5%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Not a covered
benefit
YES, Specialty Drug
Not a covered
benefit
-
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
159
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
Preferred Brand
CHST CONGEST TAB PAIN REL
3
Non-Preferred Brand
CHST CONGEST TAB PAIN/SNS
CHYMOTRYPSIN POW ALPHA
CIALIS TAB 10MG
CIALIS TAB 2.5MG
CIALIS TAB 20MG
CIALIS TAB 5MG
CICA-CARE MIS 5"X6"
CICLODAN CRE 0.77%
CICLODAN CRE KIT 0.77%
CICLODAN SOL 8%
1
2
2
2
2
2
3
1
3
1
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
3
Non-Preferred Brand
1
2
1
1
1
1
1
3
1
1
3
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
CHRYSIN POW
CICLODAN SOL KIT 8%
CICLOPIROX GEL 0.77%
CICLOPIROX POW OLAMINE
CICLOPIROX SHA 1%
CICLOPIROX SUS 0.77%
CIDAFLEX TAB 500-400
CIDATRINE TAB 500MG
CIDOFOVIR INJ 75MG/ML
CIDOFOVIR POW ANHYDROU
CILOSTAZOL TAB 100MG
CILOSTAZOL TAB 50MG
CILOXAN OIN 0.3% OP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
10 per 30 days
10 per 30 days
10 per 30 days
10 per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
160
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
CILOXAN SOL 0.3% OP
CIMETIDINE POW
CIMETIDINE SOL 300/5ML
CIMETIDINE TAB 300MG
CIMETIDINE TAB 400MG
CIMETIDINE TAB 800MG
CIMZIA KIT
CIMZIA KIT STARTER
CIMZIA PREFL KIT 200MG/ML
CINAMMN/CHRM CAP 200-1000
CINAMMN/CHRM CAP 50-500
CINNAMON ALA CAP COMPLEX
CINNAMON BRK POW CASSIA
CINNAMON CAP 500MG
CINNAMON OIL
CINNAMON PLS CAP CHROMIUM
CINNAMON TAB 500MG
CINRYZE SOL 500 UNIT
Tier
Formulary Status
3
Non-Preferred Brand
2
1
1
1
1
3
3
3
3
3
3
2
1
2
3
3
3
Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CIPRO (10%) SUS 500MG/5
3
Non-Preferred Brand
CIPRO (5%) SUS 250MG/5
3
Non-Preferred Brand
CIPRO HC SUS OTIC
3
Non-Preferred Brand
CIPRO I.V. INJ 200MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
161
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CIPRO I.V. INJ 400MG
3
Non-Preferred Brand
CIPRO TAB 250MG
3
Non-Preferred Brand
CIPRO TAB 500MG
3
Non-Preferred Brand
CIPRO XR TAB 1000MG
3
Non-Preferred Brand
CIPRO XR TAB 500MG
3
Non-Preferred Brand
2
1
1
1
1
2
2
2
1
1
1
1
1
1
1
1
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
CIPRODEX SUS 0.3-0.1%
CIPROFLOXACN INJ 200MG
CIPROFLOXACN INJ 200MG
CIPROFLOXACN INJ 400MG
CIPROFLOXACN INJ 400MG
CIPROFLOXACN POW
CIPROFLOXACN POW HCL
CIPROFLOXACN SOL 0.2%
CIPROFLOXACN SOL 0.3% OP
CIPROFLOXACN SUS 250MG/5
CIPROFLOXACN SUS 500MG/5
CIPROFLOXACN TAB 1000MG
CIPROFLOXACN TAB 100MG
CIPROFLOXACN TAB 250MG
CIPROFLOXACN TAB 500MG
CIPROFLOXACN TAB 500MG ER
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
162
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CIPROFLOXACN TAB 750MG
CISATRACURIU INJ 10MG/ML
CISATRACURIU INJ 2MG/ML
CISATRACURIU INJ 2MG/ML
CISPLATIN INJ 100MG
CISPLATIN INJ 200MG
CISPLATIN INJ 50/50ML
CISPLATIN POW
CITALOPRAM SOL 10MG/5ML
CITALOPRAM TAB 10MG
CITALOPRAM TAB 20MG
CITALOPRAM TAB 40MG
CITRA PH SOL
CITRACAL CAL CHW GUMMIES
CITRACAL CAL TAB +D SLOW
CITRACAL TAB MAXIMUM
CITRACAL TAB VIT D
CITRACAL TAB VIT D
CITRANATAL MIS 90 DHA
CITRANATAL MIS B-CALM
CITRANATAL PAK ASSURE
CITRANATAL PAK DHA
CITRANATAL TAB RX
CITRIC ACID GRA ANHYDROU
CITRIC ACID GRA MONOHYDR
CITRIC ACID POW ANHYDROU
CITRIC ACID POW MONOHYD
CITRIC ACID/ SOL SOD CITR
CITROCARBONA GRA
1
1
1
1
3
3
3
2
2
2
2
2
2
2
2
2
2
2
1
3
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
-
-
163
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CITROLITH TAB
CITROMA SOL CHERRY
CITRONELLA OIL
CITRUCEL POW ORANGE
3
1
2
2
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
CITRUCEL TAB 500MG
3
Non-Preferred Brand
3
2
3
2
1
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
Generic
Non-Preferred Brand
Non-Preferred Brand
CLAFORAN INJ 10GM
3
Non-Preferred Brand
CLAFORAN INJ 500MG
3
Non-Preferred Brand
CLAFORAN/D5W INJ 1GM
CLAFORAN/D5W INJ 2GM
CLARAVIS CAP 30MG
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
CLARIFOAM EF AER 10-5%
3
Non-Preferred Brand
CLARINEX RDT TAB 2.5MG
3
Non-Preferred Brand
CITRULLINE PAK 200
CITRULLINE POW (L)
CITRULLINE POW 1000
CITRUS BIOFL POW 13%
CL PRENATAL TAB 28-0.8MG
CLA CAP 1000MG
CLA CAP 500-1000
CLADRIBINE INJ 1MG/ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
164
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
CLARINEX RDT TAB 5MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
CLARINEX SYP 0.5MG/ML
3
Non-Preferred Brand
Maximum of 155
per 30 days
3
Non-Preferred Brand
Maximum of 30
per 30 days
CLARINEX-D TAB 2.5-120
3
Non-Preferred Brand
CLARINEX-D TAB 5-240MG
3
Non-Preferred Brand
2
1
1
1
1
1
2
2
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
CLARINEX TAB 5MG
CLARITHROMYC POW
CLARITHROMYC SUS 125/5ML
CLARITHROMYC SUS 250/5ML
CLARITHROMYC TAB 250MG
CLARITHROMYC TAB 500MG
CLARITHROMYC TAB 500MG ER
CLARITIN CAP 10MG
CLARITIN CHW 5MG
CLARITIN RDT TAB 10MG
3
Non-Preferred Brand
CLARITIN RDT TAB 5MG
CLARITIN SYP 5MG/5ML
2
2
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
2
2
1
Preferred Brand
Preferred Brand
Generic
CLARITIN TAB 10MG
CLARITIN-D TAB 10-240MG
CLARITIN-D TAB 5-120MG
CLD & FLU BP TAB 2-325MG
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 60
per 30 days
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
165
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CLD HEAD CNG TAB NIGHTTIM
CLD SINU RLF TAB 30-200MG
CLEAN EYELID PAD PADS
CLEAN SIGHTS SOL
CLEAN ZING LIQ 0.06%
CLEAN&CLEAR CRE 0.5%
CLEAN&CLEAR GEL CLEANSER
CLEAN&CLEAR GEL ERASER
CLEAN&CLEAR GEL MORNING
CLEAN&CLEAR KIT ACNE
CLEAN&CLEAR LOT 2%
CLEAN&CLEAR LOT EXFOLIAT
CLEAN&CLEAR OIN ACNE
CLEAN/DISINF SOL LENS
CLEANS/MASK LIQ 3.5%
CLEANSING CRE SKIN
CLEANSING LIQ WASH
CLEAR AWAY LIQ 17%
CLEAR AWAY PAD ONE STEP
1
1
2
3
3
3
3
3
3
3
1
3
3
1
1
2
1
1
2
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Preferred Brand
CLEAR COUGH LIQ PM
3
Non-Preferred Brand
CLEAR EYES DRO 0.03-0.5
CLEAR EYES DRO COOLING
CLEAR EYES DRO DRY EYES
CLEAR EYES DRO DRY+RED
1
3
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CLEAR EYES DRO RED/RELF
3
Non-Preferred Brand
CLEAR EYES DRO SEASONAL
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
166
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CLEAR EYES DRO TRPL RLF
CLEAR EYES SOL COMPLETE
CLEARBLUE MIS FERTILIT
CLEARBLUE MIS FERTILIT
CLEARBLUE TES OVULATIO
CLEARCANAL KIT EAR WAX
CLEARLAX POW
CLEARLAX POW
CLEMASTINE POW FUMARATE
CLEMASTINE SYP 0.5/5ML
CLEMASTINE TAB 2.68MG
CLEMIZOLE POW HCL
CLENBUTEROL POW HCL
3
3
2
2
2
3
2
2
1
2
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
CLEOCIN CAP 150MG
3
Non-Preferred Brand
CLEOCIN CAP 300MG
3
Non-Preferred Brand
CLEOCIN CAP 75MG
3
Non-Preferred Brand
CLEOCIN CRE 2% VAG
3
Non-Preferred Brand
CLEOCIN PED SOL 75MG/5ML
3
Non-Preferred Brand
CLEOCIN PHOS INJ 300MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
167
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
CLEOCIN PHOS INJ 9GM/60ML
Tier
Formulary Status
3
Non-Preferred Brand
3
Non-Preferred Brand
CLEOCIN/D5W INJ 300MG
3
Non-Preferred Brand
CLEOCIN/D5W INJ 600MG
3
Non-Preferred Brand
CLEOCIN/D5W INJ 900MG
3
Non-Preferred Brand
CLEOCIN-T GEL 1%
3
Non-Preferred Brand
CLEOCIN-T LOT 1%
3
Non-Preferred Brand
CLEOCIN-T PAD 1%
3
Non-Preferred Brand
CLEOCIN-T SOL 1%
3
Non-Preferred Brand
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
CLEOCIN SUP 100MG
CLERZ PLUS SOL
CLEVIPREX EMU 0.5MG/ML
CLIDINIUM POW BROMIDE
CLIMARA DIS 0.025MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
168
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CLIMARA DIS 0.0375MG
3
Non-Preferred Brand
CLIMARA DIS 0.05MG
3
Non-Preferred Brand
CLIMARA DIS 0.06MG
3
Non-Preferred Brand
CLIMARA DIS 0.075MG
3
Non-Preferred Brand
CLIMARA DIS 0.1MG
3
Non-Preferred Brand
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
CLIMARA PRO DIS WEEKLY
CLINDACIN KIT ETZ 1%
CLINDACIN MIS ETZ 1%
CLINDAMAX GEL 1%
CLINDAMAX LOT 10MG/ML
CLINDAMY/BEN GEL 1.2-5%
CLINDAMY/BEN GEL 1-5%
CLINDAMYCIN AER 1%
CLINDAMYCIN CAP 150MG
CLINDAMYCIN CAP 300MG
CLINDAMYCIN CAP 75MG
CLINDAMYCIN CRE 2% VAG
CLINDAMYCIN INJ 150MG/ML
CLINDAMYCIN INJ 150MG/ML
CLINDAMYCIN INJ 150MG/ML
CLINDAMYCIN INJ 150MG/ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
169
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CLINDAMYCIN INJ 150MG/ML
CLINDAMYCIN INJ 150MG/ML
CLINDAMYCIN INJ 300MG
CLINDAMYCIN INJ 600MG
CLINDAMYCIN INJ 900MG
CLINDAMYCIN POW HCL
CLINDAMYCIN POW PHOSPHAT
CLINDAMYCIN SOL 1%
CLINDAMYCIN SOL 75MG/5ML
CLINDESSE CRE 2%
CLINIMIX E INJ 2.75/D10
CLINIMIX E INJ 2.75/D5W
CLINIMIX E INJ 4.25/D10
CLINIMIX E INJ 4.25/D25
CLINIMIX E INJ 4.25/D5W
CLINIMIX E INJ 5%/D15W
CLINIMIX E INJ 5%/D20W
CLINIMIX E INJ 5%/D25W
CLINIMIX INJ 2.75/D5W
CLINIMIX INJ 4.25/D10
CLINIMIX INJ 4.25/D20
CLINIMIX INJ 4.25/D25
CLINIMIX INJ 4.25/D5W
CLINIMIX INJ 5%/D15W
CLINIMIX INJ 5%/D20W
CLINIMIX INJ 5%/D25W
CLINISTIX TES STRIPS
CLINITEST TAB 2 DROP
CLINITEST TAB CHLD RES
1
1
1
1
1
2
2
1
1
3
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
2
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
170
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CLINPRO 5000 PST 1.1%
CLIOQUINOL POW
CLOBETASOL AER 0.05%
CLOBETASOL AER 0.05%
CLOBETASOL CRE 0.05%
CLOBETASOL E CRE 0.05%
CLOBETASOL GEL 0.05%
CLOBETASOL LOT 0.05%
CLOBETASOL OIN 0.05%
CLOBETASOL POW PROPIONA
CLOBETASOL SHA 0.05%
CLOBETASOL SOL 0.05%
1
2
1
1
1
1
1
1
1
2
1
1
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
CLOBEX LOT 0.05%
3
Non-Preferred Brand
CLOBEX SHA 0.05%
3
Non-Preferred Brand
3
3
3
2
2
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CLOBEX SPR 0.05%
CLOCORTOLONE CRE PIV 0.1%
CLODAN KIT 0.05%
CLOFAZIMINE POW
CLOFERA LIQ
CLOFIBRATE POW
CLOLAR INJ 1MG/ML
CLOMIPHENE POW CITRATE
-
-
CLOMIPHENE TAB 50MG
-
-
CLOMIPRAMINE CAP 25MG
1
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Not a covered
benefit
Not a covered
benefit
-
-
-
-
171
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CLOMIPRAMINE CAP 50MG
CLOMIPRAMINE CAP 75MG
CLOMIPRAMINE POW HCL
CLONAZEP ODT TAB 0.125MG
CLONAZEP ODT TAB 0.25MG
CLONAZEP ODT TAB 0.5MG
CLONAZEP ODT TAB 1MG
CLONAZEP ODT TAB 2MG
CLONAZEPAM POW
CLONAZEPAM TAB 0.5MG
CLONAZEPAM TAB 1MG
CLONAZEPAM TAB 2MG
CLONIDINE DIS 0.1/24HR
CLONIDINE DIS 0.2/24HR
CLONIDINE DIS 0.3/24HR
CLONIDINE INJ
CLONIDINE INJ
CLONIDINE POW
CLONIDINE TAB 0.1MG
CLONIDINE TAB 0.1MG ER
CLONIDINE TAB 0.2MG
CLONIDINE TAB 0.3MG
CLOPIDOGREL TAB 300MG
CLOPIDOGREL TAB 75MG
CLOPROSTENOL POW
CLORAZ DIPOT TAB 15MG
CLORAZ DIPOT TAB 3.75MG
CLORAZ DIPOT TAB 7.5MG
CLORPACTIN POW WCS-90
1
1
2
1
1
1
1
1
2
1
1
1
1
1
1
3
3
2
1
1
1
1
1
1
3
1
1
1
2
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
PA after 25
172
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CLORPRES TAB 0.1-15MG
CLORPRES TAB 0.2-15MG
CLORPRES TAB 0.3-15MG
CLORSULON POW
CLOTRIM/BETA CRE 1-0.05%
CLOTRIM/BETA LOT DIPROP
CLOTRIMAZOLE CRE 1%
CLOTRIMAZOLE CRY
CLOTRIMAZOLE LOZ 10MG
CLOTRIMAZOLE POW
CLOTRIMAZOLE SOL 1%
CLOVE OIL
CLOVE POW
CLOVERINE OIN SALVE
CLOZAPINE TAB 100/ODT
CLOZAPINE TAB 100MG
CLOZAPINE TAB 12.5/ODT
CLOZAPINE TAB 200MG
CLOZAPINE TAB 25MG
CLOZAPINE TAB 25MG ODT
CLOZAPINE TAB 50MG
2
2
3
3
1
1
1
2
1
2
1
2
3
2
2
1
2
1
1
2
1
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Generic
CLOZARIL TAB 100MG
3
Non-Preferred Brand
CLOZARIL TAB 25MG
3
Non-Preferred Brand
3
3
Non-Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
CLRSTR PUMP MIS
C-NATE DHA CAP 28-1-200
CNL8 NAIL KIT
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
173
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CNTC CLD/FLU PAK DAY/NGHT
CNTC CLD/FLU TAB DAY/NGHT
CO MONITOR MIS
CO Q 10 CAP 100MG
CO Q 10 CAP 10MG
CO Q 10 CAP 60MG
CO Q-10 CAP 120MG
CO Q-10 CAP 150MG
CO Q-10 CAP 200MG
CO Q-10 CAP 30MG
CO Q-10 CAP 400MG
CO Q-10 CAP 50MG
CO Q-10 CAP 75MG
CO Q-10 CAP L-CARNIT
CO Q-10 CAP VIT E
CO Q-10 PLUS CAP 100-20MG
CO Q-10 PLUS CAP 60-600MG
CO Q-10 TAB
COAGUCHEK KIT XS
COAGUCHEK TES PT
COAGUCHEK TES XS PT
COAL TAR LIQ
COAL TAR MIS
COAL TAR SOL
COAL TAR SOL 20%
COARTEM TAB 20-120MG
COATS ALOE CRE VERA
COATS ALOE GEL VERA
COATS ALOE LIQ LINIMENT
3
3
3
1
1
1
3
1
1
1
1
1
1
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
174
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
COATS ALOE LOT VERA
COBALT POW GLUCONAT
COBAMAMIDE POW
COCA COLA SYP
COCAINE HCL POW
COCAINE HCL SOL 10%
COCAINE HCL SOL 4%
COCAMIDE DEA LIQ
COCAMIDOPROP LIQ HYDROXYS
COCAMIDOPROP LIQ OXIDE
COCOA BUTTER CRE
COCOA BUTTER CRE SKIN
COCOA BUTTER MIS
COCOAMPHODIA LIQ DISODIUM
COCOBETAINE LIQ
COCONUT LIQ FRAGRANC
COCONUT OIL
COCONUT OIL CAP 1000MG
COCONUT OIL CAP FLAXSEED
2
2
2
2
2
2
2
2
3
3
2
1
2
3
3
3
2
1
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
-
-
COD LIVER CHW /VIT D
-
-
COD LIVER CHW PLUS C
-
-
COD LIVER OIL
-
-
CODAR AR LIQ
CODAR D LIQ
CODAR GF LIQ
3
3
1
Non-Preferred Brand
Non-Preferred Brand
Generic
COD LIVER CAP
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
175
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CODEINE POW PHOSPHAT
CODEINE SULF SOL 15MG/2.5
CODEINE SULF TAB 15MG
CODEINE SULF TAB 30MG
CODEINE SULF TAB 60MG
CODITUSS DM SYP
COENZYME Q10 CAP
COENZYME Q10 CAP 30-250MG
COENZYME Q10 CHW 60MG
COENZYME Q10 LIQ 30MG/5ML
COENZYME Q10 POW
COENZYME Q10 TAB 100MG
COENZYME Q10 TAB 15MG
COENZYME Q10 TAB 200MG
COENZYME Q10 TAB 25MG
COENZYME Q10 TAB 50MG
COENZYME Q10 TAB 60MG
CO-ENZYME WAF Q10/E
COFFEE BEAN CAP 400MG
COFFEE FRUIT CAP 400MG
2
3
2
1
1
2
2
1
3
2
2
3
3
2
3
3
1
3
1
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
COGENTIN INJ 1MG/ML
3
Non-Preferred Brand
CO-GESIC TAB 5-500MG
COLA SYP
COLACE CAP 100MG
1
2
2
Generic
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
COLACE CAP 50MG
COLAMINE TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
176
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
COLAZAL CAP 750MG
COLCHICINE POW
COLCRYS TAB 0.6MG
COLD & COUGH LIQ 6.25-2.5
COLD & COUGH SOL 2.5-5/5
COLD & FLU LIQ NIGHTTIM
COLD & FLU TAB SEVERE
COLD & HOT OIN EXT ST
COLD COMPRES KIT MEDIUM
COLD HEAD PAK DAY/NGHT
COLD HEAD TAB CONGESTI
COLD MEDICIN CAP PLUS
COLD MS WARM LIQ NIGHTTIM
COLD PACK MIS DUO
COLD RELIEF TAB COMPLETE
COLD RELIEF TAB PLUS
COLD SORE CRE TREATMNT
COLD SORE LIQ TREATMEN
COLD SYMPTOM TAB RELIEF
COLD THERAPY GEL 3.1%
COLD WRAP MIS REUSABLE
COLD/ALLERGY ELX
COLD/ALLERY SUS CHILD
COLD/CGH DM ELX 2.5-1-5
COLD/COUGH LIQ DAYTIME
COLD/COUGH TAB SINUS PE
COLD/FLU REL CAP DAYTIME
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
2
2
1
1
1
1
1
3
1
1
1
1
3
1
1
3
1
1
3
2
1
1
1
1
1
1
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
177
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
COLD/FLU REL CAP NITETIME
COLD/FLU REL LIQ NIGHT D
COLD/FLU REL PAK DAY/NGHT
COLD/SINUS LIQ MULT SYM
COLD-EEZE GUM 13.3MG
1
1
1
1
3
Generic
Generic
Generic
Generic
Non-Preferred Brand
3
Non-Preferred Brand
COLESTID FLA GRA 5/7.5GM
3
Non-Preferred Brand
COLESTID FLA GRA 5GM
3
Non-Preferred Brand
3
Non-Preferred Brand
1
1
1
3
3
3
2
3
3
3
2
2
2
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
COLD-EEZE LOZ 13.3MG
COLESTID TAB 1GM
COLESTIPOL GRA 5GM
COLESTIPOL GRA 5GM
COLESTIPOL TAB 1GM
COLGATE TOT MIS MINT
COLHIBIN SOL
COLISTIMETH INJ 150MG
COLISTIMETHA POW SODIUM
COLLADERM LOT
COLLAGEN CAP 500MG
COLLAGEN PLU CAP VIT C
COLLAGEN POW HYDROLYS
COLLAGENASE POW
COLLODION LIQ
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
178
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Tier
Formulary Status
2
1
1
Preferred Brand
Generic
Generic
-
-
COLOSTRUM CAP 500MG
COLOX CAP
3
2
Non-Preferred Brand
Preferred Brand
COLY-MYCIN M INJ 150MG
3
Non-Preferred Brand
COLY-MYCIN S SUS OTIC
COMBIGAN SOL 0.2/0.5%
COMBINE ABD PAD 5"X9"
COMBIPATCH DIS .05/.14
COMBIPATCH DIS .05/.25
3
2
2
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
2
Preferred Brand
COMBIVENT AER RESPIMAT
2
Preferred Brand
COMBIVIR TAB 150-300
3
Non-Preferred Brand
YES, Specialty Drug
3
3
3
3
2
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Limited Distribution
Limited Distribution
Limited Distribution
COLLODION LIQ FLEXIBLE
COLLYRIUM SOL
COLOCORT ENE 100MG
COLON FORMUL CAP
COMBIVENT AER
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
COMETRIQ KIT 60MG
COMFEEL PST FILLER
COMFORT CARE PAD HOT/COLD
COMFORT CLEA MIS /SHIELD
WDRx 2/23/15
Maximum of 29.4
gm per 30 days
May be subject to
Quantity Level
Limits
179
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
COMMIT LOZ 2MG MINT
-
-
COMMIT LOZ 4MG MINT
-
-
2
3
2
Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Preferred Brand
COMP AIR MIS COMP/NEB
COMP PRNATAL MIS DHA
COMPAT 14FR MIS 5ML BALL
COMPAT 500ML MIS PUMP SET
COMPAZINE PAK 5MG
3
Non-Preferred Brand
COMPAZINE SUP 25MG
1
Generic
COMPAZINE TAB 10MG
3
Non-Preferred Brand
2
3
Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
-
-
1
3
3
2
1
3
Generic
$0 Preventative Drug
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
COMPL AMINO POW ACID MIX
COMPL PRENAT MIS +DHA
COMPLERA TAB
COMPLETE DRO PEDIATRI
COMPLETE KIT LICE
COMPLETE NAT PAK DHA
COMPLETE SIN TAB RELIEF
COMPLETE TAB PRENATAL
COMPLETENATE CHW
COMPLEX MSD POW JUNIOR
COMPLEX MSUD BAR AMINO AC
COMPOUND 347 LIQ
COMPOUND W AER FREEZE
WDRx 2/23/15
Special Plan Edits
Covered Under
Quitline at 1-800784-8669
Covered Under
Quitline at 1-800784-8669
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
YES, Specialty Drug
-
-
-
-
-
-
-
180
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
3
2
1
1
1
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
3
Non-Preferred Brand
COMTREX CLD/ PAK CGH D/NT
COMTREX COLD TAB /CGH MAX
COMTREX COLD TAB /CGH NT
COMTREX FLU PAK THERAPY
FEMCAP MIS 30MM
CO-NATAL FA TAB 29-1MG
CONCEPT DHA CAP
CONCEPT OB CAP
CONCEPTION KIT
2
2
2
1
2
Preferred Brand
Preferred Brand
Preferred Brand
Generic
$0 ACA Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
CONCEPTIONXR MIS MOTILITY
-
-
FLUARIX QUAD INJ 2013-14
-
$0 ACA Drug
CONCERTA TAB 18MG
3
Non-Preferred Brand
PA after 25
CONCERTA TAB 27MG
3
Non-Preferred Brand
PA after 25
CONCERTA TAB 36MG
3
Non-Preferred Brand
PA after 25
COMPOUND W GEL 17%
COMPOUND W KIT FREEZE
COMPOUND W LIQ 17%
COMPOUND W MIS 40%
COMPOZ CAP 50MG
COMPOZ TAB 50MG
COMPUTER EYE SOL DROPS
COMTAN TAB 200MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
181
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CONCERTA TAB 54MG
3
Non-Preferred Brand
FLULAVAL QUA INJ 2013-14
CONDROLITE TAB
CONDYLOX GEL 0.5%
1
2
$0 ACA Drug
Generic
Preferred Brand
3
Non-Preferred Brand
2
2
2
2
1
3
3
3
3
1
1
1
2
3
1
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
CONZIP CAP 100MG
3
Non-Preferred Brand
CONZIP CAP 200MG
3
Non-Preferred Brand
CONDYLOX SOL 0.5%
CONE/TUBE KIT IRRIGATE
CONEX SOL CLD/ALRG
CONEX TAB 2-60MG
CONGESTAC TAB 60-400MG
CONGESTION TAB 30MG
CONGO RED POW
CONRAY 30 INJ 30%
CONRAY 43 INJ 43%
CONRAY INJ 60%
CONSTANT-CLE LIQ
CONSTULOSE SOL 10GM/15
CONTAC TAB 5-500MG
CONTAINER MIS CLOSER
CONTROL DENT CRE ADHESIVE
CONTROLRX CRE 1.1%
CONVEX EYE MIS PROTECTR
WDRx 2/23/15
Special Plan Edits
PA after 25
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Maximum of 30
per 30 days
182
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
CONZIP CAP 300MG
COOL MIST MIS 1 GALLON
COOL 'N HEAT LIQ 16%
COOL 'N HEAT MIS
COOLING BURN SPR RELIEF
COOLMAGIC MIS
COPA FOAM PAD 3.5"X3"
COPAXONE INJ 40MG/ML
COPAXONE KIT 20MG/ML
COPE TAB 400-30MG
COPEGUS TAB 200MG
COPPER CAPS CAP 2MG
COPPER POW GLUCONAT
COPPER POW GLYCINAT
COPPER POW PEPTIDE
COPPER POW SALICYLA
COPPER SULF CRY
COPPER SULF INJ 0.4MG/ML
COPPER SULF POW PENTAHYD
COPPER TAB 2MG
COPPERMIN TAB 5MG
CO-Q 10 CAP OMEGA-3
COQ-10 CAP 100MG TR
COQ-10 FAST TAB 50MG
COQ-10 FISH CAP OIL
COQ10 GUMMIE CHW 50MG
WDRx 2/23/15
Tier
Formulary Status
Special Plan Edits
3
Non-Preferred Brand
Maximum of 30
per 30 days
2
1
1
1
2
3
3
3
1
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
3
Non-Preferred Brand
3
2
2
2
3
3
2
3
3
3
3
2
3
3
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PA Required
PA Required
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
183
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
COQ10 POW 50GM
COQ10 WAF 100MG
COQ10 WAF 300MG
COQ10 WAF 60MG
COQ10/CARNIT CAP /CARNOSI
COQ10/VIT E WAF
COQ10/VIT E WAF 300MG
CORAL CALCIU CAP
CORAL CALCIU CAP 1000MG
CORAL CALCIU CAP PLUS
CORAL CALCIU TAB 500MG
CORAL CAP CALCIUM
CORAL POW CALCIUM
3
3
3
3
3
3
3
1
3
1
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
COREG CR CAP 10MG
2
Preferred Brand
COREG CR CAP 20MG
2
Preferred Brand
COREG CR CAP 40MG
2
Preferred Brand
COREG CR CAP 80MG
2
Preferred Brand
COREG TAB 12.5MG
3
Non-Preferred Brand
CORDARONE TAB 200MG
CORDRAN 24X3 TAP 4MCG/CM
CORDRAN CRE 0.05%
CORDRAN LOT 0.05%
CORDRAN OIN 0.05%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 60
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
184
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
COREG TAB 25MG
3
Non-Preferred Brand
COREG TAB 3.125MG
3
Non-Preferred Brand
COREG TAB 6.25MG
3
Non-Preferred Brand
1
Generic
CORGARD TAB 20MG
3
Non-Preferred Brand
CORGARD TAB 40MG
3
Non-Preferred Brand
CORGARD TAB 80MG
3
Non-Preferred Brand
3
1
3
2
2
2
2
3
3
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
CORFEN-DM LIQ
CORIANDER OIL
CORICIDIN CAP CONG/CGH
CORICIDIN NT LIQ COLD/CGH
CORICIDIN TAB HBP FLU
CORICIDN HBP MIS MULTI SY
CORICIDN HBP TAB 2-325MG
CORICIDN HBP TAB CGH&COLD
CORICIDN HBP TAB COLD/FLU
CORIFACT KIT
CORLOPAM INJ 10MG/ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
185
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CORLOPAM INJ 10MG/ML
3
Non-Preferred Brand
CORN OIL
CORN STARCH POW
CORN/CALLUS LIQ 12.6%
COROMEGA EMU
COROMEGA EMU OMEGA 3
COROMEGA MIS
CORONA OIN 30%
COROWISE CAP 650MG
CORRECTOL CAP 100MG
CORRECTOL MIS HERBAL
CORTAID SPR 1%
CORTALO GEL 2%
CORTANE-B DRO AQ OTIC
CORTANE-B DRO OTIC
CORTANE-B LOT
2
2
1
3
3
3
3
3
1
3
1
3
2
2
3
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
CORTEF TAB 10MG
3
Non-Preferred Brand
CORTEF TAB 20MG
3
Non-Preferred Brand
CORTEF TAB 5MG
3
Non-Preferred Brand
3
Non-Preferred Brand
1
Generic
CORTENEMA ENE 100MG
CORTICOOL GEL 1%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
186
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CORTICOTROPI POW
CORTIFOAM AER 90MG
CORTISONE AC POW
CORTISONE AC TAB 25MG
CORTISPORIN CRE 0.5%
CORTISPORIN OIN 1%
3
2
2
2
3
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CORTISPORIN SOL 1% OTIC
3
Non-Preferred Brand
CORTIZONE-10 LIQ /ALOE 1%
3
Non-Preferred Brand
CORTROSYN INJ 0.25MG
3
Non-Preferred Brand
CORVERT INJ 1MG/10ML
3
Non-Preferred Brand
1
Generic
CORVITA TAB
-
-
CORVITE TAB
-
-
CORZIDE TAB 40-5MG
3
Non-Preferred Brand
CORZIDE TAB 80-5MG
3
Non-Preferred Brand
1
3
3
2
3
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
CORVITA 150 TAB
COSAMIN DS CAP 500-400
COSMEGEN INJ 0.5MG
COSMETIC MIS ROUNDS
COSMETIC PUF MIS JUMBO
COSMOCIL CQ LIQ
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
187
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
COSOPT PF SOL
COSOPT SOL 2-0.5%OP
COSYNTROPIN INJ 0.25MG
COTAB A TAB 4-10MG
COTAB AX TAB 4-20MG
COTABFLU TAB 20-4-500
COTTON BALLS MIS
COTTON SWABS MIS
COTTONSEED OIL
COUGH & COLD TAB
COUGH D SYP
COUGH DM LIQ 30MG/5ML
COUGH DROPS LOZ 10MG
COUGH DROPS LOZ 2.7MG
COUGH DROPS LOZ 3.1MG
COUGH DROPS LOZ 5.4MG
COUGH DROPS LOZ 5.8MG
COUGH DROPS LOZ 6.1MG
COUGH DROPS LOZ 6.5MG
COUGH DROPS LOZ 7.5MG
COUGH DROPS LOZ 7.6MG
COUGH DROPS LOZ 8.6MG
COUGH DROPS LOZ BLK CHRY
COUGH DROPS LOZ CHERRY
COUGH DROPS LOZ HON LEMN
COUGH DROPS LOZ HON-LEM
COUGH RELIEF LIQ 15MG/5ML
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
3
Non-Preferred Brand
1
3
3
3
3
2
2
1
3
1
1
3
1
1
1
1
1
3
1
1
1
1
1
1
1
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
188
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
COUGH SUPPRE SYP 15MG/5ML
COUGH/COLD LIQ ADULT
COUGH/SORE LOZ THROAT
COUGHTAB TAB 200MG
COUMADIN INJ 5 MG
1
1
3
1
-
Generic
Generic
Non-Preferred Brand
Generic
$0 Preventative Drug
COUMADIN TAB 10MG
3
Non-Preferred Brand
COUMADIN TAB 1MG
3
Non-Preferred Brand
COUMADIN TAB 2.5MG
3
Non-Preferred Brand
COUMADIN TAB 2MG
3
Non-Preferred Brand
COUMADIN TAB 3MG
3
Non-Preferred Brand
COUMADIN TAB 4MG
3
Non-Preferred Brand
COUMADIN TAB 5MG
3
Non-Preferred Brand
COUMADIN TAB 6MG
3
Non-Preferred Brand
COUMADIN TAB 7.5MG
3
Non-Preferred Brand
2
Preferred Brand
COUMARIN POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
189
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
COUNT-A-DOSE MIS
COVARYX HS TAB
COVARYX TAB
2
1
1
Preferred Brand
Generic
Generic
COZAAR TAB 100MG
3
Non-Preferred Brand
COZAAR TAB 25MG
3
Non-Preferred Brand
COZAAR TAB 50MG
3
Non-Preferred Brand
CPB WC LIQ
3
Non-Preferred Brand
C-PLEX CAP
-
-
1
1
3
1
3
1
1
3
2
1
1
3
2
1
1
Generic
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Generic
Generic
CPM/PSE DM DRO
CPM/PSE DRO 0.8-9MG
CRACKED HEEL CRE RELIEF
CRACKED SKIN CRE REPAIR
CRAMP TAB
CRAN CONC CAP 500MG
CRANBERRY CAP
CRANBERRY CAP 1000MG
CRANBERRY CAP 12600MG
CRANBERRY CAP 200MG
CRANBERRY CAP 250MG
CRANBERRY CAP 400MG
CRANBERRY CAP 405MG
CRANBERRY CAP 425MG
CRANBERRY CAP 450MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
190
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CRANBERRY CAP 475MG
CRANBERRY CAP 500MG
CRANBERRY CAP 84-20MG
CRANBERRY CAP PLUS C
CRANBERRY CAP SUPER
CRANBERRY CAP VIT C
CRANBERRY CHW SOFT
CRANBERRY POW
CRANBERRY TAB 125MG
CRANBERRY TAB 250MG
CRANBERRY TAB 300MG
CRANBERRY TAB 400MG
CRANBERRY TAB 450MG
CRANBERRY TAB 600MG
CRANBERRY/ CAP VIT C
CRANBERRY/ TAB CHOKEBER
CRANBERRY/ TAB PROBIOTC
CRANBERRY/D3 CAP 4200-500
CREATINE POW
CREATINE POW MONOHYDR
CREATINE5000 PAK 5000MG
CREATININE POW
CREME DE OIL MENTHE
CREOLIN LIQ
CREOMULSION SYP 20/15ML
1
3
1
1
3
3
3
2
3
3
1
1
1
3
3
3
3
3
2
2
3
2
3
3
3
Generic
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CREOMULSION SYP CHILDREN
3
Non-Preferred Brand
2
Preferred Brand
CREON CAP 12000UNT
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
191
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CREON CAP 24000UNT
CREON CAP 3000UNIT
CREON CAP 36000UNT
CREON CAP 6000UNIT
CREOSOTE LIQ
CREO-TERPIN SYP 10/15ML
CRESOL LIQ
CREST 3D MIS WHITENIN
2
2
2
2
3
3
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
CRESTOR TAB 10MG
2
Preferred Brand
CRESTOR TAB 20MG
2
Preferred Brand
CRESTOR TAB 40MG
2
Preferred Brand
CRESTOR TAB 5MG
2
Preferred Brand
3
3
2
2
1
2
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Preferred Brand
-
-
3
1
Non-Preferred Brand
Generic
CRESYLATE SOL 25% OTIC
CR-GTF CAP 200MCG
CRINONE GEL 4% VAG
CRINONE GEL 8% VAG
CRITIC-AID OIN 2%
CRITIC-AID PST BARRIER
CRIXIVAN CAP 200MG
CRIXIVAN CAP 400MG
CRNATAL PAK
CROFAB INJ
C-ROLLA WAF 500MG
CRO-MAN-ZIN TAB 200-5-25
CROMOLYN SOD CON 100/5ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Not a covered
benefit
YES, Specialty Drug
YES, Specialty Drug
-
-
-
-
192
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CROMOLYN SOD NEB 20MG/2ML
CROMOLYN SOD POW
CROMOLYN SOD SOL 4% OP
CROMOLYN SOD SPR 5.2/ACT
CRONO SYR MIS 10ML
CRONO SYR MIS 20ML
CROTON OIL
CR-PLUS TAB 500MCG
2
2
1
1
3
3
2
3
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
-
-
2
Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
CRUSH VIT C LOZ 60MG
CRYOSERV SOL
CRYSELLE-28 TAB 28 TABS
CRYSTAL LAKE LIQ WATER
CU-25 CAP 25MG
CU-5 CAP 5MG
CUBICIN SOL 500MG
CUCUMBER LIQ FRAGRANC
CULTURELLE CAP
CULTURELLE CAP
CULTURELLE CHW DIGESTIV
CULTURELLE CHW KIDS
CULTURELLE PAK KIDS
CUPRI CHLOR POW DIHYDRAT
CUPRIC ACETA POW MONOHYDR
CUPRIC CHLOR INJ 0.4MG/ML
CUPRIC NITRA POW TRIHYDRA
CUPRIC OXIDE POW
CUPRIC SULF POW PENTAHYD
CUPRIMINE CAP 250MG
WDRx 2/23/15
3
3
3
2
3
2
2
3
2
2
2
3
2
3
3
2
2
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
193
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CUPUACU MIS BUTTER
CURAD NON- PAD STICK
CURAD/KIDS MIS TOWELETT
CURAFOAM PAD 4"X5"
CURASOL GEL MIS 4"X4"
CURASORE LIQ 1%
CURCUMIN EXT POW 95%
CURE-ALL CRE
CURECHROME SOL 0.13%
CURITY ABDOM PAD 5"X9"
CURITY ABDOM PAD 7.5"X8"
CURITY ABDOM PAD 8"X10"
CURITY BURN PAD 18"X18"
CURITY COTTN MIS ROLL 1LB
CURITY COVER PAD 3"X3"
CURITY EYE PAD
CURITY GAUZE PAD 2"X2"
CURITY GAUZE PAD 3"X3"
CURITY GAUZE PAD 4"X3"
CURITY GAUZE PAD 4"X3.5"
CURITY NON- MIS AD 9"X16
CURITY PAD 3"X16"
CURITY PAD 3"X8"
CURITY PAD NURSING
CURITY STRIP PAD 3"X8"
CURITY WET PAD 8"X4"
CUROSURF SUS 80MG/ML
CUTAR OIL 7.5%
CUTEMOL CRE
3
3
1
3
2
3
2
1
2
3
3
2
3
3
3
2
2
2
2
3
3
3
3
2
2
2
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
194
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CUTIVATE CRE 0.05%
3
Non-Preferred Brand
CUTIVATE LOT 0.05%
3
Non-Preferred Brand
CUTIVATE OIN 0.005%
3
Non-Preferred Brand
3
1
1
1
1
1
1
1
1
3
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
CVS E OIL OIL 30000UNT
-
-
CVS ECHINACE CAP 400MG
CVS ECZEMA CRE REL 1%
CVS ENEMA ENE DISPOSAB
CVS EYE DRO DROPS
CVS EYE PAD
CVS FIBER CAP 0.52GM
CVS FIBER CHW GUMMIES
CVS FIBER LA TAB 625MG
CVS FIRST KIT AID
1
1
1
2
1
1
1
2
Generic
Generic
$0 Preventative Drug
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
CUVPOSA SOL 1MG/5ML
CVS ADVANCED OIN HEALING
CVS ALCOHOL SOL 70% RUB
CVS B-12 LIQ 1000/15
CVS B-12 TAB 1500MCG
CVS BISMUTH TAB 262MG
CVS CGH/COLD POW NIGHTTIM
CVS DAY/NGHT LIQ COUGH
CVS DIAPER CRE 1-10%
CVS DIURETIC CAP 50MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
195
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CVS FISH OIL CAP 1000MG
CVS FISH OIL CAP 1200MG
CVS FLU/COLD LIQ NIGHTIME
CVS GARLIC TAB 1250MG
CVS GAS RELF CHW 125MG
CVS GAS RELF CHW 80MG
CVS GAS RELF DRO EX ST
CVS GLOVES MIS
CVS GLUCOSAM TAB 200-300
CVS GLUCOSE CHW FRUIT
CVS GLUCOSE CHW TROPICAL
CVS GLUCOSE GEL 40%
CVS GLUCOSE LIQ SHOT
CVS GLYCERIN SUP 2.1GM
CVS HEATING PAD
CVS HEATWRAP MIS
CVS IRON TAB 27MG
CVS IRON TAB 325MG
CVS KETONE TES CARE
CVS LACTASE TAB 3000UNIT
CVS LAXATIVE CHW 15MG
CVS LAXATIVE TAB 25MG
CVS LECITHIN CAP 1200MG
CVS L-LYSINE TAB 500MG
CVS LUBRICNT DRO 0.5% OP
CVS LUTEIN CAP 40MG
CVS LUTEIN CAP 6MG
CVS LYSINE TAB 1000MG
CVS LYSINE TAB 500MG
1
1
1
1
1
1
1
2
2
2
2
1
1
1
2
2
1
1
2
1
1
1
1
1
1
1
1
1
1
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
196
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CVS MINERAL OIL
CVS MSM CAP 1000MG
CVS MUCUS ER TAB 600MG
CVS MUSCLE CRE RUB
CVS NASAL SPR MIST
CVS NATURAL POW FIBER
2
1
1
1
2
1
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
CVS NICOTINE DIS 14MG/24H
-
-
CVS NICOTINE DIS 7MG/24HR
-
-
CVS NICOTINE GUM 2MG CINN
-
-
CVS NICOTINE GUM 4MG CINN
-
-
-
-
-
-
1
Generic
-
-
1
3
1
-
Generic
Non-Preferred Brand
Generic
$0 Preventative Drug
CVS NICOTINE LOZ 2MG
CVS NICOTINE LOZ 4MG MINT
CVS NIGHTTIM LIQ COUGH
CVS NTS DIS STEP 1
CVS OMEGA-3 CAP
CVS PAIN PAD
CVS PERMETHR LOT 1%
CVS PRENATAL CHW GUMMY
WDRx 2/23/15
Special Plan Edits
Covered Under
Quitline at 1-800784-8669
Covered Under
Quitline at 1-800784-8669
Covered Under
Quitline at 1-800784-8669
Covered Under
Quitline at 1-800784-8669
Covered Under
Quitline at 1-800784-8669
Covered Under
Quitline at 1-800784-8669
Covered Under
Quitline at 1-800784-8669
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
197
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CVS PROTECT POW 81-15%
CVS REDNESS DRO RELIEF
CVS SCAR GEL
CVS SELENIUM TAB 200MCG
CVS SENNA TAB 8.6MG
CVS SI/HA/DE TAB 30-500MG
CVS SORE LOZ THROAT
CVS SORE LOZ THROAT
CVS ST JOHNS CAP 150MG
CVS TRIACTIN LIQ CGH/RUN
CVS TRIACTIN LIQ CGH/RUNN
CVS VAGINAL GEL MOISTURI
CVS VALERIAN CAP 450MG
3
1
1
1
1
1
1
1
1
1
1
1
1
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
CVS VIT B-6 TAB 200MG
-
-
CVS VIT D CAP 2000UNIT
-
$0 ACA Drug
CVS VITAMIN LOZ C POPS
-
-
CVS ZINC LOZ 10MG
CYANIDE ANTI KIT PKG UNIT
CYANOCOBAL POW
CYANOCOBALAM CRY
CYANOCOBALAM INJ 1000MCG
CYANOKIT INJ 5GM
CYCLANDELATE POW
1
2
2
2
1
3
2
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
CYCLESSA PAK
CYCLIVERT TAB 25MG
CYCLOBENZAPR CRE 20MG/GM
WDRx 2/23/15
$0 Preventative Drug
2
3
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
-
-
-
-
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
Preferred Brand
Non-Preferred Brand
198
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CYCLOBENZAPR CRE 5% KIT
CYCLOBENZAPR KIT COMFORT
CYCLOBENZAPR POW HCL
CYCLOBENZAPR TAB 10MG
CYCLOBENZAPR TAB 5MG
CYCLOBENZAPR TAB 7.5MG
CYCLODEXTRIN POW ALPHA
CYCLODEXTRIN POW BETA
CYCLOGYL SOL 0.5% OP
3
3
2
1
1
1
3
2
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
CYCLOGYL SOL 1% OP
3
Non-Preferred Brand
CYCLOGYL SOL 2% OP
3
Non-Preferred Brand
2
3
3
1
1
2
3
3
3
3
3
2
2
2
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
CYCLOMETHICO LIQ
CYCLOMYDRIL SOL OP
CYCLOPEN/PEG LIQ /PPG/DIM
CYCLOPENTOL SOL 1% OP
CYCLOPENTOL SOL 2% OP
CYCLOPENTOLA POW HCL
CYCLOPHOSPH CAP 25MG
CYCLOPHOSPH CAP 50MG
CYCLOPHOSPH INJ 1GM
CYCLOPHOSPH INJ 2GM
CYCLOPHOSPH INJ 500MG
CYCLOPHOSPH TAB 25MG
CYCLOPHOSPH TAB 50MG
CYCLOPHOSPHA POW
CYCLOSERINE CAP 250MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
199
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CYCLOSERINE POW
2
Preferred Brand
CYCLOSET TAB 0.8MG
3
Non-Preferred Brand
CYCLOSPORINE CAP 100MG
CYCLOSPORINE CAP 100MG MD
CYCLOSPORINE CAP 25MG
CYCLOSPORINE CAP 25MG MOD
CYCLOSPORINE CAP 50MG MOD
CYCLOSPORINE INJ 50MG/ML
CYCLOSPORINE POW
CYCLOSPORINE SOL MODIFIED
CYDONOL LOT
1
1
1
1
2
1
2
1
1
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Generic
Generic
CYKLOKAPRON INJ 100MG/ML
3
Non-Preferred Brand
CYMBALTA CAP 20MG
3
Non-Preferred Brand
Maximum of 60
per 30 days
CYMBALTA CAP 30MG
3
Non-Preferred Brand
Maximum of 60
per 30 days
CYMBALTA CAP 60MG
3
Non-Preferred Brand
Maximum of 60
per 30 days
1
1
2
3
3
2
3
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
CYPROHEPTAD SYP 2MG/5ML
CYPROHEPTAD TAB 4MG
CYPROHEPTADI POW
CYRAMZA INJ 100/10ML
CYRAMZA INJ 500/50ML
CYSTADANE POW
CYSTAGON CAP 150MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 180
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
Limited Distribution
200
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
3
2
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
CYSTEINE HCL INJ 50MG/ML
3
Non-Preferred Brand
CYSTEX TAB
CYSTINE PAK 500MG
CYSTO-CONRAY INJ II 17.2%
CYSTOGRAFIN INJ 30%
CYSTOGRAFIN- INJ DILUTE
CYSVIEW INJ 100MG
CYTARABINE INJ 100MG
CYTARABINE INJ 100MG/ML
CYTARABINE INJ 20MG/ML
CYTARABINE INJ 20MG/ML
CYTARABINE INJ 500MG
2
2
3
3
3
3
3
3
3
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
CYTO B2 POW
-
-
CYTOGAM INJ
3
Non-Preferred Brand
CYTOMEL TAB 25MCG
3
Non-Preferred Brand
CYTOMEL TAB 50MCG
3
Non-Preferred Brand
CYTOMEL TAB 5MCG
3
Non-Preferred Brand
CYTO-Q LIQ 80MG/10
2
Preferred Brand
CYSTAGON CAP 50MG
CYSTARAN SOL 0.44%
CYSTEAMINE POW
CYSTECH CAP 500MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
-
-
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
201
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
CYTO-Q MAX LIQ 100MG/ML
CYTOSE POW
2
3
Preferred Brand
Non-Preferred Brand
CYTOTEC TAB 100MCG
3
Non-Preferred Brand
CYTOTEC TAB 200MCG
3
Non-Preferred Brand
2
Preferred Brand
CYTOVENE INJ 500MG
3
Non-Preferred Brand
CYTRA K GRA CRYSTALS
CYTRA-3 SYP
CYTRA-K SOL
D 1000 CAP 1000UNIT
D 1000 CHW 1000UNIT
D 1000 PLUS TAB ALOE
D 400 TAB 400UNIT
1
2
1
3
-
Generic
Preferred Brand
Generic
$0 ACA Drug
$0 ACA Drug
Non-Preferred Brand
$0 ACA Drug
D.H.E. 45 INJ 1MG/ML
3
Non-Preferred Brand
D.O.S. CAP 250MG
D10W/NACL INJ 0.2%
D10W/NACL INJ 0.225%
D10W/NACL INJ 0.45%
D2.5W/NACL INJ 0.45%
1
2
2
2
1
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
-
-
-
$0 ACA Drug
$0 ACA Drug
CYTOTINE LIQ
D3 + K2 DOTS TAB
D3 CAP 400UNIT
D3 DOTS TAB 2000UNIT
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
-
-
Maximum of 20,
1mL ampules per
30 days
Not a covered
benefit
202
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Penalty applied if Brand Selected
over Generic
-
-
-
-
Drug Name
Tier
Formulary Status
D3 MAX ST DRO 5000UNIT
D3 MAXIMUM CAP 5000UNIT
D3 TAB 1000UNIT
D3 TAB 2000UNIT
-
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
D3/VITAMIN C TAB /ZINC
-
-
D5W/LR INJ
D5W/LYTES INJ #48
D5W/NACL INJ 0.2%
D5W/NACL INJ 0.225%
D5W/NACL INJ 0.3%
D5W/NACL INJ 0.33%
D5W/NACL INJ 0.45%
D5W/NACL INJ 0.9%
D5W/RINGERS INJ
DACARBAZINE INJ 100MG
DACARBAZINE INJ 200MG
DACARBAZINE POW
1
2
1
2
2
1
1
1
1
3
3
3
Generic
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
DADS MENTHOL LOZ THROAT
DAILY AMINO CHW 6000
DAILY D3 DRO 1000UNIT
DAILY GARLIC TAB 400MG
DAILY MOISTR LOT 1.3%
1
3
1
1
Generic
Non-Preferred Brand
$0 ACA Drug
Generic
Generic
-
-
DAILY MULTI TAB VIT/IRON
-
-
-
-
DAILY MULTIV TAB WOMENS
-
-
-
-
DACOGEN INJ 50MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Not a covered
benefit
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
Not a covered
benefit
203
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DAILY OVULAT KIT PREDICTR
DAIRY AID TAB 9000UNIT
DAIRY DIGES CHW 9000UNIT
DAIRY DIGEST TAB 4500UNIT
DAIRYCARE CAP 15-190MG
DAIRY-RELIEF CHW 3000UNIT
DAKINS SOL 0.125%
DAKINS SOL 0.25%
DAKINS SOL 0.5%
DAKRINA SOL 2.7-2%
D-ALANINE POW
DALIRESP TAB 500MCG
DALLERGY CHW 12.5-5MG
DALLERGY DRO 1-2.5MG
DALLERGY DRO 1-2MG/ML
DALLERGY SYP
DALLERGY TAB 1-5MG
DALLERGY TAB 25-10MG
DALVANCE SOL 500MG
DAMIANA LEAF POW TUR DIFF
D-AMPHETAMIN POW SULFATE
DANAZOL CAP 100MG
DANAZOL CAP 200MG
DANAZOL CAP 50MG
DANAZOL POW
DANDELION POW LEAF
DANTHRON POW
2
1
1
1
3
2
2
2
2
3
3
2
2
3
2
2
3
2
2
3
3
1
1
1
2
3
3
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
204
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DANTRIUM CAP 100MG
3
Non-Preferred Brand
DANTRIUM CAP 25MG
3
Non-Preferred Brand
DANTRIUM CAP 50MG
3
Non-Preferred Brand
DANTRIUM IV INJ 20MG
3
Non-Preferred Brand
2
1
1
2
2
2
2
2
2
1
3
3
3
3
2
1
1
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
$0 ACA Drug
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
DANTROLENE CAP 100MG
DANTROLENE CAP 25MG
DANTROLENE CAP 50MG
DANTROLENE POW
DAPIPRAZOLE POW HCL
DAPSONE POW
DAPSONE TAB 100MG
DAPSONE TAB 25MG
FLUVIRIN INJ 2012-13
DARAPRIM TAB 25MG
DARK TANNING OIL SPF2
DATSCAN SOL
DAUNORUBICIN INJ 20MG
DAUNORUBICIN INJ 5MG/ML
DAUNOXOME INJ 2MG/ML
DAY TIME CAP COLD/FLU
DAY TIME D CAP COLD/FLU
DAY TIME LIQ COUGH
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
205
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
1
3
Generic
Non-Preferred Brand
3
Non-Preferred Brand
DAYQL SINEX CAP 5-325MG
3
Non-Preferred Brand
DAYQUIL SEV LIQ COLD/FLU
1
Generic
DAYQUIL/NYQU LIQ COUGH
3
Non-Preferred Brand
DAY-TIME CAP SINUS
DAYTIME LIQ COLD MED
DAYTIME/ CAP NIGHTTIM
DAYTRANA DIS 10MG/9HR
DAYTRANA DIS 15MG/9HR
DAYTRANA DIS 20MG/9HR
DAYTRANA DIS 30MG/9HR
DC RED 22 POW
DC RED 28 POW
1
3
1
2
2
2
2
2
3
Generic
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
DDAVP INJ 4MCG/ML
3
Non-Preferred Brand
DDAVP SOL 0.01%
3
Non-Preferred Brand
DDAVP SPR 0.01%
3
Non-Preferred Brand
DAY/NITE MIS CLD/FLU
DAY/NYQUIL LIQ SEVERE
DAYPRO TAB 600MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA after 25
PA after 25
PA after 25
PA after 25
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
206
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DDAVP TAB 0.1MG
3
Non-Preferred Brand
DDAVP TAB 0.2MG
3
Non-Preferred Brand
2
2
3
2
1
3
3
3
2
2
2
2
3
1
1
1
2
1
1
3
$0 ACA Drug
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
DDROPS LIQ 2000UNIT
DEANOL LIQ
DEANOL POW BITARTRA
DEBACTEROL SOL 30-50%
DEBROX SOL 6.5% OT
DECARA CAP 25000UNT
DECARA CAP 50000UNT
FLUVIRIN INJ PF 12-13
DE-CHLOR DM LIQ LIQUID
DECITABINE INJ 50MG
DECON-A ELX 2-5MG/5M
DECON-A LIQ DROPS
DECONEX CAP 10-390MG
DECONEX DM CAP
DECONEX DMX TAB
DECONEX IR TAB 10-380MG
DECON-G DRO 2-1-40MG
DECONGESTANT INH NASAL
DECONGESTANT TAB 60MG
DECOREL TAB FORTE PL
DECYL METHYL POW SULFOXID
DEFEROXAMINE INJ 2GM
DEFEROXAMINE INJ 500MG
DEFINITY SUS 1.1MG/ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
-
Limited Distribution
207
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DEHYDROACETA POW SODIUM
DEHYDROCHOLI POW ACID
DEHYDROEPIAN POW MICRO
DEL CLENS GEL
DELAZINC OIN
DELBASE OIN COMPOUND
DELESTROGEN INJ 10MG/ML
3
2
2
2
3
1
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
DELESTROGEN INJ 20MG/ML
3
Non-Preferred Brand
DELESTROGEN INJ 40MG/ML
3
Non-Preferred Brand
DELFLEX-LC/ SOL 1.5% DEX
DELFLEX-LC/ SOL 2.5% DEX
DELFLEX-LC/ SOL 4.25 DEX
DELFLEX-LM SOL 2.5% DEX
DELFLEX-LM/ SOL 4.25 DEX
DELFLEX-SM/ SOL 1.5% DEX
DELFLEX-SM/ SOL 2.5% DEX
DELFLEX-SM/ SOL 4.25 DEX
DELIVRA CRE SR
DELSYM COUGH LOZ 5-5MG
DELSYM LIQ 30MG/5ML
1
2
2
3
3
3
3
3
3
3
2
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
DELTEC COZMO MIS INL PUMP
-
-
DEL-TRAC LOT
DELTUSS DP LIQ 1-30/5ML
DELUXE COMPR MIS HOT/CLD
DELZICOL CAP 400MG
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
208
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DEMADEX TAB 100MG
3
Non-Preferred Brand
DEMADEX TAB 10MG
3
Non-Preferred Brand
DEMADEX TAB 20MG
3
Non-Preferred Brand
DEMADEX TAB 5MG
3
Non-Preferred Brand
1
3
3
2
2
1
1
3
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
DEMAREST CRE DRICORT
DEMAREST PLS GEL
DEMAREST PLS SPR
DEMECARIUM POW BROMIDE
DEMECLOCYCL POW
DEMECLOCYCL TAB 150MG
DEMECLOCYCL TAB 300MG
DEMEROL INJ 100/2ML
DEMEROL INJ 100MG/ML
3
Non-Preferred Brand
DEMEROL INJ 25MG/0.5
3
Non-Preferred Brand
DEMEROL INJ 25MG/ML
3
Non-Preferred Brand
DEMEROL INJ 50MG/ML
3
Non-Preferred Brand
DEMEROL INJ 75MG/1.5
DEMEROL INJ 75MG/ML
3
3
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
209
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DEMEROL TAB 100MG
3
Non-Preferred Brand
DEMEROL TAB 50MG
3
Non-Preferred Brand
DEMSER CAP 250MG
DENATURED SOL ALCOHOL
DENAVIR CRE 1%
DENDRACIN LOT NEURODE
DENDRACIN LOT NEURODE
DENOREX DUAL SHA 1%-3%
DENOREX EXTR SHA 3%
2
2
2
2
2
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
DENOREX THER SHA 2.5%
3
Non-Preferred Brand
3
3
3
3
3
3
3
3
3
3
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
DENTAL BASE GEL
DENTAL FLOSS MIS KIDS
DENTAL NEEDL MIS 25GX21MM
DENTAL NEEDL MIS 25GX32MM
DENTAL NEEDL MIS 27GX21MM
DENTAL NEEDL MIS 27GX32MM
DENTAL NEEDL MIS 30GX12MM
DENTAL NEEDL MIS 30GX21MM
DENTAL NEEDL MIS 30GX32MM
DENTAPAINE GEL
DENTEMP MIS
DENTIVA LOZ
DENTURE TAB
DEOXYCHOLATE POW SODIUM
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
210
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DEOXYCHOLIC POW ACID
DEOXY-D-RIBO POW
2
3
Preferred Brand
Non-Preferred Brand
DEPACON INJ 100MG/ML
3
Non-Preferred Brand
DEPAKENE CAP 250MG
3
Non-Preferred Brand
DEPAKENE SYP 250/5ML
3
Non-Preferred Brand
DEPAKOTE ER TAB 250MG
3
Non-Preferred Brand
DEPAKOTE ER TAB 500MG
3
Non-Preferred Brand
DEPAKOTE SPR CAP 125MG
3
Non-Preferred Brand
DEPAKOTE TAB 125MG DR
3
Non-Preferred Brand
DEPAKOTE TAB 250MG DR
3
Non-Preferred Brand
DEPAKOTE TAB 500MG DR
3
Non-Preferred Brand
DEPEN TITRA TAB 250MG
3
Non-Preferred Brand
-
-
DEPLIN 15 CAP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
211
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DEPLIN 7.5 CAP
-
-
DEPLIN TAB 15MG
-
-
DEPLIN TAB 7.5MG
-
-
DEPOCYT INJ 50MG/5ML
DEPODUR INJ 10MG/ML
DEPODUR INJ 15/1.5ML
DEPO-ESTRADI INJ 5MG/ML
DEPO-MEDROL INJ 20MG/ML
3
3
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
DEPO-MEDROL INJ 40MG/ML
3
Non-Preferred Brand
DEPO-MEDROL INJ 80MG/ML
3
Non-Preferred Brand
DEPO-PROVERA INJ 150MG/ML
$0 Preventative Drug
DEPO-PROVERA INJ 400/ML
DEPO-SQ PROV INJ 104
2
DEPO-TESTOST INJ 100MG/ML
3
Non-Preferred Brand
DEPO-TESTOST INJ 200MG/ML
3
Non-Preferred Brand
3
Non-Preferred Brand
2
Preferred Brand
DEQUASINE TAB
DERMA CIDOL LIQ 2000
WDRx 2/23/15
Preferred Brand
$0 Preventative Drug
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
YES, Specialty Drug
Maximum of 1 per
30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
1 per 3 months
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
212
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DERMACEA ABD PAD 8"X10"
DERMACEA PAD 6"X6.75"
DERMACLOUD CRE
DERMA-G LIQ MILD
DERMAGESIC LIQ
DERMAGESIC LOT
DERMAGRAFT MIS
3
2
2
2
3
2
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
DERMAGRAN OIN HYDROPHI
DERMA-GUARD POW
3
3
Non-Preferred Brand
Non-Preferred Brand
DERMAL WOUND SPR 0.13%
3
Non-Preferred Brand
DERMAMED OIN
DERMANAIL LIQ
1
2
Generic
Preferred Brand
DERMANIC TAB
-
-
2
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
DERMA-SMOOTH OIL /FS BODY
3
Non-Preferred Brand
DERMASORB AF KIT 3-0.5%
DERMASORB HC KIT 2%
DERMASORB TA KIT 0.1%
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
DERMAGRAN OIN
DERMA-PAX LOT 0.5%
DERMA-PAX-HC LOT
DERMAREST CRE ROSACEA
DERMAREST GEL 2%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
213
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
Non-Preferred Brand
DERMASTAT AER 65%
3
Non-Preferred Brand
DERMATOP CRE 0.1%
3
Non-Preferred Brand
DERMATOP OIN 0.1%
3
Non-Preferred Brand
DERMAVIEW II MIS DRESSING
DERMAZENE CRE 1%
DERMAZINC BAR SOAP
DERMAZINC CRE
DERMAZINC DRO SCALP
DERMAZINC SPR
DERMOPLAST AER
2
1
3
2
3
2
2
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
DERMOPLAST AER ANTIBACT
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
DESFERAL INJ 2GM
3
Non-Preferred Brand
DESFERAL INJ 500MG
3
Non-Preferred Brand
2
1
Preferred Brand
Generic
DERMASORB XM KIT 39%
DERMOTIC OIL 0.01%
DESENEX FOOT AER /SNEAKER
DESIPRAMINE POW
DESIPRAMINE TAB 100MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
214
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
1
1
1
1
1
2
2
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
DESLORATADIN TAB 2.5 ODT
1
Generic
DESLORATADIN TAB 5MG
1
Generic
DESLORATADIN TAB 5MG ODT
1
Generic
DESMOPRESSIN INJ 4MCG/ML
DESMOPRESSIN POW ACETATE
DESMOPRESSIN SOL 0.01%
DESMOPRESSIN SPR 0.01%
DESMOPRESSIN SPR 0.01%
DESMOPRESSIN TAB 0.1MG
DESMOPRESSIN TAB 0.2MG
1
2
1
1
1
1
1
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
DESIPRAMINE TAB 10MG
DESIPRAMINE TAB 150MG
DESIPRAMINE TAB 25MG
DESIPRAMINE TAB 50MG
DESIPRAMINE TAB 75MG
DESITIN MAX PST 40%
DESITIN OIN 40%
DESOGEN TAB
DESONATE GEL 0.05%
DESONIDE CRE 0.05%
DESONIDE LOT 0.05%
DESONIDE OIN 0.05%
DESONIDE POW MICRONIZ
WDRx 2/23/15
$0 Preventative Drug
3
1
1
1
2
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
215
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
DESOWEN CRE 0.05%
DESOWEN CRM KIT 0.05%
DESOWEN LOT 0.05%
DESOWEN LOT KIT 0.05%
DESOWEN OIN 0.05%
DESOWEN OINT KIT 0.05%
DESOXIMETAS CRE 0.05%
DESOXIMETAS CRE 0.25%
DESOXIMETAS GEL 0.05%
DESOXIMETAS OIN 0.05%
DESOXIMETAS OIN 0.25%
DESOXIMETASN POW
DESOXYCORTIC POW ACETATE
DESOXYN TAB 5MG
DESPEC DM SYP
DESPEC DM SYP 5-10-100
DESPEC LIQ
DESPEC-DM TAB
DESQUAM-X LIQ 10% WASH
DESQUAM-X LIQ 5% WASH
DETACHOL MIS
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
3
2
1
1
2
1
2
2
Non-Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
2
1
1
2
2
2
2
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
216
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
3
Non-Preferred Brand
DETOX-KIT KIT
3
Non-Preferred Brand
DETROL LA CAP 2MG
3
Non-Preferred Brand
Maximum of30per
30 days
DETROL LA CAP 4MG
3
Non-Preferred Brand
Maximum of30per
30 days
DETROL TAB 1MG
3
Non-Preferred Brand
DETROL TAB 2MG
3
Non-Preferred Brand
DEVILS CLAW POW
DEVROM CHW 200MG
DEWEES CARMI LIQ
DEWITTS TAB 325MG
DEWITTS TAB PILLS
DEX4 CHW 1GM
3
3
3
1
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
1
1
1
1
2
2
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
DEXAMETH PHO INJ 120MG/30
DEXAMETH PHO INJ 20MG/5ML
DEXAMETH PHO INJ 4MG/ML
DEXAMETH PHO SOL 0.1% OP
DEXAMETH SOD POW PHOSPHAT
DEXAMETHASON CON 1MG/ML
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
DETANE GEL 7.5%
DEX4 GLUCOSE LIQ 15GM
Medication must be filled
through US Specialty Care
Pharmacy
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
217
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DEXAMETHASON POW
DEXAMETHASON POW ACETATE
DEXAMETHASON POW ISONICOT
DEXAMETHASON POW MICRONIZ
DEXAMETHASON SOL 0.5/5ML
DEXAMETHASON TAB 0.5MG
DEXAMETHASON TAB 0.75MG
DEXAMETHASON TAB 1.5MG
DEXAMETHASON TAB 1MG
DEXAMETHASON TAB 2MG
DEXAMETHASON TAB 4MG
DEXAMETHASON TAB 6MG
DEXATREX D ELX CF-NASAL
2
2
2
3
2
1
1
1
2
2
1
1
3
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
DEXATRIM MAX POW
-
-
DEXATRIM MAX TAB
-
-
DEXATRIM MAX TAB DAYTIME
-
-
DEXCHLORPHEN POW MALEATE
DEXCHLORPHEN SYP 2MG/5ML
3
2
Non-Preferred Brand
Preferred Brand
DEXEDRINE CAP 10MG CR
3
Non-Preferred Brand
PA after 25
DEXEDRINE CAP 15MG CR
3
Non-Preferred Brand
PA after 25
DEXEDRINE CAP 5MG CR
3
Non-Preferred Brand
PA after 25
DEXEDRINE TAB 10MG
1
Generic
PA after 25
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
218
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
DEXEDRINE TAB 5MG
DEXFERRUM INJ 50MG/ML
1
1
Generic
Generic
PA after 25
DEXILANT CAP 30MG DR
3
Non-Preferred Brand
DEXILANT CAP 60MG DR
3
Non-Preferred Brand
1
1
1
1
1
1
1
3
2
2
2
1
1
2
1
1
1
1
2
2
2
1
2
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
DEXMEDETOMID INJ 200/2ML
DEXMETHYLPH CAP 15MG ER
DEXMETHYLPH CAP 30MG ER
DEXMETHYLPH CAP 40MG ER
DEXMETHYLPH TAB 10MG
DEXMETHYLPH TAB 2.5MG
DEXMETHYLPH TAB 5MG
DEXPAK PAK 10 DAY
DEXPANTHENOL INJ 250MG/ML
DEXPANTHENOL LIQ
DEXPANTHENOL POW
DEXRAZOXANE INJ 250MG
DEXRAZOXANE INJ 500MG
DEXTRAN POW
DEXTROAMPHET CAP 10MG ER
DEXTROAMPHET CAP 15MG ER
DEXTROAMPHET CAP 5MG ER
DEXTROAMPHET SOL 5MG/5ML
DEXTROMETHOR CRY MONOHYDR
DEXTROMETHOR POW HBR
DEXTROSE GRA ANHYDROU
DEXTROSE INJ 10%
DEXTROSE INJ 20%
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
219
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
DEXTROSE INJ 25%
DEXTROSE INJ 30%
DEXTROSE INJ 40%
DEXTROSE INJ 50%
DEXTROSE INJ 70%
DEXTROSE POW
DEXTROSE POW ANHYDROU
DEX-TUSS LIQ 300-10/5
DHA CAP 200MG
DHA OMEGA 3 CAP 100MG
DHEA CAP 10MG
DHEA CAP 25MG
DHEA CAP 50MG
DHEA CRY
DHEA POW
DHEA TAB 10MG
DHEA TAB 25MG
DHEA TAB 50MG
DHS SHA
DHS TAR GEL SHA 0.5%
DHS ZINC SHA 2%
DIAB BAS HLT LOT FOOT
DIAB CRE
FLUZONE HD INJ PF 12-13
FLUZONE INJ INTRADRM
FLUZONE QUAD INJ 13-14
DIABETES TAB TRIO
DIABETIC CAP COLD/FLU
DIABETIC TUS LIQ 200MG/5
WDRx 2/23/15
Tier
Formulary Status
2
1
2
1
1
3
2
2
1
3
3
1
1
3
2
2
1
1
2
2
2
3
1
3
3
1
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
Non-Preferred Brand
Non-Preferred Brand
Generic
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
220
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DIABETIC TUS LIQ COLD/FLU
DIABETIDERM CRE ANTIFUNG
3
3
Non-Preferred Brand
Non-Preferred Brand
-
-
3
3
Non-Preferred Brand
Non-Preferred Brand
-
-
DIALYVITE TAB 3000
-
-
DIALYVITE TAB 5000
-
-
DIALYVITE TAB 800
-
-
DIALYVITE TAB 800/IRON
-
-
DIALYVITE TAB SUPREM D
-
-
-
-
2
Preferred Brand
DIAMOX SEQUE CAP 500MG CR
3
Non-Preferred Brand
DIANEAL PD-2 SOL 1.5% DEX
DIAPER GUARD OIN
DIAPER RASH CRE 10%
DIAPER RASH OIN CREAMY
DIASCREEN 10 MIS
DIASCREEN MIS CONTROL
DIASTAT ACDL GEL 12.5-20
DIASTAT ACDL GEL 5-10MG
3
3
1
1
2
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
DIABETITRIM POW CHOC
DIACETAZOTOL POW
DIAGNOSTIC KIT
DIALYVITE TAB
DIALYVITE/ TAB ZINC
DIAMINOPYRID POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
221
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DIASTAT PED GEL 2.5M GEL
DIASTIX TES STRIPS
3
2
Non-Preferred Brand
Preferred Brand
-
-
1
2
2
2
2
2
2
2
1
1
1
2
2
1
1
2
2
3
2
2
2
2
2
3
3
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
DIATX ZN TAB
DIAZEPAM CON 5MG/ML
DIAZEPAM GEL 10MG
DIAZEPAM GEL 2.5MG
DIAZEPAM GEL 20MG
DIAZEPAM INJ 10MG/2ML
DIAZEPAM INJ 5MG/ML
DIAZEPAM POW
DIAZEPAM SOL 1MG/ML
DIAZEPAM TAB 10MG
DIAZEPAM TAB 2MG
DIAZEPAM TAB 5MG
DIAZOXIDE POW
DIBENZYLINE CAP 10MG
DIBUCAINE OIN 1%
DIBUCAINE OIN 1%
DIBUCAINE POW
DIBUTYL LIQ SQUARATE
DIBUTYL POW SQUARATE
DICEL CD LIQ
DICEL CHW 2-30MG
DICEL DM CHW
DICHLORALPHE POW
DICHLOROACET LIQ
DICHLOROINDO POW SODIUM
DICHLOROPHEN POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
222
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DICKINSONS LIQ WITCH HZ
DICLAZURIL POW
DICLEGIS TAB 10-10MG
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
DICLO/MISOPR TAB 50-0.2MG
1
Generic
DICLO/MISOPR TAB 75-0.2MG
1
Generic
DICLOFEN POT TAB 50MG
DICLOFENAC GEL 3%
DICLOFENAC POW SODIUM
DICLOFENAC SOL 0.1% OP
DICLOFENAC SOL 1.5%
DICLOFENAC TAB 100MG ER
DICLOFENAC TAB 25MG DR
DICLOFENAC TAB 50MG DR
DICLOFENAC TAB 75MG DR
DICLOXACILL CAP 250MG
DICLOXACILL CAP 500MG
DICUMAROL POW
DICYANOIMIDA POW
DICYCLOMINE CAP 10MG
DICYCLOMINE POW
DICYCLOMINE SOL 10MG/5ML
DICYCLOMINE TAB 20MG
DI-DAK-SOL SOL 0.0125%
DIDANOSINE CAP 125MG
DIDANOSINE CAP 200MG
DIDANOSINE CAP 250MG
DIDANOSINE CAP 400MG
1
1
2
1
1
1
1
1
1
1
1
2
3
1
2
2
1
2
3
3
3
3
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 120
per 30 days
Maximum of 120
per 30 days
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
223
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Tier
Formulary Status
DI-DELAMINE GEL
DI-DELAMINE SPR
3
3
Non-Preferred Brand
Non-Preferred Brand
DIDREX TAB 50MG
-
-
DIDRONEL TAB 400MG
3
Non-Preferred Brand
DIENESTROL POW
DIETARY POW FIBER LX
2
1
Preferred Brand
Generic
DIETERS SUPE MIS TEA
-
-
DIETHANOLAMI LIQ
DIETHYL TOLU LIQ 98%
DIETHYLCARB POW CITRATE
DIETHYLENE LIQ MONOETHY
DIETHYLNICOT POW 97%
2
2
3
2
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
DIETHYLPROP TAB 75MG ER
-
-
2
2
Preferred Brand
Preferred Brand
DIFFERIN CRE 0.1%
3
Non-Preferred Brand
PA after 25
DIFFERIN GEL 0.1%
3
Non-Preferred Brand
PA after 25
DIFFERIN GEL 0.3%
3
Non-Preferred Brand
PA after 25
DIFFERIN LOT 0.1%
DIFF-STAT POW
2
3
Preferred Brand
Non-Preferred Brand
PA after 25
DIETHYLPROPI POW HCL
DIETHYLSTILB POW
WDRx 2/23/15
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
224
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DIFICID TAB 200MG
DIFIL-G FORT LIQ 100-100
DIFLORASONE CRE 0.05%
DIFLORASONE POW DIACETAT
3
1
2
3
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
DIFLUCAN SUS 10MG/ML
3
Non-Preferred Brand
DIFLUCAN SUS 40MG/ML
3
Non-Preferred Brand
DIFLUCAN TAB 100MG
3
Non-Preferred Brand
DIFLUCAN TAB 150MG
3
Non-Preferred Brand
DIFLUCAN TAB 200MG
3
Non-Preferred Brand
DIFLUCAN TAB 50MG
3
Non-Preferred Brand
3
1
3
3
1
1
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
DIGEX NF CAP
3
Non-Preferred Brand
DIGIBAR 190 SUS
3
Non-Preferred Brand
DIFLUNISAL POW
DIFLUNISAL TAB 500MG
DI-GEL CHW
DI-GEL SUS
DIGES PROBIO CAP 250MG
DIGESPLEN-PL TAB EC
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
225
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DIGIFAB INJ 40MG
DIGITAL EAR MIS THERMOMT
DIGITAL THER MIS FLEXIBLE
DIGITOXIN POW
DIGOX TAB 0.125MG
DIGOX TAB 0.25MG
DIGOXIN INJ 0.25MG/1
DIGOXIN POW
DIGOXIN SOL 50MCG/ML
DIHYDROCOD/ CAP ASA/CAFF
3
2
3
3
1
1
1
3
2
2
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
DIHYDROERGOT INJ 1MG/ML
1
Generic
DIHYDROERGOT POW MESYLATE
2
Preferred Brand
DIHYDROERGOT SPR 4MG/ML
2
Preferred Brand
DIHYDROTACHY POW
DIHYDROXYACE POW DIMER
DIHYROCODEIN POW BITARTRA
DIHYROTESTOS POW
DIINDOLYLMET POW
DIIODO-L- POW THYRONIN
3
2
3
3
2
2
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
DILACOR XR CAP 240MG/24
3
Non-Preferred Brand
DILANTIN CAP 100MG
3
Non-Preferred Brand
DILANTIN CAP 30MG
2
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 20,
1mL ampules per
30 days
Maximum of 16
mL per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
226
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
DILANTIN CHW 50MG
Tier
Formulary Status
3
Non-Preferred Brand
DILANTIN-125 SUS 125/5ML
3
Non-Preferred Brand
DILATRATE SR CAP 40MG
2
Preferred Brand
DILAUDID INJ 1MG/ML
3
Non-Preferred Brand
DILAUDID INJ 2MG/ML
3
Non-Preferred Brand
DILAUDID INJ 4MG/ML
3
Non-Preferred Brand
DILAUDID LIQ 1MG/ML
3
Non-Preferred Brand
DILAUDID TAB 2MG
3
Non-Preferred Brand
DILAUDID TAB 4MG
3
Non-Preferred Brand
DILAUDID TAB 8MG
3
Non-Preferred Brand
DILAUDID-HP INJ 10MG/ML
3
Non-Preferred Brand
DILAUDID-HP INJ 250MG
DILL WEED OIL
2
3
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
227
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DILTIAZEM CAP 120MG ER
DILTIAZEM CAP 120MG ER
DILTIAZEM CAP 120MG/24
DILTIAZEM CAP 180MG ER
DILTIAZEM CAP 180MG/24
DILTIAZEM CAP 240MG ER
DILTIAZEM CAP 240MG/24
DILTIAZEM CAP 300MG/24
DILTIAZEM CAP 360MG CD
DILTIAZEM CAP 360MG/24
DILTIAZEM CAP 420MG/24
DILTIAZEM CAP 60MG ER
DILTIAZEM CAP 90MG ER
DILTIAZEM ER TAB 180MG
DILTIAZEM ER TAB 240MG
DILTIAZEM ER TAB 300MG
DILTIAZEM ER TAB 360MG
DILTIAZEM ER TAB 420MG
DILTIAZEM INJ 100MG
DILTIAZEM INJ 125/25ML
DILTIAZEM INJ 25MG/5ML
DILTIAZEM INJ 50/10ML
DILTIAZEM POW
DILTIAZEM TAB 120MG
DILTIAZEM TAB 30MG
DILTIAZEM TAB 60MG
DILTIAZEM TAB 90MG
DIMENHYDRIN INJ 50MG/ML
DIMENHYDRIN POW
2
2
2
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
228
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DIMENHYDRIN TAB 50MG
DIMERCAPTOSU POW ACID
DIMETAPP CLD CHW /ALLERGY
DIMETAPP CLD ELX /ALLERGY
1
2
3
2
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
DIMETAPP DM LIQ COLD/CGH
3
Non-Preferred Brand
DIMETAPP MS LIQ COLD/FLU
DIMETAPP SYP CGH/COLD
DIMETH SILOX LIQ HYDROXYA
DIMETHYL POW FUMARATE
DIMETHYL POW SULFONE
DIMETHYL SOL SULFOXID
DIMETHYLACET LIQ
DIMETHYLAMIN LIQ LACTATE
DIMETHYLAMIN POW
DIMETHYLCOCO LIQ OXIDE
DIMETHYLGLYC POW HCL
DIMETHYLGLYO POW 99%
DIMETRIDAZOL POW
DINITROCHLOR CRY 99%
2
2
3
2
2
3
2
3
3
3
3
3
3
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
DINO-LIFE CHW IRON-ZIN
-
-
DI-N-PROPYL POW ISOCINCH
DIOCTO LIQ 50MG/5ML
DIOCTO SYP 60/15ML
DIOCTYL LIQ ADIPATE
DIOSGENIN POW
DIOSMIN POW
3
1
1
3
2
3
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
229
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DIOVAN HCT TAB 160-12.5
3
Non-Preferred Brand
DIOVAN HCT TAB 160-25MG
3
Non-Preferred Brand
DIOVAN HCT TAB 320-12.5
3
Non-Preferred Brand
DIOVAN HCT TAB 320-25MG
3
Non-Preferred Brand
DIOVAN HCT TAB 80/12.5
3
Non-Preferred Brand
DIOVAN TAB 160MG
3
Non-Preferred Brand
DIOVAN TAB 320MG
3
Non-Preferred Brand
DIOVAN TAB 40MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 60
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 60
per 30 days
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
230
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Formulary Status
Special Plan Edits
3
Non-Preferred Brand
Step Therapy
Required,
Maximum of 60
per 30 days
2
3
2
1
1
2
2
3
2
Preferred Brand
$0 ACA Drug
Non-Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
DIPRIVAN INJ 10MG/ML
3
Non-Preferred Brand
DIPROLENE AF CRE 0.05%
3
Non-Preferred Brand
DIPROLENE LOT 0.05%
3
Non-Preferred Brand
DIPROLENE OIN 0.05%
3
Non-Preferred Brand
3
1
2
1
1
Non-Preferred Brand
Generic
Preferred Brand
Generic
Generic
DIOVAN TAB 80MG
DIOXYBENZONE POW
GARDASIL INJ
DIPENTUM CAP 250MG
DIPHEN/ATROP LIQ 2.5/5
DIPHEN/ATROP TAB 2.5MG
DIPHENHYDRAM INJ 50MG/ML
DIPHENHYDRAM POW HCL
DIPHENIDOL POW HCL
DIPHENOXYLAT POW HCL
DIPHENYLCYCL POW
DIPROPYLENE LIQ GLYCOL
DIPYRIDAMOLE INJ 5MG/ML
DIPYRIDAMOLE POW
DIPYRIDAMOLE TAB 25MG
DIPYRIDAMOLE TAB 50MG
WDRx 2/23/15
Tier
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
231
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DIPYRIDAMOLE TAB 75MG
DISCOVISC SOL
DISODIUM LIQ COCAMIDO
DISOPHENOL POW 97%
DISOPHROL TAB 6-120 CR
DISOPYRAMIDE CAP 100MG
DISOPYRAMIDE CAP 150MG
DISOPYRAMIDE POW PHOSPHAT
DISP DOUCHE SOL 0.3% MED
DISP POWER KIT 1.5 VOLT
DISTILLED LIQ WATER
DISULFIRAM POW
DISULFIRAM TAB 250MG
DISULFIRAM TAB 500MG
DITIOCARB POW SODIUM
1
3
3
3
1
1
1
3
1
2
2
2
1
1
3
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
DITROPAN XL TAB 10MG
3
Non-Preferred Brand
DITROPAN XL TAB 15MG
3
Non-Preferred Brand
DITROPAN XL TAB 5MG
3
Non-Preferred Brand
1
1
1
1
1
$0 Preventative Drug
Generic
Generic
Generic
Generic
Generic
DIURIL SUS 250/5ML
DIVALPROEX CAP 125MG
DIVALPROEX TAB 125MG DR
DIVALPROEX TAB 250MG DR
DIVALPROEX TAB 250MG ER
DIVALPROEX TAB 500MG DR
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
232
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DIVALPROEX TAB 500MG ER
DIVIGEL GEL 0.25MG
DIVIGEL GEL 0.5MG
DIVIGEL GEL 1MG/GM
DIVISTA CAP
D-LIMONENE CAP 1GM
DL-METHIONIN POW
DL-PA-500 CAP 500MG
DL-PANTHENOL POW
DL-PHENYLAL POW
DLX PUMP SET MIS 1600ML
DM/CPM/PE DRO
D-MANNOSE POW
DMDM HYDANTO POW
DML FACIAL CRE MOISTURE
DMPS POW
DMSA KIT
DNZ-2 CAP 100MG
DNZ-2 CAP 250MG
DOANS PM TAB EX STR
DOANS TAB 325MG
DOBUTAM/D5W INJ 1MG/ML
DOBUTAM/D5W INJ 2MG/ML
DOBUTAMINE INJ 250MG
DOBUTAMINE POW HCL
DOC OMEGA POW
DOCEFREZ INJ 20MG
DOCEFREZ INJ 80MG
DOCETAXEL INJ 140/7ML
1
2
2
2
3
3
2
3
2
2
2
3
2
3
2
2
3
3
3
2
2
1
1
1
3
3
3
3
3
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
233
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DOCETAXEL INJ 160/16ML
DOCETAXEL INJ 160/8ML
DOCETAXEL INJ 20/0.5ML
DOCETAXEL INJ 20MG/2ML
DOCETAXEL INJ 20MG/ML
DOCETAXEL INJ 80MG/2ML
DOCETAXEL INJ 80MG/4ML
DOCETAXEL INJ 80MG/8ML
DOCOSANOL POW
DOC-Q-LAX TAB 8.6-50MG
DOCUPRENE TAB 100MG
DOCUSATE CAL CAP 240MG
DOCUSATE POW SODIUM
DOCUSOL KIDS ENE 100MG/5M
DOCUSOL MINI ENE
DOCUSOL PLUS ENE 20-283
DODECYLBENZE POW SULFONAT
DODECYLBENZY POW CHLORIDE
DOLGIC PLUS TAB
DOLOGESIC LIQ 30-500MG
DOLOGESIC TAB 30-500MG
DOLOMITE TAB 10GR
2
3
3
2
3
3
3
2
3
1
1
1
2
3
1
1
3
3
3
3
2
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
DOLOPHINE TAB 10MG
3
Non-Preferred Brand
DOLOPHINE TAB 5MG
3
Non-Preferred Brand
2
3
Preferred Brand
Non-Preferred Brand
DOMEBORO POW PACKETS
DOMETUSS-DA LIQ 1-2.5MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
234
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DOMETUSS-DMX LIQ
DONA PAK 1500MG
DONA TAB 375MG
DONA TAB 750MG
DONATUSS DC SYP
DONATUSSIN DRO
1
2
2
1
3
1
Generic
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
DONATUSSIN DRO DM
3
Non-Preferred Brand
DONATUSSIN SYP
DONEPEZIL TAB 10MG
DONEPEZIL TAB 10MG ODT
DONEPEZIL TAB 5MG
DONEPEZIL TAB 5MG ODT
2
1
1
1
1
Preferred Brand
Generic
Generic
Generic
Generic
DONEPEZIL TAB HCL 23MG
1
Generic
DONG QUAI CAP 125-7.5M
DONG QUAI CAP 500MG
3
1
Non-Preferred Brand
Generic
DONNATAL ELX
3
Non-Preferred Brand
DONNATAL TAB
3
Non-Preferred Brand
3
2
2
1
2
1
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
DONNATAL TAB EXTENTAB
DOPAMINE HCL POW
DOPAMINE INJ 160MG/ML
DOPAMINE INJ 40MG/ML
DOPAMINE INJ 80MG/ML
DOPAMINE/D5W INJ 0.8MG/ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
235
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DOPAMINE/D5W INJ 1.6MG/ML
DOPAMINE/D5W INJ 3.2MG/ML
1
1
Generic
Generic
DOPRAM INJ 20MG/ML
3
Non-Preferred Brand
DORAL TAB 15MG
DORIBAX INJ 250MG
DORIBAX INJ 500MG
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
DORYX TAB 150MG
3
Non-Preferred Brand
3
1
1
3
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
3
Non-Preferred Brand
1
3
Generic
Non-Preferred Brand
3
Non-Preferred Brand
3
3
1
3
1
1
1
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Generic
DORYX TAB 200MG
DORZOL/TIMOL SOL 2-0.5%OP
DORZOLAMIDE SOL 2% OP
DOTAREM INJ 50MMOL
DOUBLE-TUSSN LIQ DM
DOUCHE SOL VIN&WATE
DOVER PISTON MIS 60ML SYR
DOVONEX CRE 0.005%
DOW CORNING LIQ 1501 FL
DOW CORNING LIQ 200
DOXAPRAM HCL INJ 20MG/ML
DOXAPRAM HCL POW MONOHYDR
DOXAZOSIN TAB 1MG
DOXAZOSIN TAB 2MG
DOXAZOSIN TAB 4MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
236
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DOXAZOSIN TAB 8MG
DOXEPIN HCL CAP 100MG
DOXEPIN HCL CAP 10MG
DOXEPIN HCL CAP 150MG
DOXEPIN HCL CAP 25MG
DOXEPIN HCL CAP 50MG
DOXEPIN HCL CAP 75MG
DOXEPIN HCL CON 10MG/ML
DOXEPIN HCL POW
DOXERCALCIF CAP 0.5MCG
DOXERCALCIF CAP 1MCG
DOXERCALCIF CAP 2.5MCG
DOXERCALCIF INJ
DOXIL INJ 2MG/ML
DOXORUBICIN INJ 2MG/ML
DOXY 100 INJ 100MG
DOXYCYC MONO CAP 100MG
DOXYCYC MONO CAP 50MG
DOXYCYC MONO TAB 150MG
DOXYCYC MONO TAB 50MG
DOXYCYC MONO TAB 75MG
DOXYCYCL HYC CAP 100MG
DOXYCYCL HYC CAP 50MG
DOXYCYCL HYC TAB 100MG
DOXYCYCL HYC TAB 100MG DR
DOXYCYCL HYC TAB 150MG DR
DOXYCYCL HYC TAB 75MG DR
DOXYCYCLINE CAP 150MG
DOXYCYCLINE CAP 75MG
1
1
1
1
1
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Generic
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
237
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
DOXYCYCLINE POW HYCLATE
DOXYCYCLINE SUS 25MG/5ML
DOXYCYCLINE TAB 20MG
DOXYLAMINE POW SUCCINAT
DOXYTEX LIQ
DPI VERSIFIX LIQ
DPM CRE
DR SMITHS OIN DIAPER
DRAIN COLLEC MIS TO 3"
DRAMAMINE CHW 50MG
DRAMAMINE TAB 25MG
2
1
1
2
2
3
3
2
2
3
1
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
DRAMAMINE TAB 50MG
3
Non-Preferred Brand
DRAX IMAGE KIT DTPA
D-RIBOSE POW
DRI-EAR SOL OTIC
3
2
1
Non-Preferred Brand
Preferred Brand
Generic
DRISDOL CAP 50000UNT
-
-
DRISDOL DRO 8000/ML
-
-
DRITHO-CREME CRE HP 1%
DRIXORAL CAP CGH & ST
2
3
Preferred Brand
Non-Preferred Brand
DRIXORAL CLD TAB /ALLERGY
3
Non-Preferred Brand
3
1
1
1
Non-Preferred Brand
Generic
Generic
Generic
DRIXORAL TAB ALLERGY
DRONABINOL CAP 10MG
DRONABINOL CAP 2.5MG
DRONABINOL CAP 5MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
238
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Drug Name
Tier
Formulary Status
DROPERIDOL INJ 2.5MG/ML
DROPERIDOL POW
DROSPIR/ETHI TAB 3-0.03MG
DROXIA CAP 200MG
DROXIA CAP 300MG
DROXIA CAP 400MG
1
2
2
2
2
Generic
Preferred Brand
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
DRY E-SYNTH TAB 400UNIT
-
-
3
2
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
2
3
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
DUAVEE TAB 0.45-20
2
Preferred Brand
May be subject to
Quantity Level
Limits
DUETACT TAB 30-2MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
DUETACT TAB 30-4MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
DRY MOUTH LIQ RELIEF
DRYMAX AF SYP
DRYMAX AF TAB 15-4-25
DRYSOL SOL 20%
DSS/SOD BENZ POW 85-15%
DT FINGER CA LOT
DUAC GEL 1.2-5%
DUAL ACTION KIT FREEZE
DUAL RELIEF LIQ
DUAL RELIEF LIQ 5-33%
WDRx 2/23/15
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
239
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
DUEXIS TAB 800-26.6
3
Non-Preferred Brand
Maximum of 90
per 30 days
DULCOLAX KIT BOWEL
DULCOLAX MOM SUS MINT
DULCOLAX SUP 10MG
DULCOLAX TAB 5MG EC
2
1
2
2
Preferred Brand
Generic
Preferred Brand
Preferred Brand
DULERA AER 100-5MCG
2
Preferred Brand
DULERA AER 200-5MCG
2
Preferred Brand
DULOXETINE CAP 20MG
1
Generic
DULOXETINE CAP 30MG
1
Generic
DULOXETINE CAP 60MG
1
Generic
DULOXETINE POW HCL
DULSE FLAKES POW
DUOCAINE INJ
DUODERM CGF MIS 2"X4"
DUODERM CGF MIS 4"X5"
DUODERM GEL HYDROACT
DUODERM PST HYDROACT
DUODOTE INJ
DUOFILM SOL 17%
3
3
3
2
3
2
2
3
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
3
Non-Preferred Brand
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
DUONEB SOL
DUOVISC KIT 0.35/0.4
DUOVISC KIT 0.5/0.55
DURAFLEX GEL COMFORT
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 13
gm per 30 days
Maximum of 13
gm per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
240
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
2
Non-Preferred Brand
Preferred Brand
DURAGESIC DIS 100MCG/H
3
Non-Preferred Brand
DURAGESIC DIS 12MCG/HR
3
Non-Preferred Brand
DURAGESIC DIS 25MCG/HR
3
Non-Preferred Brand
DURAGESIC DIS 50MCG/HR
3
Non-Preferred Brand
DURAGESIC DIS 75MCG/HR
3
Non-Preferred Brand
DURAPROXIN DIS 1.25-3%
DURAPROXIN DIS ES
DURASAF MINI KIT SPIN/EPI
DURAVENT DM TAB
DURAVENT PE TAB 10-395MG
DURAXIN CAP
DUREZOL EMU 0.05%
3
3
3
3
3
1
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
DUTOPROL TAB 100-12.5
3
Non-Preferred Brand
DUTOPROL TAB 25-12.5
3
Non-Preferred Brand
DUTOPROL TAB 50-12.5
3
Non-Preferred Brand
D-VI-SOL LIQ 400UNIT
D-VITA LIQ 400UNIT
-
$0 ACA Drug
$0 ACA Drug
DURAFLEX TAB
DURAFLU TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 60
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
-
-
241
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
D-VITAMIN E POW SUCCINAT
D-XYLOSE POW
2
2
Preferred Brand
Preferred Brand
DYAZIDE CAP 37.5-25
3
Non-Preferred Brand
DYCLONINE POW
2
Preferred Brand
DYMISTA SPR 137-50
2
Preferred Brand
DYNACIN TAB 100MG
3
Non-Preferred Brand
DYNACIN TAB 50MG
3
Non-Preferred Brand
DYNACIN TAB 75MG
3
Non-Preferred Brand
DYNE SCRUB SOL 7.5%
1
Generic
DY-O-DERM SOL STAIN
-
-
Not a covered
benefit
-
DYPHYLLINE POW
DYRENIUM CAP 100MG
DYRENIUM CAP 50MG
DYSPORT INJ 500UNIT
E.E.S. 400 TAB 400MG
E.E.S. GRAN SUS 200/5ML
E.S.P. SUS 200-600
2
3
3
3
2
3
1
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
PA Required
YES, Specialty Drug
E/SELENIUM CAP
-
-
E600 CAP 600UNIT
-
-
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
242
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
EAR DRYING DRO 95-5%
EAR PAIN DRO RELIEF
EARIGATE SPR ADULT
EARLOOP MIS MASK
EASY FIBER PAK
EASY FIBER POW
EASY FIBER/ CHW CALCIUM
EASY TOUCH MIS 31GX3/16
EASY TOUCH MIS 32GX1/4"
EASY TOUCH MIS 32GX3/16
EASYGEL GEL 0.4%
1
3
3
3
3
1
1
1
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Generic
-
-
3
3
3
3
1
3
3
1
3
3
1
3
2
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
ECEE PLUS TAB
ECHINACEA CAP 125MG
ECHINACEA CAP 350MG
ECHINACEA CAP 380MG
ECHINACEA CAP 450MG
ECHINACEA CAP 500MG
ECHINACEA CAP 80MG
ECHINACEA CAP EXTRACT
ECHINACEA CAP GLD SEAL
ECHINACEA CAP GLDNSEAL
ECHINACEA CAP PLUS
ECHINACEA TAB 125MG
ECHINACEA TIN
ECHINACEA/ CAP GLD SEAL
ECHINACEA/ LIQ GOLDENSL
ECHINACEA/C CAP 250-250
ECLIPSE NDLE MIS 25GX1.5"
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
243
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
EC-NAPROSYN TAB 375MG
3
Non-Preferred Brand
EC-NAPROSYN TAB 500MG
3
Non-Preferred Brand
ECONAZOLE CRE 1%
ECONAZOLE POW NITRATE
1
2
Generic
Preferred Brand
ECOTRIN M/S TAB 500MG EC
3
Non-Preferred Brand
ECOTRIN TAB 325MG EC
ECOZA AER 1%
E-CREAM CRE 6000UNIT
ECZEMA THRPY KIT CARE
ED A-HIST LIQ 4-10/5ML
ED CHLORPED DRO D
ED CHLORPED LIQ 2MG/ML
ED CYTE F TAB
ED-A-HIST TAB 3-10MG
3
1
3
2
2
2
3
2
$0 ACA Drug
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
EDARBI TAB 40MG
2
Preferred Brand
EDARBI TAB 80MG
2
Preferred Brand
2
Preferred Brand
EDARBYCLOR TAB 40-12.5
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
244
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Step Therapy
Required,
Maximum of 30
per 30 days
EDARBYCLOR TAB 40-25MG
2
Preferred Brand
EDECRIN TAB 25MG
EDETATE ACID POW
EDETATE CALC POW DISODIUM
EDETATE POW DISODIUM
EDETATE POW SODIUM
EDETATE POW TRISODIU
EDEX KIT 10MCG
EDEX KIT 20MCG
EDEX KIT 40MCG
EDLUAR SUB 10MG
EDLUAR SUB 5MG
EDROPHONIUM POW CHLORIDE
ED-SPAZ TAB 0.125MG
EDURANT TAB 25MG
EFFACLAR DUO SOL 5.5%
EFFERDENT PAK PWR CLN
EFFER-K TAB 10MEQ
EFFER-K TAB 20MEQ
EFFER-K TAB 25MEQ EF
EFFERVESCENT POW
EFFERVESCENT TAB COLD RLF
3
2
2
2
2
2
3
3
3
3
3
2
1
3
3
3
3
3
1
3
1
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
3
Non-Preferred Brand
EFFEXOR XR CAP 150MG
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
10 per 30 days
10 per 30 days
10 per 30 days
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
245
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
EFFEXOR XR CAP 37.5MG
3
Non-Preferred Brand
EFFEXOR XR CAP 75MG
3
Non-Preferred Brand
EFFIENT TAB 10MG
EFFIENT TAB 5MG
2
2
Preferred Brand
Preferred Brand
EFUDEX CRE 5%
3
Non-Preferred Brand
2
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
ELDERTONIC ELX
-
-
ELDOPAQUE CRE 2%
-
-
-
-
-
-
ELDOQUIN CRE 4% FORTE
-
-
ELELYSO INJ 200UNIT
ELENZAPATCH DIS 4-1%
3
3
Non-Preferred Brand
Non-Preferred Brand
EGCG POW
EGRIFTA INJ 1MG
EGRIFTA SOL 2MG
ELAPRASE INJ 6MG/3ML
ELDEPRYL CAP 5MG
ELDERBERRY POW MALTODEX
ELDOPAQUE CRE 4% FORTE
ELDOQUIN CRE 2%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
Limited Distribution
Limited Distribution
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
-
-
-
-
Limited Distribution
246
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ELESTAT DRO 0.05%
3
Non-Preferred Brand
ELESTRIN GEL 0.06%
ELIDEL CRE 1%
ELIGARD INJ 22.5MG
ELIGARD INJ 30MG
ELIGARD INJ 45MG
ELIGARD INJ 7.5MG
3
2
3
3
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
2
2
2
3
3
3
3
2
2
3
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
ELIMITE CRE 5%
ELIPHOS TAB 667MG
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
ELITE CA/MG TAB 100-50MG
ELITE CALCIU TAB 150MG
ELITE IRON TAB 15MG
ELITE ZINC CAP 15MG
ELITEK INJ 1.5MG
ELITEK INJ 7.5MG
ELITE-OB TAB
ELIXOPHYLLIN ELX 80/15ML
ELIXSURE GEL CONGEST
ELIXSURE GEL COUGH
ELIXSURE GEL F/P BGUM
ELLA TAB 30MG
ELLIOTTS B INJ
ELM BARK POW
ELMIRON CAP 100MG
WDRx 2/23/15
3
3
2
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
247
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
ELOCON CRE 0.1%
3
Non-Preferred Brand
ELOCON LOT 0.1%
3
Non-Preferred Brand
ELOCON OIN 0.1%
3
Non-Preferred Brand
3
3
3
3
3
3
3
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
ELOXATIN INJ 100MG
3
Non-Preferred Brand
YES, Specialty Drug
ELOXATIN INJ 200MG
3
Non-Preferred Brand
YES, Specialty Drug
ELOXATIN INJ 50MG
3
Non-Preferred Brand
YES, Specialty Drug
3
3
3
3
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
YES, Specialty Drug
ELOCTATE INJ 1000UNIT
ELOCTATE INJ 1500UNIT
ELOCTATE INJ 2000UNIT
ELOCTATE INJ 250UNIT
ELOCTATE INJ 3000UNIT
ELOCTATE INJ 500UNIT
ELOCTATE INJ 750UNIT
ELON NAIL OIN
ELSPAR INJ 10000UNT
ELTA SILVER GEL
ELTA TAR CRE 2%
ELTALITE TAR LOT 10%
EMADINE SOL 0.05% OP
EMCYT CAP 140MG
EMEND CAP 125MG
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
248
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
EMEND CAP 40MG
EMEND CAP 80MG
EMEND PAK 80 & 125
EMEND SOL 150MG
2
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
EMETROL SOL CHERRY
3
Non-Preferred Brand
EMJOI TENS MIS
3
Non-Preferred Brand
EMLA CRE 2.5-2.5%
3
Non-Preferred Brand
EMSAM DIS 12MG/24H
3
Non-Preferred Brand
EMSAM DIS 6MG/24HR
3
Non-Preferred Brand
EMSAM DIS 9MG/24HR
3
Non-Preferred Brand
3
3
2
3
1
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
ENABLEX TAB 15MG
3
Non-Preferred Brand
ENABLEX TAB 7.5MG
3
Non-Preferred Brand
EMTRIVA CAP 200MG
EMTRIVA SOL 10MG/ML
EMU OIL
EMULGADE CM LIQ
EMULSIFIED LIQ OMEGA-3
EMULSIFIX LIQ 205 BASE
EMULSIFYING MIS WAX
EMULSION SB EMU
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
YES, Specialty Drug
YES, Specialty Drug
Maximum of 30
per 30 days
Maximum of 30
per 30 days
249
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ENALAPR/HCTZ TAB 10-25MG
ENALAPR/HCTZ TAB 5-12.5MG
ENALAPRIL POW MALEATE
ENALAPRIL TAB 10MG
ENALAPRIL TAB 2.5MG
ENALAPRIL TAB 20MG
ENALAPRIL TAB 5MG
ENALAPRILAT INJ 1.25/ML
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
GYNOL II GEL 3%
ENDACOF-C LIQ 2-10MG/5
ENDACOF-DM LIQ 2.5-1-5
ENDACON SYP
ENDO DERMAL MIS 10X12.7
ENDO DERMAL MIS 5X5 CM
ENDOCET TAB 10-325MG
ENDOCET TAB 10-650MG
ENDOCET TAB 2.5-325
ENDOCET TAB 5-325MG
ENDOCET TAB 7.5-325
ENDOCET TAB 7.5-500M
ENDODAN TAB
ENDOMETRIN SUP 100MG
ENDRATE INJ 150MG/ML
2
1
3
3
3
1
1
2
3
3
1
1
1
1
1
1
1
2
3
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
ENDUR-ACIN TAB 250MG SR
-
-
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
PA Required
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
-
Penalty applied if Brand Selected
over Generic
-
250
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
ENDUR-ACIN TAB 500MG SR
-
-
Not a covered
benefit
-
-
ENEMA BAG KIT TUBE/24F
ENERGY CHEWS CHW CHOCOLAT
3
3
Non-Preferred Brand
Non-Preferred Brand
-
-
-
-
-
-
-
-
2
Preferred Brand
ENFAMIL GENT POW FUSS/GAS
-
-
-
-
ENFAMIL HUMA POW FORTIFIE
-
-
-
-
2
2
2
2
2
2
2
$0 Preventative Drug
$0 ACA Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
-
-
-
-
-
-
3
1
1
1
1
Non-Preferred Brand
Generic
Generic
Generic
Generic
ENERGY POW BOOSTER
ENFA NUTRAMI CON LIPIL
ENFALYTE SOL
ENFAMIL MIS EXPECTA
HAVRIX INJ 720 UNIT
HAVRIX INJ 100/ML
ENJUVIA TAB 0.3MG
ENJUVIA TAB 0.45MG
ENJUVIA TAB 0.625MG
ENJUVIA TAB 0.9MG
ENJUVIA TAB 1.25MG
ENLON INJ 150/15ML
ENLON-PLUS INJ 10-0.14
ENLYTE CAP
ENNDS TAB 10MG
ENOXAPARIN INJ 100MG/ML
ENOXAPARIN INJ 120/0.8
ENOXAPARIN INJ 150MG/ML
ENOXAPARIN INJ 30/0.3ML
WDRx 2/23/15
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Penalty applied if Brand Selected
over Generic
251
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ENOXAPARIN INJ 300/3ML
ENOXAPARIN INJ 40/0.4ML
ENOXAPARIN INJ 60/0.6ML
ENOXAPARIN INJ 80/0.8ML
ENPRESSE-28 TAB
ENROFLOXACIN POW
ENTACAPONE TAB 200MG
ENTECAVIR TAB 0.5MG
ENTECAVIR TAB 1MG
ENTENSION ST MIS 4 FOOT
1
1
1
1
3
1
3
3
2
Generic
Generic
Generic
Generic
$0 Preventative Drug
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
ENTERAGAM POW 5GM
-
-
ENTEREG CAP 12MG
ENTERO VU POW 13%
ENTERO VU SUS 13%
ENTERO VU SUS 24%
ENTEROCOCCUS POW FAECIUM
ENTEX LQ LIQ
ENTEX PAC KIT
ENTEX T TAB 60-375MG
3
3
3
3
3
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
ENTOCORT EC CAP 3MG/24HR
3
Non-Preferred Brand
ENTRE-B SUS 6-10MG/5
ENTRE-COUGH LIQ
ENTRE-COUGH SUS TANNATE
ENTRE-HIST LIQ 0.938-10
ENTSOL NASAL GEL
ENTSOL NASAL SOL WASH
1
1
2
1
2
3
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
252
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ENTSOL NASAL SPR
ENTYVIO INJ 300MG
ENUCLENE SOL OP
ENULOSE SOL 10GM/15
ENZYMATIC TAB DIGESTAN
E-OIL OIL 24000UNT
EOVIST INJ
EPA/GLA CAP
EPANED SOL 1MG/ML
EPC SKIN CAR KIT STARTER
EPHEDRA POW SINICA
EPHEDRINE POW HCL
EPHEDRINE POW SULFATE
EPHEDRINE SU CAP 25MG
EPHEDRINE SU INJ 50MG/ML
EPHEDRINE TAB 25MG
EPICERAM EMU
EPIDUO GEL 0.1-2.5%
EPIDUR NEEDL MIS 14GX3"
EPIDUR NEEDL MIS 16GX3"
EPIDUR NEEDL MIS 17GX3"
EPIDUR NEEDL MIS 17GX3.5"
EPIDUR NEEDL MIS 17GX5"
EPIDUR NEEDL MIS 17GX7"
EPIDUR NEEDL MIS 17GX8CM
EPIDUR NEEDL MIS 18GX2"
EPIDUR NEEDL MIS 18GX3"
EPIDUR NEEDL MIS 18GX4"
EPIDUR NEEDL MIS 18GX5"
2
2
2
1
3
1
2
3
3
3
3
2
2
2
1
3
3
2
3
3
3
3
3
3
3
3
3
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
PA Required
YES, Specialty Drug
Penalty applied if Brand Selected
over Generic
253
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
EPIDUR NEEDL MIS 18GX8CM
EPIDUR NEEDL MIS 20GX2"
EPIFIX MIS 14MM
EPIFIX MIS 5CMX6CM
EPIFIX MIS 7CMX7CM
EPIFOAM AER 1%
EPINASTINE DRO 0.05%
3
3
3
3
3
3
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
EPINEPHRINE INJ 0.15MG
2
Preferred Brand
EPINEPHRINE INJ 0.1MG/ML
1
Generic
2
Preferred Brand
1
2
3
2
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
EPIPEN-JR INJ 2-PAK
2
Preferred Brand
EPIQUIN MICR CRE 4%
-
-
EPIRUBICIN INJ 200MG
EPIRUBICIN INJ 50/25ML
EPIRUBICIN INJ 50MG
EPISIL LIQ
EPIVIR HBV SOL 5MG/ML
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
EPINEPHRINE INJ 0.3MG
EPINEPHRINE INJ 1MG/ML
EPINEPHRINE POW
EPINEPHRINE POW BASE
EPINEPHRINE POW BITARTRA
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
4 per 12 months
May be subject to
Quantity Level
Limits
Not a covered
benefit
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
254
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
EPIVIR HBV TAB 100MG
3
Non-Preferred Brand
YES, Specialty Drug
EPIVIR SOL 10MG/ML
3
Non-Preferred Brand
YES, Specialty Drug
EPIVIR TAB 150MG
3
Non-Preferred Brand
YES, Specialty Drug
EPIVIR TAB 300MG
3
Non-Preferred Brand
YES, Specialty Drug
1
1
3
3
3
3
3
3
3
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Limited Distribution
Limited Distribution
EPLERENONE TAB 25MG
EPLERENONE TAB 50MG
EPOGEN INJ 10000/ML
EPOGEN INJ 2000/ML
EPOGEN INJ 20000/ML
EPOGEN INJ 3000/ML
EPOGEN INJ 4000/ML
EPOPROSTENOL INJ 0.5MG
EPOPROSTENOL INJ 1.5MG
EPROSART MES TAB 600MG
1
Generic
EPSOM SALT GRA
EPSOM SALT POW
EPZICOM TAB
EQ ASPIRIN TAB 500MG EC
EQ COLD TAB RELIEF
EQ DAYTIME LIQ COLD/FLU
EQ FEMININE SOL DOUCHE
EQ FLU/COLD PAK CONGESTI
3
2
3
1
1
1
1
1
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
WDRx 2/23/15
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Step Therapy
Required,
Maximum of 30
per 30 days
YES, Specialty Drug
255
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
EQ GENTLE DRO 0.3%
EQ HYGIENIC PAD CLEANSNG
EQ LUBRICANT DRO EYE DROP
EQ LUBRICANT LIQ PERSONAL
EQ NITE TIME CAP COLD/FLU
EQ NON-DRY CAP SINUS
EQ SLEEP-AID CAP 25MG
EQ TAMPONS TAM MULTI
EQ TRIACTING LIQ COLD/CGH
EQ TRIACTING LIQ NIGHT TM
EQ TRIACTING SYP COLD/ALL
EQ WART AER REMOVAL
EQL CALCIUM CAP VIT D
EQL COLD/CGH CAP
1
1
1
1
1
1
1
3
1
1
1
3
3
1
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
EQL GUMMIES CHW CHILDRNS
-
-
EQL INFANT DRO DCON/CGH
EQL LICE KIT SOLUTION
EQL MENSTRUA TAB COMPLETE
EQL MSM TAB 1000MG
EQL MSM TAB 1500MG
EQL NATURAL POW FIBER
EQL NONI CAP 250MG
EQL OMEGA 3 CAP 1200MG
EQL OMEGA 3 CAP 1400MG
EQL SAM-E TAB 200MG
EQL TUSSIN LIQ CF
EQL TUSSIN LIQ CGH/COLD
EQL TUSSIN SYP CGH/COLD
3
1
1
1
1
1
1
1
3
1
1
1
1
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
256
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
1
3
2
3
3
3
2
2
3
3
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ERGOCALCIFER CAP 50000UNT
-
-
ERGOCALCIFER POW 40000UNT
-
-
-
-
1
2
3
2
2
3
3
3
3
1
2
3
2
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
EQL VIT D-3 TAB
EQL ZINC TAB 50MG
EQUAGESIC TAB 200-325
EQUALACTIN CHW 625MG
EQUETRO CAP 100MG
EQUETRO CAP 200MG
EQUETRO CAP 300MG
ERAXIS INJ 100MG
ERAXIS INJ 50MG
ERBITUX INJ 100MG
ERBITUX INJ 200MG
ERGOCALCIFRL POW
ERGOLOID MES TAB 1MG ORAL
ERGOLOID POW MESYLATE
ERGOMAR SUB 2MG
ERGONOVINE POW MALEATE
ERGOTAMINE POW TARTRATE
ERIVEDGE CAP 150MG
EROS-CTD MIS
ERTACZO CRE 2%
ERWINAZE INJ 10000UNT
ERY PAD 2%
ERYGEL GEL 2%
ERYPED SUS 400/5ML
ERY-TAB TAB 250MG EC
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
Limited Distribution
Limited Distribution
257
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ERY-TAB TAB 333MG EC
ERY-TAB TAB 500MG EC
ERYTHROCIN INJ 1000MG
ERYTHROCIN INJ 500MG
ERYTHROCIN TAB 250MG
ERYTHROMYCIN GEL /BENZOYL
ERYTHROMYCIN GEL 2%
ERYTHROMYCIN OIN 5MG/GM
ERYTHROMYCIN POW
ERYTHROMYCIN POW BASE
ERYTHROMYCIN POW ESTOLATE
ERYTHROMYCIN POW ETHYLSUC
ERYTHROMYCIN SOL 2%
ERYTHROMYCIN TAB 250MG BS
ERYTHROMYCIN TAB 500MG BS
ESBERITOX CHW
2
3
2
2
2
1
1
1
2
3
2
2
1
2
2
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
ESCAVITE CHW
-
-
ESCAVITE D CHW
-
-
ESCAVITE LQ DRO
-
-
1
1
1
1
Generic
Generic
Generic
Generic
3
Non-Preferred Brand
ESCITALOPRAM SOL 5MG/5ML
ESCITALOPRAM TAB 10MG
ESCITALOPRAM TAB 20MG
ESCITALOPRAM TAB 5MG
ESGIC CAP
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
258
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ESGIC TAB
Tier
Formulary Status
3
Non-Preferred Brand
ESGIC-PLUS CAP
3
Non-Preferred Brand
ESGIC-PLUS TAB
3
Non-Preferred Brand
ESKIMO KIDS LIQ VIT D
ESKIMO-3 CAP 500MG
ESMOLOL HCL INJ 100MG/10
ESOCOR P SUS 30-30-4
3
1
1
3
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
ESOMEPRAZOLE CAP 24.65MG
3
Non-Preferred Brand
ESOMEPRAZOLE CAP 49.3MG
3
Non-Preferred Brand
ESOMEPRAZOLE INJ 20MG
ESOMEPRAZOLE INJ 40MG
ESOPHO-CAT CRE 3%
2
1
3
Preferred Brand
Generic
Non-Preferred Brand
ESOTERICA CRE SENSITIV
-
-
ESPUMIL AER
ESTARYLLA TAB 0.25-35
ESTAZOLAM TAB 1MG
ESTAZOLAM TAB 2MG
2
1
1
Preferred Brand
$0 Preventative Drug
Generic
Generic
-
-
1
1
Generic
Generic
ESTER-C TAB 500MG
ESTRA/NORETH TAB 0.5-0.1
ESTRA/NORETH TAB 1-0.5MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Not a covered
benefit
-
-
Not a covered
benefit
-
-
259
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ESTRACE TAB 0.5MG
3
Non-Preferred Brand
ESTRACE TAB 1MG
3
Non-Preferred Brand
ESTRACE TAB 2MG
3
Non-Preferred Brand
2
1
1
1
1
1
1
1
1
1
2
2
2
2
2
1
1
1
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
ESTRASORB EMU
3
Non-Preferred Brand
ESTRING MIS 2MG
2
Preferred Brand
ESTRACE VAG CRE 0.1MG/GM
ESTRAD VAL INJ 10MG/ML
ESTRAD VAL INJ 200MG/5
ESTRAD VAL INJ 20MG/ML
ESTRADIOL DIS 0.025MG
ESTRADIOL DIS 0.0375MG
ESTRADIOL DIS 0.05MG
ESTRADIOL DIS 0.06MG
ESTRADIOL DIS 0.075MG
ESTRADIOL DIS 0.1MG
ESTRADIOL POW
ESTRADIOL POW BENZOATE
ESTRADIOL POW CYP USP
ESTRADIOL POW MICRONIZ
ESTRADIOL POW VALERATE
ESTRADIOL TAB 0.5MG
ESTRADIOL TAB 1MG
ESTRADIOL TAB 2MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 56
per 30 days
Maximum of 1 per
30 days
260
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ESTRIOL POW
ESTRO SUPPRT TAB ES
ESTROGEL GEL
ESTRONE CRY
ESTRONE POW
ESTROPIPATE POW
ESTROPIPATE TAB 0.75MG
ESTROPIPATE TAB 1.5MG
ESTROPIPATE TAB 3MG
Tier
Formulary Status
3
Non-Preferred Brand
-
-
3
2
2
3
1
1
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
ESTROSTEP FE TAB
1
Generic
ESZOPICLONE TAB 2MG
1
Generic
ESZOPICLONE TAB 3MG
1
Generic
2
3
1
1
2
2
2
3
1
2
1
Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Generic
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
$0 Preventative Drug
ESZOPICLONE TAB 1MG
ETHACRYNIC POW ACID
ETHAMBUTOL POW HCL
ETHAMBUTOL TAB 100MG
ETHAMBUTOL TAB 400MG
ETHAMOLIN INJ 5%
ETHER SOL
ETHINYL POW ESTRADIO
ETHOPROPAZIN POW HCL
ETHOSUXIMIDE CAP 250MG
ETHOSUXIMIDE POW
ETHOSUXIMIDE SOL 250/5ML
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Step Therapy
Required
Step Therapy
Required
Step Therapy
Required
261
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Drug Name
Tier
Formulary Status
ETHOXY LIQ DIGLYCOL
ETHOXYBENZ POW ACID
ETHY ALCOHOL SOL 70% RUB
ETHY ALCOHOL SOL 70% RUB
ETHYL ACETAT SOL
ETHYL ALCOHO SOL 100%
ETHYL ALCOHO SOL 95%
ETHYL CHLOR AER FINE PIN
ETHYL OLEATE LIQ
ETHYL VANILL MIS FLAKES
ETHYLCELLULO POW
ETHYLENEDIAM LIQ 99%
2
3
2
2
2
2
2
2
2
3
3
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
YES, Specialty Drug
2
2
3
1
1
1
1
1
2
1
1
1
2
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
YES, Specialty Drug
ETHYOL INJ 500MG
ETIDRON DISD TAB 200MG
ETIDRON DISD TAB 400MG
ETILEFRINE POW HCL
ETODOLAC CAP 200MG
ETODOLAC CAP 300MG
ETODOLAC ER TAB 400MG
ETODOLAC ER TAB 500MG
ETODOLAC ER TAB 600MG
ETODOLAC POW
ETODOLAC TAB 400MG
ETODOLAC TAB 500MG
ETOMIDATE INJ 2MG/ML
ETOMIDATE POW
ETOPOPHOS INJ 100MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
262
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ETOPOSIDE CAP 50MG
ETOPOSIDE INJ 100/5ML
ETOPOSIDE INJ 20MG/ML
ETOPOSIDE INJ 20MG/ML
ETOPOSIDE POW
EUCALYPTOL LIQ
EUCALYPTUS OIL
EUCALYPTUS OIL
EUCERIN CALM LOT 0.1%
EUCERIN CRE
EUDRAGIT POW S-100
EUFLEXXA INJ 10MG/ML
EUGENOL SOL
EURAX CRE 10%
EURAX LOT 10%
EVAC POW
EVAMIST SPR 1.53MG
EVANS BLUE POW
EVE PRIM OIL CAP 1000MG
EVE PRIM OIL CAP 500MG
EVERYDAY PAD LONG
EVICEL KIT 2ML
EVICEL KIT 5ML
EVISTA TAB 60MG
WDRx 2/23/15
Tier
Formulary Status
3
3
3
3
2
2
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
3
3
2
3
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
2
2
1
1
2
3
3
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
263
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
3
Non-Preferred Brand
Non-Preferred Brand
EVOCLIN AER 1%
3
Non-Preferred Brand
EVOXAC CAP 30MG
3
Non-Preferred Brand
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
EXALGO TAB 12MG
3
Non-Preferred Brand
EXALGO TAB 16MG
3
Non-Preferred Brand
EXALGO TAB 32MG
EXALGO TAB 8MG
EXCEDRIN ES TAB EXPR GEL
EXCEDRIN PM TAB 500-38MG
3
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
EXCEDRIN SIN TAB HEADACHE
3
Non-Preferred Brand
EXCEDRIN TAB BACK/BOD
EXCEDRIN TAB EX ST
EXCEDRIN TNS TAB EXPR GEL
2
3
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
EXCEDRIN TNS TAB HEADACHE
3
Non-Preferred Brand
3
Non-Preferred Brand
EVITHROM SOL 800-1200
EVNG PRIMROS OIL
EVZIO INJ
EXACTA-MED MIS DISPNSER
EXACTUSS LIQ
EXCEL AP MIS 7.5-72%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
264
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
EXEFEN DMX TAB
EXELDERM CRE 1%
EXELDERM SOL 1%
1
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
EXELON CAP 1.5MG
3
Non-Preferred Brand
EXELON CAP 3MG
3
Non-Preferred Brand
EXELON CAP 4.5MG
3
Non-Preferred Brand
EXELON CAP 6MG
3
Non-Preferred Brand
EXELON DIS 13.3/24
2
Preferred Brand
EXELON DIS 4.6MG/24
2
Preferred Brand
EXELON DIS 9.5MG/24
2
Preferred Brand
2
1
1
3
Preferred Brand
Generic
Generic
Non-Preferred Brand
EXFORGE TAB 10-160MG
3
Non-Preferred Brand
EXFORGE TAB 10-320MG
3
Non-Preferred Brand
EXFORGE TAB 5-160MG
3
Non-Preferred Brand
EXFORGE TAB 5-320MG
3
Non-Preferred Brand
EXELON SOL 2MG/ML
EXEMESTANE TAB 25MG
EXFOLIATING OIN MOISTURI
EXFOLIX FOOT BAR SOAP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Maximum of30per
30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
265
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
EXFORGEH/10- TAB 160-12.5
2
Preferred Brand
EXFORGEH/10- TAB 160-25
2
Preferred Brand
EXFORGEH/10- TAB 320-25
2
Preferred Brand
EXFORGEH/5- TAB 160-12.5
2
Preferred Brand
EXFORGEH/5- TAB 160-25
2
Preferred Brand
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
EX-LAX CHW 15MG
3
Non-Preferred Brand
EX-LAX TAB 15MG
EX-LAX TAB MAX ST
EXOCAINE CRE
EXOCAINE PLS CRE 30%
EXODERM BAR
EXODERM LOT 25-1%
EXOTEN-C LOT PAIN REL
EXPAREL INJ 1.3%
2
2
3
1
3
1
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
EXPECTA LIPI CAP 200MG
3
Non-Preferred Brand
EXTAVIA INJ 0.3MG
EXTEND TERM KIT ORAL SYS
3
3
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
EXTINA AER 2%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Limited Distribution
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
266
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
EXTRA-VIRT CAP PLUS DHA
-
$0 Preventative Drug
EXTRESS-30 CAP
-
-
EXTUSSIVE LIQ 100-10/5
1
Generic
EXUVIANCE GEL 2%
-
-
1
1
1
3
2
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
EYEAID IRRIG SOL OP
3
Non-Preferred Brand
EYEGLASS KIT SCREWDRI
EYE-SED SOL OP
EYLEA INJ 2/0.05ML
EZ CAP BAG MIS 1000ML
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
EZ CHAR SUS PELLETS
3
Non-Preferred Brand
3
3
3
1
-
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
$0 Preventative Drug
EYE ALLERGY SOL RELIEF
EYE DROPS DRO
EYE DROPS DRO 0.5-0.9%
EYE OMEGA CAP VIT D-3
EYE STREAM SOL OP
HUMALOG INJ 100/ML
HUMALOG KWIK INJ 100/ML
HUMULIN INJ 70/30
HUMULIN INJ 70/30KWP
E-Z-CAT DRY PAK
E-Z-DISK TAB 700MG
E-Z-DOSE ENE
EZFE 200 CAP 200MG
EZFE FORTE CAP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
Not a covered
benefit
-
-
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
267
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
E-Z-GAS II GRA
E-Z-HD SUS 98%
EZO CUSHIONS MIS LOW HEAV
E-Z-PAQUE SUS 60%
E-Z-PAQUE SUS 96%
E-Z-PASTE CRE 60%
EZ-VAC MIS
FA/B6/B12 TAB
FA-8 CAP 800MCG
FA-8 TAB 0.8MG
FA-B6-B12 TAB
FABB TAB
FABIOR AER 0.1%
FABRAZYME INJ 35MG
FABRAZYME INJ 5MG
FACTIVE TAB 320MG
FALESSA KIT
FAMCICLOVIR POW
FAMCICLOVIR TAB 125MG
FAMCICLOVIR TAB 250MG
FAMCICLOVIR TAB 500MG
FAMOTIDINE INJ 10MG/ML
FAMOTIDINE INJ 10MG/ML
FAMOTIDINE INJ 10MG/ML
FAMOTIDINE INJ 20MG/50M
FAMOTIDINE POW
FAMOTIDINE SUS 40MG/5ML
FAMOTIDINE TAB 40MG
3
3
3
3
3
3
3
3
3
1
1
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
WDRx 2/23/15
3
1
1
1
1
1
1
2
2
1
1
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
Limited Distribution
268
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FAMVIR TAB 125MG
3
Non-Preferred Brand
FAMVIR TAB 250MG
3
Non-Preferred Brand
FAMVIR TAB 500MG
3
Non-Preferred Brand
3
Non-Preferred Brand
FANAPT TAB 10MG
3
Non-Preferred Brand
FANAPT TAB 12MG
3
Non-Preferred Brand
FANAPT TAB 1MG
3
Non-Preferred Brand
FANAPT TAB 2MG
3
Non-Preferred Brand
FANAPT TAB 4MG
3
Non-Preferred Brand
FANAPT TAB 6MG
3
Non-Preferred Brand
FANAPT TAB 8MG
3
Non-Preferred Brand
FARESTON TAB 60MG
2
Preferred Brand
FARXIGA TAB 10MG
2
Preferred Brand
FARXIGA TAB 5MG
2
Preferred Brand
3
1
Non-Preferred Brand
Generic
FANAPT PAK
FASLODEX INJ 250MG
FAST DISSOLV CHW ANTACID
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
YES, Specialty Drug
269
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FAST FREEZE LIQ ROLL-ON
FAST FREEZE SPR PRO STYL
FATHER JOHNS SOL PLUS
FATHER JOHNS SYP 10MG/5ML
FATTIBASE OIN
FATTYBLEND MIS
FAZACLO TAB 100/ODT
FAZACLO TAB 12.5/ODT
FAZACLO TAB 150MG
FAZACLO TAB 200MG
FAZACLO TAB 25MG ODT
FBL KIT CRE 15-4-5%
HUMULIN N INJ U-100KWP
FD&C YELLOW POW #10
FD&C YELLOW POW #6 LAKE
FDC BLUE 1 POW
FDC BLUE 1 POW AL LAKE
FDC BLUE 2 POW
FDC GREEN #3 POW
FDC RED #3 POW
FDC RED #40 POW AL LAKE
FDC RED 40 POW
FDC YELLOW 5 POW
FDC YELLOW 5 POW AL LAKE
FDC YELLOW 6 POW
FDC YELLOW 6 POW AL LAKE
FE 90 PLUS TAB
FE AMMON CIT POW BROWN
FE ASPARTATE TAB
3
3
3
1
2
2
3
3
3
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
270
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FE C PLUS TAB
FE C TAB
FE CAPS/ TAB SOFTENER
FE GLUCONATE POW
FE GLUCONATE TAB 325MG
FE SUCC/AC-C CAP THRE/B12
FE SULFATE POW
FE SULFATE TAB 27MG
FE TABS TAB 325MG EC
FEBROL SOL 325/5ML
FEEDING BAG MIS 1000ML
FEEDING TUBE MIS ATTACHMT
FEIBA NF INJ
FELBAMATE SUS 600/5ML
FELBAMATE TAB 400MG
FELBAMATE TAB 600MG
1
1
3
3
1
2
2
1
1
3
3
3
3
1
1
1
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
FELBATOL SUS 600/5ML
3
Non-Preferred Brand
FELBATOL TAB 400MG
3
Non-Preferred Brand
FELBATOL TAB 600MG
3
Non-Preferred Brand
FELDENE CAP 10MG
3
Non-Preferred Brand
FELDENE CAP 20MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
271
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FELODIPINE TAB 10MG ER
FELODIPINE TAB 2.5MG ER
FELODIPINE TAB 5MG ER
FEM PH GEL
2
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
3
Non-Preferred Brand
-
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
FEMARA TAB 2.5MG
HUMULIN R INJ U-100
HUMULIN R INJ U-500
IPOL INJ INACTIVE
FEMCON FE CHW
FEME GAUZE MIS SLEEVES
Non-Preferred Brand
FEMHRT TAB 0.5-2.5
3
Non-Preferred Brand
FEMINEASE CRE
FEMIRON TAB
3
3
Non-Preferred Brand
Non-Preferred Brand
FEMRING MIS 0.05/24H
3
Non-Preferred Brand
FEMRING MIS 0.1MG/24
3
Non-Preferred Brand
3
3
3
-
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
$0 Preventative Drug
3
FENBENDAZOLE POW
FENESIN DM TAB 15-400MG
FENNEL OIL
FENOFIBRATE CAP 130MG
FENOFIBRATE CAP 134MG
FENOFIBRATE CAP 150MG
FENOFIBRATE CAP 200MG
FENOFIBRATE CAP 43MG
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Maximum of 30
per 30 days
Maximum of 1per
30 days
Maximum of 1per
30 days
272
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
FENOFIBRATE CAP 50MG
FENOFIBRATE CAP 67MG
FENOFIBRATE TAB 145MG
FENOFIBRATE TAB 160MG
FENOFIBRATE TAB 48MG
FENOFIBRATE TAB 54MG
FENOFIBRIC CAP 135MG DR
FENOFIBRIC CAP 45MG DR
FENOFIBRIC TAB 105MG
FENOFIBRIC TAB 35MG
FENOGLIDE TAB 120MG
FENOGLIDE TAB 40MG
FENOLDOPAM INJ 10MG/ML
FENOLDOPAM INJ 20MG/2ML
FENOPROFEN CAP 400MG
FENOPROFEN POW CALCIUM
FENOPROFEN TAB 600MG
FENTANYL CIT INJ 0.05MG/1
FENTANYL DIS 100MCG/H
FENTANYL DIS 12MCG/HR
FENTANYL DIS 25MCG/HR
FENTANYL DIS 50MCG/HR
FENTANYL DIS 75MCG/HR
FENTANYL OT LOZ 1200MCG
FENTANYL OT LOZ 1600MCG
FENTANYL OT LOZ 200MCG
FENTANYL OT LOZ 400MCG
FENTANYL OT LOZ 600MCG
FENTANYL OT LOZ 800MCG
WDRx 2/23/15
Tier
Formulary Status
Special Plan Edits
1
1
3
3
2
1
1
1
1
1
1
1
1
1
1
1
1
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
273
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FENTANYL POW CITRATE
FENTORA TAB 100MCG
FENTORA TAB 200MCG
FENTORA TAB 400MCG
FENTORA TAB 600MCG
FENTORA TAB 800MCG
FENUGREEK CAP 610MG
FENUGREEK CAP BLD SUGR
FEOSOL TAB 200MG
FEOSOL TAB 45MG
FERAHEME INJ 510/17ML
FERATE TAB 28MG
FERGON TAB 240MG
FER-IN-SOL DRO 15MG/ML
FER-IRON DRO 15MG/ML
FERIVA CAP 75-1MG
FERIVAFA CAP
FEROCON CAP
FEROSUL ELX 220/5ML
FERR BISGLYC POW CHELATE
FERRALET 90 TAB
FERRAPLUS 90 TAB
FERRETTS FE CHW 18MG
FERRETTS IPS SOL
FERRETTS TAB 325MG
FERREX 150 CAP 150MG
FERREX 150 CAP FORTE
FERREX 150 CAP PLUS
FERREX 28 TAB
2
2
2
2
2
2
1
2
2
2
2
2
2
3
3
1
1
3
3
2
3
2
1
1
1
2
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
$0 ACA Drug
$0 ACA Drug
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
PA Required
PA Required
PA Required
PA Required
PA Required
274
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FERRIC CHLOR MIS HEXAHYDR
FERRIC CHLOR MIS LUMP
FERRIC FERRO POW CYANIDE
FERRIC GLUCO INJ 12.5MG/M
FERRIC OXIDE POW RED
FERRIC POW CHLORIDE
FERRIC POW SUBSULFA
FERRIC POW SULFATE
FERRIC SUBSU SOL
FERRIMIN 150 TAB
FERRIPROX TAB 500MG
2
3
3
1
3
3
2
2
2
2
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
FERRLECIT INJ 12.5MG/M
3
Non-Preferred Brand
FERROCITE TAB PLUS
FERROGELS FO CAP FORTE
FERRO-PLEX TAB
FERRO-SEQUEL TAB 50MG
FERROSOFERRI POW OXIDE
FERROTRIN CAP
FERROUS FUM TAB 29MG
FERROUS FUMA TAB
FERROUS GLUC TAB 225MG
FERROUS GRA GLUCONAT
FERROUS POW FUMARATE
FERROUS SUL LIQ 220/5ML
FERROUS SULF GRA
FERROUS SULF SYP 300/5ML
FERROUS SULF TAB
1
1
3
3
3
3
3
2
2
2
2
2
2
2
1
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
275
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FERROUS SULF TAB 140MG
FERROUS SULF TAB 324MG EC
FERULIC ACID POW
2
2
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
FETZIMA CAP 120MG
3
Non-Preferred Brand
FETZIMA CAP 20MG
3
Non-Preferred Brand
FETZIMA CAP 40MG
3
Non-Preferred Brand
FETZIMA CAP 80MG
3
Non-Preferred Brand
FETZIMA CAP TITRATIO
FEVER STRIP MIS THERMOME
FEVERALL INF SUP 80MG
FEVERFEW CAP 100MG
FEVERFEW CAP 380MG
FEVERFEW POW
FEXMID TAB 7.5MG
FEXOFENADINE POW
FEXOFENADINE SUS 30MG/5ML
FIBER 7 POW
FIBER CHOICE CHW 1.5GM
FIBER CHW
FIBER DIET TAB
FIBER PLUS CAP CALCIUM
WDRx 2/23/15
3
Non-Preferred Brand
2
2
3
1
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
3
Non-Preferred Brand
3
1
3
3
2
3
1
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 1
Disp Pack (qty 28)
per 12 months per
30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
276
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FIBER THERAP POW 48.57%
FIBER THERAP POW LAXATIVE
FIBER THERAP TAB 500MG
1
1
1
Generic
Generic
Generic
FIBER WEIGHT CHW MANAGEME
-
-
FIBER/D3 CHW 2.5-500
FIBERCHOICE CHW /CALCIUM
3
2
Non-Preferred Brand
Preferred Brand
FIBERCHOICE CHW 2GM
3
Non-Preferred Brand
FIBERCON TAB 625MG
FIBEREX F15 LIQ 15/30ML
FIBRICOR TAB 105MG
FIBRICOR TAB 35MG
FILTER NEEDL MIS 18GX1.5"
FILTER NEEDL MIS 18X1-1/2
FILTER NEEDL MIS 20GX1.5"
FINACEA GEL 15%
FINACEA PLUS KIT
FINASTERIDE CRY
FINASTERIDE POW
2
3
2
2
2
2
2
2
2
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
FINASTERIDE TAB 1MG
-
-
FINASTERIDE TAB 5MG
1
Generic
3
Non-Preferred Brand
3
Non-Preferred Brand
FIORICET CAP
FIORICET CAP CODEINE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
-
-
Not a covered
benefit
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
277
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
FIORICET/COD CAP
FIORINAL CAP
FIORINAL/COD CAP 30MG
FIRAZYR INJ 30MG/3ML
FIRMAGON INJ 120MG
FIRMAGON INJ 80MG
FIRST AID GEL 0.2-2.5%
FIRST AID KIT
FIRST AID OIN ANTIBIOT
FIRST AID SPR
FIRST DUKES SUS MOUTHWSH
FIRST-MARYS SUS MOUTHWSH
FIRST-MOUTHW SUS BLM
FIRST-OMEPRA SUS 2MG/ML
FIRST-TESTOS CRE MC 2%
FIRST-TESTOS OIN 2%
FISH MEAL POW
FISH OIL CAP
FISH OIL CAP + D3
FISH OIL CAP +D3
FISH OIL CAP 1000MG
FISH OIL CAP 1200MG
FISH OIL CAP 1360MG
FISH OIL CAP 150MG
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
3
3
3
3
3
1
1
3
3
2
2
3
3
3
1
1
1
1
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
YES, Specialty Drug
YES, Specialty Drug
278
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
1
3
3
1
3
2
3
3
3
3
3
3
3
3
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
FLAGYL TAB 250MG
3
Non-Preferred Brand
FLAGYL TAB 500MG
3
Non-Preferred Brand
FLAREX SUS 0.1% OP
3
Non-Preferred Brand
FLAVOR PAK CHER-VAN
-
-
FLAVOXATE TAB 100MG
FLAX OIL
1
3
Generic
Non-Preferred Brand
FISH OIL CAP 180MG
FISH OIL CAP 300MG
FISH OIL CAP 306MG
FISH OIL CAP 600MG
FISH OIL CAP 645MG
FISH OIL CAP 875MG
FISH OIL CAP 900MG
FISH OIL CHW 875MG
FISH OIL EXT CAP 870MG
FISH OIL OIL
FISH OIL PLU CAP CO Q-10
FISH OIL/D3 CAP 900-1000
FISH OIL/D3 CHW 184-250
FISH OIL/PHY CAP 450-400
FIXODENT POW XTR HOLD
FLAGYL CAP 375MG
FLAGYL ER TAB 750MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
279
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FLAX OIL CAP XTRA
FLAX SEED CAP 1000MG
FLAX SEED CAP 1300MG
FLAX SEEDS POW
FLAXSEED MIS WHOLE
FLAXSEED OIL CAP 1030MG
FLAXSEED OIL CAP 1200MG
FLEBOGAMMA INJ 10%
FLEBOGAMMA INJ 5%
FLECAINIDE TAB 100MG
FLECAINIDE TAB 150MG
FLECAINIDE TAB 50MG
FLECTOR DIS 1.3%
FLEET BISACO ENE 10/30ML
3
1
1
1
3
3
1
3
3
1
1
1
3
2
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
2
3
2
3
1
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
FLEXERIL TAB 10MG
3
Non-Preferred Brand
FLEXERIL TAB 5MG
3
Non-Preferred Brand
FLEXI JOINT TAB
3
Non-Preferred Brand
FLEET ENE
FLEET LIQUID ENE GLYCERIN
FLEET NATURL ENE CLEANSNG
FLEET OIL ENE
FLEX-ALL GEL ULTRA PL
FLEXALL MAX GEL STRNGTH
FLEXALL PAIN GEL RELIEVNG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
PA Required
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
280
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
Tier
Formulary Status
2
Preferred Brand
FLINTSTONES CHW COMPLETE
-
-
FLINTSTONES CHW GUMMIES
-
-
FLINTSTONES CHW TODDLER
-
-
FLOGEN TAB 250-650
-
-
FLOLAN INJ 0.5MG
3
Non-Preferred Brand
Limited Distribution
FLOLAN INJ 1.5MG
3
Non-Preferred Brand
Limited Distribution
FLOMAX CAP 0.4MG
3
Non-Preferred Brand
FLONASE SPR 0.05%
3
Non-Preferred Brand
FLO-PRED SUS
FLORAJEN CAP ACIDOPHI
FLORANEX GRA
FLORASTOR CAP 250MG
FLORASTOR PAK KIDS
FLORICAL CAP
FLORICAL TAB
3
3
1
2
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
FLOVENT DISK AER 100MCG
2
Preferred Brand
FLEXZAN PAD 2 X 3
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 60
DISP PACK per 30
days
281
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FLOVENT DISK AER 250MCG
2
Preferred Brand
FLOVENT DISK AER 50MCG
2
Preferred Brand
FLOVENT HFA AER 110MCG
2
Preferred Brand
FLOVENT HFA AER 220MCG
2
Preferred Brand
FLOVENT HFA AER 44MCG
2
Preferred Brand
2
2
3
2
2
1
1
1
1
2
1
1
1
1
1
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
$0 ACA Drug
$0 Preventative Drug
Generic
$0 ACA Drug
Preferred Brand
Generic
Generic
Generic
Generic
Generic
FLOW-EZE MIS VENTED
FLOWING VAPR PAD
FLOXURIDINE INJ 0.5GM
FLOXURIDINE POW
FLU & SORE POW THROAT
FLU BP TAB MAX ST
FLU RELIEF TAB
FLU/COLD/CGH POW DAYTIME
KIMONO MICRO MIS THIN
METOPROLOL POW TARTRATE
FLUCAINE SOL 0.25-0.5
M-M-R II INJ LIVE
FLUCONAZOLE POW
FLUCONAZOLE SUS 10MG/ML
FLUCONAZOLE SUS 40MG/ML
FLUCONAZOLE TAB 100MG
FLUCONAZOLE TAB 150MG
FLUCONAZOLE TAB 200MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 60
DISP PACK per 30
days
Maximum of 60
DISP PACK per 30
days
Maximum of 12
gm per 30 days
Maximum of 12
gm per 30 days
Maximum of 12
gm per 30 days
YES, Specialty Drug
282
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Drug Name
Tier
Formulary Status
FLUCONAZOLE TAB 50MG
FLUCONAZOLE/ INJ DEX 200
FLUCONAZOLE/ INJ DEX 400
FLUCONAZOLE/ INJ NACL 100
FLUCONAZOLE/ INJ NACL 200
FLUCONAZOLE/ INJ NACL 400
FLUCYTOSINE CAP 250MG
FLUCYTOSINE CAP 500MG
FLUCYTOSINE POW
1
1
1
2
1
1
1
1
2
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
3
Non-Preferred Brand
YES, Specialty Drug
3
2
1
2
-
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
$0 ACA Drug
YES, Specialty Drug
3
Non-Preferred Brand
1
1
3
2
2
3
1
1
Generic
Generic
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
FLUDARA INJ 50MG
FLUDARABINE INJ 50MG
FLUDROCORT POW ACETATE
FLUDROCORT TAB 0.1MG
FLUID ADMINI MIS LG-BORE
ORTHO FLEX DPR 65MM
FLUMADINE TAB 100MG
FLUMAZENIL INJ 0.5MG/5
FLUMAZENIL INJ 1MG/10ML
FLUMAZENIL POW
ORTHO FLEX DPR 70MM
ORTHO FLEX DPR 75MM
FLUNISOLIDE POW ANHYDR
FLUNISOLIDE SPR 29MCG
FLUNIXIN POW MEGLUMIN
FLUOCIN ACET CRE 0.01%
FLUOCIN ACET CRE 0.025%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Generic Available. Brand copay + the
difference between the brand and the
generic.
283
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FLUOCIN ACET OIL 0.01%
FLUOCIN ACET OIL 0.01% SC
FLUOCIN ACET OIN 0.025%
FLUOCIN ACET SOL 0.01%
FLUOCINOLONE POW ACETONID
FLUOCINONIDE CRE 0.05%
FLUOCINONIDE CRE 0.05%
FLUOCINONIDE CRE 0.1%
FLUOCINONIDE GEL 0.05%
FLUOCINONIDE OIN 0.05%
FLUOCINONIDE POW MICRONIZ
FLUOCINONIDE SOL 0.05%
FLUORABON DRO
1
1
1
1
2
1
1
1
1
1
2
1
-
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
$0 ACA Drug
3
Non-Preferred Brand
2
2
2
2
2
2
1
3
1
Preferred Brand
Preferred Brand
Preferred Brand
$0 ACA Drug
Preferred Brand
Preferred Brand
Preferred Brand
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
Generic
Non-Preferred Brand
Generic
FLUORACAINE SOL OP
FLUOR-A-DAY CHW 0.25MG F
FLUOR-A-DAY CHW 0.5MG F
FLUOR-A-DAY CHW 1MG F
FLUOR-A-DAY DRO 0.125MG
FLUORESCEIN POW
FLUORESCEIN POW SODIUM
FLUORESCITE INJ 10% OP
FLUORIDE CHW 0.25MG F
FLUORIDE CHW 0.5MG F
FLUORIDE CHW 1MG F
FLUORIDEX DD PST SENSITIV
FLUORIDEX GEL SENSITIV
FLUOROMETHOL SUS 0.1% OP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
284
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FLUOROPLEX CRE 1%
FLUOROURACIL CRE 5%
FLUOROURACIL DRO 2%
FLUOROURACIL DRO 5%
FLUOROURACIL INJ 1GM/20ML
FLUOROURACIL POW
FLUOXETINE CAP 10MG
FLUOXETINE CAP 10MG
FLUOXETINE CAP 20MG
FLUOXETINE CAP 20MG
FLUOXETINE CAP 40MG
FLUOXETINE CAP 90MG DR
FLUOXETINE POW HCL
FLUOXETINE SOL 20MG/5ML
FLUOXETINE TAB 10MG
FLUOXETINE TAB 20MG
FLUOXETINE TAB 60MG
FLUOXYMESTER POW
FLUPHENAZ DE INJ 25MG/ML
FLUPHENAZINE CON 5MG/ML
FLUPHENAZINE ELX 2.5/5ML
FLUPHENAZINE INJ 2.5MG/ML
FLUPHENAZINE LIQ DECANOAT
FLUPHENAZINE POW DECANOAT
FLUPHENAZINE POW HCL
FLUPHENAZINE TAB 10MG
FLUPHENAZINE TAB 1MG
FLUPHENAZINE TAB 2.5MG
FLUPHENAZINE TAB 5MG
3
1
1
1
3
2
1
1
2
2
1
2
2
2
3
2
3
1
1
1
1
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
Generic
$0 Preventative Drug
Generic
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
285
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FLURA-DROPS DRO 0.25MG F
FLURA-SAFE SOL
FLURAZEPAM CAP 15MG
FLURAZEPAM CAP 30MG
FLURBIPROFEN POW
FLURBIPROFEN SOL 0.03% OP
FLURBIPROFEN TAB 100MG
FLURBIPROFEN TAB 50MG
3
1
1
2
1
1
1
$0 ACA Drug
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Generic
3
Non-Preferred Brand
FLUSH SYRING INJ 0.9%
FLUTAMIDE CAP 125MG
FLUTICASONE CRE 0.05%
FLUTICASONE LOT 0.05%
FLUTICASONE OIN 0.005%
FLUTICASONE POW PROPIONA
FLUTICASONE SPR 50MCG
FLUVASTATIN CAP 20MG
FLUVASTATIN CAP 40MG
ORTHO FLEX DPR 80MM
PEDVAX HIB INJ
1
1
1
1
1
2
1
-
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
$0 Preventative Drug
$0 Preventative Drug
$0 ACA Drug
$0 ACA Drug
FLUVOXAMINE CAP 100MG ER
1
Generic
FLUVOXAMINE CAP 150MG ER
1
Generic
FLUVOXAMINE TAB 100MG
FLUVOXAMINE TAB 25MG
FLUVOXAMINE TAB 50MG
PNEUMOVAX 23 INJ 25/0.5
1
1
1
-
Generic
Generic
Generic
$0 ACA Drug
FLURESS SOL OP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Maximum of 30
per 30 days
286
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PREVNAR 13 INJ
PULMICORT SUS 1MG/2ML
FLXFLO PATRL MIS PUMP
F-MELT POW
FML FORTE SUS 0.25% OP
2
3
3
$0 ACA Drug
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
FML LIQUIFLM SUS 0.1% OP
3
Non-Preferred Brand
FML OIN 0.1% OP
2
Preferred Brand
FOCALIN TAB 10MG
3
Non-Preferred Brand
PA after 25
FOCALIN TAB 2.5MG
3
Non-Preferred Brand
PA after 25
FOCALIN TAB 5MG
3
Non-Preferred Brand
PA after 25
FOCALIN XR CAP 10MG
2
Preferred Brand
PA after 25
FOCALIN XR CAP 15MG
3
Non-Preferred Brand
PA after 25
FOCALIN XR CAP 20MG
FOCALIN XR CAP 25MG
2
2
Preferred Brand
Preferred Brand
PA after 25
PA after 25
FOCALIN XR CAP 30MG
3
Non-Preferred Brand
PA after 25
FOCALIN XR CAP 35MG
2
Preferred Brand
PA after 25
FOCALIN XR CAP 40MG
3
Non-Preferred Brand
PA after 25
FOCALIN XR CAP 5MG
2
Preferred Brand
PA after 25
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
287
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FOILLE OIN 5-0.1%
3
Non-Preferred Brand
FOLASTIN TAB
-
-
FOLBEE AR TAB
-
-
FOLBEE PLUS TAB
-
-
-
-
-
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
FOLGARD OS TAB
-
-
FOLGARD RX TAB
3
Non-Preferred Brand
2
2
3
3
3
2
2
1
3
3
2
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
$0 ACA Drug
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
FOLBEE PLUS TAB CZ
FOLCAL DHA CAP
FOLCAPS CAP OMEGA 3
FOLET DHA PAK
FOLET ONE CAP 38-1-225
FOLGARD TAB
FOLGARD TAB
FOLIC + B12 TAB
FOLIC ACID CAP 20MG
FOLIC ACID CAP 5MG
FOLIC ACID INJ 5MG/ML
FOLIC ACID POW
FOLIC ACID TAB 1000MCG
FOLIC ACID TAB 400MCG
FOLIC ACID TAB XTRA
FOLINIC-PLUS TAB 4-50-2MG
FOLITAB 500 TAB
FOLIVANE-F CAP
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
288
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FOLIVANE-OB CAP
FOLIVANE-PLS CAP
FOLIVANE-PRX CAP DHA NF
2
-
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
FOLLISTIM AQ INJ 150UNIT
3
Non-Preferred Brand
FOLLISTIM AQ INJ 300UNIT
3
Non-Preferred Brand
FOLLISTIM AQ INJ 600UNIT
3
Non-Preferred Brand
FOLLISTIM AQ INJ 75UNIT
-
-
FOLLISTIM AQ INJ 900UNIT
3
Non-Preferred Brand
FOLOTYN INJ 20MG/ML
FOLOTYN INJ 40MG/2ML
FOLTABS 800 TAB
3
3
1
Non-Preferred Brand
Non-Preferred Brand
Generic
-
-
FOLTANX TAB
-
-
FOLTX TAB
-
-
1
1
1
1
1
2
2
2
2
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
FOLTANX RF CAP
FOMEPIZOLE INJ 1.5GM
FONDAPARINUX SOL 10/0.8
FONDAPARINUX SOL 2.5/0.5
FONDAPARINUX SOL 5.0/0.4
FONDAPARINUX SOL 7.5/0.6
FOOD COLOR LIQ BLUE
FOOD COLOR LIQ GREEN
FOOD COLOR LIQ PINK
FOOD COLOR LIQ RED
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
289
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
FOOD COLOR LIQ WHITE
FOOD COLOR LIQ YELLOW
FOOD COLOR POW BLACK
FOOD COLOR POW BLUE
FOOD COLOR POW BLUE RYL
FOOD COLOR POW BROWN
FOOD COLOR POW FLESH
FOOD COLOR POW GREEN
FOOD COLOR POW LIME GRN
FOOD COLOR POW RED
FOOD COLOR POW VIOLET
FOOT POW
FOOT SOAP POW JOHNSONS
FORADIL CAP AEROLIZE
FORANE SOL
FORFIVO XL TAB 450MG
FORM44 CHEST SYP 20-200
FORM44 DRY LIQ 10-5ML
FORMADON SOL
FORMALDEHYDE SOL 37%
FORMA-RAY SOL 20%
FORMIC ACID SOL 98%
FORMOTEROL POW FUMARATE
FORMULA 44 LIQ CGH/CLD
FORSKOLIN POW
FORTADERM MIS
WDRx 2/23/15
Tier
Formulary Status
2
2
2
3
2
2
3
2
2
3
2
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
2
Preferred Brand
2
Preferred Brand
3
Non-Preferred Brand
3
3
1
2
2
3
2
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 60
gm per 30 days
May be subject to
Quantity Level
Limits
290
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
Non-Preferred Brand
FORTAMET TAB 1000MG
3
Non-Preferred Brand
Maximum of 60
per 30 days
FORTAMET TAB 500MG
3
Non-Preferred Brand
Maximum of 60
per 30 days
FORTAZ INJ 1GM
FORTAZ INJ 2GM
FORTAZ INJ 500MG
2
2
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
FORTADERM MIS ANTIMICR
FORTAZ INJ 6GM
3
Non-Preferred Brand
FORTEO SOL 600/2.4
FORTESTA GEL 10MG/ACT
FORTICAL SPR 200/ACT
FORTIFENSE POW
FOS POW
3
3
2
3
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
FOSAMAX + D TAB 70-2800
3
Non-Preferred Brand
FOSAMAX + D TAB 70-5600
3
Non-Preferred Brand
3
Non-Preferred Brand
2
3
1
1
1
1
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
FOSAMAX TAB 70MG
FOSCARNET INJ 24MG/ML
FOSCAVIR INJ 24MG/ML
FOSINOP/HCTZ TAB 10/12.5
FOSINOP/HCTZ TAB 20/12.5
FOSINOPRIL TAB 10MG
FOSINOPRIL TAB 20MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Maximum of 4 per
30 days
Maximum of 4 per
30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
291
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FOSINOPRIL TAB 40MG
FOSPHENYTOIN INJ 100/2ML
FOSPHENYTOIN INJ 500/10ML
FOSRENOL CHW 1000MG
FOSRENOL CHW 500MG
FOSRENOL CHW 750MG
1
1
1
2
2
2
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
-
-
FOUR BLADE MIS DISPOSBL
FRAGMIN INJ 10000/ML
FRAGMIN INJ 12500UNT
FRAGMIN INJ 15000UNT
FRAGMIN INJ 18000UNT
FRAGMIN INJ 2500/0.2
FRAGMIN INJ 25000/ML
FRAGMIN INJ 5000/0.2
FRAGMIN INJ 7500/0.3
FRANKINCENSE OIL
FREAMINE HBC INJ 6.9%
FREAMINE III INJ 3%
FREEDOM LIQ ESTERDER
FREEDOM ODT POW BASE
FREESTYLE KIT FREEDOM
FREESTYLE KIT SYSTEM
FREESTYLE MIS LITE
FREESTYLE TES
1
2
2
2
2
2
2
2
2
3
2
2
2
2
-
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
FREEZE IT GEL 0.2-3.5%
3
Non-Preferred Brand
FOSTEUM CAP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
292
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
3
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
FRUIT C CHW 200MG
-
-
FRUIT C-100 CHW
-
-
1
Generic
FRUIT FROSTR LOZ 7MG
3
Non-Preferred Brand
FUL-GLO TES 0.6MG OP
3
Non-Preferred Brand
FULL SPECT TAB B/ VIT C
-
-
FULLERS POW EARTH
FULYZAQ TAB 125MG
FUMARIC ACID POW
FUNGAL NAIL KIT MANAGEME
FUNGI-NAIL SOL 25%
FUNGOID TINC KIT
2
3
3
3
2
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
FURADANTIN SUS 25MG/5ML
3
Non-Preferred Brand
FURAZOLIDONE POW
FUROSEMIDE INJ 100/10ML
FUROSEMIDE POW
2
-
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
FREEZONE LIQ 17.6%
FRESH N BRIT PST
FROVA TAB 2.5MG
FRST-HYDRCRT GEL 10%
FRUCTOOLIGOS POW
FRUCTOSE GRA
FRUCTOSE POW
FRUIT COOLER LOZ BERY ICE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
Maximum of 12
per 30 days
Not a covered
benefit
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
293
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
FUROSEMIDE SOL 10MG/ML
FUROSEMIDE SOL 8MG/ML
FUROSEMIDE TAB 20MG
FUROSEMIDE TAB 40MG
FUROSEMIDE TAB 80MG
FURSULTIAMIN POW HCL
FUSILEV INJ 50MG
FUSION PLUS CAP
FUZEON INJ 90MG
FYCOMPA TAB 10MG
FYCOMPA TAB 12MG
FYCOMPA TAB 2MG
FYCOMPA TAB 4MG
FYCOMPA TAB 6MG
FYCOMPA TAB 8MG
G4 PLATINUM KIT PEDIATRC
G4 PLATINUM KIT SENSOR
GABA POW
GABAPENTIN CAP 100MG
GABAPENTIN CAP 300MG
GABAPENTIN CAP 400MG
GABAPENTIN POW
GABAPENTIN SOL 250/5ML
GABAPENTIN TAB 600MG
GABAPENTIN TAB 800MG
GABAVALE-5 PAK
GABAZOLAMINE PAK
GABAZOLAMINE PAK 0.5MG
GABAZOLPIDEM PAK 5MG
3
2
3
3
2
2
2
2
2
2
3
2
3
1
1
1
2
1
1
1
3
3
3
3
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
294
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
GABITRIL TAB 2MG
3
Non-Preferred Brand
GABITRIL TAB 4MG
3
Non-Preferred Brand
3
3
3
3
3
3
2
3
1
1
1
2
1
1
1
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
GABITIDINE PAK 150MG
GABITRIL TAB 12MG
GABITRIL TAB 16MG
GABLOFEN INJ 10000/20
GABLOFEN INJ 20000/20
GABLOFEN INJ 40000/20
GABLOFEN INJ 50MCG/ML
GABOXETINE PAK
GADAVIST INJ 1MMOL/ML
GALACTOSE POW
GALANGAL POW ROOT
GALANTAMINE CAP 16MG ER
GALANTAMINE CAP 24MG ER
GALANTAMINE CAP 8MG ER
GALANTAMINE SOL 4MG/ML
GALANTAMINE TAB 12MG
GALANTAMINE TAB 4MG
GALANTAMINE TAB 8MG
GALLIC ACID POW
GALLIUM POW NITRATE
GALZIN CAP 25MG
GALZIN CAP 50MG
GAMASTAN S/D INJ
GAMMAGARD INJ 10GM/100
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
295
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GAMMAGARD INJ 1GM/10ML
GAMMAGARD INJ 2.5GM/25
GAMMAGARD INJ 20GM/200
GAMMAGARD INJ 30GM/300
GAMMAGARD INJ 5GM/50ML
GAMMAGARD SD INJ 10GM HU
GAMMAGARD SD INJ 2.5GM HU
GAMMAGARD SD INJ 5GM HU
GAMMAKED INJ 10GM/100
GAMMAKED INJ 1GM/10ML
GAMMAKED INJ 2.5GM/25
GAMMAKED INJ 20GM/200
GAMMAKED INJ 5GM/50ML
GAMMA-LINIC CAP 500MG
GAMMA-ORYZAN POW
GANCICLOVIR INJ 500MG
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
-
-
GANITE INJ 25MG/ML
GARAMYCIN OIN 0.3% OP
GARAMYCIN SOL 0.3% OP
GARCINIA CAM TAB 500-200
3
1
2
3
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
QVAR AER 80MCG
-
$0 Preventative Drug
2
1
1
3
3
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
GANIRELIX AC INJ
GARDENIA OIL FRAGRANC
GARLIC 1500 CAP
GARLIC CAP 1000MG
GARLIC CAP 10MG
GARLIC CAP 2000MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
-
-
YES, Specialty Drug
Maximum of 17.4
gm per 30 days
296
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
GARLIC CAP 300MG
GARLIC CAP 37.5MG
GARLIC CAP 3MG
GARLIC CAP 450MG
GARLIC CAP 500MG
GARLIC CAP 705MG
GARLIC OIL CAP 1000
GARLIC POW
GARLIC TAB 100MG
GARLIC TAB 1250MG
GARLIC TAB 2000MG
GARLIC TAB 200MG
GARLIC TAB 350MG
GARLIC TAB 500MG
GARLIC/EPA CAP
GARLIC/LECIT CAP
GARLIC/PARSL CAP
GARLIC/PARSL TAB
GARLIC-PARSL CAP
GARLIQUE TAB 400MG EC
Tier
Formulary Status
3
3
1
3
1
2
3
3
1
3
3
3
1
1
3
3
1
1
3
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
3
Non-Preferred Brand
GAS FREE CAP 125MG
GAS RELIEF DRO 20/0.3ML
GASTRACE DIG CAP SUPPORT
GASTRINEX NF CAP
1
1
2
2
Generic
Generic
Preferred Brand
Preferred Brand
GASTROCROM CON 100/5ML
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
297
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GASTROGRAFIN SOL 66-10%
3
Non-Preferred Brand
GASTROMARK SUS 175MCG
3
Non-Preferred Brand
GAS-X CAP PREVENT
3
Non-Preferred Brand
GAS-X CHILD MIS 40MG
GAS-X CHW 80MG
3
2
Non-Preferred Brand
Preferred Brand
GAS-X EX-STR CHW 125MG
3
Non-Preferred Brand
3
3
1
3
1
1
2
2
2
2
2
3
3
3
3
1
2
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
$0 Preventative Drug
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
GAS-X EX-STR MIS 62.5MG
GAS-X/MAALOX CHW EXTRA ST
GATIFLOXACIN SOL 0.5%
GATTEX KIT 5MG
GAVILYTE-C SOL
GAVILYTE-G SOL
GAVILYTE-N SOL FLAV PK
GAVISCON CHW
GAVISCON CHW EX-STR
GAVISCON SUS
GAVISCON SUS
GAZYVA INJ 25MG/ML
GE-150 CAP 150MG
GEBAUERS SPR AER /STRETCH
GEL HEEL MIS SLEEVES
GELATEIN20 GEL PROSOURC
GELATIN CAP 10GR
GELATIN CAP 600MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
298
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GELATIN POW
GELCLAIR GEL
GELFILM MIS ENVELOPE
GELFILM MIS OP
GELFOAM MIS DENTAL 4
GELFOAM MIS SPON COM
GELFOAM MIS SPONG 50
GELFOAM MIS SPONG100
GELFOAM MIS SPONG200
GELFOAM POW
GELFOAM SPNG MIS 12-7MM
2
3
3
3
3
3
3
3
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
GEL-KAM CON 0.63%
3
Non-Preferred Brand
GEL-KAM GEL 0.4%
GELNIQUE GEL 10%
GELNIQUE GEL 3%
GELONASAL SPR
GEL-ONE INJ 30MG/3ML
GELRITE LIQ SANITIZE
2
2
2
3
3
1
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
GELUSIL CHW
GELX GEL
GEMFIBROZIL POW
GEMFIBROZIL TAB 600MG
GEMZAR INJ 1GM
WDRx 2/23/15
3
Non-Preferred Brand
3
-
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
3
Non-Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
299
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
GEMZAR INJ 200MG
GENADUR KIT
GENERESS FE CHW
GENICIN CAP 500MG
GENOTROPIN INJ 0.2MG
GENOTROPIN INJ 0.4MG
GENOTROPIN INJ 0.6MG
GENOTROPIN INJ 0.8MG
GENOTROPIN INJ 1.2MG
GENOTROPIN INJ 1.4MG
GENOTROPIN INJ 1.6MG
GENOTROPIN INJ 1.8MG
GENOTROPIN INJ 12MG
GENOTROPIN INJ 1MG
GENOTROPIN INJ 2MG
GENOTROPIN INJ 5MG
GENTAM/NACL INJ 0.9MG/ML
GENTAM/NACL INJ 1.4MG/ML
GENTAM/NACL INJ 100MG
GENTAM/NACL INJ 100MG PB
GENTAM/NACL INJ 120MG
GENTAM/NACL INJ 80MG
GENTAM/NACL INJ 80MG
GENTAMICIN CRE 0.1%
GENTAMICIN INJ 10MG/ML
GENTAMICIN INJ 10MG/ML
GENTAMICIN INJ 40MG/ML
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
3
Non-Preferred Brand
$0 Preventative Drug
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
1
3
3
3
3
3
3
3
3
3
3
3
3
2
2
1
2
1
1
1
2
1
1
1
Special Plan Edits
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
-
300
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GENTAMICIN OIN 0.1%
GENTAMICIN POW SULFATE
GENTAMICIN SOL 0.3% OP
GENTEAL DRO OPTH
GENTEAL GEL
GENTEAL GEL 0.3%
GENTEAL MILD DRO 0.2%
GENTIAN CRY VIOLET
GENTIAN VIOL POW
GENTIAN VIOL SOL 1%
GENTIAN VIOL SOL 2%
GENTLE IRON CAP 28MG
2
2
1
2
2
2
2
3
2
2
2
1
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
GENTLE RAIN LIQ ANTIBACT
3
Non-Preferred Brand
GEODON CAP 20MG
3
Non-Preferred Brand
GEODON CAP 40MG
3
Non-Preferred Brand
GEODON CAP 60MG
3
Non-Preferred Brand
GEODON CAP 80MG
3
Non-Preferred Brand
GEODON INJ 20MG
GERANIOL POW
GERANIUM OIL
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
301
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GERAVIM LIQ
-
-
GERAVINE ELX
-
-
GERBR SOOTHE DRO COLIC
3
Non-Preferred Brand
GERIATRIC LIQ VITAMIN
-
-
GERI-HYDROLA LOT 5%
GERI-MUCIL POW 68%
GERISILK OIL BATH
1
1
2
Generic
Generic
Preferred Brand
GERITOL LIQ TONIC
-
-
GERITOL TAB COMPLETE
-
-
GERMALL PLUS LIQ
GERMANIUM POW
GESTICARE PAK DHA
GIANVI TAB 3-0.02MG
GIAZO TAB 1.1GM
GIBBERELLIC POW ACID
GILDESS FE TAB 1.5/30
GILDESS FE TAB 1/20
GILDESS TAB 1.5/30
GILDESS TAB 1/20
GILENYA CAP 0.5MG
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
GILPHEX TR TAB 10-388MG
GILTUSS LIQ PED-C
2
3
-
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
3
3
3
3
3
3
3
3
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
PA Required
PA Required
PA Required
PA Required
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
-
-
YES, Specialty Drug
Limited Distribution
Limited Distribution
Limited Distribution
302
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GILTUSS PED LIQ
GILTUSS TR CAP 7-14-288
GINGER CAP 500MG
GINGER EXTRA CAP 250MG
GINGER OIL
GINGER ROOT CAP 550MG
GINGER ROOT POW
GINGKO BILOB CAP 60MG
GINKGO BILOB CAP 100MG
GINKGO BILOB CAP 120MG
GINKGO BILOB CAP 200MG
GINKGO BILOB CAP 30MG
GINKGO BILOB CAP 400MG
GINKGO BILOB CAP 440MG
GINKGO BILOB CAP 500MG
GINKGO BILOB CAP 50MG
GINKGO BILOB CAP 80MG
GINKGO BILOB EXT
GINKGO BILOB POW
GINKGO BILOB POW
GINKGO BILOB TAB 120MG
GINKGO BILOB TAB 230MG
GINKGO BILOB TAB 40MG
GINKGO BILOB TAB 50MG
GINKGO BILOB TAB PLUS
GINKGO VIN TAB 20-120MG
GINSENG CAP 100MG
GINSENG CAP 250MG
GINSENG EDGE CAP 125-85MG
1
3
1
1
2
1
2
1
3
1
3
3
3
3
1
3
3
3
2
2
1
3
1
3
3
3
1
1
3
Generic
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
303
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GINSENG EXTR CAP 50MG
GINSENG ROOT POW
GINSENG ROYA CAP JELLY
GINSENG/ROYA CAP JELLY
GLA-45 CAP 45MG
GLASSIA INJ
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
GLIADEL WAF 7.7MG
GLIMEPIRIDE TAB 1MG
GLIMEPIRIDE TAB 2MG
GLIMEPIRIDE TAB 4MG
GLIP/METFORM TAB 2.5-250M
GLIP/METFORM TAB 2.5-500M
GLIP/METFORM TAB 5-500MG
GLIPIZIDE ER TAB 10MG
GLIPIZIDE ER TAB 2.5MG
GLIPIZIDE ER TAB 5MG
GLIPIZIDE POW
GLIPIZIDE TAB 10MG
GLIPIZIDE TAB 5MG
GLOFIL-125 INJ 0.1%
GLOVES IN A LOT BOTTLE
GLUC CHONDR CHW 500-400
GLUC/CHON/D3 TAB MSM
GLUC/CHOND/ TAB PLS D-3
GLUCAGEN INJ 1MG
GLUCAGON KIT 1MG
1
2
3
3
3
3
3
3
3
3
3
3
3
3
2
2
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
YES, Specialty Drug
YES, Specialty Drug
2 per 12 months
2 per 12 months
304
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
GLUCERNA MEA BAR CHO CHUN
-
-
Not a covered
benefit
-
GLUCO/CHOND/ CAP COLLAGEN
GLUCO/CHONDR CAP /COLLAGE
GLUCO/CHONDR CAP /MSM
GLUCO/CHONDR CAP 1500 COM
GLUCO/CHONDR CAP COMPLEX
GLUCO/CHONDR POW VIT D3
GLUCO/CHONDR TAB /MSM
GLUCO/CHONDR TAB /MSM
GLUCO/CHONDR TAB /MSM
GLUCO/CHONDR TAB COMPLEX
GLUCO/SCHOND TAB /MSM
GLUCONIC ACD POW LACTONE
GLUCONOLACTO POW
3
3
3
1
3
3
1
1
1
1
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
GLUCOPHAGE TAB 1000MG
3
Non-Preferred Brand
GLUCOPHAGE TAB 500MG
3
Non-Preferred Brand
GLUCOPHAGE TAB 500MG XR
3
Non-Preferred Brand
GLUCOPHAGE TAB 750MG XR
3
Non-Preferred Brand
GLUCOPHAGE TAB 850MG
3
Non-Preferred Brand
GLUCOS CHOND TAB /MSM
3
Non-Preferred Brand
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
305
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GLUCOS/CA/D TAB
GLUCOS/CHOND CAP 250-200
GLUCOS/CHOND CAP 500-250
GLUCOS/CHOND CAP PLUS
GLUCOS/CHOND CHW 750-600
GLUCOS/CHOND LIQ
GLUCOS/CHOND LIQ MAX-STR
GLUCOS/CHOND TAB /MSM
GLUCOS/CHOND TAB 250-200
GLUCOS/CHOND TAB 500-400
GLUCOS/CHOND TAB 750-600
GLUCOS/CHOND TAB COMPLEX
GLUCOS/CHOND TAB DOUBLE
GLUCOS/CHOND TAB JOINT
GLUCOS/CHOND TAB MSM
GLUCOSAMINE CAP 1000MG
GLUCOSAMINE CAP 750MG
GLUCOSAMINE CAP FISH OIL
GLUCOSAMINE CAP MSM
GLUCOSAMINE LIQ MSM
GLUCOSAMINE POW ACETYL-D
GLUCOSAMINE POW HCL
GLUCOSAMINE POW SUL NACL
GLUCOSAMINE POW SULFATE
GLUCOSAMINE POW SULFATE
GLUCOSAMINE TAB /MSM
GLUCOSAMINE TAB 1000MG
GLUCOSAMINE TAB 1500MG
GLUCOSAMINE TAB 500MG
3
1
3
3
1
3
1
3
1
2
1
2
3
3
1
1
3
3
1
3
2
2
2
2
2
3
1
1
3
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
306
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GLUCOSAMINE TAB 750MG
GLUCOSAMINE TAB COMPLEX
GLUCOSAMINE TAB MSM CMPL
GLUCOSAMINE TAB PLUS D
GLUCOSAMINE TAB -VIT D
GLUCOSAMINE/ TAB MSM
GLUCOSE CHW 4GM
GLUCOSE CHW FRT PNCH
GLUCOSE DRNK LIQ 15/59ML
GLUCOSE LIQ SHOT
3
2
3
3
3
3
3
3
1
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
GLUCOTROL TAB 10MG
3
Non-Preferred Brand
GLUCOTROL TAB 5MG
3
Non-Preferred Brand
GLUCOTROL XL TAB 10MG
3
Non-Preferred Brand
GLUCOTROL XL TAB 2.5MG
3
Non-Preferred Brand
GLUCOTROL XL TAB 5MG
3
Non-Preferred Brand
GLUCOVANCE TAB 1.25-250
3
Non-Preferred Brand
GLUCOSE NURS LIQ 5%
GLUCOSMN/MSM CAP COLLAGEN
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
307
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GLUCOVANCE TAB 2.5-500
3
Non-Preferred Brand
GLUCOVANCE TAB 5-500MG
3
Non-Preferred Brand
GLUMETZA TAB 1000MG
3
Non-Preferred Brand
GLUMETZA TAB 500MG
3
Non-Preferred Brand
3
1
2
2
2
2
3
2
3
1
1
1
2
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 ACA Drug
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
GLUTAMENT POW
GLUTAMINE POW
GLUTARALDEHY LIQ 50%
GLUTARALDEHY SOL 25%
GLUTARALDEHY SOL 25%
GLUTATHIONE POW
GLUTATHIONE TAB 50MG
GLUTOL SOL
GLYB/METFORM TAB 1.25-250
GLYB/METFORM TAB 2.5-500
GLYB/METFORM TAB 5-500MG
GLYBURID MCR TAB 1.5MG
GLYBURID MCR TAB 3MG
GLYBURID MCR TAB 6MG
RECOMBIVA HB INJ 10MCG/ML
GLYCATE TAB 1.5MG
GLYCE & ROSE LIQ WATER
GLYCERIN PED SUP 1.2GM
GLYCERIN PED SUP 1GM
GLYCERIN SOL SYNTHETC
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 60
per 30 days
Maximum of 90
per 30 days
308
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GLYCERIN SUP 80.7%
GLYCEROL POW MONOOLEA
GLYCERYL MIS MONOSTEA
GLYCINE (L) POW
GLYCINE POW
GLYCINE SOYA SOL EXTRACT
GLYCINE SOYA SOL PROTEIN
GLYCINE500 PAK 500MG
GLYCOFUROL LIQ
GLYCOLIC ACD CRY
GLYCOLIC ACD GRA
GLYCOLIC ACD SOL 70%
GLYCOPHOS SOL 1MM/ML
GLYCOPYRROL INJ 0.2MG/ML
GLYCOPYRROL INJ 0.2MG/ML
GLYCOPYRROL INJ 0.2MG/ML
GLYCOPYRROL INJ 0.2MG/ML
GLYCOPYRROL POW
GLYCOPYRROL TAB 1MG
GLYCOPYRROL TAB 2MG
GLYCOSAMINOG LIQ
1
3
2
2
2
3
2
2
2
2
2
2
2
1
1
1
1
2
1
1
2
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Preferred Brand
-
-
2
Preferred Brand
GLYNASE TAB 1.5MG
3
Non-Preferred Brand
GLYNASE TAB 3MG
3
Non-Preferred Brand
GLYCO-TECH TAB
GLYCYRRHIZIC POW ACID
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
309
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GLYNASE TAB 6MG
3
Non-Preferred Brand
GLYSET TAB 100MG
3
Non-Preferred Brand
GLYSET TAB 25MG
3
Non-Preferred Brand
GLYSET TAB 50MG
3
Non-Preferred Brand
3
1
2
3
1
1
1
3
2
1
1
2
1
1
1
1
3
Non-Preferred Brand
Generic
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
GNP NIACIN TAB 250MG
-
-
GNP PETROLEU GEL JELLY
2
Preferred Brand
GNP ALCOHOL SOL DENATURE
GNP BANDAGE LIQ
GNP DAILY MIS PRENATAL
GNP DAY TIME LIQ MUCUS DM
GNP FISH OIL CAP 840MG
GNP FLU/COLD PAK DAYTIME
GNP HEADACHE TAB RELIEF
GNP HERBAL LOZ 4.8MG
GNP IODIDES TIN
GNP IODINE TIN 2% MILD
GNP IRON TAB 45MG
GNP IRON TAB 65MG
GNP ISOP ALC SOL 99%
GNP LICE EGG GEL REMOVER
GNP L-LYSINE TAB 600MG
GNP LUTEIN TAB 10MG
GNP MAGNESIU TAB 250MG
GNP MSM GLUC TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 90
per 30 days
Maximum of 90
per 30 days
Maximum of 90
per 30 days
Not a covered
benefit
-
-
-
-
310
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
1
1
2
1
Generic
Generic
Preferred Brand
Generic
-
-
1
3
3
3
3
3
3
2
3
3
2
1
1
3
3
3
3
2
$0 ACA Drug
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
GONAL-F INJ 1050UNIT
3
Non-Preferred Brand
GONAL-F INJ 450UNIT
3
Non-Preferred Brand
GNP PMS RELF TAB MAX ST
GNP SAW PALM CAP 160MG
GNP TRIPLE CAP OMEGA
GNP TUSSIN LIQ NIGHTTIM
GNP VIT B1 TAB 100MG
GNP VIT D TAB 5000UNIT
GOAT WEED/ CAP MACA
GOLD BOND AER FOOT
GOLD BOND CRE INTENSVE
GOLD BOND CRE ULTIMATE
GOLD BOND FT CRE PAIN RLF
GOLD BOND LIQ FRST AID
GOLD BOND LOT MEDICATD
GOLD BOND POW
GOLD BOND UL LIQ SANITZER
GOLD DUST POW WOUND
GOLD SODIUM POW THIOMALA
GOLDEN SEAL CAP 400MG
GOLDEN SEAL CAP 500MG
GOLDEN SEAL CAP 535MG
GOLDENSEAL CAP 470MG
GOLDENSEAL CAP ROOT
GOLDENSEAL POW
GONAK SOL OP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
-
-
Not a covered
benefit
Not a covered
benefit
YES, Specialty Drug
YES, Specialty Drug
311
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
GONAL-F RFF INJ 300
3
Non-Preferred Brand
GONAL-F RFF INJ 450
3
Non-Preferred Brand
3
Non-Preferred Brand
GONAL-F RFF INJ 900
3
Non-Preferred Brand
GONIOSOFT SOL 2.5% OP
1
Generic
3
Non-Preferred Brand
3
2
1
3
3
3
3
3
3
3
2
3
1
3
3
2
1
3
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
GONAL-F RFF INJ 75UNIT
GONIOSOL SOL OP
GONIOVISC SOL 2%
GOOD START LIQ WATER
GOOD START SOL 5% GLUCO
GOODYS BODY POW PAIN
GOODYS PM POW 38-500MG
GOODYS TAB EX ST
GORDOFILM SOL
GORDOMATIC CRY
GORDONS UREA OIN 22%
GORDONS UREA OIN 40%
GORDONS-VITE CRE A
GORDONS-VITE LOT A
GORMEL CRE 20%
GOTU KOLA POW
GOWEY TIN TINCTURE
G-PREPROTEIN LIQ
GRAFCO SILVR MIS NIT APPL
GRAFIX CORE MIS 2CMX2CM
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
312
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
GRALISE STAR MIS 300/600
2
Preferred Brand
GRALISE TAB 300MG
2
Preferred Brand
GRALISE TAB 600MG
2
Preferred Brand
78 per 12 months
Maximum of 30
per 30 days
Maximum of 90per
30 days
2
3
3
3
3
3
1
1
1
1
2
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
1
1
3
1
3
2
2
3
3
Generic
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
GRAMICIDIN D POW
GRAM-O-LECI CHW 1000MG
GRANDPAS BAR PINE TAR
GRANDPAS BAR THYLOX
GRANDPAS LIQ PINE TAR
GRANDPAS SHA PINE TAR
GRANISETRON INJ 0.1MG/ML
GRANISETRON INJ 1MG/ML
GRANISETRON INJ 1MG/ML
GRANISETRON TAB 1MG
GRANISOL SOL 2MG/10ML
GRANIX INJ 300/0.5
GRANIX INJ 480/0.8
GRANULEX AER
GRAPE SEED CAP 100MG
GRAPE SEED CAP 25MG
GRAPE SEED CAP 30MG
GRAPE SEED CAP 50MG
GRAPE SEED CAP 60MG
GRAPE SEED OIL
GRAPE SEED POW 95%
GRAPE SEED TAB 50MG
GRAPEFRUIT EXT SEED 60%
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
313
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
GRASTEK SUB 2800BAU
GREEN COFFEE CAP BEAN EXT
GREEN GLO MIS 1.5MG
GREEN LIPPED POW MUSSEL
GREEN SOAP EMU
GREEN SOAP TIN
GREEN TEA CAP 150MG
GREEN TEA CAP 200MG
GREEN TEA CAP 250MG
GREEN TEA CAP 315-12.5
GREEN TEA CAP 315MG
GREEN TEA EX LIQ 90%
GREEN TEA OIL FRAGRANC
GRIFULVIN V TAB 500MG
GRIPE WATER LIQ
GRIPE WATER LIQ COLIC
GRISEOFULVIN POW
GRISEOFULVIN POW MICRONIZ
GRISEOFULVIN SUS 125/5ML
GRISEOFULVIN TAB MICR 500
GRISEOFULVIN TAB ULTR 125
GRISEOFULVIN TAB ULTR 250
GRIS-PEG TAB 125MG
WDRx 2/23/15
Tier
Formulary Status
Special Plan Edits
2
Preferred Brand
May be subject to
Quantity Level
Limits
3
1
3
3
2
1
3
1
3
1
2
2
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
3
3
3
2
1
1
1
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
3
Non-Preferred Brand
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
314
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
GRIS-PEG TAB 250MG
GRX DYNE MIS 10%
GRX RNS-FREE LIQ FOAM
GRX WHITE OIN PETROLAT
G-TUSICOF LIQ
GUADALUPANO MIS 0.15%
GUAIACOL SOL
GUAIFENESIN POW
GUANABENZ POW ACETATE
GUANETHIDINE POW MONOSULF
GUANETHIDINE POW SULFATE
GUANFACINE TAB 1MG
GUANFACINE TAB 2MG
GUANIDINE POW HCL
GUANIDINE TAB 125MG
GUANIDINEACE POW ACID
GUAR GUM POW
GUARANA EXTR POW
GUARANA TAB 1000MG
GUGULIPID CAP 500MG
GUGULIPID/ TAB BIOPERIN
GUIZAZO CABA CAP 500MG
GUM BASE GEL GELATIN
GUMMY BITES CHW
GUMMY TROCHE GEL GELATIN
GUMSOL LIQ
GYMNEMA SYLV POW LEAF
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
1
2
3
2
3
2
2
2
3
2
1
1
3
2
2
2
3
3
3
3
3
3
3
2
3
2
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
315
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
Non-Preferred Brand
GYNE-LOTRIM CRE 1% VAG
3
Non-Preferred Brand
GYNE-LOTRIMI CRE 3
RECOMBIVA HB INJ 5MCG/0.5
G-ZYNCOF SYP 20-400/5
H2Q POW 200MG/GM
HAEMATOPORPH POW
2
2
3
3
Preferred Brand
$0 ACA Drug
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
HAIR REGROW AER 5%
-
-
HAIR REGROWT SOL 2%
-
-
HAIR REGROWT SOL 5%
-
-
HALAC KIT
HALAVEN INJ 1MG/2ML
HALAZONE POW
1
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
HALCION TAB 0.25MG
3
Non-Preferred Brand
HALDOL DECAN INJ 100MG/ML
3
Non-Preferred Brand
HALDOL DECAN INJ 50MG/ML
3
Non-Preferred Brand
3
Non-Preferred Brand
2
$0 Preventative Drug
Preferred Brand
GYNAZOLE-1 CRE 2%
HALDOL INJ 5MG/ML
HALFLYTELY KIT FLAV PKS
HALFPRIN TAB 162MG EC
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
316
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HALOBETASOL CRE 0.05%
HALOBETASOL OIN 0.05%
HALOG CRE 0.1%
HALOG OIN 0.1%
HALONATE KIT
HALOPER DEC INJ 100MG/ML
HALOPER DEC INJ 50MG/ML
HALOPER LAC INJ 5MG/ML
HALOPERIDOL CON 2MG/ML
HALOPERIDOL POW
HALOPERIDOL POW DECANOAT
HALOPERIDOL TAB 0.5MG
HALOPERIDOL TAB 10MG
HALOPERIDOL TAB 1MG
HALOPERIDOL TAB 20MG
HALOPERIDOL TAB 2MG
HALOPERIDOL TAB 5MG
HALOTIN CRE 1%
HAND SANITIZ LIQ 70%
HARD CONTACT SOL CLEANER
1
1
3
3
2
1
1
1
1
2
2
1
1
1
1
1
1
3
1
3
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
-
-
1
3
3
2
3
$0 ACA Drug
$0 ACA Drug
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
HARD NAILS CAP 2.5MG
RECOMBIVA-HB INJ 40MCG/JL
ROTATEQ SOL
HAWTHORN BER CAP 565MG
HAWTHORN BER POW 2%
HAWTHORN CAP 150MG
HAWTHORN POW BERRY
HAWTHORNE CAP BERRY
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
317
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HC BUTYRATE OIN 0.1%
HC BUTYRATE SOL 0.1%
HC DERMAPAX SPR 0.5-0.5%
HC PRAMOXINE CRE 1-1%
HC PRAMOXINE CRE 1-2.5%
HC PRAMOXINE CRE 2.5-1%
HC VALERATE CRE 0.2%
HC VALERATE OIN 0.2%
HC/ALOE CRE 0.5%
HC-1% HEMORR OIN 1%
H-CHLOR 12 SOL 0.125%
HCTZ/TRIAMT TAB 50-75MG
HDL BENEFIT CAP 500MG
1
1
3
1
1
1
1
1
1
1
1
1
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
$0 Preventative Drug
Generic
HEAD&SHOULDR SHA 1% 2IN1
3
Non-Preferred Brand
HEADACHE PM TAB 500-38MG
HEALON GV INJ 14MG/ML
HEALON INJ 10MG/ML
HEALON5 INJ 23MG/ML
HEALTHY HEAR EMU
HEAR AID BAT MIS SIZE 10
HEARTBURN TR CAP 15MG
HEARTSTART KIT HOME
HEAT WRAPS MIS BACK/HIP
HECORIA CAP 0.5MG
HECORIA CAP 1MG
HECORIA CAP 5MG
1
3
3
3
3
2
1
3
3
1
1
1
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
318
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HECTOROL CAP 0.5MCG
3
Non-Preferred Brand
HECTOROL CAP 1MCG
3
Non-Preferred Brand
HECTOROL CAP 2.5MCG
3
Non-Preferred Brand
HECTOROL INJ 2MCG/ML
2
Preferred Brand
HECTOROL INJ 4MCG/2ML
3
Non-Preferred Brand
HELIDAC MIS
HELIOCARE CAP 240MG
HELIXATE FS INJ 1000UNIT
HELIXATE FS INJ 2000UNIT
HELIXATE FS INJ 250UNIT
HELIXATE FS INJ 3000UNIT
HELIXATE FS INJ 500UNIT
HEMABATE INJ 250MCG
HEMA-CHEK LIQ
HEMA-CHEK MIS
HEMANGEOL SOL 4.28/ML
HEMASTIX TES
HEMATEST TAB
HEMATINIC/FA TAB
HEMATOGEN CAP
HEMATOGEN FA CAP
HEMATOXYLIN POW
3
2
3
3
3
3
3
2
3
3
3
3
1
1
2
2
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
319
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HEMATRON DRO
3
Non-Preferred Brand
HEMATRON-AF TAB
3
Non-Preferred Brand
2
3
3
2
3
3
3
3
3
3
3
3
3
1
1
1
1
1
1
1
1
2
2
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
HEMENATAL OB MIS + DHA
HEMENATAL OB TAB 28-6-1MG
HEMETAB TAB
HEMLOCK OIL
HEMOCYTE PLS CAP
HEMOCYTE TAB 324MG
HEMOCYTE-F ELX
HEMOFIL M INJ 1000UNIT
HEMOFIL M INJ 1700UNIT
HEMOFIL M INJ 220-400
HEMOFIL M INJ 250UNIT
HEMOFIL M INJ 401-800
HEMOFIL M INJ 500UNIT
HEMOFIL M SOL 501-2000
HEMOFIL M SOL 801-1500
HEMORRHOID SUP
HEMORRHOIDAL CRE
HEMORRHOIDAL CRE
HEMORRHOIDAL CRE -HC 2.5%
HEMORRHOIDAL GEL 0.25-50%
HEMORRHOIDAL OIN
HEMORRHOIDAL OIN
HEMORRHOIDAL OIN
HEMORRHOIDAL SUP
HEMORRHOIDAL SUP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
320
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HEMORRHOIDAL SUP 51%
HEMRIL-30 SUP 30MG
HEP FLUSH-10 INJ 10UNT/ML
HEP SOD/D5W INJ 100/ML
HEP SOD/D5W INJ 20000UNT
HEP SOD/D5W INJ 25000UNT
HEP SOD/D5W INJ 25000UNT
HEP SOD/NACL INJ 12500UNT
HEP SOD/NACL INJ 25000UNT
HEP SOD/NACL INJ 25000UNT
HEPAGAM B INJ
HEPARIN LOCK INJ 100/ML
HEPARIN LOCK INJ 2UNIT/ML
HEPARIN LOCK KIT 100/ML
HEPARIN LOCK KIT 10UNT/ML
HEPARIN SOD INJ 1000/ML
HEPARIN SOD INJ 10000/ML
HEPARIN SOD INJ 10000/ML
HEPARIN SOD INJ 2000/ML
HEPARIN SOD INJ 20000/ML
HEPARIN SOD INJ 2500/ML
HEPARIN SOD INJ 5000/ML
HEPARIN SOD POW PORCINE
HEPATITIS PAK SUPPORT
HEPES POW
1
1
1
2
1
1
1
3
2
2
2
1
3
1
1
1
1
1
2
1
3
1
2
3
2
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
HEPSERA TAB 10MG
3
Non-Preferred Brand
HEPTAMINOL POW
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
321
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HERBAL EXPEC LIQ 150/15ML
HERCEPTIN INJ 440MG
HERPECIN-L MIS
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
1
3
3
2
2
2
3
3
2
2
3
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
2
3
2
2
3
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
HESPAN INJ 6%/NACL
HESPERIDIN POW 98%
HETASTARCH INJ 6%/NACL
HETLIOZ CAP 20MG
HEXABRIX INJ
HEXALEN CAP 50MG
HEXAPEPTIDE SOL ACETYL
HEXTEND SOL 6%
HEXYLENE LIQ GLYCOL
HEXYLRESORCI POW
TETANUS TOX INJ 5LF ADS
HIBICLENS LIQ 4%
HIBISTAT MIS 0.5%
HIPPURIC POW ACID
HIPREX TAB 1GM
HISTAFLEX TAB 325-25MG
HISTAMINE CRY DIPHOSPH
HISTAMINE POW DIHYDROC
HISTAMINE POW PHOSPHAT
HISTATROL INJ 0.275/ML
HISTATROL INJ 2.75/ML
HISTEX PD DRO 0.938MG
HISTEX SYP 2.5MG/5
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
322
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HISTEX-DM SYP
HISTEX-PE SYP 2.5-10/5
HISTOACRYL LIQ
HIZENTRA INJ 10/50ML
HIZENTRA INJ 1GM/5ML
HIZENTRA INJ 2GM/10ML
HIZENTRA INJ 4GM/20ML
HM EYE DROPS SOL RED RELF
HM FISH OIL CAP 554MG
HM LUTEIN CAP 20MG
HM MAGNESIUM TAB 250MG
HM MEGAKRILL CAP 300MG
HM MELATONIN TAB
HM MUCUS REL TAB CLD/SINU
HM NIGHTTIME TAB 25MG
3
3
3
3
3
3
3
1
3
1
1
1
2
1
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
HM ONE DAILY TAB ESSENTIA
-
-
HM POTASSIUM TAB 99MG
HM VIT B12 CHW 2500MCG
HM Z-SLEEP LIQ 50MG/30
HOLD LOZ 5MG CHER
HOMATROPAIRE SOL 5% OP
HOMATROPINE CRY METHYLBR
HOMATROPINE POW HBR
HOMATROPINE POW METHYLBR
HOME ACCESS KIT HIV-1
HOMOCYSTEINE TAB FORMULA
HONEY ALMOND LIQ FRAGRANC
1
3
1
2
1
3
3
2
3
3
2
Generic
Non-Preferred Brand
Generic
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
-
-
323
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
-
Not a covered
benefit
-
3
3
3
1
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
HORIZANT TAB 300MG
3
Non-Preferred Brand
HORIZANT TAB 600MG
3
Non-Preferred Brand
3
3
1
3
3
1
1
2
1
2
3
3
2
2
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Drug Name
HONEY BEARS CHW
HONEY BEE INJ 1000MCG
HONEY BEE KIT 100MCG
HONEYSUCKLE LIQ FRAGRANC
HOODIA CAP 250MG
HOPS FLOWER POW
HORNET VENOM INJ 1300MCG
HORNET VENOM INJ 550MCG
HORSE CHESTN CAP 300MG
HORSE CHESTN TAB 300MG
HORSECHESTNU POW EXTRACT
HOT STEAM LIQ
HOT STEAM LIQ 6.2%
HOT/COLD MIS COMPRESS
HPA LANOLIN OIN
HPR AER
HPR PLUS MB KIT HYDROGEL
HRT BASE CRE
HRT BASE GEL FOR MEN
HRT NATURAL LOT BASE
HSA DILUENT SOL STERILE
HUBER NEEDLE MIS 19GX1"
HUBER NEEDLE MIS 19GX1.25
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
-
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
324
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HUBER NEEDLE MIS 19GX3/4"
HUBER NEEDLE MIS 20GX1"
HUBER NEEDLE MIS 20GX1.25
HUBER NEEDLE MIS 20GX3/4"
HUBER NEEDLE MIS 22GX1.25
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
2
$0 Preventative Drug
$0 ACA Drug
$0 ACA Drug
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
Preferred Brand
HUGGIES CRE RASH
TRIAMT/HCTZ CAP 50-25MG
TRIPEDIA SUS P/F
VARIVAX INJ
HUMALOG MIX INJ 50/50
HUMALOG MIX INJ 50/50KWP
HUMALOG MIX INJ 75/25KWP
HUMALOG MIX SUS 75/25
HUMATE-P INJ 600UNIT
HUMATE-P SOL 1200UNIT
HUMATE-P SOL 2400UNIT
HUMATROPE INJ 12MG
HUMATROPE INJ 24MG
HUMATROPE INJ 5MG
HUMATROPE INJ 6MG
HUMATROPEN MIS FOR 12MG
HUMIRA KIT 20MG/0.4
HUMIRA KIT 40MG/0.8
HUMIRA PEN KIT 40MG/0.8
VCF VAGINAL AER CONTRACP
VCF VAGINAL MIS CONTRACP
HUMULIN N INJ U-100
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
PA Required
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
-
325
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ZOSTAVAX INJ
ADACEL INJ
ALDACTAZIDE TAB 50/50
HUPRZN SER A POW 1%
2
$0 ACA Drug
$0 ACA Drug
$0 Preventative Drug
Preferred Brand
HURRICAINE MIS SWAB
3
Non-Preferred Brand
HURRICAINE SOL 20%
2
Preferred Brand
HURRICAINE SPR ONE 20%
3
Non-Preferred Brand
HURRISEPT GEL 70%
HURRIVIEW II MIS
HURRIVIEW MIS
HYALGAN INJ 20MG/2ML
HYALURONATE GEL 0.2%
HYALURONATE POW SODIUM
HYALURONIC CAP
HYALURONIC CAP 20MG
HYALURONIC POW ACID
HYALURONIDAS POW
HYALURONIDAS POW BOVINE
HYCAMTIN CAP 0.25MG
HYCAMTIN CAP 1MG
2
3
3
3
1
2
3
1
3
3
2
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
HYCAMTIN INJ 4MG
3
Non-Preferred Brand
HYCET SOL 7.5-325
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
YES, Specialty Drug
Limited Distribution
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
326
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HYD POL/CPM LIQ 10-8/5ML
HYDRALAZINE INJ 20MG/ML
HYDRALAZINE POW HCL
HYDRALAZINE TAB 100MG
HYDRALAZINE TAB 10MG
HYDRALAZINE TAB 25MG
HYDRALAZINE TAB 50MG
HYDRAZINE CRY SULFATE
1
1
2
1
1
1
1
2
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
HYDREA CAP 500MG
3
Non-Preferred Brand
HYDRIODIC POW ACID
HYDRISALIC GEL 17%
3
1
Non-Preferred Brand
Generic
3
Non-Preferred Brand
3
Non-Preferred Brand
1
2
2
1
2
2
Generic
Preferred Brand
Preferred Brand
Generic
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
HYDRO 35 AER
HYDRO 40 AER FOAM
HYDRO/CHLOR/ LIQ PSE HCL
HYDROCHL ACD LIQ 10%
HYDROCHL ACD LIQ 37%
HYDROCHLORIC INJ 1:500
HYDROCHLORIC LIQ ACID
HYDROCHLOROT CAP 12.5MG
HYDROCHLOROT POW
HYDROCHLOROT TAB 12.5MG
HYDROCHLOROT TAB 25MG
HYDROCHLOROT TAB 25MG
HYDROCIL INS POW 95%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
327
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HYDROCIL POW 95%
HYDROCO/APAP SOL
HYDROCO/APAP SOL 10-325MG
HYDROCO/APAP SOL 7.5-500
HYDROCO/APAP TAB 10-300MG
HYDROCO/APAP TAB 10-325MG
HYDROCO/APAP TAB 10-500MG
HYDROCO/APAP TAB 10-650MG
HYDROCO/APAP TAB 10-660MG
HYDROCO/APAP TAB 2.5-500
HYDROCO/APAP TAB 5-300MG
HYDROCO/APAP TAB 5-325MG
HYDROCO/APAP TAB 7.5-300
HYDROCO/APAP TAB 7.5-325
HYDROCOD/HOM SYP 5-1.5/5
HYDROCOD/IBU TAB 10-200MG
HYDROCOD/IBU TAB 2.5-200
HYDROCOD/IBU TAB 5-200MG
HYDROCOD/IBU TAB 7.5-200
HYDROCODONE CRY BITARTRA
HYDROCODONE POW BITARTRA
HYDROCODONE/ TAB HOMATROP
HYDROCORT AC CRE 0.5%
HYDROCORT AC POW
HYDROCORT AC POW MICRONIZ
HYDROCORT CRE 0.5%
HYDROCORT CRE 2.5%
HYDROCORT LOT 2.5%
HYDROCORT OIN 0.5%
2
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
1
2
2
3
1
1
1
1
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
328
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HYDROCORT OIN 2.5%
HYDROCORT POW
HYDROCORT POW
HYDROCORT POW HEMISUCC
HYDROCORT TAB 10MG
HYDROCORT TAB 20MG
HYDROCORT TAB 5MG
HYDROCORT/ KIT PRAMOXIN
HYDROFLUMETH POW
HYDROFLUORIC LIQ 48%
HYDROGEL DRE PAD 2"X3"
HYDROGEL DRE PAD 4"X5"
HYDROGEN PER SOL 3%
HYDROGEN PER SOL 30%
HYDROGEN PER SOL 35% FCC
HYDROGESIC CAP 5-500MG
HYDROLYZED POW ELASTIN
HYDROMORPHON INJ 10MG/ML
HYDROMORPHON INJ 1MG/ML
HYDROMORPHON INJ 4MG/ML
HYDROMORPHON LIQ 1MG/ML
HYDROMORPHON POW HCL
HYDROMORPHON SUP 3MG
HYDROMORPHON TAB 12MG ER
HYDROMORPHON TAB 16MG ER
HYDROMORPHON TAB 2MG
HYDROMORPHON TAB 32MG ER
HYDROMORPHON TAB 4MG
HYDROMORPHON TAB 8MG
1
2
2
3
1
1
1
1
3
2
3
3
2
2
3
1
3
1
1
1
1
2
2
1
1
1
2
1
1
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
329
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HYDROMORPHON TAB 8MG ER
HYDROPEL OIN 30%
HYDROPHILIC OIN PETROLAT
1
3
2
Generic
Non-Preferred Brand
Preferred Brand
-
-
-
-
-
-
1
2
2
2
3
3
2
2
2
3
1
2
2
2
3
3
2
1
2
2
1
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
HYDROQUINONE CRE 4%
HYDROQUINONE CRE 4% TR
HYDROQUINONE POW
HYDRO-TABS TAB
HYDROXOCOBAL INJ 1000MCG
HYDROXOCOBAL POW
HYDROXOCOBAL POW HCL
HYDROXY CITR POW EXTRACT
HYDROXY GRA ETHYLCEL
HYDROXY METH POW 4000
HYDROXYAMPHE POW HBR
HYDROXYANISO POW BUTYLATE
HYDROXYAPATI POW CALCIUM
HYDROXYCHLOR TAB 200MG
HYDROXYETHYL POW CELLULOS
HYDROXYETHYL POW METHACRY
HYDROXYPROG POW CAPROATE
HYDROXYPROPY POW BETA-CYC
HYDROXYQUINO CRY
HYDROXYQUINO POW SULFATE
HYDROXYUREA CAP 500MG
HYDROXYUREA POW
HYDROXYZ HCL INJ 25MG/ML
HYDROXYZ HCL INJ 50MG/ML
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
330
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HYDROXYZ HCL SOL 10MG/5ML
HYDROXYZ HCL TAB 10MG
HYDROXYZ HCL TAB 25MG
HYDROXYZ HCL TAB 50MG
HYDROXYZ PAM CAP 100MG
HYDROXYZ PAM CAP 25MG
HYDROXYZ PAM CAP 50MG
HYDROXYZINE POW HCL
HYDROXYZINE POW PAMOATE
HYFIBER WITH LIQ FOS
HYLATOPIC AER
HYLENEX INJ 150 UNIT
1
1
1
1
2
1
1
2
2
2
3
3
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
1
1
1
1
2
1
1
2
3
2
3
3
3
Non-Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
HYLIRA GEL 0.2%
HYLIRA LOT 0.1%
HYOMAX-SL SUB 0.125MG
HYOPHEN TAB
HYOSCYAMINE DRO 0.125/ML
HYOSCYAMINE ELX 0.125/5
HYOSCYAMINE POW SULFATE
HYOSCYAMINE TAB 0.125MG
HYOSCYAMINE TAB 0.375 ER
HYPERHEP B INJ S/D
HYPERLYTE-CR INJ
HYPERRAB S/D INJ 150/ML
HYPERRHO S/D INJ 300MCG
HYPERRHO S/D INJ 50MCG
HYPERSAL NEB 3.5%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
331
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
HYPER-SAL NEB 7%
HYPERTENEVID PAK 12.5MG
HYPERTENIPIN PAK 2.5MG
HYPERTENSOLO PAK
HYPERTET S/D INJ 250/ML
HYPO NEEDLE MIS 14GX1"
HYPO NEEDLE MIS 14GX1.5"
HYPO NEEDLE MIS 14GX2"
HYPO NEEDLE MIS 16GX1"
HYPO NEEDLE MIS 16GX3/4"
HYPO NEEDLE MIS 16GX5/8"
HYPO NEEDLE MIS 18GX1.5"
HYPO NEEDLE MIS 19GX1.25
HYPO NEEDLE MIS 20GX3/4"
HYPO NEEDLE MIS 21GX1.25
HYPO NEEDLE MIS 21GX2"
HYPO NEEDLE MIS 23GX1.5"
HYPO NEEDLE MIS 23GX1/2"
HYPO NEEDLE MIS 23GX3/4"
HYPO NEEDLE MIS 24GX1"
HYPO NEEDLE MIS 25GX1"
HYPO NEEDLE MIS 25GX1.25
HYPO NEEDLE MIS 25GX2"
HYPO NEEDLE MIS 25GX3/4"
HYPO NEEDLE MIS 26GX1.5"
HYPO NEEDLE MIS 26GX1/2"
HYPO NEEDLE MIS 26GX3/8"
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
3
3
3
2
2
2
2
2
2
2
3
2
2
3
2
2
2
2
2
2
2
2
2
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
332
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
HYPO NEEDLE MIS 26GX5/8"
HYPO NEEDLE MIS 27GX1.25
HYPO NEEDLE MIS 27GX1.5"
HYPO NEEDLE MIS 30GX3/4"
HYPOPHOSPHOR SOL ACID
HYPOPHOSPHOR SOL ACID 50%
HYPOTEARS SOL 1-1%
HYPOTHERM MIS CELSIUS
HYSEPT SOL 0.25%
HYSEPT SOL 0.5%
HYSKON SOL
2
3
2
2
3
3
2
3
1
1
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
HYZAAR TAB 100-12.5
3
Non-Preferred Brand
HYZAAR TAB 100-25
3
Non-Preferred Brand
HYZAAR TAB 50-12.5
3
Non-Preferred Brand
2
3
1
1
Preferred Brand
Non-Preferred Brand
Generic
Generic
IBUDONE TAB 10-200MG
3
Non-Preferred Brand
IBUPRFN LIQD CAP 200MG
IBUPROFEN CRE 10%
IBUPROFEN KIT COMFORT
1
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
I.L.X. B-12 ELX
IBANDRONATE INJ 3MG/3ML
IBANDRONATE TAB 150MG
IBU/DIPHENHY CAP 200-25MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
333
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
IBUPROFEN PM TAB 200-38MG
IBUPROFEN POW
IBUPROFEN SUS 100/5ML
IBUPROFEN TAB 400MG
IBUPROFEN TAB 600MG
IBUPROFEN TAB 800MG
IBUTILIDE INJ 1MG/10ML
IC 400 KIT 400MG
IC 800 KIT 800MG
IC GREEN INJ 25MG
1
2
1
1
1
1
1
3
3
2
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
ICAPS LUTEIN TAB ZEAXANTH
-
-
ICAPS LUTEIN TAB ZEAXANTH
-
-
ICAR CHW 15MG
ICAR PEDS SUS
2
2
Preferred Brand
Preferred Brand
ICAR-C PLUS TAB
3
Non-Preferred Brand
2
2
2
3
3
3
3
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
ICAR-C TAB
ICHTHAMMOL OIN 20%
ICHTHAMMOL POW
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
ICY HOT ADV PAD RLF 7.5%
ICY HOT CRE NATURALS
ICY HOT MIS 16%
ICY HOT MIS 7.5%
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Limited Distribution
334
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ICY HOT MIS EX ST
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Generic Available. Brand copay + the
difference between the brand and the
generic.
3
Non-Preferred Brand
ICY HOT NO- GEL MESS KID
ICY HOT PAIN GEL 2.5%
ICY HOT PM DIS 0.025-5%
ICY HOT PM LOT 7.5%
3
2
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
IDAMYCIN PFS INJ 10/10ML
3
Non-Preferred Brand
YES, Specialty Drug
IDAMYCIN PFS INJ 20/20ML
3
Non-Preferred Brand
YES, Specialty Drug
IDAMYCIN PFS INJ 5MG/5ML
3
Non-Preferred Brand
YES, Specialty Drug
IDARUBICIN INJ 10/10ML
IDARUBICIN INJ 20/20ML
IDARUBICIN INJ 5MG/5ML
IDEBENONE POW
IDOXURIDINE POW
3
3
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
3
Non-Preferred Brand
YES, Specialty Drug
3
3
3
3
3
2
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Limited Distribution
IFEX INJ 1GM
IFEX INJ 3GM
IFOSFAMIDE INJ 1GM
IFOSFAMIDE INJ 3GM
IFOSFAMIDE KIT MESNA
ILARIS INJ 180MG
ILEVRO DRO 0.3% OP
IMBRUVICA CAP 140MG
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
335
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
IMDUR TAB 120MG ER
3
Non-Preferred Brand
IMDUR TAB 30MG ER
3
Non-Preferred Brand
IMDUR TAB 60MG ER
3
Non-Preferred Brand
IMIDUREA POW
IMIPENEM/CIL INJ 250MG
IMIPENEM/CIL INJ 500MG
IMIPRAM HCL TAB 10MG
IMIPRAM HCL TAB 25MG
IMIPRAM HCL TAB 50MG
IMIPRAM PAM CAP 100MG
IMIPRAM PAM CAP 125MG
IMIPRAM PAM CAP 150MG
IMIPRAM PAM CAP 75MG
IMIPRAMINE POW HCL
IMIQUIMOD CRE 5%
IMIQUIMOD POW
2
1
1
1
1
1
1
1
1
1
2
1
2
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Preferred Brand
IMITREX SPR 20MG/ACT
3
Non-Preferred Brand
IMITREX SPR 5MG/ACT
3
Non-Preferred Brand
IMITREX TAB 100MG
3
Non-Preferred Brand
Maximum of 12
units per 30 days
IMITREX TAB 25MG
3
Non-Preferred Brand
Maximum of 12
units per 30 days
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Maximum of 12
units per 30 days
Maximum of 12
units per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
336
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Formulary Status
Special Plan Edits
3
Non-Preferred Brand
Maximum of 12
units per 30 days
IMMUNE HEALT CAP BLEND
IMODIUM A-D CHW 2MG
3
3
Non-Preferred Brand
Non-Preferred Brand
IMODIUM A-D LIQ 1MG/7.5
3
Non-Preferred Brand
IMODIUM A-D TAB 2MG
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
IMOVAX RABIE INJ 2.5/ML
2
Preferred Brand
IMPLANON IMP 68MG
-
$0 Preventative Drug
IMURAN TAB 50MG
3
Non-Preferred Brand
INATAL ADV TAB
INATAL ULTRA TAB
INCISION/ KIT DRAINAGE
INCIVEK TAB 375MG
INCRELEX INJ 40MG/4ML
INDAPAMIDE POW
INDAPAMIDE TAB 1.25MG
INDAPAMIDE TAB 2.5MG
3
3
3
3
1
1
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
INDERAL LA CAP 120MG
3
Non-Preferred Brand
IMITREX TAB 50MG
IMODIUM ADV CHW 2-125MG
IMODIUM ADV TAB
WDRx 2/23/15
Tier
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Covered Under
Medical
PA Required
PA Required
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
YES, Specialty Drug
Limited Distribution
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
337
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
INDERAL LA CAP 160MG
3
Non-Preferred Brand
INDERAL LA CAP 60MG
3
Non-Preferred Brand
INDERAL LA CAP 80MG
3
Non-Preferred Brand
3
1
3
3
3
3
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
3
1
2
2
1
1
1
2
-
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Preferred Brand
$0 ACA Drug
INDERAL XL CAP 120MG
INDERAL XL CAP 80MG
INDICLOR INJ
INDIGO CARMI INJ 8MG/ML
INDIUM IN111 INJ DTPA
INDIUM IN111 INJ OXYQUINO
INDIUM POW
INDIUM POW SULFATE
INDOCIN IV INJ 1MG
INDOCIN SUP 50MG
INDOCIN SUS 25MG/5ML
INDOCYANINE INJ 25MG
INDOCYANINE POW GREEN
INDOLE-3- POW CARBINOL
INDOMETHACIN CAP 25MG
INDOMETHACIN CAP 50MG
INDOMETHACIN CAP 75MG CR
INDOMETHACIN POW
ATLAS CONDOM MIS COLR/SPM
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
338
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
INFASURF SUS 35MG/ML
INFERGEN INJ 15MCG
INFERGEN INJ 9MCG
ATLAS CONDOM MIS LUB/COLR
INFUMORPH INJ 10MG/ML
INFUMORPH INJ 25MG/ML
INFUS SYRING MIS 100ML
3
3
3
2
2
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Preferred Brand
Preferred Brand
Non-Preferred Brand
-
-
3
3
3
3
3
2
2
3
2
1
3
3
3
3
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
INFUVITE INJ
INGROWN TOE GEL PAIN REL
INJECTAFER INJ 750/15ML
INLYTA TAB 1MG
INLYTA TAB 5MG
INOSINE POW
INOSITOL POW
INOSITOL POW HEXANICO
INOSITOL POW HEXAPHOS
INOSITOL TAB 500MG
INOSITOL TAB 650MG
INOSITOL-5 TAB 325MG
INOVA 4/1 KIT ACNE CON
INOVA 8/2 KIT ACNE CON
INOVA KIT 4%
INOVA KIT 8%
INSPIREASE MIS BAGS
INSPIREASE MIS MOUTHPCE
INSPRA TAB 25MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
-
-
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
339
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
INSPRA TAB 50MG
Tier
Formulary Status
3
Non-Preferred Brand
INSTACLEAN LIQ
INSTA-GLUCOS GEL 77.4%
INSTAT PAD 2.5X5.1
INSTRINSI TAB B12/FOL
INSUFLON MIS 25GX0.71
INSULIN BEEF CRY
2
2
3
3
2
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
INSULIN PUMP MIS PEDIATRI
-
-
INSULIN SYRG MIS 0.3/28G
INSULIN SYRG MIS 0.3/29G
INSULIN SYRG MIS 0.3/29G
INSULIN SYRG MIS 0.3/29G
INSULIN SYRG MIS 0.3/29G
INSULIN SYRG MIS 0.3/30G
INSULIN SYRG MIS 0.3/30G
INSULIN SYRG MIS 0.3/30G
INSULIN SYRG MIS 0.3/30G
INSULIN SYRG MIS 0.3/31G
INSULIN SYRG MIS 0.3/31G
INSULIN SYRG MIS 0.3/31G
INSULIN SYRG MIS 0.5/27G
INSULIN SYRG MIS 0.5/28G
INSULIN SYRG MIS 0.5/29G
INSULIN SYRG MIS 0.5/29G
INSULIN SYRG MIS 0.5/29G
INSULIN SYRG MIS 0.5/29G
-
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
340
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
INSULIN SYRG MIS 0.5/30G
INSULIN SYRG MIS 0.5/30G
INSULIN SYRG MIS 0.5/30G
INSULIN SYRG MIS 0.5/31G
INSULIN SYRG MIS 0.5/31G
INSULIN SYRG MIS 0.5/31G
INSULIN SYRG MIS 1ML
INSULIN SYRG MIS 1ML/25G
INSULIN SYRG MIS 1ML/25G
INSULIN SYRG MIS 1ML/25G
INSULIN SYRG MIS 1ML/26G
INSULIN SYRG MIS 1ML/27G
INSULIN SYRG MIS 1ML/27G
INSULIN SYRG MIS 1ML/28G
INSULIN SYRG MIS 1ML/29G
INSULIN SYRG MIS 1ML/29G
INSULIN SYRG MIS 1ML/30G
INSULIN SYRG MIS 1ML/30G
INSULIN SYRG MIS 1ML/30G
INSULIN SYRG MIS 1ML/31G
INSULIN SYRG MIS 1ML/31G
INSULIN SYRG MIS 1ML/31G
INSULIN SYRG MIS 2/27.5G
INSULIN SYRG MIS 2ML/29G
INSUL-TOTE MIS
INSUPEN SENS MIS 32GX8MM
INSUPEN ULTR MIS 30GX8MM
INTEGRA CAP
INTEGRA F CAP
3
2
3
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
341
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
INTEGRA PLUS CAP
INTEGRILIN INJ 0.75MG/1
INTEGRILIN INJ 2MG/ML
INTELENCE TAB 100MG
INTELENCE TAB 200MG
INTELENCE TAB 25MG
INTENSE COUG LIQ RELIEVER
INTENSE COUG LIQ RELIEVER
INTERARTICUL KIT JOINT
INTERCED TC7 PAD 1.5"X2"
INTERMEZZO SUB 1.75MG
INTERMEZZO SUB 3.5MG
INTRALIPID INJ 20%
3
2
2
3
3
3
1
1
3
3
3
3
1
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
3
Non-Preferred Brand
3
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
INTRALIPID INJ 30%
INTRO NEEDLE MIS 18GX1.25
INTROL SOL 75%
INTRON-A INJ 10MU
INTRON-A INJ 18MU
INTRON-A INJ 18MU
INTRON-A INJ 25MU
INTRON-A INJ 50MU
INTROVALE TAB
INTUNIV TAB 1MG
INTUNIV TAB 2MG
INTUNIV TAB 3MG
INTUNIV TAB 4MG
INULIN FIBER CAP 833.25MG
WDRx 2/23/15
2
2
2
2
3
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
PA after 25
PA after 25
PA after 25
PA after 25
342
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
INULIN INJ 100MG/ML
INVANZ INJ 1GM
INVANZ INJ 1GM
INVEGA SUST INJ 117/0.75
INVEGA SUST INJ 156MG/ML
INVEGA SUST INJ 234/1.5
INVEGA SUST INJ 39/0.25
INVEGA SUST INJ 78/0.5ML
3
2
2
3
3
3
3
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
INVEGA TAB 1.5MG
3
Non-Preferred Brand
INVEGA TAB 3MG
3
Non-Preferred Brand
INVEGA TAB 6MG
3
Non-Preferred Brand
INVEGA TAB 9MG
3
Non-Preferred Brand
3
3
Non-Preferred Brand
Non-Preferred Brand
INVOKAMET TAB 150-1000
2
Preferred Brand
INVOKAMET TAB 150-500
2
Preferred Brand
INVOKAMET TAB 50-1000
2
Preferred Brand
INVOKAMET TAB 50-500MG
2
Preferred Brand
INVIRASE CAP 200MG
INVIRASE TAB 500MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 60
per 30 days
Maximum of 30
per 30 days
YES, Specialty Drug
YES, Specialty Drug
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
343
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
INVOKANA TAB 100MG
2
Preferred Brand
INVOKANA TAB 300MG
2
Preferred Brand
3
3
3
2
2
2
2
2
3
2
2
2
3
3
1
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
IOPIDINE SOL 0.5% OP
3
Non-Preferred Brand
IOPIDINE SOL 1% OP
IOSAT TAB 130MG
IPECAC SYP
3
2
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
INZO CRE BARRIER
IODEX OIN 4.7%
IODEX/METHYL OIN SALICYLA
IODINE CRY RESUBLIM
IODINE GRA RESUBLIM
IODINE SOL STRONG
IODINE SOL STRONG
IODINE TIN STRONG
IODOFLEX PAD PAD
IODOFORM POW
IODOPEN INJ 100MCG
IODOQUINOL POW
IODOSORB GEL
IONIL SHA
IONIL-T SHA 1%
IONOSOL-B/ INJ D5W
IONOSOL-MB INJ /D5W
IOPANOIC POW ACID
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Generic Available. Brand copay + the
difference between the brand and the
generic.
344
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
BOOSTRIX INJ
IPRATROPIUM POW BROMIDE
IPRATROPIUM SOL 0.02%INH
IPRATROPIUM SPR 0.03%
IPRATROPIUM SPR 0.06%
IPRATROPIUM/ SOL ALBUTER
IPRIFLAVONE POW
IPRIVASK INJ 15MG
2
1
1
1
3
3
$0 ACA Drug
Preferred Brand
$0 Preventative Drug
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
IRBESAR/HCTZ TAB 150-12.5
1
Generic
IRBESAR/HCTZ TAB 300-12.5
1
Generic
IRBESARTAN TAB 150MG
1
Generic
IRBESARTAN TAB 300MG
1
Generic
IRBESARTAN TAB 75MG
1
Generic
IRINOTECAN INJ 100/5ML
IRINOTECAN INJ 40MG/2ML
IRINOTECAN INJ 500MG/25
IROFOL LIQ
IROFOL TAB
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
3
2
3
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
IROMIN-G TAB
IRON 21/7 MIS
IRON CHEWS CHW PEDIATRI
IRON FORMULA CAP
IRON HIGH CAP POTENCY
IRON OXIDE POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
-
-
345
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
IRON OXIDE PST BLACK
IRON OXIDE PST RED
IRON OXIDE PST YELLOW
IRON SLOW TAB 45MG
IRON TAB 18MG
IRON TAB 18MG CR
IRON TAB 28MG
IRON UP LIQ
IRON/VIT C TAB 65-125MG
IRON-150 TAB
IROSPAN 24/6 MIS
ISCAR MALI INJ 5MG/ML
ISENTRESS CHW 100MG
ISENTRESS CHW 25MG
ISENTRESS POW 100MG
ISENTRESS TAB 400MG
3
3
3
1
3
3
3
3
2
3
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ISO ATROPINE SOL 1% OP
3
Non-Preferred Brand
ISO CARBACHO SOL 1.5% OP
ISO CARBACHO SOL 3% OP
ISO HOMATROP SOL 2% OP
2
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ISO HOMATROP SOL 5% OP
3
Non-Preferred Brand
ISO HYOSCINE SOL 0.25% OP
ISO-BLU LIQ 50%
ISODITRATE TAB 40MG ER
ISOFLAVONE POW COMPOUND
ISOFLUPREDON POW ACETATE
3
3
1
3
3
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
346
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ISOFLURANE SOL
ISOLEUCINE PAK 50MG
ISOLEUCINE POW 1000
ISOLYTE-M INJ /D5W
ISOLYTE-P INJ /D5W
ISOLYTE-S INJ
ISOLYTE-S INJ PH 7.4
ISOMETH/APAP CAP DICHLOR
ISOMETHEPTEN POW MUCATE
ISONIAZID INJ 100MG/ML
ISONIAZID POW
ISONIAZID SYP 50MG/5ML
ISONIAZID TAB 100MG
ISONIAZID TAB 300MG
ISOP ALCOHOL GEL 70%
ISOP ALCOHOL SOL 50%
ISOP ALCOHOL SOL 70%
ISOP ALCOHOL SOL 91%
ISOP ALCOHOL SOL 99%
ISOPROPAMIDE POW IODIDE
ISOPROPYL LIQ PALMITAT
ISOPROPYL SOL ALCOHOL
ISOPROPYL SOL MYRISTAT
ISOPROTEREN POW SULFATE
ISOPROTERENO POW HCL
1
2
3
1
2
2
2
1
2
2
2
2
1
1
3
2
2
2
3
2
2
3
2
2
2
Generic
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
ISOPTO CARP SOL 1% OP
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
347
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ISOPTO CARP SOL 2% OP
3
Non-Preferred Brand
ISOPTO CARP SOL 4% OP
3
Non-Preferred Brand
ISOPTO TEARS SOL 0.5% OP
ISORDIL TAB 40MG
2
3
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
2
1
1
1
1
1
1
1
1
2
3
1
3
3
3
2
3
3
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ISORDIL TAB 5MG
ISOREL CAP 250MG
ISOSORB DIN SUB 2.5MG
ISOSORB DIN TAB 10MG
ISOSORB DIN TAB 20MG
ISOSORB DIN TAB 5MG
ISOSORB MONO TAB 10MG
ISOSORB MONO TAB 120MG ER
ISOSORB MONO TAB 20MG
ISOSORB MONO TAB 30MG ER
ISOSORB MONO TAB 60MG ER
ISOSORBIDE POW
ISOSORBIDE POW DIMETHYL
ISOSULFAN INJ BLUE 1%
ISOTRETINOIN POW
ISOVUE-200 INJ 41%
ISOVUE-250 INJ 51%
ISOVUE-300 INJ 61%
ISOVUE-370 INJ 76%
ISOVUE-M 200 INJ 41%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
348
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ISOVUE-M 300 INJ 61%
ISOXSUPRINE POW HCL
ISOXSUPRINE TAB 10MG
ISOXSUPRINE TAB HCL 20MG
ISRADIPINE CAP 2.5MG
ISRADIPINE CAP 5MG
ISTALOL SOL 0.5% OP
ISTODAX INJ 10MG
ISUPREL INJ 0.2MG/ML
ITCH-X GEL 1-10%
ITCH-X SPR
ITRACONAZOLE CAP 100MG
ITRACONAZOLE POW
IV PREP WIPE PAD
IVAREST MED LIQ FOAM
IVAREST POIS CRE IVY ITCH
IVERMECTIN POW
IVY BLOCK LOT 5%
IVY DRY CRE
IVY DRY LIQ SUPER
IVY DRY LOT
IVY WASH LOT 1%
IVY-RID AER
IXEMPRA KIT INJ 15MG
IXEMPRA KIT INJ 45MG
IXIARO INJ
J&J EYE PAD SM OVAL
J&J HVY BACK MIS PLASTER
JAKAFI TAB 10MG
2
2
1
2
2
2
3
3
3
2
2
1
2
2
3
3
2
3
3
3
3
3
3
3
3
2
3
3
3
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Limited Distribution
349
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
JAKAFI TAB 5MG
JALYN CAP
JANTOVEN TAB 10MG
JANTOVEN TAB 1MG
JANTOVEN TAB 2.5MG
JANTOVEN TAB 2MG
JANTOVEN TAB 3MG
JANTOVEN TAB 4MG
JANTOVEN TAB 5MG
JANTOVEN TAB 6MG
JANTOVEN TAB 7.5MG
3
3
3
3
3
-
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
JANUMET TAB 50-1000
2
Preferred Brand
JANUMET TAB 50-500MG
2
Preferred Brand
JANUMET XR TAB 100-1000
2
Preferred Brand
JANUMET XR TAB 50-1000
2
Preferred Brand
JANUMET XR TAB 50-500MG
2
Preferred Brand
JANUVIA TAB 100MG
2
Preferred Brand
JANUVIA TAB 25MG
2
Preferred Brand
JANUVIA TAB 50MG
2
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 30
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
350
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
JARDIANCE TAB 10MG
2
Preferred Brand
JARDIANCE TAB 25MG
2
Preferred Brand
JASMINE LIQ FRAGRANC
JASMINE OIL
J-COF DHC LIQ
JELENE OIN
2
3
3
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
JENTADUETO TAB 2.5-1000
2
Preferred Brand
JENTADUETO TAB 2.5-500
2
Preferred Brand
JENTADUETO TAB 2.5-850
2
Preferred Brand
JESSNERS SOL
JETREA INJ 2.5MG/ML
JEVTANA INJ 60/1.5ML
JH MCLEANS LIQ VOLCANIC
3
3
3
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
JINTELI TAB 1MG-5MCG
2
Preferred Brand
J-MAX DHC LIQ
J-MAX SYP 5-200MG
JOHNSON BABY GEL OIL
JOHNSONS CRE BABY
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Step Therapy
Required,
Maximum of 60
per 30 days
Step Therapy
Required,
Maximum of 60
per 30 days
Step Therapy
Required,
Maximum of 60
per 30 days
Limited Distribution
YES, Specialty Drug
Maximum of30per
30 days
351
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
JOHNSONS MIS BALM
JOINT HEALTH TAB
JOINTFLEX CRE 3.1%
JOINTFLEX LOT 8.5%
JOJOBA OIL
J-TAN D PD DRO 1-7.5MG
J-TAN PD DRO 1MG/ML
J-TIP KIT KIT ADAPTERS
JUBLIA SOL 10%
JUNIPER TAR OIL
3
3
3
3
2
3
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
JUVISYNC TAB 100-10MG
2
Preferred Brand
JUVISYNC TAB 100-20MG
2
Preferred Brand
JUVISYNC TAB 100-40MG
2
Preferred Brand
JUVISYNC TAB 50-10MG
2
Preferred Brand
JUVISYNC TAB 50-20MG
2
Preferred Brand
JUVISYNC TAB 50-40MG
2
Preferred Brand
JUXTAPID CAP 10MG
JUXTAPID CAP 20MG
JUXTAPID CAP 5MG
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
K 100 TAB 100MCG
-
-
K2 & D3 CAP 45/2000
-
-
WDRx 2/23/15
Special Plan Edits
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
PA Required
PA Required
PA Required
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
Limited Distribution
Limited Distribution
-
-
-
-
352
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
K-99 CAP
KADCYLA INJ 100MG
KADCYLA INJ 160MG
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
KADIAN CAP 100MG CR
3
Non-Preferred Brand
KADIAN CAP 10MG CR
3
Non-Preferred Brand
KADIAN CAP 130MG CR
KADIAN CAP 150MG CR
KADIAN CAP 200MG CR
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
KADIAN CAP 20MG CR
3
Non-Preferred Brand
KADIAN CAP 30MG CR
3
Non-Preferred Brand
KADIAN CAP 40MG CR
3
Non-Preferred Brand
KADIAN CAP 50MG CR
3
Non-Preferred Brand
KADIAN CAP 60MG CR
3
Non-Preferred Brand
KADIAN CAP 70MG CR
3
Non-Preferred Brand
KADIAN CAP 80MG CR
3
Non-Preferred Brand
KALBITOR INJ 10MG/ML
KALETRA SOL
KALETRA TAB 100-25MG
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
YES, Specialty Drug
YES, Specialty Drug
353
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
1
3
2
2
2
3
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
2
2
3
2
3
1
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
KAZ VAPORIZR MIS 1 GALLON
KAZ VAPORIZR MIS 1.5 GAL
2
3
Preferred Brand
Non-Preferred Brand
KAZANO 12.5- TAB 1000MG
3
Non-Preferred Brand
KAZANO 12.5- TAB 500MG
3
Non-Preferred Brand
3
Non-Preferred Brand
KALETRA TAB 200-50MG
KALEXATE POW
KALYDECO TAB 150MG
KANAMYCIN INJ 333MG/ML
KANAMYCIN POW SULFATE
KAOLIN POW
KAPVAY MIS 0.1&0.2
KAPVAY TAB 0.1 MG
KARAYA GUM
KARAYA GUM POW
KARBINAL ER SUS 4MG/5ML
KARBOZYME TAB EC
KAVA KAVA CAP 200MG
KAVA KAVA CAP 425MG
KAVA KAVA POW ROOT
KAVA KAVA RT CAP 1000MG
KAYEXALATE POW
K-BICARB CAP 99MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
PA Required
Limited Distribution
PA after 25
PA after 25
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
354
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
KCENTRA KIT 1000UNIT
KCENTRA KIT 500UNIT
KCL IN NACL INJ
KCL IN NACL INJ .15-0.45
KCL/D5W INJ 0.15%
KCL/D5W INJ 0.3%
KCL/D5W/LR INJ 0.15%
KCL/D5W/LR INJ 0.3%
KCL/D5W/NACL INJ .075/.45
KCL/D5W/NACL INJ .15-.45%
KCL/D5W/NACL INJ .15/.33%
KCL/D5W/NACL INJ .22/.45
KCL/D5W/NACL INJ 0.3/0.45
KCL/D5W/NACL INJ 0.3/0.9%
3
3
1
2
1
1
2
2
1
1
1
1
1
2
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
KEFLEX CAP 250MG
3
Non-Preferred Brand
KEFLEX CAP 500MG
3
Non-Preferred Brand
KEFLEX CAP 750MG
3
Non-Preferred Brand
3
1
3
2
3
2
$0 Preventative Drug
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
KELNOR TAB 1/35
KELO-COTE AER
KELP TAB 0.15MG
KELP TAB 100MG
KELP/LEC/B6 CAP
KENALOG AER SPRAY
KENALOG-10 INJ 10MG/ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
355
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
KENALOG-40 INJ 40MG/ML
KEND SCALPEL MIS SIZE 10
KEPIVANCE INJ 6.25MG
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
KEPPRA INJ 500/5ML
3
Non-Preferred Brand
KEPPRA SOL 100MG/ML
3
Non-Preferred Brand
KEPPRA TAB 1000MG
3
Non-Preferred Brand
KEPPRA TAB 250MG
3
Non-Preferred Brand
KEPPRA TAB 500MG
3
Non-Preferred Brand
KEPPRA TAB 750MG
3
Non-Preferred Brand
KEPPRA XR TAB 500MG
3
Non-Preferred Brand
KEPPRA XR TAB 750MG
3
Non-Preferred Brand
KERAFOAM 42 AER 42%
KERAFOAM AER 30%
KERALAC CRE 47%
KERALYT GEL 3%
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
356
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
KERALYT GEL 6%
Tier
Formulary Status
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
2
2
Preferred Brand
Preferred Brand
KERLONE TAB 10MG
3
Non-Preferred Brand
KERLONE TAB 20MG
3
Non-Preferred Brand
3
3
Non-Preferred Brand
Non-Preferred Brand
KETALAR INJ 100MG/ML
3
Non-Preferred Brand
KETALAR INJ 10MG/ML
3
Non-Preferred Brand
KETALAR INJ 50MG/ML
3
Non-Preferred Brand
KETAMINE HCL POW
KETAMINE INJ 100MG/ML
KETAMINE INJ 10MG/ML
KETAMINE INJ 50MG/ML
KETEK TAB 300MG
KETEK TAB 400MG
2
1
1
1
3
3
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
KERALYT KIT SCALP 6%
KERASAL OIN 5-10%
KERLIX SPONG PAD EX LARGE
KERLIX SPONG PAD LARGE
KERR TRIPLE MIS DYE SWAB
KERYDIN SOL 5%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
357
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
KETOCONAZOLE AER 2%
KETOCONAZOLE CRE 2%
KETOCONAZOLE POW
KETOCONAZOLE SHA 2%
KETOCONAZOLE TAB 200MG
KETODAN KIT 2%
KETOGLUTARIC POW ACID
KETOPROFEN CAP 200MG ER
KETOPROFEN CAP 50MG
KETOPROFEN CAP 75MG
KETOPROFEN CRE 5% KIT
KETOPROFEN POW
KETOROLAC INJ 15MG/ML
KETOROLAC INJ 60MG/2ML
KETOROLAC POW TROMETHA
KETOROLAC SOL 0.4%
KETOROLAC SOL 0.5%
KETOROLAC TAB 10MG
KETOTIFEN POW FUMARATE
KEY OMEGA POW
KEY-E CHW 400UNIT
KIDNEY BEAN CAP 500MG
K-III SOL POWDER
CONDOMS MIS
KINERASE CRE 0.1%
KINERASE CRE 0.125%
KINERASE LOT 0.1%
WDRx 2/23/15
Tier
Formulary Status
1
1
2
1
1
2
2
2
1
1
3
2
1
1
2
1
1
Generic
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
1
Generic
2
3
Preferred Brand
Non-Preferred Brand
-
-
3
3
2
2
2
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Preferred Brand
Preferred Brand
Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
Maximum of 20
per 30 days
Not a covered
benefit
358
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
3
2
2
3
1
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Generic
Preferred Brand
PA Required
3
Non-Preferred Brand
KLATSKIN BIO MIS 16X4"
KLB6 CAP
3
3
Non-Preferred Brand
Non-Preferred Brand
KLONOPIN TAB 0.5MG
3
Non-Preferred Brand
KLONOPIN TAB 1MG
3
Non-Preferred Brand
KLONOPIN TAB 2MG
3
Non-Preferred Brand
1
1
1
2
1
1
3
3
3
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
KINERET INJ
KINETIN POW
KINEVAC INJ 5MCG
KINLYTIC INJ 250000
DECAVAC INJ 5-2LF
KIONEX SUS 15GM/60
KIWI LIQ FRAGRANC
KLARON LOT 10%
KLOR-CON 10 TAB 10MEQ ER
KLOR-CON 8 TAB 8MEQ ER
KLOR-CON M10 TAB 10MEQ ER
KLOR-CON M15 TAB
KLOR-CON M20 TAB 20MEQ ER
KLOR-CON POW 20MEQ
KLOR-CON-25 POW 25MEQ
KLOUT SHA
K-MAG ASPART TAB
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
359
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
K-MAG CAP 40-40MG
K-MAG-70 CAP
KOGENATE FS INJ 1000/BS
KOGENATE FS INJ 2000/BS
KOGENATE FS INJ 250/BS
KOGENATE FS INJ 3000/BS
KOGENATE FS INJ 500/BS
KOJIC ACID POW
KOLA NUT POW
3
3
3
3
3
3
3
2
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
KOMBIGLYZE TAB 2.5-1000
2
Preferred Brand
KOMBIGLYZE TAB 5-1000MG
2
Preferred Brand
KOMBIGLYZE TAB 5-500MG
2
Preferred Brand
KONDREMUL EMU 50%
KONJAC ROOT CAP 1000MG
KONSYL POW 100%
KONSYL POW 100%
KONSYL POW 28.3%
KONSYL POW 60.3%
KONSYL POW 71.67%
KONSYL-D POW 52.3%
KOREAN CAP GINSENG
KOREAN GINSE TAB 1000MG
KORLYM TAB 300MG
KP MELATONIN TAB 3MG
KP SILICONE MIS SCAR THP
2
3
2
2
2
2
2
2
3
3
3
1
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
KP VITAMIN E CAP 100UNIT
-
-
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Maximum of 60
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Limited Distribution
Not a covered
benefit
-
-
360
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
K-PHOS TAB
K-PHOS TAB NEUTRAL
K-PHOS TAB NO 2
KPN PRENATAL TAB
KREBS MAG- TAB POTASSIU
KRILL OIL CAP 1000MG
KRILL OIL CAP 1500MG
KRIS-ESTER LIQ 236
KRISGEL 100 GEL
KRISTALOSE PAK 10GM
KRISTALOSE PAK 20GM
KRN GINSENG CAP 520MG
KRN GINSENG CAP COMPLEX
KRYSTEXXA INJ 8MG/ML
2
2
3
3
3
3
3
2
3
3
2
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
3
3
3
3
3
3
3
2
2
-
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
K-TAB TAB 10MEQ CR
K-TAB TAB 20MEQ
KUVAN POW 100MG
KUVAN TAB 100MG
K-Y LIQUIBDS SUP
K-Y LONG CRE LASTING
K-Y SILK-E GEL
KYNAMRO INJ 200MG/ML
KYPROLIS SOL 60MG
L-5-METHYLTE POW HYDROFOL
LABETALOL INJ 5MG/ML
LABETALOL POW
LABETALOL TAB 100MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Limited Distribution
PA Required
YES, Specialty Drug
361
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LABETALOL TAB 200MG
LABETALOL TAB 300MG
-
$0 Preventative Drug
$0 Preventative Drug
LAC-HYDRIN CRE 12%
3
Non-Preferred Brand
LAC-HYDRIN LOT 12%
3
Non-Preferred Brand
LACRISERT MIS 5MG OP
3
Non-Preferred Brand
LACTA/CARE LIQ CHOCOLAT
-
-
LACTAID CHW 4500 ES
LACTAID FAST CHW 9000UNIT
3
2
Non-Preferred Brand
Preferred Brand
LACTAID FAST TAB 9000UNIT
3
Non-Preferred Brand
LACTAID TAB 3000UNIT
LACTASE 5000 POW
LACTATED RIN INJ
LACTATED RIN SOL IRRIGAT
LACTIC ACID CRE /VIT E
LACTIC ACID LOT 10%
LACTIC ACID SOL
LACTIC ACID SOL 85% USP
2
2
1
1
1
1
2
3
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
2
2
3
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
LACTICARE LOT 5%
LACTINEX CHW
LACTINEX GRA
LACTO-BIFIDU CAP -600
LACTOSE POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
362
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
2
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
LAMICTAL CHW 25MG
3
Non-Preferred Brand
LAMICTAL CHW 2MG
3
Non-Preferred Brand
LAMICTAL CHW 5MG
3
Non-Preferred Brand
LAMICTAL KIT START 35
LAMICTAL KIT START 49
LAMICTAL KIT START 98
LAMICTAL ODT KIT
LAMICTAL ODT KIT
LAMICTAL ODT KIT
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
LAMICTAL ODT TAB 100MG
3
Non-Preferred Brand
LAMICTAL ODT TAB 200MG
3
Non-Preferred Brand
LAMICTAL ODT TAB 25MG
3
Non-Preferred Brand
LAMICTAL ODT TAB 50MG
3
Non-Preferred Brand
LAMICTAL TAB 100MG
3
Non-Preferred Brand
LAMICTAL TAB 150MG
3
Non-Preferred Brand
LACTOSE POW ANHYDROU
LACTOSE POW MONOHYDR
LACTRASE CAP 250MG
LACTULOSE POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
363
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
LAMICTAL TAB 200MG
3
Non-Preferred Brand
LAMICTAL TAB 25MG
3
Non-Preferred Brand
LAMICTAL XR KIT
LAMICTAL XR KIT
LAMICTAL XR KIT
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
LAMICTAL XR TAB 100MG
3
Non-Preferred Brand
Maximum of30per
30 days
LAMICTAL XR TAB 200MG
3
Non-Preferred Brand
Maximum of30per
30 days
LAMICTAL XR TAB 250MG
3
Non-Preferred Brand
Maximum of30per
30 days
LAMICTAL XR TAB 25MG
3
Non-Preferred Brand
Maximum of30per
30 days
LAMICTAL XR TAB 300MG
3
Non-Preferred Brand
Maximum of30per
30 days
LAMICTAL XR TAB 50MG
3
Non-Preferred Brand
Maximum of30per
30 days
LAMISIL ADV GEL 1%
LAMISIL AT CRE 1%
LAMISIL AT POW
LAMISIL AT SPR 1%
LAMISIL GRA 125MG
2
2
3
2
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
364
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LAMISIL GRA 187.5MG
LAMISIL SPR 1%
2
3
Preferred Brand
Non-Preferred Brand
LAMISIL TAB 250MG
3
Non-Preferred Brand
LAMISILK LIQ CLEANSE
LAMIVUD/ZIDO TAB 150-300
LAMIVUDINE TAB 100MG
LAMIVUDINE TAB 150MG
LAMIVUDINE TAB 300MG
LAMOTRIGINE CHW 25MG
LAMOTRIGINE CHW 5MG
LAMOTRIGINE POW
LAMOTRIGINE TAB 100MG
3
3
3
3
3
1
1
2
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
LAMOTRIGINE TAB 100MG ER
1
Generic
1
1
Generic
Generic
LAMOTRIGINE TAB 200MG ER
1
Generic
LAMOTRIGINE TAB 250MG ER
1
Generic
1
Generic
LAMOTRIGINE TAB 25MG ER
1
Generic
LAMOTRIGINE TAB 300MG ER
1
Generic
LAMOTRIGINE TAB 50MG ER
1
Generic
LANACANE AER ANTIBACT
LANACANE CRE
1
3
Generic
Non-Preferred Brand
LAMOTRIGINE TAB 150MG
LAMOTRIGINE TAB 200MG
LAMOTRIGINE TAB 25MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
365
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LANACANE CRE 20-0.2%
LANOLIN ANHY OIN
LANOLIN HYDR OIN GRX 72%
LANOLIN MIS ALCOHOL
LANOLIN OIL
LANOLIN OIN ALCOHOL
LANOLIN POW ALCOHOL
1
2
3
2
2
2
3
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
2
3
Preferred Brand
Non-Preferred Brand
LANOXIN TAB 0.125MG
3
Non-Preferred Brand
LANOXIN TAB 0.1875MG
3
Non-Preferred Brand
LANOXIN TAB 0.25MG
3
Non-Preferred Brand
1
1
2
2
1
2
2
3
1
Generic
Generic
Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
LANOXIN INJ 0.25MG/1
LANOXIN PED INJ 0.1MG/ML
LANOXIN TAB 0.0625MG
LANSOPR/AMOX MIS /CLARITH
LANSOPRAZOLE CAP 30MG DR
LANSOPRAZOLE POW
LANSOPRAZOLE SUS 3MG/ML
LANTUS INJ 100/ML
LANTUS INJ SOLOSTAR
L-ARGININE- CAP 500
L-ARGININE POW
L-ARGININE POW
L-ARGININE POW HCL
L-ARGININE TAB 1000MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
366
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
Non-Preferred Brand
LASIX TAB 20MG
3
Non-Preferred Brand
LASIX TAB 40MG
3
Non-Preferred Brand
LASIX TAB 80MG
3
Non-Preferred Brand
2
3
3
1
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
LATISSE SOL 0.03%
-
-
LATRIX SUS 50%
LATRIX XM EMU 45%
1
2
Generic
Preferred Brand
LATUDA TAB 120MG
2
Preferred Brand
LATUDA TAB 20MG
2
Preferred Brand
LATUDA TAB 40MG
2
Preferred Brand
LATUDA TAB 60MG
2
Preferred Brand
LATUDA TAB 80MG
2
Preferred Brand
3
2
2
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
LARTUS LIQ
L-ASPARTIC POW
L-ASPARTIC POW SODIUM
LASTACAFT SOL 0.25%
LATANOPROST SOL 0.005%
LAURETH-4 POW
LAURETH-9 LIQ POLIDOCA
LAURIC ACID POW
LAVARE WOUND GEL WASH
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
367
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LAVENDER OIL
LAVOCLEN-4 KIT ACNE WSH
LAVOCLEN-4 LIQ CREM WSH
LAVOCLEN-8 KIT ACNE WSH
LAVOCLEN-8 LIQ CREM WSH
LAX DIET SUP TAB 500MG
LAXATIVE TAB 15MG
LAZANDA SPR 100MCG
LAZANDA SPR 400MCG
LAZERCREME CRE
L-CARNITINE CAP 250MG
L-CARNITINE CAP 500MG
L-CARNITINE LIQ
L-CARNITINE LIQ 1500-10
L-CARNITINE POW
L-CARNITINE TAB 250MG
L-CARNITINE TAB 500
L-CITRULLINE CAP 600MG
L-CITRULLINE POW
L-CYSTEINE POW
L-CYSTEINE POW HCL
L-CYSTEINE POW MONO HCL
L-CYSTEINE TAB 500MG
L-CYSTINE POW
LDL BENEFIT CAP 25-600MG
LEAD ACETATE POW TRIHYDRA
LEAD OXIDE POW
LEAD TETROXI POW 99%
LEC/KELP/B-6 CAP VINEGAR
2
1
2
1
2
1
1
3
3
1
1
1
3
3
3
3
3
2
2
2
2
3
3
2
3
2
3
2
3
Preferred Brand
Generic
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
PA Required
PA Required
368
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LEC/KELP/B-6 TAB VINEGAR
LECITHIN CAP 400MG
LECITHIN GEL
LECITHIN GRA
LECITHIN GRA
LECITHIN GRA
LECITHIN IN OIL SOYA
LECITHIN SOY POW
LECITHIN/KEL TAB B-6
LEFLUNOMIDE POW
LEFLUNOMIDE TAB 10MG
LEFLUNOMIDE TAB 20MG
LEMON BALM POW
LEMON OIL
LENZAGEL GEL 4-1%
3
2
2
2
2
2
3
3
3
3
1
1
3
2
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
LESCOL CAP 20MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
LESCOL CAP 40MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
LESCOL XL TAB 80MG
-
$0 Preventative Drug
LETAIRIS TAB 10MG
LETAIRIS TAB 5MG
LETROZOLE POW
LETROZOLE TAB 2.5MG
LETS KIT
LEUCINE PAK 100MG
LEUCINE POW
3
3
2
1
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Maximum of 30
per 30 days
PA Required
PA Required
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Limited Distribution
369
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LEUCOVOR CA INJ 100MG
LEUCOVOR CA INJ 10MG/ML
LEUCOVOR CA INJ 200MG
LEUCOVOR CA INJ 350MG
LEUCOVOR CA INJ 50MG
LEUCOVOR CA TAB 10MG
LEUCOVOR CA TAB 15MG
LEUCOVOR CA TAB 25MG
LEUCOVOR CA TAB 5MG
LEUCOVORIN INJ CALCIUM
LEUKERAN TAB 2MG
LEUKINE INJ 250MCG
LEUKINE INJ 500 MCG
LEUPROLIDE INJ 1MG/0.2
LEUPROLIDE POW ACETATE
LEVACET TAB
LEVALBUTEROL NEB 0.31MG
LEVALBUTEROL NEB 0.63MG
LEVALBUTEROL NEB 1.25/0.5
LEVALBUTEROL NEB 1.25MG
LEVALBUTEROL POW HCL
LEVAMISOLE POW HCL
1
2
1
1
1
2
2
1
1
2
2
3
3
3
2
2
1
1
1
1
3
2
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
LEVAQUIN SOL 25MG/ML
3
Non-Preferred Brand
LEVAQUIN TAB 250MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
370
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LEVAQUIN TAB 500MG
3
Non-Preferred Brand
LEVAQUIN TAB 750MG
3
Non-Preferred Brand
LEVAQUIN/D5W INJ 250/50ML
3
Non-Preferred Brand
LEVAQUIN/D5W INJ 500/100M
3
Non-Preferred Brand
LEVAQUIN/D5W INJ 750/150
3
Non-Preferred Brand
LEVATOL TAB 20MG
3
Non-Preferred Brand
LEVBID TAB 0.375 ER
3
Non-Preferred Brand
2
2
3
3
3
2
1
1
1
1
1
1
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
LEVEMIR INJ
LEVEMIR INJ FLEXPEN
LEVETIRACETA INJ 10MG/ML
LEVETIRACETA INJ 15MG/ML
LEVETIRACETA INJ 5MG/ML
LEVETIRACETA POW
LEVETIRACETA SOL 100MG/ML
LEVETIRACETA TAB 1000MG
LEVETIRACETA TAB 250MG
LEVETIRACETA TAB 500MG
LEVETIRACETA TAB 500MG ER
LEVETIRACETA TAB 750MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
371
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LEVETIRACETA TAB 750MG ER
LEVETIRACETM INJ 500/5ML
LEVITRA TAB 10MG
LEVITRA TAB 2.5MG
LEVITRA TAB 20MG
LEVITRA TAB 5MG
LEVOBUNOLOL SOL 0.25% OP
LEVOBUNOLOL SOL 0.5% OP
LEVOCARNITIN INJ 200MG/ML
LEVOCARNITIN SOL 1GM/10ML
LEVOCARNITIN TAB 330MG
LEVOCETIRIZI POW DHCL
LEVOCETIRIZI SOL 2.5/5ML
LEVOCETIRIZI TAB 5MG
LEVODOPA POW
LEVOFLOX/D5W INJ 250/50ML
LEVOFLOX/D5W INJ 500/100M
LEVOFLOX/D5W INJ 750/150
LEVOFLOXACIN INJ 25MG/ML
LEVOFLOXACIN POW
LEVOFLOXACIN POW HEMIHYDR
LEVOFLOXACIN SOL 0.5%
LEVOFLOXACIN SOL 25MG/ML
LEVOFLOXACIN TAB 250MG
LEVOFLOXACIN TAB 500MG
LEVOFLOXACIN TAB 750MG
LEVOMEFOLATE CAP DHA
LEVOMEFOLATE MIS
LEVOMEFOLATE POW CALCIUM
1
1
3
3
3
3
2
1
1
1
1
2
1
1
2
1
1
1
1
2
2
1
1
1
1
1
3
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
10 per 30 days
10 per 30 days
10 per 30 days
10 per 30 days
372
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
LEVSIN/SL SUB 0.125MG
3
Non-Preferred Brand
LEVULAN KERA SOL 20%
3
Non-Preferred Brand
LEVONORGESTR TAB 0.75MG
LEVONORGESTR TAB 1.5MG
LEVOPHED INJ 1MG/ML
LEVORPHANOL POW TARTRATE
LEVORPHANOL TAB 2MG
LEVOTHROID TAB 100MCG
LEVOTHROID TAB 112MCG
LEVOTHROID TAB 125MCG
LEVOTHROID TAB 137MCG
LEVOTHROID TAB 150MCG
LEVOTHROID TAB 175MCG
LEVOTHROID TAB 200MCG
LEVOTHROID TAB 25MCG
LEVOTHROID TAB 300MCG
LEVOTHROID TAB 50MCG
LEVOTHROID TAB 75MCG
LEVOTHROID TAB 88MCG
LEVOTHYROXIN INJ 100MCG
LEVOTHYROXIN INJ 200MCG
LEVOTHYROXIN INJ 500MCG
LEVOTHYROXIN POW SODIUM
LEVSIN INJ 0.5MG/ML
LEVSIN TAB 0.125MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
373
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
LEXAPRO SOL 5MG/5ML
Tier
Formulary Status
3
Non-Preferred Brand
LEXAPRO TAB 10MG
3
Non-Preferred Brand
LEXAPRO TAB 20MG
3
Non-Preferred Brand
LEXAPRO TAB 5MG
3
Non-Preferred Brand
-
-
2
3
3
3
2
2
2
1
2
2
2
2
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
LEXINAL TAB 2500MCG
LEXISCAN INJ 0.4MG
LEXIVA SUS 50MG/ML
LEXIVA TAB 700MG
L-GLUTAMIC POW
L-GLUTAMIC POW ACID
L-GLUTAMIC POW ACID HCL
L-GLUTAMINE POW
L-GLUTAMINE TAB 500MG
L-GLUTATHION CRY
L-HISTIDINE CRY MONOHYDR
L-HISTIDINE POW
L-HISTIDINE POW MONOHYDR
LIALDA TAB 1.2GM
LIBRAX CAP 5-2.5MG
LICE B GONE KIT
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
374
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LICE B GONE SHA
LICE CURE SOL
LICE KILLING SHA 0.33-4%
LICE TRTMNT LIQ
LICE TRTMNT LIQ 1%
LICIDE TREAT KIT
LICORICE EXT FLUIDEXT
LICORICE POW DEGLYCY
LICORICE POW ROOT
LID SCRUB KIT
LID SCRUB LIQ ORIGINAL
LIDAZONE CRE
LIDO/DEXTROS INJ 5-7.5%
LIDO/EPI 1%- INJ 1:100000
LIDO/EPI INJ 0.5%
LIDO/EPI INJ 1.5%
LIDO/EPI INJ 2%
LIDO/EPI INJ 2%
LIDO/EPI INJ 2%
LIDO/PRILOCN CRE 2.5-2.5%
LIDO/PRILOCN KIT 2.5-2.5%
LIDOCAIN/D5W INJ 4MG/ML
LIDOCAIN/D5W INJ 8MG/ML
LIDOCAINE CRE 10%
LIDOCAINE CRE 3%
LIDOCAINE CRE 5%
LIDOCAINE CRY
LIDOCAINE GEL 2%
LIDOCAINE INJ 0.5%
3
3
1
1
1
3
3
2
2
2
3
1
2
1
1
1
1
1
1
1
2
1
1
3
1
3
2
1
1
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
375
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LIDOCAINE INJ 0.5%
LIDOCAINE INJ 1%
LIDOCAINE INJ 1%
LIDOCAINE INJ 1.5%
LIDOCAINE INJ 10MG/ML
LIDOCAINE INJ 2%
LIDOCAINE INJ 2%
LIDOCAINE INJ 20MG/ML
LIDOCAINE INJ 4%
LIDOCAINE LOT 3%
LIDOCAINE OIN 5%
LIDOCAINE PAD 5%
LIDOCAINE POW
LIDOCAINE POW HCL
LIDOCAINE SOL 2% VISC
LIDOCAINE SOL 4%
LIDOCAINE SOL 4%
LIDOCAINE/HC KIT 3%-0.5%
LIDOCAINE/HC KIT 3%-1%
LIDOCAINE/HC KIT 3-2.5%
1
1
1
1
2
1
1
1
1
2
1
1
2
2
1
1
1
1
1
1
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
3
Non-Preferred Brand
2
3
2
3
3
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
LIDODERM DIS 5%
LIDO-HYDRO GEL 2.8-0.55
LIDOLOG KIT
LIDOPRO OIN
LIDOPROFEN CRE 5-5-2%
LIDORX GEL 3%
LIDOVIR OIN 4-4%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
PA Required
PA Required
Generic Available. Brand copay + the
difference between the brand and the
generic.
376
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LIMBREL CAP 250MG
-
-
LIMBREL CAP 500MG
-
-
LIMBREL250 CAP 250-50MG
-
-
LIMBREL500 CAP 500-50MG
-
-
2
2
3
3
2
1
3
1
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
LINK ASSIST MIS ACCU-CHK
-
-
LINOLEIC ACD POW MTHYL ES
LINOLEIC LIQ ACID
LINOLENIC LIQ ACID
LINOLENIC LIQ ACID 55%
LINSEED OIL
LINSEED OIL RAW
LINZESS CAP 145MCG
LINZESS CAP 290MCG
LIORESAL INT INJ 0.05MG/1
LIORESAL INT INJ 10MG/20
LIORESAL INT INJ 10MG/5ML
3
2
3
3
3
2
2
2
3
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
LIME OIL
LIMONENE LIQ
LINALYL LIQ ACETATE
LINCOCIN INJ 300MG/ML
LINCOMYCIN POW HCL
LINDANE LOT 1%
LINDANE POW 99%
LINDANE SHA 1%
LINI MIST AER ANALGES
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
377
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LIORESAL INT INJ 40MG/20
LIOTHYRONINE INJ 10MCG/ML
LIOTHYRONINE POW
LIOTHYRONINE POW SODIUM
LIOTHYRONINE TAB 25MCG
LIOTHYRONINE TAB 50MCG
LIOTHYRONINE TAB 5MCG
LIP BALM OIN NATURAL
LIP MOISTURE MIS SPF15
LIPACTIVE IN LIQ INCHI WO
LIPASE POW PORCINE
3
1
2
2
1
1
1
3
2
3
3
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
LIPITOR TAB 10MG
3
Non-Preferred Brand
LIPITOR TAB 20MG
3
Non-Preferred Brand
LIPITOR TAB 40MG
3
Non-Preferred Brand
LIPITOR TAB 80MG
3
Non-Preferred Brand
LIPMAX SOL
LIPOCHOL NR CAP
LIPOCHOL TAB PLUS
LIPOFEN CAP 150MG
LIPOFEN CAP 50MG
LIPOFOAM RX AER
LIPO-GEL CAP
2
2
3
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
378
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LIPOIC ACID CAP 150MG
LIPOIL OIL
LIPOSYN III INJ 10%
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
LIPOSYN III INJ 20%
3
Non-Preferred Brand
LIPOSYN III INJ 30%
1
Generic
LIPOTRIAD TAB
-
-
2
Preferred Brand
LIPTRUZET TAB 10-10MG
2
Preferred Brand
LIPTRUZET TAB 10-20MG
2
Preferred Brand
LIPTRUZET TAB 10-40MG
2
Preferred Brand
LIPTRUZET TAB 10-80MG
2
Preferred Brand
LIQ-10 SYP
LIQ-10 SYP
LIQSORB LIQ 100MG/ML
LIQUACEL LIQ FRZ POP
LIQUAFIBER LIQ 5GM/15ML
LIQUIBID PD- TAB R
LIQUICET SOL 10-500MG
2
2
2
3
3
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
LIQUID C 500 LIQ 500/15ML
-
-
LIPOVAN BASE CRE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
-
-
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Not a covered
benefit
379
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
-
Not a covered
benefit
-
-
3
3
Non-Preferred Brand
Non-Preferred Brand
-
-
Not a covered
benefit
-
-
LIQUIGEN EMU
LIQUIMAT LOT 5%
LISINOP/HCTZ TAB 10-12.5
LISINOP/HCTZ TAB 20-12.5
LISINOP/HCTZ TAB 20-25MG
LISINOPRIL POW
LISINOPRIL TAB 10MG
LISINOPRIL TAB 2.5MG
LISINOPRIL TAB 20MG
LISINOPRIL TAB 30MG
LISINOPRIL TAB 40MG
LISINOPRIL TAB 5MG
L-ISOLEUCINE POW
L-ISOLEUCINE POW
LISSAMINE POW GREEN B
LISTERINE GEL ESSENTL
LISTERINE GEL WHITEN
LISTERINE MIS POCKETPK
LISTERINE PST ESSENTL
2
2
2
2
2
3
3
3
3
3
Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
LISTERINE SOL RESTORIN
3
Non-Preferred Brand
LITHIUM CARB CAP 300MG
LITHIUM CARB POW
-
$0 Preventative Drug
$0 Preventative Drug
Drug Name
LIQUID C LIQ
LIQUID CALC CAP VIT A&D
LIQUID CALCI CAP WITH D3
LIQUI-E LIQ 400/15ML
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
380
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LITHIUM CARB TAB 300MG
LITHIUM CARB TAB 300MG ER
LITHIUM CARB TAB 450MG ER
LITHIUM CITR POW TETRAHYD
LITHIUM CITR SOL 8MEQ/5ML
LITHIUM POW BROMIDE
LITHIUM POW CHLORIDE
2
3
3
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
3
3
3
3
3
3
2
3
3
3
3
3
1
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
LITHOBID TAB 300MG CR
LITHOSTAT TAB 250MG
LITTLE COLDS DRO 2.5MG/ML
LITTLE COLDS DRO 7.5MG/ML
LITTLE COLDS LOZ COLD REL
LITTLE COLDS MIS THROAT
LITTLE FEVER PAD COOLING
LITTLE NOSES AER SALINE
LITTLE NOSES DRO 0.125%
LITTLE NOSES GEL NASAL
LITTLE REMED LIQ COLDS
LITTLE REMED LIQ GRIPE
LITTLE REMED LIQ HONEY
LITTLE REMED LOZ HONEY
LITTLE REMED SUS POISON
LITTLE REMED SYP 575/5ML
LITTLE TEETH MIS PAIN REL
LITTLE TUMMY DRO LAXATIVE
LIVALO TAB 1MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
381
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LIVALO TAB 2MG
3
Non-Preferred Brand
LIVALO TAB 4MG
3
Non-Preferred Brand
3
3
3
3
2
2
1
2
2
1
2
2
3
-
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
L-METHYLFOLA TAB 15MG
-
-
L-METHYLFOLA TAB 7.5MG
-
-
LMX 4 CRE 4%
LMX 4 PLUS KIT 4%
LMX 5 CRE 5%
LO LOESTRIN TAB
LO MINASTRIN PAK FE
LOBELINE POW SULFATE
LOCALNESIUM TAB
LOCALNESIUM TAB -C
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
LIVER CAP 500MG
LIVER EXTR TAB 455MG
LIVER/KIDNEY CAP CLEANSER
LIVERITE TAB
L-LEUCINE POW
L-LYSINE ACE TAB 500MG
L-LYSINE CAP 500MG
L-LYSINE HCL CAP 500MG
L-LYSINE HCL POW
L-LYSINE TAB 1000MG
LMD 10%/D5W INJ
LMD 10%/NACL INJ 0.9%
L-METHIONINE POW
L-METHYLFOLA CAP PNV DHA
WDRx 2/23/15
3
2
3
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Not a covered
benefit
Not a covered
benefit
382
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
LOCOID CRE 0.1%
Tier
Formulary Status
3
Non-Preferred Brand
3
Non-Preferred Brand
LOCOID LOT 0.1%
3
Non-Preferred Brand
LOCOID OIN 0.1%
3
Non-Preferred Brand
LOCOID SOL 0.1%
3
Non-Preferred Brand
2
Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
LOCOID LIPO CRE 0.1%
LOCUST BEAN POW GUM
LODOSYN TAB 25MG
LODRANE D CAP 4-60MG
LOESTRIN 21 TAB 1.5/30
$0 Preventative Drug
LOESTRIN 24 TAB FE
$0 Preventative Drug
LOESTRIN FE TAB 1.5/30
$0 Preventative Drug
LOESTRIN FE TAB 1/20
$0 Preventative Drug
LOESTRIN TAB 1/20-21
$0 Preventative Drug
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
383
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LOFIBRA CAP 134MG
3
Non-Preferred Brand
LOFIBRA CAP 200MG
3
Non-Preferred Brand
LOFIBRA CAP 67MG
3
Non-Preferred Brand
LOFIBRA TAB 160MG
3
Non-Preferred Brand
LOFIBRA TAB 54MG
3
Non-Preferred Brand
2
1
1
2
Preferred Brand
Generic
Generic
Preferred Brand
3
Non-Preferred Brand
2
1
Preferred Brand
Generic
3
Non-Preferred Brand
LOPRESS HCT TAB 100-25MG
3
Non-Preferred Brand
LOPRESS HCT TAB 50-25MG
3
Non-Preferred Brand
LOHIST-D LIQ
LOHIST-PEB LIQ 4-10/5ML
LOHIST-PSB LIQ 4-20/5ML
LOLLIBASE POW
LOMOTIL TAB 2.5MG
LOPERAMIDE POW HCL
LOPERAMIDE SUS 1MG/7.5
LOPID TAB 600MG
WDRx 2/23/15
Special Plan Edits
Maximum of30per
30 days
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
384
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LOPRESSOR INJ 5MG/5ML
3
Non-Preferred Brand
LOPRESSOR TAB 100MG
3
Non-Preferred Brand
LOPRESSOR TAB 50MG
3
Non-Preferred Brand
LOPROX GEL 0.77%
3
Non-Preferred Brand
LOPROX SHA 1%
3
Non-Preferred Brand
LORATADINE POW
LORAZEPAM INJ 2MG/ML
LORAZEPAM INJ 4MG/ML
LORAZEPAM POW
LORAZEPAM TAB 0.5MG
LORAZEPAM TAB 1MG
LORAZEPAM TAB 2MG
2
1
1
2
1
1
1
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Generic
LORCET TAB 10-650MG
3
Non-Preferred Brand
L-ORNITHINE CAP 500MG
L-ORNITHINE POW
L-ORNITHINE POW HCL
LORTAB ELX 10-300MG
1
2
2
3
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
LORTAB ELX 7.5-500
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
385
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LORTAB TAB 10-500MG
3
Non-Preferred Brand
LORTAB TAB 5-500MG
3
Non-Preferred Brand
2
3
2
3
3
1
1
1
1
1
1
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
LORTUSS DM LIQ
LORTUSS EX LIQ
LORTUSS LQ LIQ
LORZONE TAB 375MG
LORZONE TAB 750MG
LOSARTAN POT TAB 100MG
LOSARTAN POT TAB 25MG
LOSARTAN POT TAB 50MG
LOSARTAN/HCT TAB 100-12.5
LOSARTAN/HCT TAB 100-25
LOSARTAN/HCT TAB 50-12.5
LOSEASONIQUE TAB
LO-SO PREP KIT
LOTEMAX GEL 0.5%
LOTEMAX OIN 0.5%
LOTEMAX SUS 0.5%
$0 Preventative Drug
2
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
LOTENSIN HCT TAB 10-12.5
3
Non-Preferred Brand
LOTENSIN HCT TAB 20-12.5
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
386
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
LOTENSIN HCT TAB 20-25MG
Tier
Formulary Status
3
Non-Preferred Brand
LOTENSIN TAB 10MG
3
Non-Preferred Brand
LOTENSIN TAB 20MG
3
Non-Preferred Brand
LOTENSIN TAB 40MG
3
Non-Preferred Brand
LOTREL CAP 10-20MG
3
Non-Preferred Brand
LOTREL CAP 10-40MG
3
Non-Preferred Brand
LOTREL CAP 2.5-10MG
3
Non-Preferred Brand
LOTREL CAP 5-10MG
3
Non-Preferred Brand
LOTREL CAP 5-20MG
3
Non-Preferred Brand
LOTREL CAP 5-40MG
3
Non-Preferred Brand
LOTRIMIN AF CRE 1%
LOTRIMIN ULT CRE 1%
2
2
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
387
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
LOTRISONE CRE
Tier
Formulary Status
3
Non-Preferred Brand
2
2
3
-
Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
2
Preferred Brand
LOVENOX INJ 100MG/ML
3
Non-Preferred Brand
LOVENOX INJ 120/0.8
3
Non-Preferred Brand
LOVENOX INJ 150MG/ML
3
Non-Preferred Brand
LOVENOX INJ 30/0.3ML
3
Non-Preferred Brand
LOVENOX INJ 300/3ML
3
Non-Preferred Brand
LOVENOX INJ 40/0.4ML
3
Non-Preferred Brand
LOVENOX INJ 60/0.6ML
3
Non-Preferred Brand
LOTRONEX TAB 0.5MG
LOTRONEX TAB 1MG
LOUTREX CRE
LOVASTATIN TAB 10MG
LOVASTATIN TAB 20MG
LOVASTATIN TAB 40MG
LOVAZA CAP 1GM
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 120
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
388
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
LOVENOX INJ 80/0.8ML
3
Non-Preferred Brand
LOXAPINE CAP 10MG
LOXAPINE CAP 25MG
LOXAPINE CAP 50MG
LOXAPINE CAP 5MG
LOXAPINE SUC POW
LOXASPERSE POW BASE
1
1
1
1
2
2
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
LOXITANE CAP 10MG
3
Non-Preferred Brand
LOXITANE CAP 25MG
3
Non-Preferred Brand
LOXITANE CAP 5MG
3
Non-Preferred Brand
2
2
1
3
2
2
2
3
2
3
3
3
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
LOZIBASE MIS
LOZI-FLUR LOZ 1MG F
L-PHENYLALAN TAB 500MG
L-PROLINE CAP 500MG
L-PROLINE POW
L-SELENOMETH POW
L-SERINE POW
LT GREEN SF POW YELLOWIS
LTA 360 KIT SOL 4%
L-TAURINE POW
L-THEANINE CAP 100MG
L-THREONINE TAB 500MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
389
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
L-TRYPTOPHAN CAP 500MG
L-TRYPTOPHAN POW
L-TRYPTOPHAN TAB 500MG
LTTL BOTTOMS SPR DAILY CA
L-TYROSINE CAP 500MG
L-TYROSINE POW
L-TYROSINE POW
L-TYROSINE TAB 1000MG
L-TYROSINE TAB 500MG
LUBRICANT EY DRO 0.95%
LUBRICNT GEL DRO 1%
LUBRIN SUP
LUCENTIS SOL 0.3MG
LUCENTIS SOL 0.5MG
3
2
3
3
1
2
2
3
1
3
1
2
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
LUDENS LOZ BLK CHRY
LUER-LOK SYR MIS 1ML/20G
LUFYLLIN TAB 200MG
LUFYLLIN TAB 400MG
LUGOLS SOL STRONG
3
2
3
3
2
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
LUKAID GLA EMU 1GM/ML
-
-
LUMIGAN SOL 0.01%
2
Preferred Brand
LUMITENE CAP 30MG
-
-
LUMIZYME INJ 50MG
3
Non-Preferred Brand
LUDENS LOZ BERRY
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Not a covered
benefit
-
-
Limited Distribution
390
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
LUNESTA TAB 1MG
3
Non-Preferred Brand
Step Therapy
Required
LUNESTA TAB 2MG
3
Non-Preferred Brand
Step Therapy
Required
LUNESTA TAB 3MG
3
Non-Preferred Brand
Step Therapy
Required
3
3
3
3
3
3
3
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
LURIDE CHW 0.25MG F
3
Non-Preferred Brand
LURIDE CHW 0.5MG F
3
Non-Preferred Brand
LURIDE CHW 1MG F
3
Non-Preferred Brand
LUPANETA KIT 11.25-5
LUPANETA KIT 3.75-5
LUPR DEP-PED INJ 11.25MG
LUPR DEP-PED INJ 11.25MG
LUPR DEP-PED INJ 15MG
LUPR DEP-PED INJ 30MG
LUPR DEP-PED INJ 7.5MG
LUPRON DEPOT INJ 11.25MG
LUPRON DEPOT INJ 22.5MG
LUPRON DEPOT INJ 3.75MG
LUPRON DEPOT INJ 30MG
LUPRON DEPOT INJ 45MG
LUPRON DEPOT INJ 7.5MG
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
391
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
LURIDE DRO 0.5MG/ML
Tier
Formulary Status
Special Plan Edits
Non-Preferred Brand
2
Preferred Brand
-
-
2
3
3
3
2
3
1
3
3
2
1
3
2
1
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
LUVOX CR CAP 100MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
LUVOX CR CAP 150MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
3
Non-Preferred Brand
3
Non-Preferred Brand
LUSTRA-ULTRA CRE 4%
LUTEIN BEA 5%
LUTEIN CAP 15-0.7MG
LUTEIN ESTER CAP 18.6MG
LUTEIN PLUS CAP BILBERRY
LUTEIN POW
LUTEIN POW 5%
LUTEIN TAB 20MG
LUTEIN TAB 6MG
LUTEIN W/ZEA TAB 6-1MG
LUTEIN/ZEAXA CAP 20-0.8MG
LUTEIN/ZEAXA CAP 25-5MG
LUTEIN/ZEAXA CAP 45-1.8MG
LUTEIN/ZEAXA CAP 6-0.24MG
LUVENA MIS 1%
LUVENA SOL LUBRICAN
LUXIQ AER 0.12%
LUZU CRE 1%
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
3
LUSAIR LIQ
Medication must be filled
through US Specialty Care
Pharmacy
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
392
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
L-VALINE POW
L-VALINE POW
LYCELLE GEL
LYCOPENE BEA 1%
LYCOPENE BEA 10%
LYCOPENE BEA 5%
LYCOPENE CAP
LYCOPENE CAP 10MG
LYCOPENE CAP 5MG
LYCOPENE TAB 25MG
LYCOPODIUM POW
2
2
3
3
3
3
3
1
3
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
LYMPHAZURIN INJ 1%
3
Non-Preferred Brand
LYRICA CAP 100MG
2
Preferred Brand
LYRICA CAP 150MG
2
Preferred Brand
LYRICA CAP 200MG
2
Preferred Brand
LYRICA CAP 225MG
2
Preferred Brand
LYRICA CAP 25MG
2
Preferred Brand
LYRICA CAP 300MG
2
Preferred Brand
LYRICA CAP 50MG
2
Preferred Brand
LYRICA CAP 75MG
2
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 90
per 30 days
Maximum of 90
per 30 days
Maximum of 90
per 30 days
Maximum of 90
per 30 days
Maximum of 90
per 30 days
Maximum of 60
per 30 days
Maximum of 90
per 30 days
Maximum of 90
per 30 days
393
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Formulary Status
Special Plan Edits
2
Preferred Brand
May be subject to
Quantity Level
Limits
3
3
2
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
LYSTEDA TAB 650MG
3
Non-Preferred Brand
LYTENSOPRIL MIS -90 KIT
3
Non-Preferred Brand
M.V.I PEDIAT INJ
-
-
M2 B-60 TAB TR
-
-
-
-
1
Generic
-
-
MAALOX ADV CHW 1000-60
MAALOX CHW 600MG
MAALOX JR CHW /ANTIGAS
2
2
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
MAALOX MAX CHW 1000-60
3
Non-Preferred Brand
MAALOX TC SUS
MACA CAP 500MG
MACADAMIA OIL NUT OIL
MACNATAL CN CAP DHA
3
1
3
-
Non-Preferred Brand
Generic
Non-Preferred Brand
$0 Preventative Drug
LYRICA SOL 20MG/ML
LYSINE4000 PAK 4000MG
LYSINYL POW
LYSODREN TAB 500MG
LYSOZYME POW
M2 C CAP
M2 MAGNESIUM CAP 100MG
M2K CAP 60MG
WDRx 2/23/15
Tier
Medication must be filled
through US Specialty Care
Pharmacy
Generic Available. Brand copay + the
difference between the brand and the
generic.
30 per 28 days
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
394
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
MACROBID CAP 100MG
Tier
Formulary Status
3
Non-Preferred Brand
MACRODANTIN CAP 100MG
3
Non-Preferred Brand
MACRODANTIN CAP 25MG
3
Non-Preferred Brand
MACRODANTIN CAP 50MG
3
Non-Preferred Brand
3
Non-Preferred Brand
MACUGEN INJ
MACUTEK TAB
MAFENIDE ACE PAK 5%
MAFENIDE POW ACETATE
MAG CARB GRA
MAG CARBONAT POW 250MG/GM
MAG CARBONAT POW HEAVY
MAG CITRATE POW
MAG CITRATE POW TRIBASIC
MAG CITRATE TAB 100MG
MAG OXIDE CAP 400MG
MAG OXIDE TAB 400MG
MAG OXIDE TAB 400MG
MAG OXIDE TAB 400MG
MAG OXIDE TAB 420MG
MAG-200 TAB
MAG64 TAB 64MG
MAG-AL LIQ
MAG-G TAB 500MG
WDRx 2/23/15
-
-
1
2
3
3
2
2
3
3
3
1
1
1
1
3
1
2
1
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Generic
Preferred Brand
Generic
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Not a covered
benefit
-
-
395
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MAGIMIN TAB 80MG
MAGINEX DS GRA 1230MG
MAGINEX TAB 615 MG
MAGN CHLORID CRY HEXAHYDR
MAGN CHLORID POW
MAGN OXIDE POW HEAVY
MAGN OXIDE POW LIGHT
MAGN SULFATE CAP 70MG
MAGN SULFATE POW HEPTAHYD
MAGNACET TAB 10-400MG
MAGNACET TAB 5-400MG
MAGNACET TAB 7.5-400
MAGNASWEET LIQ 110
MAGNASWEET POW 135
MAGNEBIND TAB 200
MAGNEBIND TAB 300
MAGNEBIND TAB 400
MAGNES/ZINC TAB 133.33-5
MAGNESIUM CAP 300MG
MAGNESIUM CAP 400MG
MAGNESIUM CAP 500MG
MAGNESIUM CRY ACETATE
MAGNESIUM GL TAB 550MG
MAGNESIUM POW ALUMINUM
MAGNESIUM POW ASCORBAT
MAGNESIUM POW FIZZ-PLS
MAGNESIUM POW GLUCONAT
MAGNESIUM POW GLYCINAT
MAGNESIUM POW HYDROXID
3
3
2
2
2
2
3
3
3
3
3
3
2
2
3
2
3
1
2
3
1
3
3
2
3
3
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
396
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MAGNESIUM POW MALATE
MAGNESIUM POW OXIDE
MAGNESIUM POW PEROXIDE
MAGNESIUM POW PHOSPHAT
MAGNESIUM POW SALICYLA
MAGNESIUM POW STEARATE
MAGNESIUM POW TRISILIC
MAGNESIUM SU INJ 40MG/ML
MAGNESIUM SU INJ 50%
MAGNESIUM SU INJ 80MG/ML
MAGNESIUM TAB 200MG
MAGNESIUM TAB 250MG
MAGNESIUM TAB 500MG
MAGNEVIST INJ 46.9%
MAGNSIUM BIS POW DIHYDRAT
2
3
3
2
3
2
3
2
1
2
1
1
1
2
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
-
-
MAGONATE LIQ 1000/5ML
3
Non-Preferred Brand
MAGOX 400 TAB 400MG
3
Non-Preferred Brand
1
3
3
3
3
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
MAGNUM-75 TAB
MAG-SR PLUS TAB CALCIUM
MAG-TAB SR TAB 84MG
MAG-VIT D3/ CAP TURMERIC
MAITAKE POW MUSHROOM
MAJOR-PREP CRE HEMMOR
MAKENA INJ 250MG/ML
MALACHITE GR POW OXALATE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
397
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MALARONE TAB 250-100
3
Non-Preferred Brand
MALARONE TAB 62.5-25
3
Non-Preferred Brand
3
1
2
3
2
2
1
2
3
2
2
2
2
2
3
3
1
1
1
1
1
2
3
2
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
MALATHION LIQ
MALATHION LOT 0.5%
MALEIC ACID POW
MALEIC ACID POW DI ESTER
MALIC ACID POW
MALTODEXTRIN POW
MANDELAY GEL MAX STR
MANDELIC POW ACID
MANGANESE AS TAB 93MG
MANGANESE CL INJ 0.1MG/ML
MANGANESE POW CHLORIDE
MANGANESE POW GLUCONAT
MANGANESE POW SULFATE
MANGANESE SU INJ 0.1MG/ML
MANGANESE TAB 15MG
MANGIMIN TAB 10MG
MANNITOL INJ 10%
MANNITOL INJ 15%
MANNITOL INJ 20%
MANNITOL INJ 25%
MANNITOL INJ 5%
MANNITOL POW
MAPAP PLUS TAB HEADACHE
MAPROTILINE TAB 25MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
398
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MAPROTILINE TAB 50MG
MAPROTILINE TAB 75MG
MARCAINE INJ 0.75%
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
MARCAINE INJ SPINAL
3
Non-Preferred Brand
MARCAINE/ INJ EPI 0.25
3
Non-Preferred Brand
MARCAINE/EPI INJ 0.25%
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
MARDROPS-EX LIQ
MAREZINE TAB 50MG
MARIGOLD EXT
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
MARINOL CAP 10MG
3
Non-Preferred Brand
MARINOL CAP 2.5MG
3
Non-Preferred Brand
MARINOL CAP 5MG
3
Non-Preferred Brand
3
3
3
Non-Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
MAR-COF BP LIQ
MAR-COF CG LIQ EXPECT
MARLIDO KIT
MARNATAL-F CAP
MARPLAN TAB 10MG
MARQIBO INJ 5MG/31ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
YES, Specialty Drug
399
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MASK VORTEX/ MIS BABY DUC
MASK VORTEX/ MIS FROG
MASSENGILL PAD CLOTH BP
MASSENGILL SOL BABY POW
MASSENGILL SOL C FLOWER
MASSENGILL SOL VIN&WAT
MASTIC GUM TEARS
MASTISOL LIQ ADHESIVE
MATULANE CAP 50MG
2
3
3
3
2
3
3
2
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
MAVIK TAB 1MG
3
Non-Preferred Brand
MAVIK TAB 2MG
3
Non-Preferred Brand
MAVIK TAB 4MG
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
Maximum of 28
gm per 30 days
MAXALT TAB 10MG
3
Non-Preferred Brand
Maximum of 12
per 30 days
MAXALT TAB 5MG
3
Non-Preferred Brand
Maximum of12per
30 days
3
Non-Preferred Brand
Maximum of12per
30 days
MAX VIRILITY TAB TR
MAXAIR AUTOH AER 200MCG
MAXALT-MLT TAB 10MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
400
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Maximum of12per
30 days
MAXALT-MLT TAB 5MG
3
Non-Preferred Brand
MAXARON TAB FORTE
MAXFE TAB
MAX-FREEZE GEL 3.7%
MAXIBAR SUS 210%
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
MAXICHLOR TAB PEH DM
3
Non-Preferred Brand
MAXICHLOR TAB PSE DM
3
Non-Preferred Brand
MAXIDEX SUS 0.1% OP
3
Non-Preferred Brand
MAXIDONE TAB 10-750MG
3
Non-Preferred Brand
MAXIFED CD TAB
MAXIFED CDX TAB
MAXIFED DM LIQ
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
MAXIFED DM TAB
3
Non-Preferred Brand
MAXIFED-G CD TAB
3
Non-Preferred Brand
3
Non-Preferred Brand
3
3
Non-Preferred Brand
Non-Preferred Brand
MAXICHLOR DM TAB 4-20MG
MAXIFED-G TAB 40-400MG
MAXIFED-G TAB CDX
MAXIFLU CD TAB
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
401
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MAXIFLU CDX TAB
MAXIFLU DM TAB
MAXINATE TAB
MAXIPHEN CD TAB
MAXIPHEN CDX TAB
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
MAXIPHEN DM TAB
3
Non-Preferred Brand
MAXITROL OIN 0.1% OP
3
Non-Preferred Brand
MAXITROL SUS 0.1% OP
3
Non-Preferred Brand
MAXLIFE RICE CAP TOCOTRIE
-
-
MAXORB EXTRA MIS ROPE 12"
MAXORB EXTRA PAD 2"X2"
3
3
Non-Preferred Brand
Non-Preferred Brand
MAXZIDE TAB 75-50
3
Non-Preferred Brand
MAXZIDE-25 TAB
3
Non-Preferred Brand
2
2
1
2
3
1
3
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
MB HYDROGEL KIT
M-CLEAR CAP 200-9MG
M-CLEAR WC LIQ
MCT OIL
MD-76 R INJ
MD-GASTROVIE SOL 66-10%
ME-500 CAP 500MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
402
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MEBENDAZOLE POW
MECAMYLAMINE POW HCL
MECHLORETHAM POW HCL
MECHOLYL OIN
MECLIZINE CHW 25MG
MECLIZINE POW HCL
MECLIZINE TAB 12.5MG
MECLOCYCLINE POW SULFOSAL
MECLOFEN SOD CAP 100MG
MECLOFEN SOD CAP 50MG
MECLOFEN SOD POW
MECLOFENOXAT POW HCL
MED DOUCHE SOL 10%
MED ID BRCLT MIS LYNX
MED ID PLATE MIS CLASSIC
MEDADYNE LIQ
MEDERMA CRE SPF 30
MEDERMA FOR GEL KIDS
MEDICATED CRE 5-0.13%
MEDICATED POW BODY
MEDICONE OIN MAX ST
MEDI-DERM CRE
MEDI-DERM/L CRE
MEDI-DOZE TAB 6-30-50
2
2
2
1
1
2
1
3
2
2
2
2
1
3
3
3
2
2
3
1
3
3
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
MEDIFIN PE TAB 10-400MG
3
Non-Preferred Brand
3
3
Non-Preferred Brand
Non-Preferred Brand
MEDI-FIRST CRE
MEDI-FLEXX TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
403
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MEDI-GRAINE TAB
MEDI-JECTOR MIS ADAPTERS
MEDI-JECTOR MIS VISION
MEDI-LYTE TAB
MEDI-PATCH PAD LIDOCAIN
MEDI-PHENYL TAB 5MG
MEDIPLAST MIS 40%
MEDIPORE+PAD PAD 2"X2-3/4
MEDIPORE+PAD PAD 3-1/2"X6
MEDIPORE+PAD PAD 3-1/2X10
MEDIPORE+PAD PAD DRESSING
MEDI-RDT KIT
MEDI-SELTZER TAB
MEDI-SLEEP TAB 25MG
MEDISPRAY AER
MEDI-TUSSIN CAP CGH/COLD
MEDIUM CHAIN LIQ TRIGLYCE
3
2
2
3
3
3
3
3
2
3
3
3
2
1
3
1
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
MEDROL PAK 4MG
3
Non-Preferred Brand
MEDROL TAB 16MG
3
Non-Preferred Brand
MEDROL TAB 2MG
3
Non-Preferred Brand
MEDROL TAB 32MG
3
Non-Preferred Brand
MEDROL TAB 4MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
404
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
MEDROL TAB 8MG
MEDROX OIN
MEDROX PAD
MEDROX PAD 0.0375-5
MEDROX-RX OIN
Tier
Formulary Status
3
Non-Preferred Brand
2
2
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
MEDROXYPR AC INJ 150MG/ML
$0 Preventative Drug
MEDROXYPR AC TAB 10MG
MEDROXYPR AC TAB 2.5MG
MEDROXYPR AC TAB 5MG
MEDROXYPROG POW MICRONIZ
MEDROXYPROGE POW ACETATE
MEFENAM ACID CAP 250MG
MEFENAMIC POW ACID
MEFLOQUINE TAB 250MG
MEFOXIN INJ 1GM/50ML
MEFOXIN INJ 2GM/50ML
MEGA TAURINE CAP 1000MG
MEGA ZINC TAB 100MG CR
MEGACE ES SUS
1
1
1
2
2
1
2
1
3
3
3
3
3
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
MEGACE ORAL SUS 40MG/ML
3
Non-Preferred Brand
MEGESTROL AC SUS 400MG/10
MEGESTROL AC TAB 20MG
MEGESTROL AC TAB 40MG
MEGESTROL POW ACETATE
MEGLUMINE POW
1
1
1
2
3
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 1 per
30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
405
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
MELA/THEANIN TAB 3-40MG
MELADOX TAB 3MG CR
MELATIN TAB 3-1MG
MELATONEX TAB
MELATONIN + CAP THEANINE
MELATONIN CAP 10MG
MELATONIN CAP 1MG
MELATONIN CAP 2.5MG
MELATONIN CAP 3MG
MELATONIN CAP 5MG
MELATONIN CHW 2.5MG
MELATONIN LIQ 1MG/4ML
MELATONIN LIQ 1MG/ML
MELATONIN LIQ 5MG/15ML
MELATONIN POW
MELATONIN SUB 2.5-338
MELATONIN SUB 5MG
MELATONIN TAB 10-10MG
MELATONIN TAB 10MG CR
MELATONIN TAB 1-10MG
MELATONIN TAB 1MG
MELATONIN TAB 200MCG
MELATONIN TAB 300MCG
MELATONIN TAB 3-10MG
MELATONIN TAB 3-2MG
MELATONIN TAB 3MG
MELATONIN TAB 500MCG
3
3
3
2
1
2
3
1
3
3
1
1
1
2
3
1
2
3
2
1
1
3
1
3
1
2
1
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Generic
Preferred Brand
Preferred Brand
PA Required
PA Required
Limited Distribution
Limited Distribution
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
406
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
MELATONIN TAB 5-10MG
MELATONIN TAB 5MG
MELATONIN TAB 5MG
MELATONIN TR TAB /VIT-B6
MELATONIN TR TAB 5-10MG
MELATONIN/ TAB VIT B-6
MELLODYN CAP
MELLOW-TONE MIS
MELOXICAM KIT COMFORT
MELOXICAM POW
MELOXICAM SUS 7.5/5ML
MELOXICAM TAB 15MG
MELOXICAM TAB 7.5MG
MELPHALAN INJ 50MG
MELQUIN 3 SOL 3%
MEMANTINE POW
MEMBRANEBLUE SOL 0.15%
MENACTRA INJ
MENADIONE NA CRY BISULFIT
MENADIONE POW
MENASTIL OIL
M-END DM LIQ
M-END DMX LIQ
M-END MAX D LIQ
M-END PE LIQ
M-END WC LIQ
MENEST TAB 0.3MG
WDRx 2/23/15
Tier
Formulary Status
3
1
1
1
1
2
3
3
3
2
2
1
1
3
Non-Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
-
-
3
3
2
2
3
1
2
3
3
1
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
3
Non-Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Not a covered
benefit
-
-
Maximum of 30
per 30 days
407
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MENEST TAB 0.625MG
3
Non-Preferred Brand
MENEST TAB 1.25MG
3
Non-Preferred Brand
MENEST TAB 2.5MG
3
Non-Preferred Brand
MENHIBRIX INJ
MENOMUNE INJ A/C/Y/W
3
-
Non-Preferred Brand
$0 ACA Drug
MENOPAUSE MIS AM/PM
-
-
MENOPAUSE TAB TRIO
3
Non-Preferred Brand
MENOPUR INJ 75UNIT
-
-
3
1
3
2
1
2
1
1
2
3
1
1
3
3
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
$0 ACA Drug
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
-
-
MENOSTAR DIS 14MCG
MENSTRUAL TAB 500-25MG
MENTAX CRE 1%
MENTHOL CRY
MENVEO INJ
MEPERIDINE INJ 100MG/ML
MEPERIDINE INJ 10MG/ML
MEPERIDINE INJ 25MG/ML
MEPERIDINE INJ 50MG/ML
MEPERIDINE POW
MEPERIDINE SOL 50MG/5ML
MEPERIDINE TAB 100MG
MEPERIDINE TAB 50MG
MEPERIDINE/ CAP PROMETH
MEPHENTERMIN POW SULFATE
MEPHYTON TAB 5MG
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Not a covered
benefit
YES, Specialty Drug
Not a covered
benefit
-
Special Plan Edits
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
-
408
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MEPIVACAINE INJ 3%
MEPIVACAINE POW
MEPROBAMATE TAB 200MG
MEPROBAMATE TAB 400MG
MEPRON SUS
MEQUINOL POW
MERBROMIN POW
MERCAPTOACET POW ACID NA
MERCAPTOBENZ POW
MERCAPTOETHA LIQ
MERCAPTOPUR TAB 50MG
MERCAPTOPURI POW
MERCAPTOPURI POW
MERCUR OXIDE POW YELLOW
MERCURIC IOD POW RED
MERCUROCLEAR LIQ
MERCURY POW DISTILLD
MEROPENEM INJ 1GM
MEROPENEM INJ 500MG
3
3
1
1
3
2
3
3
3
3
1
2
2
3
3
2
3
1
1
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
MERREM INJ 1GM
3
Non-Preferred Brand
MERREM INJ 500MG
3
Non-Preferred Brand
3
3
1
1
3
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
MERTHIOLATE TIN 0.13-50%
MERTHIOLATE TIN NEW FORM
MESALAMINE ENE 4GM
MESALAMINE KIT 4GM
MESNA INJ 1GM
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
409
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
MESNEX INJ 1GM
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
3
Non-Preferred Brand
YES, Specialty Drug
3
2
Non-Preferred Brand
Preferred Brand
YES, Specialty Drug
3
Non-Preferred Brand
MESTINON TAB TIMESPAN
METACMUCIL CAP PLUS CA
METACRESOL LIQ ACETATE
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
METADATE CD CAP 10MG
3
Non-Preferred Brand
PA after 25
METADATE CD CAP 20MG
3
Non-Preferred Brand
PA after 25
METADATE CD CAP 30MG
3
Non-Preferred Brand
PA after 25
METADATE CD CAP 40MG
3
Non-Preferred Brand
PA after 25
METADATE CD CAP 50MG
3
Non-Preferred Brand
PA after 25
METADATE CD CAP 60MG
3
Non-Preferred Brand
PA after 25
METADATE TAB 20MG ER
1
Generic
-
-
PA
Not a covered
benefit
2
Preferred Brand
MESNEX TAB 400MG
MESTINON SYP 60MG/5ML
MESTINON TAB 60MG
METAFOLBIC TAB
METAMUCIL CAP 0.52GM
WDRx 2/23/15
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
410
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
2
3
2
2
2
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
-
-
METAPROTEREN POW SULFATE
METAPROTEREN SYP 10MG/5ML
METAPROTEREN TAB 10MG
METAPROTEREN TAB 20MG
METASILICATE POW SODIUM
METASTRON INJ
METAXALONE TAB 800MG
METER BUFFER SOL PH 10
METER BUFFER SOL PH 4
METER BUFFER SOL PH 7
2
2
2
2
3
3
1
3
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
METFORMIN ER TAB 1000MG
-
$0 Preventative Drug
METFORMIN POW HCL
METFORMIN TAB 1000MG
METFORMIN TAB 500MG
2
-
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
METFORMIN TAB 500MG ER
-
$0 Preventative Drug
METFORMIN TAB 500MG ER
-
$0 Preventative Drug
METFORMIN TAB 750MG ER
METFORMIN TAB 850MG
-
$0 Preventative Drug
$0 Preventative Drug
METAMUCIL POW 28%
METAMUCIL POW 48.57%
METAMUCIL POW 55.46%
METAMUCIL POW 58.12%
METAMUCIL POW 63%
METAMUCIL POW CLEAR
METAMUCIL WAF
METANX TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Maximum of 60
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
411
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
METHACHOLINE CRY CHLORIDE
METHACHOLINE POW CHLORIDE
METHACRYLATE LIQ METHYL
METHACRYLIC POW COPOLYME
METHADONE CON 10MG/ML
METHADONE INJ 10MG/ML
METHADONE POW
METHADONE TAB 10MG
METHADONE TAB 40MG
METHADONE TAB 5MG
METHADOSE CON 10MG/ML
METHAMPHETAM TAB 5MG
METHANESULFO LIQ ACID 99%
METHANOL SOL
METHANOL SOL 99%
METHAZOLAMID POW
METHAZOLAMID TAB 25MG
METHAZOLAMID TAB 50MG
METHENAM HIP TAB 1GM
METHENAM MAN TAB 1000MG
METHENAM MAN TAB 500MG
METHENAMINE POW
METHENAMINE POW MANDELAT
2
2
3
3
1
2
2
1
1
1
2
1
2
2
3
2
1
1
1
1
2
2
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
PA after 25
METHERGINE INJ 0.2MG/ML
3
Non-Preferred Brand
METHERGINE TAB 0.2MG
3
Non-Preferred Brand
2
Preferred Brand
METHIMAZOLE POW
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
412
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
METHIMAZOLE TAB 10MG
METHIMAZOLE TAB 5MG
METHIONINE POW
METHIONINE TAB 500MG
METHITEST TAB 10MG
METHOCARBAM POW
METHOCARBAM TAB 500MG
METHOCARBAM TAB 750MG
METHOTREXATE INJ 100/4ML
METHOTREXATE INJ 1GM
METHOTREXATE INJ 25MG/ML
METHOTREXATE POW
METHOTREXATE TAB 2.5MG
METHOXSALEN CAP 10MG
1
1
3
3
2
2
1
1
1
1
1
2
1
1
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
-
-
2
2
2
1
1
3
2
3
3
3
3
3
2
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
METHOXSALEN POW
METHOXYETHAN LIQ
METHSCOPOLAM POW BROMIDE
METHSCOPOLAM POW NITRATE
METHSCOPOLAM TAB 2.5MG
METHSCOPOLAM TAB 5MG
METHYCLOTHIA POW
METHYCLOTHIA TAB 5MG
METHYL ACETA POW
METHYL BENZO LIQ 99%
METHYL ETHYL LIQ KETONE
METHYL METHA POW CROSSPOL
METHYL NICOT CRY
METHYL OIL SALICYLA
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
413
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
METHYL POW FOLATE
METHYL SALIC LIQ
METHYL SULF CRY
METHYLAMINE POW HCL
METHYLCELLUL GEL 1%
METHYLCELLUL GEL 2%
METHYLCELLUL GEL 3%
METHYLCELLUL POW
METHYLCELLUL POW 400CPS
METHYLCOBALA POW
METHYLD/HCTZ TAB 250/15
METHYLD/HCTZ TAB 250/25
METHYLDOPA POW
METHYLDOPA TAB 250MG
METHYLDOPA TAB 500MG
METHYLDOPATE INJ 250/5ML
METHYLENE BL INJ 1%
METHYLENE LIQ CHLORIDE
METHYLENE POW BLUE
METHYLENE POW IODIDE
METHYLERGON INJ 0.2MG/ML
METHYLERGON TAB 0.2MG
METHYLIN CHW 10MG
METHYLIN CHW 2.5MG
METHYLIN CHW 5MG
3
2
2
3
2
2
2
2
3
2
2
2
3
1
1
2
1
3
2
3
1
1
3
3
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PA after 25
PA after 25
PA after 25
3
Non-Preferred Brand
PA after 25
METHYLIN SOL 10MG/5ML
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
414
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
METHYLIN SOL 5MG/5ML
METHYLPARABE POW
METHYLPHENID CAP 10MG
METHYLPHENID CAP 20MG
METHYLPHENID CAP 20MG ER
METHYLPHENID CAP 30MG
METHYLPHENID CAP 30MG ER
METHYLPHENID CAP 40MG
METHYLPHENID CAP 40MG ER
METHYLPHENID CAP 50MG
METHYLPHENID CAP 60MG
METHYLPHENID POW HCL
METHYLPHENID SOL 10MG/5ML
METHYLPHENID SOL 5MG/5ML
METHYLPHENID TAB 10MG
METHYLPHENID TAB 10MG ER
METHYLPHENID TAB 18MG ER
METHYLPHENID TAB 20MG
METHYLPHENID TAB 27MG ER
METHYLPHENID TAB 36MG ER
METHYLPHENID TAB 54MG ER
METHYLPHENID TAB 5MG
METHYLPR ACE INJ 40MG/ML
METHYLPR ACE INJ 80MG/ML
METHYLPR SS INJ 1000MG
METHYLPRED PAK 4MG
METHYLPRED POW
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
2
2
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Special Plan Edits
PA after 25
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
415
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
METHYLPRED POW ACETATE
METHYLPRED TAB 16MG
METHYLPRED TAB 32MG
METHYLPRED TAB 4MG
METHYLPRED TAB 8MG
METHYLPREDNI POW SUCCINAT
METHYLPYRAZO LIQ
METHYLTESTOS POW
METHYSERGIDE POW MALEATE
METIPRANOLOL SOL 0.3% OPH
METOCLOPRAM INJ 10MG/2ML
METOCLOPRAM POW MONOHYDR
METOCLOPRAM SOL 10/10ML
METOCLOPRAM TAB 10MG
METOCLOPRAM TAB 5MG
METOCLOPRAMI POW HCL USP
METOLAZONE TAB 10MG
METOLAZONE TAB 2.5MG
METOLAZONE TAB 5MG
METOPIRONE CAP 250MG
METOPRL/HCTZ TAB 100-25MG
METOPRL/HCTZ TAB 100-50MG
METOPRL/HCTZ TAB 50-25MG
METOPROL TAR TAB 100MG
METOPROL TAR TAB 25MG
METOPROL TAR TAB 50MG
METOPROLOL INJ 1MG/ML
DIABETA TAB 1.25MG
METOPROLOL TAB 100MG ER
2
1
1
1
1
2
2
2
2
2
1
2
1
1
1
2
1
1
1
3
-
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
416
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
METOPROLOL TAB 200MG ER
METOPROLOL TAB 25MG ER
METOPROLOL TAB 50MG ER
METOZOLV ODT TAB 5MG
METRO IV INJ 5MG/ML
METROCREAM CRE 0.75%
METROGEL GEL 1%
3
2
3
3
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PA Required
PA Required
-
METROGEL-VAG GEL 0.75%
3
Non-Preferred Brand
3
1
1
1
1
1
1
1
2
2
1
1
3
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
PA Required
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
PA Required
PA Required
-
-
PA Required
PA Required
-
-
MEVACOR TAB 20MG
3
Non-Preferred Brand
MEVACOR TAB 40MG
3
Non-Preferred Brand
MEXILETINE CAP 200MG
1
Generic
METROLOTION LOT 0.75%
METRON/NACL INJ 500MG
METRONIDAZOL CAP 375MG
METRONIDAZOL CRE 0.75%
METRONIDAZOL GEL 0.75%
METRONIDAZOL GEL 0.75%VAG
METRONIDAZOL GEL 1%
METRONIDAZOL LOT 0.75%
METRONIDAZOL POW
METRONIDAZOL POW BENZOATE
METRONIDAZOL TAB 250MG
METRONIDAZOL TAB 500MG
METVIXIA CRE 16.8%
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
417
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MEXILETINE CAP 250MG
MEXILETINE POW HCL
MEXSANA POW
MG ASPARTATE TAB 65MG
MG GLUCONATE TAB 250MG
MG SO4/D5W INJ 10MG/ML
MG SO4/D5W INJ 20MG/ML
MG/TAURINE CAP FORTE
MG217 LOT 1%
MG217 MEDIC LOT TAR
MG217 MEDIC OIN TAR
MG217 OIN 3%
MG217 PSORIA CRE 3%
MG217 PSORIA GEL 1.5%
MG217 PSORIA OIN 2%
MG217 SHA 3%
MG217 TAR SHA 15% MEDI
MIACALCIN INJ 200/ML
1
2
2
3
3
2
3
3
3
3
3
3
3
3
1
3
1
2
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
MIACALCIN SPR 200/ACT
3
Non-Preferred Brand
MICARDIS HCT TAB 40/12.5
3
Non-Preferred Brand
MICARDIS HCT TAB 80/12.5
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 60
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
418
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
MICARDIS HCT TAB 80-25MG
Tier
Formulary Status
3
Non-Preferred Brand
MICARDIS TAB 20MG
3
Non-Preferred Brand
MICARDIS TAB 40MG
3
Non-Preferred Brand
MICARDIS TAB 80MG
3
Non-Preferred Brand
2
1
2
1
1
2
1
1
2
2
3
3
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
MICATIN CRE 2%
MICONAZOLE 1 KIT
MICONAZOLE 1 KIT COMBO
MICONAZOLE 3 KIT 4%
MICONAZOLE 3 KIT COMBO PK
MICONAZOLE 3 SUP 200MG
MICONAZOLE 7 CRE
MICONAZOLE 7 SUP 100MG
MICONAZOLE POW
MICONAZOLE POW NITRATE
MICRHOGAM PL INJ 50MCG
MICRO-BUMIN KIT
MICRO-K CAP 10MEQ CR
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
419
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MICRO-K CAP 8MEQ CR
3
Non-Preferred Brand
MICROLIPID EMU 50%
2
Preferred Brand
MICROZIDE CAP 12.5MG
3
Non-Preferred Brand
MIDAZOLAM INJ 10/10ML
MIDAZOLAM INJ 10MG/2ML
MIDAZOLAM INJ 25MG/5ML
MIDAZOLAM INJ 2MG/2ML
MIDAZOLAM INJ 50MG/10
MIDAZOLAM INJ 5MG/5ML
MIDAZOLAM INJ 5MG/ML
MIDAZOLAM POW
MIDAZOLAM SYP 2MG/ML
MIDODRINE TAB 10MG
MIDODRINE TAB 2.5MG
MIDODRINE TAB 5MG
1
1
1
1
1
1
1
2
1
1
1
1
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
3
Non-Preferred Brand
MIFEPREX TAB 200MG
MIGERGOT SUP 2/100
MIGRAL TAB 130MG
MIGRALAM CAP
3
2
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
MIGRANAL SPR 4MG/ML
3
Non-Preferred Brand
MIGRELIEF TAB
MILADRENE TAB 80MG
3
3
Non-Preferred Brand
Non-Preferred Brand
MIDOL MAX ST TAB MENSTRUA
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 16
mL per 30 days
420
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MIL-A-MULSIO EMU
-
-
MILCO-B-FORT TAB
-
-
2
3
2
2
2
3
3
1
3
1
1
1
2
3
3
3
2
2
3
2
2
3
2
1
1
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
MILCO-ZYME TAB
MILK DIGESTA TAB 25-2MG
MILK OF MAGN CHW 311MG
MILK OF MAGN SUS 2400MG
MILK OF MAGN SUS 800/5ML
MILK THISTLE CAP
MILK THISTLE CAP 1000MG
MILK THISTLE CAP 140MG
MILK THISTLE CAP 150MG
MILK THISTLE CAP 175MG
MILK THISTLE CAP 200MG
MILK THISTLE CAP 250MG
MILK THISTLE CAP 300MG
MILK THISTLE CAP 500MG
MILK THISTLE CAP 87.5MG
MILK THISTLE CAP XTRA
MILK THISTLE POW
MILK THISTLE POW EXTRACT
MILK THISTLE POW SEED
MILK THISTLE TAB 175MG
MILLIPRED DP PAK 5MG
MILLIPRED SOL 10MG/5ML
MILLIPRED TAB 5MG
MILRINONE INJ 10/10ML
MILRINONE INJ 1MG/ML
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
421
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MILRINONE INJ 1MG/ML
MILRINONE/D5 INJ 20/100ML
MILRINONE/D5 INJ 40/200ML
MINASTRIN 24 CHW FE
MINCAPS OMGA CAP -3 350MG
MINERAL OIL
MINERAL OIL ENE
MINERAL OIL LIGHT
MINERAL OIL LIGHT
MINICAPS VIT CAP D/OMGA-3
1
1
1
3
2
1
2
2
3
Generic
Generic
Generic
$0 Preventative Drug
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
MINIPRESS CAP 1MG
3
Non-Preferred Brand
MINIPRESS CAP 2MG
3
Non-Preferred Brand
MINIPRESS CAP 5MG
3
Non-Preferred Brand
MINITRAN DIS 0.1MG/HR
MINITRAN DIS 0.2MG/HR
MINITRAN DIS 0.4MG/HR
MINITRAN DIS 0.6MG/HR
1
1
1
1
Generic
Generic
Generic
Generic
MINIVELLE DIS 0.0375MG
2
Preferred Brand
MINIVELLE DIS 0.05MG
2
Preferred Brand
MINIVELLE DIS 0.075MG
2
Preferred Brand
MINIVELLE DIS 0.1MG
2
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 1
pack per 30 days
Maximum of 8 per
30 days
Maximum of 8 per
30 days
Maximum of 8 per
30 days
422
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MINK OIL LT FRACT
3
Non-Preferred Brand
MINOCIN CAP 100MG
3
Non-Preferred Brand
MINOCIN CAP 50MG
3
Non-Preferred Brand
MINOCIN CAP 75MG
3
Non-Preferred Brand
2
3
3
1
1
1
2
1
1
1
1
1
1
3
2
1
1
3
1
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Preferred Brand
MINOCIN INJ 100MG
MINOCIN KIT 100MG
MINOCIN KIT 50MG
MINOCYCLINE CAP 100MG
MINOCYCLINE CAP 50MG
MINOCYCLINE CAP 75MG
MINOCYCLINE POW
MINOCYCLINE TAB 100MG
MINOCYCLINE TAB 135MG ER
MINOCYCLINE TAB 45MG ER
MINOCYCLINE TAB 50MG
MINOCYCLINE TAB 75MG
MINOCYCLINE TAB 90MG ER
MIN-O-EAR DRO
MINOXIDIL POW
MINOXIDIL TAB 10MG
MINOXIDIL TAB 2.5MG
MIOCHOL-E SOL 1:100
MI-OMEGA NF CAP
MIOSTAT INJ 0.01% OP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
423
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MIRALAX POW 3350 NF
3
Non-Preferred Brand
MIRALAX POW 3350 NF
3
Non-Preferred Brand
MIRAPEX ER TAB 0.375MG
2
Preferred Brand
MIRAPEX ER TAB 0.75MG
2
Preferred Brand
MIRAPEX ER TAB 1.5MG
2
Preferred Brand
MIRAPEX ER TAB 2.25MG
2
Preferred Brand
MIRAPEX ER TAB 3.75MG
2
Preferred Brand
MIRAPEX ER TAB 3MG
2
Preferred Brand
MIRAPEX ER TAB 4.5MG
2
Preferred Brand
MIRAPEX TAB 0.125MG
3
Non-Preferred Brand
MIRAPEX TAB 0.25MG
3
Non-Preferred Brand
MIRAPEX TAB 0.5MG
3
Non-Preferred Brand
MIRAPEX TAB 0.75MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
424
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MIRAPEX TAB 1.5MG
3
Non-Preferred Brand
MIRAPEX TAB 1MG
3
Non-Preferred Brand
MIRCETTE TAB 28 DAY
MIRENA IUD SYSTEM
MIRTAZAPINE POW ANHYDROU
MIRTAZAPINE TAB 15MG
MIRTAZAPINE TAB 15MG ODT
MIRTAZAPINE TAB 30MG
MIRTAZAPINE TAB 30MG ODT
MIRTAZAPINE TAB 45MG
MIRTAZAPINE TAB 45MG ODT
MIRTAZAPINE TAB 7.5MG
MIRVASO GEL 0.33%
MISOPROSTOL POW 1%
MISOPROSTOL TAB 100MCG
MISOPROSTOL TAB 200MCG
MISSION PREN TAB
MISSION PREN TAB HP
MITOMYCIN C POW
MITOMYCIN INJ 20MG
MITOMYCIN INJ 40MG
MITOMYCIN INJ 5MG
MITOMYCIN POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
$0 Preventative Drug
-
$0 Preventative Drug
2
1
1
1
1
1
1
1
2
2
1
1
2
3
3
3
3
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Penalty applied if Brand Selected
over Generic
Covered under
Medical
-
-
PA Required
-
-
-
-
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
425
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MITOSOL KIT 0.2MG
MITOTANE POW
MITOXANTRON INJ 2MG/ML
MITOXANTRON INJ 2MG/ML
MITOXANTRON INJ 2MG/ML
MIXED VESPID INJ 1650MCG
MIXED VESPID INJ 3900MCG
MIXED VESPID KIT 3000MCG
MIXED VESPID KIT 300MCG
MLK F1 KIT
DIABETA TAB 2.5MG
MN-50 CAP 16.67MG
MOBIC SUS 7.5/5ML
3
2
3
3
3
2
3
3
3
3
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
MOBIC TAB 15MG
3
Non-Preferred Brand
MOBIC TAB 7.5MG
3
Non-Preferred Brand
1
1
3
3
3
3
3
3
1
1
1
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
MODAFINIL TAB 100MG
MODAFINIL TAB 200MG
MODERIBA PAK 1000/DAY
MODERIBA PAK 1200/DAY
MODERIBA PAK 600/DAY
MODERIBA PAK 800/DAY
MODERIBA TAB 200MG
MODIFIED TAB PECTIN
MOEXIPR/HCTZ TAB 15-12.5
MOEXIPR/HCTZ TAB 15-25MG
MOEXIPR/HCTZ TAB 7.5-12.5
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
PA Required
PA Required
PA Required
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
426
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MOEXIPRIL TAB 15MG
MOEXIPRIL TAB 7.5MG
MOIST TOWEL MIS ANTIBAC
MOISTURE BAR OIN SKIN
MOISTURE CRE BARRIER
MOISTURE EYE DRO
MOISTURIZING CRE SKIN 8%
MOISTURIZING LOT 1.5%
MOLESKIN PAD
MOLYBDENUM CAP 30MCG
MOLYBDENUM POW
1
1
2
3
3
2
3
1
1
3
2
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
MOMENTUM MUS TAB BACKACHE
3
Non-Preferred Brand
MOMETASONE CRE 0.1%
MOMETASONE OIN 0.1%
MOMETASONE POW
MOMETASONE SOL 0.1%
MONIST SOOTH CRE CARE 1%
MONISTAT 1 KIT 1200/2%
MONISTAT 3 CRE 4%
MONISTAT 3 KIT 200MG/2%
MONISTAT 7 CRE 2%
MONISTAT 7 KIT COMPLETE
MONISTAT GEL 1.2%
MONOCAL TAB 3-250
MONOCETE MIS 80%
MONOCLATE-P INJ 1000UNIT
MONOCLATE-P INJ 1500UNIT
1
1
2
1
2
2
2
2
2
2
3
2
3
3
3
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
427
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MONOCLATE-P INJ 250UNIT
MONOCLATE-P INJ 500UNIT
3
3
Non-Preferred Brand
Non-Preferred Brand
MONODOX CAP 100MG
3
Non-Preferred Brand
MONODOX CAP 75MG
3
Non-Preferred Brand
2
2
2
2
2
2
3
3
3
2
2
3
1
3
3
3
3
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
MONOETHANOLA LIQ
MONOJECT MIS 20GX1"
MONOJECT MIS 20GX1.5
MONOJECT MIS 21GX1"
MONOJECT MIS 22GX1"
MONOMETHIONI POW ZINC
MONONINE INJ 250UNIT
MONONINE INJ 500UNIT
MONOVISC INJ 88MG/4ML
MONSELS FERR SOL SUBSULF
MONTELUKAST CHW 4MG
MONTELUKAST CHW 5MG
MONTELUKAST GRA 4MG
MONTELUKAST POW SODIUM
MONTELUKAST TAB 10MG
MONUROL PAK GRANULES
MOOD PLUS TAB 400MG
MORANTEL POW TARTRATE
MORE-DOPHILU POW ACIDOPHI
MORGIDOX KIT 1X100MG
MORGIDOX KIT 2X100MG
MORPHINE POW SULFATE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
428
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MORPHINE SUL CAP 100MG ER
MORPHINE SUL CAP 10MG ER
MORPHINE SUL CAP 120MG ER
MORPHINE SUL CAP 20MG ER
MORPHINE SUL CAP 30MG ER
MORPHINE SUL CAP 30MG ER
MORPHINE SUL CAP 45MG ER
MORPHINE SUL CAP 50MG ER
MORPHINE SUL CAP 60MG ER
MORPHINE SUL CAP 60MG ER
MORPHINE SUL CAP 75MG ER
MORPHINE SUL CAP 80MG ER
MORPHINE SUL CAP 90MG ER
MORPHINE SUL INJ 10/0.7ML
MORPHINE SUL INJ 150/30ML
MORPHINE SUL INJ 1MG/ML
MORPHINE SUL INJ 25MG/ML
MORPHINE SUL INJ 2MG/ML
MORPHINE SUL INJ 2MG/ML
MORPHINE SUL INJ 4MG/ML
MORPHINE SUL INJ 4MG/ML
MORPHINE SUL INJ 50MG/ML
MORPHINE SUL INJ 5MG/ML
MORPHINE SUL INJ 8MG/ML
MORPHINE SUL SOL 100/5ML
MORPHINE SUL SOL 10MG/5ML
MORPHINE SUL SOL 20MG/5ML
MORPHINE SUL SUP 10MG
MORPHINE SUL SUP 20MG
1
1
1
1
1
1
1
1
1
1
1
1
1
3
2
1
2
2
2
2
2
2
2
1
1
1
1
2
2
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
429
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MORPHINE SUL SUP 30MG
MORPHINE SUL SUP 5MG
MORPHINE SUL TAB 100MG CR
MORPHINE SUL TAB 15MG
MORPHINE SUL TAB 15MG CR
MORPHINE SUL TAB 200MG CR
MORPHINE SUL TAB 30MG
MORPHINE SUL TAB 30MG CR
MORPHINE SUL TAB 60MG CR
MORRHUAT SOD INJ 5%
MOSCO CALLUS SOL CRN RMVR
MOTOFEN TAB
MOTRIN DRO 40MG/ML
2
2
1
2
1
1
2
1
1
1
2
3
2
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
MOTRIN JR ST CHW 100MG
3
Non-Preferred Brand
MOTRIN JR ST TAB 100MG
3
Non-Preferred Brand
MOUTH RINSE SOL
MOVANA TAB 300MG
MOVIPREP SOL
MOXEZA SOL 0.5%
MOXIFLOXACIN TAB 400MG
MOXISYLYTE POW HCL
MOZOBIL INJ
1
1
2
1
2
3
Generic
Generic
$0 Preventative Drug
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
MS CONTIN TAB 100MG CR
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
430
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MS CONTIN TAB 15MG CR
3
Non-Preferred Brand
MS CONTIN TAB 200MG CR
3
Non-Preferred Brand
MS CONTIN TAB 30MG CR
3
Non-Preferred Brand
MS CONTIN TAB 60MG CR
3
Non-Preferred Brand
1
3
1
3
2
2
2
2
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
MSM CAP 500MG
MSM CAP 750MG
MSM/GLUCOSAM CAP
MSM/GLUCOSAM CRE
MUCINEX CGH GRA 5-100MG
MUCINEX CHLD LIQ MULTISYM
MUCINEX COLD LIQ /KIDS
MUCINEX COLD LIQ CHILD
MUCINEX COLD LIQ FLU&SORE
3
Non-Preferred Brand
MUCINEX COLD LIQ SINUS
MUCINEX D TAB 120-1200
MUCINEX D TAB 60-600MG
MUCINEX DM TAB 30-600ER
MUCINEX DM TAB 60-1200
MUCINEX FAST MIS DAY/NGHT
MUCINEX FAST TAB 5-10-200
MUCINEX TAB 1200MG
2
2
2
2
2
1
3
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
431
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
MUCINEX TAB 600MG ER
Tier
Formulary Status
3
Non-Preferred Brand
MUCINEX/KIDS GRA 100MG
MUCINEX/KIDS GRA 50MG
MUCOTROL WAF
MUCUS RELIEF LIQ CHILDREN
MUCUS-DM MAX TAB 60-1200
MUCUS-DM TAB 30-600MG
MUGARD LIQ
MUIRA PUAMA POW
MULLEIN EAR DRO GARLIC
2
2
3
1
1
1
3
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
MULT VIT-BET CHW FL 0.5MG
-
-
MULT VIT-BET CHW FL0.25MG
-
-
3
Non-Preferred Brand
3
3
3
-
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
MULTAQ TAB 400MG
MULTI GINSEN CAP 1000MG
MULTI GINSEN CAP 500-500M
MULTI- KIT SPECIALT
MULTI PRENAT TAB
MULTI VIT/FL CHW 1MG
-
-
-
-
MULTI-DELYN LIQ /IRON
-
-
MULTI-DRAW MIS 21GX1.5"
MULTIGEN PLS TAB
MULTIGEN TAB
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
MULTI-DELYN LIQ
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
Maximum of 60
per 30 days
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
-
-
-
-
-
-
432
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MULTIGEN TAB FOLIC
MULTIHANCE SOL
MULTITRACE-4 INJ
MULTITRACE-4 INJ CONC
MULTITRACE-4 INJ NEONATAL
MULTITRACE-4 INJ PED
MULTITRACE-5 INJ
MULTITRACE-5 INJ REGULAR
2
3
2
1
2
2
1
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Preferred Brand
MULTI-VIT/FL DRO 0.25MG
-
-
MULTI-VIT/FL DRO 0.5MG/ML
-
-
MUPIROCIN CA CRE 2%
MUPIROCIN OIN 2%
MUPIROCIN POW
MURO 128 OIN 5% OP
MURO 128 SOL 2% OP
MURO 128 SOL 5% OP
MUSE SUP 1000MCG
MUSE SUP 125MCG
MUSE SUP 250MCG
MUSE SUP 500MCG
MUSK OIL LIQ FRAGRANC
MUSTARD OIL
MUSTARGEN INJ 10MG
MV&MIN CAP FE-FA-DH
M-VIT TAB 27-1MG
MYALEPT INJ 11.3MG
1
1
2
2
2
2
2
2
2
2
3
2
3
3
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
YES, Specialty Drug
Limited Distribution
-
10 per 30 days
10 per 30 days
10 per 30 days
10 per 30 days
PA Required
433
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
MYAMBUTOL TAB 100MG
3
Non-Preferred Brand
MYAMBUTOL TAB 400MG
3
Non-Preferred Brand
2
2
3
3
3
3
2
1
1
1
1
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
MYDFRIN SOL 2.5% OP
3
Non-Preferred Brand
MYDRAL SOL 0.5% OP
MYDRAL SOL 1% OP
1
1
Generic
Generic
MYDRIACYL SOL 1% OP
3
Non-Preferred Brand
MYFORTIC TAB 180MG
3
Non-Preferred Brand
MYFORTIC TAB 360MG
3
Non-Preferred Brand
MYCAMINE INJ 100MG
MYCAMINE INJ 50MG
MYCO NAIL SPR
MYCOBUTIN CAP 150MG
MYCOCIDE CX CRE 12-0.1%
MYCOMIST SPR
MYCO-NAIL SOL
MYCOPHENOLAT CAP 250MG
MYCOPHENOLAT TAB 500MG
MYCOPHENOLIC TAB 180MG DR
MYCOPHENOLIC TAB 360MG DR
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
434
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
MYKIDZ IRON SUS 10MG/2ML
-
-
Not a covered
benefit
-
-
MYKIDZ IRON SUS 15/1.5ML
2
Preferred Brand
MYKIDZ IRON SUS FL
-
-
Not a covered
benefit
-
-
MYLANTA CHW 400MG
3
Non-Preferred Brand
2
Preferred Brand
3
Non-Preferred Brand
2
Preferred Brand
MYLANTA SUS SUPREME
3
Non-Preferred Brand
MYLANTA SUS ULTIMATE
2
Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
2
-
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
MYLANTA DS SUS
MYLANTA GAS CAP 125MG
MYLANTA SUS
MYLANTA TAB
MYLANTA ULTR CHW CHERRY
MYLERAN TAB 2MG
MYLICON DRO 40/0.6ML
MYLICON INFA DRO 20/0.3ML
MYNATAL CAP
MYNATAL PLUS TAB
MYNATE 90 TAB PLUS
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
435
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
-
-
MYOBLOC INJ 10000/2
MYOBLOC INJ 2500/0.5
MYOBLOC INJ 5000/ML
MYOFIBEX TAB
MYOFLEX CRE 10%
MYOVIEW KIT
MYOXIN SUS OTIC
3
3
3
2
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
MYRBETRIQ TAB 25MG
2
Preferred Brand
MYRBETRIQ TAB 50MG
2
Preferred Brand
MYRJ 53 POW
MYRRH GUM TIN
MYRRH OIL FRAGRANC
3
2
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
MYSOLINE TAB 250MG
3
Non-Preferred Brand
MYSOLINE TAB 50MG
3
Non-Preferred Brand
NA ASCORBATE POW
-
-
2
3
3
2
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
MYNEPHROCAPS CAP
NA CITRATE POW ANHYDROU
NA COCOYL LIQ GLUTAMTE
NA HYDROXIDE SOL 1.0 N
NA HYDROXIDE SOL 10%
NA HYDROXIDE SOL 20%
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
PA Required
PA Required
PA Required
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
436
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NA MONOFLUOR POW PHOSPHAT
NA PHOS MONO POW ANHYDROU
NABUMETONE POW
NABUMETONE TAB 500MG
NABUMETONE TAB 750MG
NAC 600 CAP
N-ACETYL-DL POW PENICILL
NACL/BACT INJ 0.9%BENZ
NACL/NA BICA POW
NADH DISODIU POW
NADOLOL POW
NADOLOL TAB 20MG
NADOLOL TAB 40MG
NADOLOL TAB 80MG
NADOLOL/BEND TAB 40-5MG
NADOLOL/BEND TAB 80-5MG
NAFCILLIN INJ 10GM
NAFRINSE DLY SOL /NEUTRAL
NAFRINSE SOL DAILY
NAFRINSE WK SOL 0.2%
NAFTIN CRE 1%
NAFTIN CRE 2%
NAFTIN GEL 1%
NAFTIN GEL 2%
NAGLAZYME INJ 1MG/ML
NAIL STRENGT CAP /GELATIN
NALBUPHINE INJ 10MG/ML
NALBUPHINE INJ 20MG/ML
NALBUPHINE POW HCL
3
2
2
1
1
1
3
2
3
2
2
1
1
1
1
1
1
2
2
3
3
3
3
3
3
3
1
1
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
437
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NALIDIXIC POW ACID
NALLPEN/DEX INJ 1GM/50ML
NALLPEN/DEX INJ 2GM/100
NALOXONE HCL POW
NALOXONE HCL POW DIHYDRAT
NALOXONE INJ 0.4MG/ML
NALOXONE INJ 1MG/ML
NALTREXONE POW
NALTREXONE POW HCL
NALTREXONE TAB 50MG
2
2
2
2
3
1
2
3
2
1
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
2
Preferred Brand
NAMENDA TAB 10MG
2
Preferred Brand
NAMENDA TAB 5-10MG
2
Preferred Brand
2
Preferred Brand
NAMENDA XR CAP 14MG
2
Preferred Brand
NAMENDA XR CAP 21MG
2
Preferred Brand
NAMENDA XR CAP 28MG
2
Preferred Brand
NAMENDA XR CAP 7MG
2
Preferred Brand
NAMENDA SOL 10MG/5ML
NAMENDA TAB 5MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 360
mL per 30 days
Maximum of 60
per 30 days
May be subject to
Quantity Level
Limits
Maximum of 60
per 30 days
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
438
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
May be subject to
Quantity Level
Limits
NAMENDA XR CAP TITRATIO
2
Preferred Brand
NANDROLONE POW DECANOAT
2
Preferred Brand
-
-
-
-
3
3
2
2
3
3
3
3
2
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
NAPROSYN SUS 125/5ML
3
Non-Preferred Brand
NAPROSYN TAB 250MG
3
Non-Preferred Brand
NAPROSYN TAB 375MG
3
Non-Preferred Brand
NAPROSYN TAB 500MG
3
Non-Preferred Brand
3
1
Non-Preferred Brand
Generic
NANOVM POW 1-3 YRS
NANOVM T/F LIQ
NAPHAZOLINE CRY HCL
NAPHAZOLINE POW HCL
NAPHAZOLINE SOL 0.1% OP
NAPHCON-A SOL OP
NAPRELAN PAK
NAPRELAN TAB 375MG CR
NAPRELAN TAB 500MG CR
NAPRELAN TAB 750MG CR
NAPRO CRE 15%
NAPRODERM CRE 15%
NAPROXEN CRE 10%
NAPROXEN DR TAB 375MG
WDRx 2/23/15
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
439
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
1
3
2
2
1
1
1
1
1
1
1
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
NARATRIPTAN TAB 1MG
1
Generic
NARATRIPTAN TAB 2.5MG
1
Generic
3
Non-Preferred Brand
NAROPIN INJ 10MG/ML
NAROPIN INJ 2MG/ML
2
2
Preferred Brand
Preferred Brand
NAROPIN INJ 5MG/ML
3
Non-Preferred Brand
NAROPIN INJ 7.5MG/ML
NASACORT ALR SPR 55MCG/AC
2
3
Preferred Brand
Non-Preferred Brand
NASACORT AQ AER 55MCG/AC
3
Non-Preferred Brand
NASADOCK PAK PLUS
NASADROPS DRO 0.9%
NASAL DECON SYP 30MG/5ML
2
3
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
NAPROXEN DR TAB 500MG
NAPROXEN KIT COMFORT
NAPROXEN POW
NAPROXEN POW SODIUM
NAPROXEN SOD CAP 220MG
NAPROXEN SOD TAB 275MG
NAPROXEN SOD TAB 550MG
NAPROXEN SUS 125/5ML
NAPROXEN TAB 250MG
NAPROXEN TAB 375MG
NAPROXEN TAB 500MG
NARDIL TAB 15MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 12
per 30 days
Maximum of 12
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
440
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NASAL DECONG LIQ 30MG/5ML
NASAL DECONG TAB 10MG
NASAL EASE POW ALLERGY
NASAL MIST AER 3%
NASAL MOIST GEL
NASALCARE KIT FOR KIDS
2
1
3
3
3
2
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
3
2
2
1
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
2
Preferred Brand
2
3
2
1
1
3
2
-
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
NASALCROM SPR 5.2/ACT
NASAMIST AER HYPERTON
NASCOBAL SPR 500MCG
NASOHIST DM DRO
NASOHIST DRO 1-2MG/ML
NASONEB NSL MIS REPLACEM
NASONEX SPR 50MCG/AC
NASOPEN LIQ
NASOPEN PE LIQ
NAT FIBER POW 58.6%
NAT FIBER POW THERAPY
NAT OATMEAL LOT 1.25%
NAT SENNA TAB LAXATIVE
NATA KOMPLET TAB 25-1MG
NATACHEW CHW
NATACYN SUS 5% OP
NATAFORT TAB
NATAL-V RX TAB 29-1MG
NATALVIRT CA PAK
NATALVIRT MIS 90 DHA
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 17
gm per 30 days
-
-
-
-
441
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NATALVIT TAB 75-1MG
NATAPRES LIQ
NATAZIA TAB
NATEGLINIDE TAB 120MG
NATEGLINIDE TAB 60MG
NATELLE ONE CAP
NATRECOR INJ 1.5MG
NATROBA SUS 0.9%
NATTOKINASE CAP 100MG
NATURAL EMU GEL RELIEF
NATURAL HERB TAB DIURETIC
NATURAL VEG TAB LAXATIVE
NATURE THROI TAB 162.5MG
NATURE-THROI TAB 113.75MG
NATURE-THROI TAB 130MG
NATURE-THROI TAB 146.25MG
NATURE-THROI TAB 16.25MG
NATURE-THROI TAB 195MG
NATURE-THROI TAB 260MG
NATURE-THROI TAB 32.5MG
NATURE-THROI TAB 325MG
NATURE-THROI TAB 48.75MG
NATURE-THROI TAB 65MG
NATURE-THROI TAB 81.25MG
NATURE-THROI TAB 97.5MG
NATURL WATER TAB
NAUZENE CHW
NAUZENE LIQ
2
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
Generic
Generic
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
1
1
2
3
3
3
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
442
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
NAVELBINE INJ 10MG/ML
3
Non-Preferred Brand
YES, Specialty Drug
NAVELBINE INJ 50MG/5ML
3
Non-Preferred Brand
YES, Specialty Drug
NEATSFOOT OIL
NEBUPENT INH 300MG
NEBUSAL NEB 3%
NEBUSAL NEB 6%
NECON TAB 0.5/35
NECON TAB 1/50-28
NECON TAB 10/11-28
NEEDLE-FREE KIT A
NEEVO DHA CAP
NEEVO DHA CAP 27-1.13
NEFAZODONE TAB 100MG
NEFAZODONE TAB 150MG
NEFAZODONE TAB 200MG
NEFAZODONE TAB 250MG
NEFAZODONE TAB 50MG
NEMBUTAL SOD INJ 50MG/ML
NEO AC SYP
3
2
1
3
2
3
3
3
1
3
2
3
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
1
Generic
NEO DM SYP
NEO TO GO SPR 1-0.13%
NEO/POLY GU SOL 40/ML IR
WDRx 2/23/15
-
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
443
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NEO/POLY/BAC OIN /HC 1%OP
NEO/POLY/DEX OIN 0.1% OP
NEO/POLY/DEX SUS 0.1% OP
NEO/POLY/GRA SOL OP
NEO/POLY/HC SUS 1% OTIC
NEO/POLY/HC SUS OP
NEOMYCIN POW SULFATE
NEOMYCIN TAB 500MG
NEOPROFEN SOL 10MG/ML
NEOQ10 CAP 125MG
1
1
1
1
1
2
2
1
2
3
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
NEORAL CAP 100MG
3
Non-Preferred Brand
NEORAL CAP 25MG
3
Non-Preferred Brand
NEORAL SOL 100MG/ML
3
Non-Preferred Brand
NEOSPORIN CRE PLUS
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
NEOSPORIN GU SOL 40/ML IR
NEOSPORIN KIT TRIAL
NEOSPORIN LIQ CLEANSER
NEOSPORIN LT OIN
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
444
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NEOSPORIN OIN ORIGINAL
3
Non-Preferred Brand
NEOSPORIN OIN PLUS MS
3
Non-Preferred Brand
3
Non-Preferred Brand
NEOSTIG METH INJ 0.5MG/ML
NEOSTIG METH INJ 1MG/ML
NEOSTIGMINE POW BROMIDE
NEOSTIGMINE POW METHYLSU
NEO-SYNALAR CRE
NEO-SYNALAR KIT
1
1
3
2
3
3
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
NEO-SYNEPHRI INJ 10MG/ML
3
Non-Preferred Brand
NEO-SYNEPHRI SOL 0.25%
3
Non-Preferred Brand
NEO-SYNEPHRI SPR 0.25%
NEO-SYNEPHRI SPR 0.5%
NEO-SYNEPHRI SPR 1%
NEOTUSS PLUS LIQ
NEOTUSS-D LIQ
NEOX 100 MIS 2CMX2CM
NEOX CORD 1K MIS 1.5X1.5
NEOX CORD 1K MIS 2.5X2.5
NEOX CORD 1K MIS 4CMX3CM
NEOX CORD 1K MIS 6CMX3CM
2
2
2
2
2
3
3
3
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
NEOSPORIN SOL OP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
445
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NEOX CORD 1K MIS 8CMX3CM
NEPHRAMINE INJ 5.4%
3
2
Non-Preferred Brand
Preferred Brand
-
-
-
-
NEPHRON FA TAB
3
Non-Preferred Brand
NEPHRONEX LIQ
-
-
NEPHRO-VITE TAB RX
-
-
NEPTAZANE TAB 25MG
3
Non-Preferred Brand
NEPTAZANE TAB 50MG
3
Non-Preferred Brand
NERVO B-12 LOZ SL
-
-
NESACAINE INJ 1%
2
Preferred Brand
NESACAINE INJ 2%
3
Non-Preferred Brand
3
Non-Preferred Brand
NESINA TAB 12.5MG
3
Non-Preferred Brand
NESINA TAB 25MG
3
Non-Preferred Brand
NEPHROCAPS CAP
NEPHROCAPS TAB QT
NESACAINE INJ -MPF 3%
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
446
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
May be subject to
Quantity Level
Limits
NESINA TAB 6.25MG
3
Non-Preferred Brand
NESTABS ABC MIS
NESTABS DHA PAK
NESTABS TAB
-
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
-
-
NETI POT KIT 2300-700
NETTLE LEAF CAP 435MG
NETTLE LEAF POW
NETTLES ROOT POW
NEUAC KIT 1.2-5%
NEULASTA INJ 6MG/0.6M
NEUMEGA INJ 5MG
NEUPOGEN INJ 300/0.5
NEUPOGEN INJ 300MCG
NEUPOGEN INJ 480/0.8
NEUPOGEN INJ 480MCG
1
3
3
2
3
3
3
3
3
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
NEUPRO DIS 1MG/24HR
3
Non-Preferred Brand
NEUPRO DIS 2MG/24HR
3
Non-Preferred Brand
NEUPRO DIS 3MG/24HR
3
Non-Preferred Brand
NEUPRO DIS 4MG/24HR
3
Non-Preferred Brand
NESTLE FLAVO PAK FOR KIDS
WDRx 2/23/15
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
447
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NEUPRO DIS 6MG/24HR
3
Non-Preferred Brand
NEUPRO DIS 8MG/24HR
3
Non-Preferred Brand
NEURIN-SL SUB
3
Non-Preferred Brand
NEURO VITE TAB
-
-
NEURODEP SOL
-
-
NEURO-K-250 CAP T.D.
-
-
NEUROKININ A POW
NEUROMED7 CRE 4%
3
3
Non-Preferred Brand
Non-Preferred Brand
NEURONTIN CAP 100MG
3
Non-Preferred Brand
NEURONTIN CAP 300MG
3
Non-Preferred Brand
NEURONTIN CAP 400MG
3
Non-Preferred Brand
NEURONTIN SOL 250/5ML
3
Non-Preferred Brand
NEURONTIN TAB 600MG
3
Non-Preferred Brand
NEURONTIN TAB 800MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
448
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NEUROPEN KIT
NEUROPEN MON MIS 10G
NEURO-PS CAP 50MG
NEUT INJ 4%
NEUTRAHIST DRO 9-0.8-3
NEUTRASAL POW
NEUTREXIN INJ 25MG
NEUTRO MOIST LOT SPF15
NEUTRO T/GEL LIQ CONDITNR
3
3
3
2
2
3
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
NEUTRO T/GEL SHA STB ITCH
3
Non-Preferred Brand
NEUTROGENA CRE 2.5%
NEUTROGENA GEL RAINBATH
NEVANAC SUS 0.1%
NEVIRAPINE SUS 50MG/5ML
NEVIRAPINE TAB 200MG
NEVIRAPINE TAB 400MG ER
NEW TEROCIN LOT
NEWGEN TAB 32-1MG
NEXAFED TAB 30MG
NEXAVAR TAB 200MG
NEXAVIR INJ
NEXICLON XR SUS 0.09/ML
NEXICLON XR TAB 0.17MG
2
1
2
3
3
3
3
1
3
3
3
3
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
2
Preferred Brand
2
Preferred Brand
NEXIUM 24HR CAP 20MG
NEXIUM CAP 40MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
-
-
Limited Distribution
Maximum of 30
per 30 days
Maximum of 30
per 30 days
449
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
NEXIUM GRA 10MG DR
2
Preferred Brand
Maximum of 30
per 30 days
NEXIUM GRA 2.5MG DR
2
Preferred Brand
NEXIUM GRA 20MG DR
2
Preferred Brand
NEXIUM GRA 40MG DR
2
Preferred Brand
NEXIUM GRA 5MG DR
NEXIUM I.V. INJ 40MG
NEXTERONE INJ
NEXTERONE INJ
2
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
NIACIN CAP 250MG ER
-
-
NIACIN CAP 400-100
-
-
NIACIN CAP 500MG SR
-
-
3
Non-Preferred Brand
NIACIN ER TAB 1000MG
1
Generic
NIACIN ER TAB 500MG
1
Generic
NIACIN ER TAB 750MG
1
Generic
NIACIN FLUSH CAP FREE
2
Preferred Brand
-
-
NIACIN TAB 100MG
-
-
NIACIN TAB 250MG
-
-
NIACIN TAB 500MG
-
-
NIACIN CAP 590MG
NIACIN POW
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Maximum of 60
per 30 days
Maximum of 30
per 30 days
Maximum of 60
per 30 days
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
450
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NIACIN TAB 500MG
-
-
NIACIN TAB 50MG
-
-
NIACIN TAB 750MG TR
-
-
NIACIN TR TAB 1000MG
-
-
-
-
-
-
-
-
3
Non-Preferred Brand
3
Non-Preferred Brand
NIASPAN TAB 1000 ER
3
Non-Preferred Brand
Maximum of 60
per 30 days
NIASPAN TAB 500MG ER
3
Non-Preferred Brand
Maximum of 30
per 30 days
NIASPAN TAB 750MG ER
3
Non-Preferred Brand
Maximum of 60
per 30 days
NICARDIPINE CAP 20MG
NICARDIPINE CAP 30MG
NICARDIPINE INJ 25/10ML
NICAZELDOXY KIT 30
NICE PURE POW BAK SODA
NICLOSAMIDE POW
1
1
1
3
3
2
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
NIACINAMIDE POW
NIACINAMIDE TAB 100MG
NIACINAMIDE TAB 500MG PR
NIACOR TAB 500MG
NIAOULI OIL
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Maximum of 360
per 30 days
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
451
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NICODERM CQ DIS 14MG/24H
-
-
NICODERM CQ DIS 21MG/24H
-
-
NICODERM CQ DIS 7MG/24HR
-
-
-
-
NICORETTE GUM 2MG CINN
-
-
NICORETTE GUM 4MG CINN
-
-
NICORETTE LOZ 2MG CHRY
-
-
NICORETTE LOZ 4MG CHRY
-
-
NICOTINAMIDE POW ADENINE
NICOTINE POW POLACRIL
NICOTINE POW TARTRATE
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
NICOTINE SYS KIT TRANSDER
-
-
NICOTINIC AC POW N-HEXYL
NICOTROL INH
NICOTROL NS SPR 10MG/ML
NIFEDIAC CC TAB 90MG ER
3
1
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
Generic
NICOMIDE TAB
WDRx 2/23/15
Special Plan Edits
Covered Under
Quitline at 1-800784-8669
Covered Under
Quitline at 1-800784-8669
Covered Under
Quitline at 1-800784-8669
Not a covered
benefit
Covered Under
Quitline at 1-800784-8669
Covered Under
Quitline at 1-800784-8669
Covered Under
Quitline at 1-800784-8669
Covered Under
Quitline at 1-800784-8669
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Covered Under
Quitline at 1-800784-8669
452
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
1
1
1
1
2
1
1
3
2
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
NIMBEX INJ 10MG/ML
3
Non-Preferred Brand
NIMODIPINE CAP 30MG
NIMODIPINE POW
NIPENT INJ 10MG
1
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
NIRAVAM TAB 0.25MG
3
Non-Preferred Brand
NIRAVAM TAB 0.5MG
3
Non-Preferred Brand
NIRAVAM TAB 1MG
3
Non-Preferred Brand
NIRAVAM TAB 2MG
3
Non-Preferred Brand
3
1
2
2
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
NIFEDICAL XL TAB 30MG
NIFEDICAL XL TAB 60MG
NIFEDIPINE CAP 10MG
NIFEDIPINE CAP 20MG
NIFEDIPINE POW
NIFEDIPINE TAB 90MG ER
NIGHT TIME CAP SINUS
NIGROSIN POW
NILANDRON TAB 150MG
NIRON KOMPLE TAB 30-1MG
NISOLDIPINE TAB 17MG ER
NISOLDIPINE TAB 20MG
NISOLDIPINE TAB 25.5MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
453
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NISOLDIPINE TAB 30MG
NISOLDIPINE TAB 34MG ER
NISOLDIPINE TAB 40MG
NISOLDIPINE TAB 8.5MG ER
NITEBITE BAR CHOCFUDG
NITE-TIME LIQ COLD/FLU
NITHIODOTE KIT
NITRIC ACID LIQ
NITRO-BID OIN 2%
2
1
2
1
3
3
3
2
2
Preferred Brand
Generic
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
NITRO-DUR DIS 0.1MG/HR
3
Non-Preferred Brand
NITRO-DUR DIS 0.2MG/HR
3
Non-Preferred Brand
NITRO-DUR DIS 0.3MG/HR
3
Non-Preferred Brand
NITRO-DUR DIS 0.4MG/HR
3
Non-Preferred Brand
NITRO-DUR DIS 0.6MG/HR
3
Non-Preferred Brand
3
1
1
2
1
2
3
1
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Generic
NITRO-DUR DIS 0.8MG/HR
NITROFUR MAC CAP 100MG
NITROFUR MAC CAP 50MG
NITROFURAN POW ANHYDROU
NITROFURANTN CAP 100MG
NITROFURANTN POW
NITROFURANTN POW ANHYDR
NITROFURANTN SUS 25MG/5ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
454
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NITROFURAZON POW
NITROGLY/D5W INJ
NITROGLY/D5W INJ 25MG
NITROGLYCER AER 400MCG
NITROGLYCER CAP 2.5MG ER
NITROGLYCER CAP 6.5MG ER
NITROGLYCER CAP 9MG ER
NITROGLYCER INJ 5MG/ML
NITROGLYCRN SPR 0.4MG
2
1
2
2
1
1
1
2
1
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
NITROLINGUAL SPR PUMPSPRA
3
Non-Preferred Brand
3
3
3
2
2
2
2
1
1
1
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
3
Non-Preferred Brand
2
3
3
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
NITROMIST AER 400MCG
NITRONAL SOL 1MG/ML
NITROPRESS INJ 25MG/ML
NITROSTAT SUB 0.3MG
NITROSTAT SUB 0.4MG
NITROSTAT SUB 0.6MG
NIVATOPIC CRE PLUS
NIZATIDINE CAP 150MG
NIZATIDINE CAP 300MG
NIZATIDINE SOL 15MG/ML
NIZORAL A-D SHA 1%
NIZORAL SHA 2%
N-JELLY GEL
NO FUNGUS LIQ NAIL PRO
NO MORE RASH CRE
NOBLE FORMUL BAR 2%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
455
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NOBLE FORMUL CRE 0.25%
NOBLE FORMUL SPR 0.25%
NOBLE MYSTIQ CRE EMU-LAC
NOHIST-LQ LIQ 4-10/5ML
NON-ASA COLD SYP COUGH
NON-ASPIRIN TAB 500MG QM
NON-DRY SINU TAB 5-200MG
NONI CAP 250MG
NONI JUICE LIQ
NONI MORINDA CAP 400MG
NONOXYNOL-9 LIQ
3
1
3
1
1
3
1
3
1
3
3
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
NORCO TAB 10-325MG
3
Non-Preferred Brand
NORCO TAB 5-325MG
3
Non-Preferred Brand
NORCO TAB 7.5-325
3
Non-Preferred Brand
NORDETTE-28 TAB
NORDITROPIN INJ 10/1.5ML
NORDITROPIN INJ 15/1.5ML
NORDITROPIN INJ 30/3ML
NORDITROPIN INJ 5/1.5ML
NOREL AD TAB 4-10-325
NOREL CS LIQ
NOREPHEDRINE POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
$0 Preventative Drug
3
3
3
3
2
2
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
PA Required
PA Required
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
456
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NOREPINEPHR INJ 1MG/ML
NORETHIN ACE TAB 5MG
NORETHINDRON POW
NORETHINDRON POW ACETATE
1
1
2
2
Generic
Generic
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
1
Generic
$0 Preventative Drug
NORFLEX INJ 30MG/ML
NORFORMS SUP
NORGEST/ETHI TAB ESTRADIO
NORINYL TAB 1/35
3
3
3
2
2
3
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
NORPACE CAP 100MG
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
NORPACE CAP 150MG CR
3
Non-Preferred Brand
NORPRAMIN TAB 100MG
3
Non-Preferred Brand
NORPACE CAP 150MG
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
$0 Preventative Drug
NORINYL TAB 1+50-28
NORITATE CRE 1%
NORMLSHIELD CRE 4.5%
NORMOSOL -R INJ
NORMOSOL -R INJ /D5W
NORMOSOL-R INJ PH 7.4
NOROXIN TAB 400MG
NORPACE CAP 100MG CR
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
PA Required
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
457
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NORPRAMIN TAB 10MG
3
Non-Preferred Brand
NORPRAMIN TAB 150MG
3
Non-Preferred Brand
NORPRAMIN TAB 25MG
3
Non-Preferred Brand
NORPRAMIN TAB 50MG
3
Non-Preferred Brand
NORPRAMIN TAB 75MG
3
Non-Preferred Brand
NOR-QD TAB 0.35MG
3
$0 Preventative Drug
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
3
Non-Preferred Brand
NORTHERA CAP 100MG
NORTHERA CAP 200MG
NORTHERA CAP 300MG
NORTRIPTYLIN CAP 10MG
NORTRIPTYLIN CAP 25MG
NORTRIPTYLIN CAP 50MG
NORTRIPTYLIN CAP 75MG
NORTRIPTYLIN POW HCL
NORTRIPTYLIN SOL 10MG/5ML
NORTUSS-EX LIQ 200-20/5
NORVASC TAB 10MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
458
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NORVASC TAB 2.5MG
3
Non-Preferred Brand
NORVASC TAB 5MG
3
Non-Preferred Brand
3
3
3
3
3
3
3
3
3
2
3
3
2
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
NORVIR TAB 100MG
NOSE BETTER GEL
NOSE BETTER SPR 1-0.35%
NOSEBLEEDQR POW
NO-STING MIS SKINPREP
NOT NICE TO AER LICE
NOT NICE TO SHA LICE
NOVA MAX PLS TES KETONE
NOVACORT GEL
NOVAFERRUM CAP 50MG
NOVAFERRUM DRO 15MG/ML
NOVAFERRUM LIQ 125
NOVAFERRUM SOL
NOVOFINE AUT MIS 30GX8MM
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
NOVOSEVEN RT INJ 1MG
NOVOSEVEN RT INJ 2MG
NOVOSEVEN RT INJ 5MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
459
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
NOVOSEVEN RT INJ 8MG
NOXAFIL INJ 300/16.7
NOXAFIL SUS 40MG/ML
NOXAFIL TAB 100MG
NOXICARE CRE
NP THYROID TAB 30MG
NP THYROID TAB 60MG
NP THYROID TAB 90MG
NPLATE INJ 250MCG
NPLATE INJ 500MCG
3
2
2
2
3
1
1
1
3
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
NUBAIN INJ 10MG/ML
3
Non-Preferred Brand
NUCORT LOT 2%
NUCYNTA ER TAB 100MG
NUCYNTA ER TAB 150MG
NUCYNTA ER TAB 200MG
NUCYNTA ER TAB 250MG
NUCYNTA ER TAB 50MG
NUCYNTA TAB 100MG
NUCYNTA TAB 50MG
NUCYNTA TAB 75MG
3
2
2
2
2
2
2
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
NUEDEXTA CAP 20-10MG
2
Preferred Brand
3
2
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
NULLO TAB 100MG
NULOJIX INJ 250MG
NULYTELY SOL FLAV PKS
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 60
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
460
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
NUMOISYN LOZ
NUOX GEL 6-3%
NUPERCAINAL OIN 1%
NUPREP 5% SOL POV-IODI
NUQUIN HP GEL 4%
NUTMEG OIL
NUTRA/PRO PAK STRAWBER
NUTRAMIX PAK
NUTRA-SUPPRT CAP BONE
NUTRATEAR SOL 0.6%
NUTRESTORE PAK 5GM
NUTRICION TAB PORVIDA
NUTRIDOX KIT
NUTRIENTS TAB PRENATAL
NUTRILYTE II INJ
NUTRISOURCE PAK FIBER
NUTRISOURCE POW FIBER
NUTRI-TAB OB MIS + DHA
NUTRIVIT LIQ 800-15-1
NUTROPIN AQ INJ 10MG/2ML
NUTROPIN AQ INJ 20MG/2ML
NUTROPIN AQ INJ NUSPIN 5
NUTROPIN INJ 10MG
NUVARING MIS
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
3
2
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
-
-
2
2
Preferred Brand
Preferred Brand
-
-
3
3
3
3
1
2
2
-
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
$0 Preventative Drug
Generic
Preferred Brand
Preferred Brand
$0 Preventative Drug
-
-
3
3
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
$0 Preventative Drug
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Not a covered
benefit
-
-
-
-
-
-
-
-
-
-
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
-
Not a covered
benefit
PA Required
PA Required
PA Required
PA Required
Maximum of 1 per
30 days
461
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
2
2
2
2
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PA Required
PA Required
PA Required
PA Required
3
Non-Preferred Brand
1
2
3
Generic
Preferred Brand
Non-Preferred Brand
NYQUIL COUGH LIQ 6.25-15
3
Non-Preferred Brand
NYQUIL SINEX CAP NT RELF
3
Non-Preferred Brand
NYSTAT/TRIAM CRE
NYSTAT/TRIAM OIN
NYSTATIN CRE 100000
NYSTATIN OIN 100000
NYSTATIN POW
NYSTATIN SUS 100000
NYSTATIN VAG TAB 100000
1
1
1
1
2
1
2
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Preferred Brand
NYTOL MX-STR TAB 50MG
3
Non-Preferred Brand
OASIS MATRIX MIS 3X7CM
OASIS MOUTH SPR 35%
3
3
Non-Preferred Brand
Non-Preferred Brand
NUVIGIL TAB 150MG
NUVIGIL TAB 200MG
NUVIGIL TAB 250MG
NUVIGIL TAB 50MG
NUVORAWHITE LOZ
NUX VOMICA POW
NUZON GEL 2%
NYAMYC POW 100000
NYLIDRIN HCL POW
NYMALIZE SOL 60/20ML
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
462
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
OASIS ULTRA MIS 3X3.5CM
OASIS ULTRA MIS 5 X 7CM
OAT BRAN POW SOLUBLE
OB COMPLETE CAP 400
OB COMPLETE CAP ONE
OB COMPLETE CAP PETITE
OB COMPLETE CHW
OB COMPLETE TAB
OB COMPLETE TAB PREMIER
OB COMPLETE/ CAP DHA
OBSTETRIX EC TAB
OBSTETRIX PAK DHA
OBTREX DHA PAK
OC8 GEL 7%
O-CAL TAB PRENATAL
OCEAN COMPL AER SINUS
OCEAN NASAL SPR 0.65%
OCTAGAM INJ 1GM
OCTAGAM INJ 25GM
OCTAPLAS INJ GROUP A
OCTINOXATE LIQ
OCTREOSCAN KIT
OCTREOTIDE INJ 1000MCG
OCTREOTIDE INJ 1000MCG
OCTREOTIDE INJ 100MCG
OCTREOTIDE INJ 500MCG
OCTREOTIDE INJ 50MCG/ML
OCTYL LIQ METHOXYC
OCTYL LIQ STEARATE
3
3
3
2
3
2
3
3
3
2
3
3
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
463
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
OCTYL SALICY LIQ
OCUCOAT SOL 2% OP
OCUDOX KIT
3
1
2
Non-Preferred Brand
Generic
Preferred Brand
OCUFEN SOL 0.03% OP
3
Non-Preferred Brand
OCUFLOX DRO 0.3% OP
3
Non-Preferred Brand
OCUSOFT KIT DRY EYE
ODOR DESTROY AER DEODORNT
ODOR DESTROY POW MEDICATE
OFF-EZY WART KIT REMOVER
OFIRMEV INJ 10MG/ML
OFLOXACIN DRO 0.3% OP
OFLOXACIN DRO 0.3%OTIC
OFLOXACIN TAB 200MG
OFLOXACIN TAB 300MG
OGESTREL TAB
OINTMENT BAS OIN EMULSIFY
OK-GARLIC TAB
3
3
3
3
2
1
1
1
1
2
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
$0 Preventative Drug
Preferred Brand
Generic
OLANZA/FLUOX CAP 12-25MG
1
Generic
OLANZA/FLUOX CAP 12-50MG
1
Generic
OLANZA/FLUOX CAP 3-25MG
1
Generic
OLANZA/FLUOX CAP 6-25MG
1
Generic
OLANZA/FLUOX CAP 6-50MG
1
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
464
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
OLANZAPINE INJ 10MG
OLANZAPINE TAB 10MG
OLANZAPINE TAB 10MG ODT
OLANZAPINE TAB 15MG
OLANZAPINE TAB 15MG ODT
OLANZAPINE TAB 2.5MG
OLANZAPINE TAB 20MG
OLANZAPINE TAB 20MG ODT
OLANZAPINE TAB 5MG
OLANZAPINE TAB 5MG ODT
OLANZAPINE TAB 7.5MG
OLEIC ACID LIQ
1
1
1
1
1
1
1
1
1
1
1
2
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
OLEPTRO TAB 24HR150
-
$0 Preventative Drug
OLEPTRO TAB 24HR300
-
$0 Preventative Drug
OLEYL LIQ ALCOHOL
OLIVE LEAF CAP 150MG
OLIVE LEAF CAP 250MG
OLIVE LEAF CAP 500MG
OLIVE OIL
3
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
OLUX AER 0.05%
3
Non-Preferred Brand
OLUX-E AER 0.05%
3
Non-Preferred Brand
OLYSIO CAP 150MG
OMECLAMOX- MIS PAK
OMEGA 3 CAP 340MG
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
YES, Specialty Drug
465
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
OMEGA 3-6-9 CAP
OMEGA POWER CAP 1050MG
OMEGA-3 2100 CAP 1050MG
OMEGA-3 CAP
OMEGA-3 CAP 1400MG
OMEGA-3 CAP COMPLEX
OMEGA-3 CAP FISH OIL
OMEGA-3 CHW GUMMIES
OMEGA-3 DHA POW
OMEGA-3 DUAL CAP SPECTRUM
OMEGA-3 EPA CAP 1205MG
OMEGA-3 FISH CAP NATURAL
OMEGA-3 IQ CHW 240MG
OMEGA-3 KRIL CAP 450MG
OMEGA-3 KRIL CAP 500MG
OMEGA-3 LIQ FUSION
OMEGA-3/D3 CHW 117-100
2
3
2
3
2
3
3
3
3
1
3
3
3
3
3
3
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
1
Generic
1
1
3
1
1
1
1
2
2
Generic
Generic
Non-Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
OMEGA-3-ACID CAP 1GM
OMEPRA/BICAR CAP 20-1100
OMEPRA/BICAR CAP 40-1100
OMEPRAZOLE + SUS SYRSPEND
OMEPRAZOLE CAP 10MG
OMEPRAZOLE CAP 20.6MGDR
OMEPRAZOLE CAP 20MG
OMEPRAZOLE CAP 40MG
OMEPRAZOLE POW
OMEPRAZOLE TAB 20MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 120
per 30 days
466
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
OMNARIS SPR
3
Non-Preferred Brand
OMNICAP TAB
-
-
2
3
2
2
2
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
-
-
-
-
3
Non-Preferred Brand
3
3
3
3
3
3
3
1
1
2
1
1
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Generic
DIABETA TAB 5MG
OMNIPAQUE INJ 140MG/ML
OMNIPAQUE INJ 180MG/ML
OMNIPAQUE INJ 240MG/ML
OMNIPAQUE INJ 300MG/ML
OMNIPAQUE INJ 350MG/ML
OMNIPOD KIT STARTER
OMNIPOD MIS
OMNIPRED SUS 1% OP
OMNISCAN INJ /NACL
OMNITROPE INJ 10/1.5ML
OMNITROPE INJ 5.8MG
OMNITROPE INJ 5/1.5ML
OMONTYS INJ 10MG/ML
OMONTYS INJ 20MG/2ML
ONCASPAR INJ 750/ML
ONDANSETRON INJ 40/20ML
ONDANSETRON INJ 4MG/2ML
ONDANSETRON POW HCL
ONDANSETRON SOL 4MG/5ML
ONDANSETRON TAB 24MG
ONDANSETRON TAB 4MG
WDRx 2/23/15
Special Plan Edits
Maximum of 12.5
gm per 30 days
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
-
467
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ONDANSETRON TAB 4MG ODT
ONDANSETRON TAB 8MG
ONDANSETRON TAB 8MG ODT
ONE A DAY MIS PRENATAL
1
1
1
-
Generic
Generic
Generic
$0 Preventative Drug
ONE-A-DAY TAB WOMENS
-
-
ONETOUCH MIS LANC DEV
ONETOUCH SOL VERIO-HI
ONFI SUS 2.5MG/ML
ONFI TAB 10MG
ONFI TAB 20MG
ONFI TAB 5MG
2
2
2
2
2
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
ONGLYZA TAB 2.5MG
2
Preferred Brand
ONGLYZA TAB 5MG
2
Preferred Brand
ONION POW EXTRACT
3
Non-Preferred Brand
ONMEL TAB 200MG
3
Non-Preferred Brand
ONSET FORTE TAB
OPANA ER TAB 10MG
OPANA ER TAB 15MG
OPANA ER TAB 20MG
OPANA ER TAB 30MG
OPANA ER TAB 40MG
OPANA ER TAB 5MG
OPANA ER TAB 7.5MG
OPANA INJ 1MG/ML
3
2
2
2
2
2
2
2
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
Maximum of 30
per 30 days
Maximum of 30
per 30 days
PA Required and
Quantity Level
Limits
468
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
OPANA TAB 10MG
3
Non-Preferred Brand
OPANA TAB 5MG
3
Non-Preferred Brand
2
1
2
3
3
1
3
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
3
Non-Preferred Brand
OPTIMARK INJ 330.9MG
OPTIRAY 160 INJ 34%
OPTIRAY 240 INJ 51%
OPTIRAY 300 INJ 64%
OPTIRAY 320 INJ 68%
OPTIRAY 350 INJ 74%
OPTISON INJ
3
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
OPTIVAR DRO 0.05%
3
Non-Preferred Brand
OPURITY CALC CHW CIT PLUS
3
Non-Preferred Brand
OPURITY VIT CHW D 5000UN
-
$0 ACA Drug
2
Preferred Brand
OPCON-A SOL OP
OPIUM TIN 1%
OPIUM TINCT TIN 2MG/5ML
OPSUMIT TAB 10MG
OPTASE GEL
OPTICS MINI DRO
OPTIFLEX-C CAP 400MG
OPTI-GAR TAB
ORABASE PST 20%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
469
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ORABASE-B PST 20%
ORACEA CAP 40MG
ORACIT SOL
ORAFATE PST 10%
ORA-FILM MIS 6%
ORA-HESIVE PST BASE
ORAJEL COVER CRE LIGHT
ORAJEL DRY GEL MOUTH
ORAJEL GEL MOUTHAID
ORAJEL MAX SOL 20%
ORAJEL PERIO LIQ 15%
ORAL ANALGES PST MAX ST
ORAL CLEANSR SOL 1.5-6%
ORAL MED CON MIS 15ML
ORAL PAIN CRE REL 20%
ORAL RELIEF GEL DRY MOUT
ORAL RELIEF KIT DRY MOUT
ORAL SALINE SOL LAXATIVE
ORAL SWAB MIS PETITE
ORAL THERMOM MIS
ORALAIR SUB 300 IR
ORALBALANCE GEL DRY MTH
ORALONE PST 0.1%
ORAMAGIC PLS SUS 10%
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
2
3
3
3
2
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
3
1
1
2
1
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
2
1
2
Preferred Brand
Generic
Preferred Brand
Special Plan Edits
PA Required
Medication must be filled
through US Specialty Care
Pharmacy
-
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
470
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ORAMAGICRX SUS
ORANGE OIL
ORANGE OIL CALIFORN
ORANGE SYP
ORAP TAB 1MG
ORAP TAB 2MG
ORAPRED ODT TAB 10MG
ORAPRED ODT TAB 15MG
ORAPRED ODT TAB 30MG
3
2
3
2
3
3
3
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ORAPRED SOL 15MG/5ML
3
Non-Preferred Brand
ORASEP SPR
ORAVIG TAB 50MG
ORAXYL CAP 20MG
ORAZINC CAP 220MG
ORAZINC TAB 110MG
OREGANO CAP OIL
OREGON GRAPE POW ROOT
ORENCIA INJ 125MG/ML
ORENCIA INJ 250MG
ORENITRAM TAB 0.125MG
ORENITRAM TAB 0.25MG
ORENITRAM TAB 1MG
ORENITRAM TAB 2.5MG
ORFADIN CAP 10MG
ORFADIN CAP 2MG
ORFADIN CAP 5MG
ORIGANUM OIL
2
3
3
1
2
3
3
2
3
3
3
3
3
3
3
3
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
YES, Specialty Drug
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
471
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ORIGINAL OIN 1.24%
ORNIDAZOLE POW
ORPH/ASA/CAF TAB
ORPHENADRINE INJ 30MG/ML
ORPHENADRINE POW CITRATE
ORPHENADRINE TAB 100MG CR
ORRIS ROOT POW
DIP/TET PED INJ 25-5LFU
ENCARE SUP 100MG
ENGERIX-B INJ 10/0.5ML
3
3
1
1
2
1
3
-
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Generic
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
ORTHO EVRA DIS WEEK
ENGERIX-B INJ 20MCG/ML
EZ FLU SHOT KIT 13-14
EZ FLU SHOT KIT 2014-15
EZ FLU SHOT KIT PF 12-13
EZ USE FLU KIT 2012-13
FC FEMALE MIS CONDOM
FLUBLOK SOL 2013-14
FLUCELVAX INJ 2012-13
FLUMIST NASA LIQ 2012-13
FLUMIST QUAD SUS 2013-14
GLYBURIDE POW
HAVRIX INJ 1440UNIT
HIBERIX SOL 10-25MCG
$0 Preventative Drug
3
-
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 Preventative Drug
$0 ACA Drug
$0 ACA Drug
ORTHO TRI- TAB CYCLEN
$0 Preventative Drug
ORTHO TRI- TAB CYCLN LO
$0 Preventative Drug
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Generic Available. Brand copay + the
difference between the brand and the
generic.
472
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
ORTHO-CS 250 INJ 250MG/ML
-
-
Not a covered
benefit
-
ORTHO-CYCLEN TAB 0.25/35
ORTHO-PHENYL POW
ORTHO-TOLUID LIQ
ORTHOVANADAT POW SODIUM
ORTHOVISC INJ 15MG/ML
OS-CAL 500 CHW
OS-CAL CHW
OS-CAL ULTRA TAB 600MG
$0 Preventative Drug
3
3
3
3
1
1
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
OSENI TAB 12.5-15
3
Non-Preferred Brand
OSENI TAB 12.5-30
3
Non-Preferred Brand
OSENI TAB 12.5-45
3
Non-Preferred Brand
OSENI TAB 25-15MG
3
Non-Preferred Brand
OSENI TAB 25-30MG
3
Non-Preferred Brand
OSENI TAB 25-45MG
3
Non-Preferred Brand
WDRx 2/23/15
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
$0 Preventative Drug
ORTHO-NOVUM TAB 7/7/7
Penalty applied if Brand Selected
over Generic
PA Required
YES, Specialty Drug
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
473
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
OSGOOD BIOPS MIS
OSGOOD BIOPS MIS 18GX1"
OSHA LIQ
OSHA ROOT SYP COUGH
OSMOPREP TAB 1.5GM
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
OSTEO BI-FLX TAB 5-LOXIN
OSTEO-PORETI TAB
OSTIGEN MIS 350MG
OTEZLA TAB 10/20/30
OTEZLA TAB 30MG
OTIC CARE DRO
OTICIN DRO 1-0.1%
OTICIN HC DRO
OTOZIN DRO
OTREXUP INJ 10MG
OTREXUP INJ 15MG
OTREXUP INJ 20MG
OTREXUP INJ 25MG
OUTGRO LIQ 20%
OVACE PLUS CRE 10%
3
3
3
3
3
1
1
3
2
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
OVACE PLUS GEL 10% WASH
3
Non-Preferred Brand
OVACE PLUS LIQ 10% WASH
3
Non-Preferred Brand
3
Non-Preferred Brand
OSPHENA TAB 60MG
OVACE PLUS LOT 9.8%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
May be subject to
Quantity Level
Limits
PA Required
PA Required
Limited Distribution
Limited Distribution
PA Required
PA Required
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
474
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
OVACE PLUS SHA 10%
Tier
3
OVCON-35 TAB
OVIDE LOT 0.5%
Formulary Status
$0 Preventative Drug
Non-Preferred Brand
3
Non-Preferred Brand
2
3
1
1
1
2
3
3
3
3
3
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
OXANDRIN TAB 10MG
-
-
OXANDRIN TAB 2.5MG
-
-
OXANDROLONE POW
2
Preferred Brand
OXANDROLONE TAB 10MG
-
-
OXANDROLONE TAB 2.5MG
-
-
OXAPROZIN TAB 600MG
1
Generic
OVULATION TES PREDICT
OX BILE POW EXTRACT
OXACILLIN INJ 10GM
OXACILLIN INJ 1GM
OXACILLIN INJ 2GM
OXALIC ACID CRY
OXALIC ACID POW DIHYDRAT
OXALIPLATIN INJ 100MG
OXALIPLATIN INJ 100MG
OXALIPLATIN INJ 50MG
OXALIPLATIN INJ 50MG
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Non-Preferred Brand
3
OVIDREL INJ
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Not a covered
benefit
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
-
-
475
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
OXAZEPAM CAP 10MG
OXAZEPAM CAP 15MG
OXAZEPAM CAP 30MG
OXCARBAZEPIN SUS 300MG/5M
OXCARBAZEPIN TAB 150MG
OXCARBAZEPIN TAB 300MG
OXCARBAZEPIN TAB 600MG
OXECTA TAB 5MG
OXECTA TAB 7.5MG
OXIPOR VHC LOT PSORIASI
OXISTAT CRE 1%
OXISTAT LOT 1%
1
1
1
1
1
1
1
3
3
2
3
3
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
OXSORALEN-UL CAP 10MG
3
Non-Preferred Brand
OXTELLAR XR TAB 150MG
OXTELLAR XR TAB 300MG
OXTELLAR XR TAB 600MG
OXTRIPHYLLIN POW
OXYBENZONE POW
OXYBUTININ POW CHLORIDE
OXYBUTYNIN SYP 5MG/5ML
OXYBUTYNIN TAB 10MG ER
OXYBUTYNIN TAB 15MG ER
OXYBUTYNIN TAB 5MG
OXYBUTYNIN TAB 5MG ER
OXYCEL COTTN PAD 2"X1"X1"
2
2
2
3
2
2
1
1
1
1
1
2
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
OXSORALEN LOT 1%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
476
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
OXYCOD/APAP CAP 5-500MG
OXYCOD/IBU TAB 5-400MG
OXYCODONE CAP 5MG
OXYCODONE POW HCL
OXYCODONE TAB 10MG
OXYCODONE TAB 15MG
OXYCODONE TAB 20MG
OXYCODONE TAB 30MG
OXYCODONE TAB 5MG
OXYCONTIN TAB 10MG CR
OXYCONTIN TAB 15MG CR
OXYCONTIN TAB 20MG CR
OXYCONTIN TAB 30MG CR
OXYCONTIN TAB 40MG CR
OXYCONTIN TAB 60MG CR
OXYCONTIN TAB 80MG CR
OXYMETAZOLIN POW HCL
OXYMETHOLONE POW
OXYMORPHONE TAB 10MG ER
OXYMORPHONE TAB 15MG ER
OXYMORPHONE TAB 20MG ER
OXYMORPHONE TAB 30MG ER
OXYMORPHONE TAB 40MG ER
OXYMORPHONE TAB 5MG ER
OXYMORPHONE TAB 7.5MG ER
OXYMORPHONE TAB HCL 10MG
OXYMORPHONE TAB HCL 5MG
OXYPHENCYCLI POW HCL
OXYPURINOL POW
1
1
1
2
1
1
1
1
1
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
3
3
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
477
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
OXYTETRACYC POW HCL
OXYTETRACYCL POW DIHYDRAT
OXYTOCIN INJ 10UNT/ML
OXYTOCIN POW
2
3
1
2
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
3
Non-Preferred Brand
3
1
3
1
3
3
2
2
2
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
-
-
3
3
Non-Preferred Brand
Non-Preferred Brand
-
-
-
-
3
3
3
3
2
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
OXYTROL DIS 3.9MG/24
OXYZAL WET SOL DRESSING
OYS SHELL+D TAB 250-125
OYST SHELL/D TAB 250MG
OYST SHELL/D TAB 500MG
OYSTER SHELL GRA CALCIUM
OYSTER SHELL TAB PLUS D
OZURDEX IMP 0.7MG
P & S LIQ
P & S SHA 2%
P-1000 CAP 500MG
PA CLA CAP 1000MG
PA GLUCOSAMI CAP CHONDROI
PABA POW
PABA TAB 100MG
PACLITAXEL INJ 100MG
PACLITAXEL INJ 150/25ML
PACLITAXEL INJ 300/50ML
PACLITAXEL INJ 30MG/5ML
PADIMATE O SOL
PAIN RELIEF PAK AM/PM
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
Maximum of 1 box
= 8 patches per 30
days
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
478
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PAIN RELIEF TAB
PAIN RELIEF TAB 120-220
PAIN RELIEV PAD MEDICATE
PAIN RELIVNG SPR 4-10-30%
PAIRE OB MIS
PALGIC SOL 4MG/5ML
PALGIC TAB 4MG
PALLADIUM POW CHLORIDE
PALM OIL
PALMAROSA OIL
PALMITOYL GEL PENT-3
PALMITOYL SOL TRIPEPTI
PAMABROM POW
2
1
2
3
2
2
3
3
2
2
3
3
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PAMELOR CAP 10MG
3
Non-Preferred Brand
PAMELOR CAP 25MG
3
Non-Preferred Brand
PAMELOR CAP 50MG
3
Non-Preferred Brand
PAMELOR CAP 75MG
3
Non-Preferred Brand
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PAMIDRONATE INJ 30/10ML
PAMIDRONATE INJ 30MG
PAMIDRONATE INJ 6MG/ML
PAMIDRONATE INJ 90/10ML
PAMIDRONATE INJ 90MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
479
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
PAMINE FORTE TAB 5MG
Tier
Formulary Status
3
Non-Preferred Brand
3
Non-Preferred Brand
PAMINE TAB 2.5MG
3
Non-Preferred Brand
PAMIX SUS 50MG/ML
1
Generic
PAMPRIN MAX TAB PAIN FRM
3
Non-Preferred Brand
PAMPRIN TAB MULT-SYM
PANATUSS DXP LIQ
PANATUSS DXP LIQ PEDIATRI
PANATUSS PED DRO
PANATUSS PED LIQ 60-2-25
PANAX GINSNG TAB 300MG
PANCREATIN CAP 500MG
PANCREATIN POW
PANCREATIN TAB 325MG
PANCREAZE CAP 10500UNT
PANCREAZE CAP 16800UNT
PANCREAZE CAP 21000UNT
PANCREAZE CAP 4200UNIT
PANCRELIPASE CAP 5000UNIT
PANCURONIUM INJ 1MG/ML
PANCURONIUM INJ 2MG/ML
PANCURONIUM POW BROMIDE
PANDEL CRE 0.1%
PANGAMIC ACD POW SODIUM
2
3
3
3
3
3
3
2
3
3
3
3
3
2
1
1
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PAMINE FQ KIT
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
480
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
3
Preferred Brand
Non-Preferred Brand
PANOXYL LIQ 2.5%
3
Non-Preferred Brand
PANRETIN GEL 0.1%
PANTHODERM CRE 2%
3
3
Non-Preferred Brand
Non-Preferred Brand
-
-
PANTOPRAZOLE INJ 40MG
PANTOPRAZOLE TAB 20MG
PANTOPRAZOLE TAB 40MG
1
1
1
Generic
Generic
Generic
PANTOTHENIC TAB 500MG
-
-
PAPAIN POW
PAPAVERINE INJ 30MG/ML
PAPAVERINE POW HCL
PAPAYA CHW
PAPAYA ENZYM CHW
PAPAYA TAB
PAPAYA TAB 100MG
PARACHLOROPH POW
PARAFFIN MIS
2
1
2
1
1
3
3
2
2
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
PARAFON FORT TAB 500MG
3
Non-Preferred Brand
3
Non-Preferred Brand
$0 Preventative Drug
Medical ONLY
Non-Preferred Brand
PANHEMATIN INJ 313MG
PANOXYL GEL 3%
PANTO-250 CAP
PARAFORMALDE POW
PARAGARD IUD T380A
PARALDEHYDE LIQ
WDRx 2/23/15
3
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Covered Under
Medical
-
-
481
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PARCAINE SOL 0.5% OP
1
Generic
PARCOPA TAB 10-100MG
3
Non-Preferred Brand
PARCOPA TAB 25-100MG
3
Non-Preferred Brand
PARCOPA TAB 25-250MG
3
Non-Preferred Brand
PAREMYD SOL 1-0.25%
PARICALCITOL CAP 1 MCG
PARICALCITOL CAP 2 MCG
PARICALCITOL CAP 4 MCG
3
1
1
1
Non-Preferred Brand
Generic
Generic
Generic
PARLODEL CAP 5MG
3
Non-Preferred Brand
PARLODEL TAB 2.5MG
3
Non-Preferred Brand
PARNATE TAB 10MG
3
Non-Preferred Brand
1
2
1
1
1
1
1
1
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
PAROMOMYCIN CAP 250MG
PAROMOMYCIN POW SULFATE
PAROXETIN ER TAB 12.5MG
PAROXETIN ER TAB 37.5MG
PAROXETINE TAB 10MG
PAROXETINE TAB 20MG
PAROXETINE TAB 25MG ER
PAROXETINE TAB 30MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
482
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PAROXETINE TAB 40MG
PARSLEY POW LEAVES
PARVA-CAL TAB 250-100
PARVA-CAL TAB 500MG
PASER GRA 4GM
PASSION FLOW CAP 500-500M
PASSION POW FLOWER
PATADAY SOL 0.2%
1
3
3
3
3
3
3
2
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
2
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PAXIL CR TAB 12.5MG
3
Non-Preferred Brand
PAXIL CR TAB 25MG
3
Non-Preferred Brand
PAXIL CR TAB 37.5MG
3
Non-Preferred Brand
PAXIL SUS 10MG/5ML
3
Non-Preferred Brand
PAXIL TAB 10MG
3
Non-Preferred Brand
PAXIL TAB 20MG
3
Non-Preferred Brand
PAXIL TAB 30MG
3
Non-Preferred Brand
PATANASE SPR 0.6%
PATANOL SOL 0.1% OP
PATCHOULI OIL FRAGRANC
PAU D'ARCO CAP 1000MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30.5
gm per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
483
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
PAXIL TAB 40MG
PAZOL XS SHA 1-2-2%
PCCA ACACIA SYP BASE
PCCA BASE MIS TRSDRML
PCCA COBASE OIN #1
PCCA FIXED LIQ OIL BASE
PCCA GELATIN OIN BASE
PCCA LIPOSOM CRE DEHYDRAT
PCCA MBK MIS FAT ACID
PCCA PLURONI GEL F127 30%
PCCA POLOXAM GEL 407/20%
PCCA POLYGLY POW TROCHE
PCE TAB 333MG EC
PCE TAB 500MG EC
PEANUT OIL
PEARBERRY LIQ FRAGRANC
PEARL DROPS SOL SPEARMNT
PECGEN DMX LIQ 15-125MG
PECGEN LIQ PSE
PECTIN POW
PECTIN POW CITRUS
PEDIACARE LIQ LONG-ACT
PEDIADERM AF KIT COMPLETE
PEDIADERM HC KIT
PEDIA-LAX CHW 400MG
PEDIA-LAX CHW YUMS
PEDIA-LAX LIQ 50MG
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
1
2
3
2
2
2
3
2
2
2
2
3
3
2
3
3
2
1
2
2
1
3
3
2
3
2
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
484
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PEDIA-LAX SUP 1GM
PEDIA-LAX SUP 2.8GM
2
3
Preferred Brand
Non-Preferred Brand
PEDIAPRED SOL 6.7/5ML
3
Non-Preferred Brand
-
$0 ACA Drug
3
Non-Preferred Brand
2
3
3
3
2
2
3
2
3
2
2
2
3
2
3
2
3
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
INFANRIX INJ
PEDIATEX TD LIQ
PEDIATEX TDM SUS
PEDIAVENT CHW 1MG
PEDIAVENT SYP 2MG/5ML
PEDIPIROX-4 KIT NAIL
PEDI-SKIN LIQ ADHERE 2
PEDITRACE INJ
PEDI-WHIRL SOL CONCENT
INFLUENZA A SPR 09 H1N1
PEG 1000 LIQ
PEG 1000 POW BASE J
PEG 3350 POW
PEG 400 LIQ
PEG 400 POW MONOSTEA
PEG-120 METH POW GLUCOSE
PEG-40 CASTO OIL
PEG-7 GLYCER LIQ COCOATE
PEGANONE TAB 250MG
PEGASYS INJ
PEGASYS INJ 180MCG/M
PEGASYS INJ PROCLICK
PEGASYS KIT
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
485
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PEG-INTRON KIT 120 RP
PEG-INTRON KIT 150 RP
PEG-INTRON KIT 50MCG
PEG-INTRON KIT 80MCG
PEMOLINE POW
PEN G PROC INJ 600000
PEN G SOD INJ 5000000
PEN NEEDLES MIS 31GX5/16
PENICILL GK/ INJ DEX 1MU
PENICILL GK/ INJ DEX 2MU
PENICILL GK/ INJ DEX 3MU
PENICILLAMIN POW
PENICILLN GK INJ 20MU
PENICILLN GK INJ 5MU
PENICILLN VK SOL 125/5ML
PENICILLN VK SOL 250/5ML
PENICILLN VK TAB 250MG
PENICILLN VK TAB 500MG
3
3
3
3
3
2
2
2
2
2
2
1
1
1
1
1
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
3
Non-Preferred Brand
3
3
2
1
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
$0 ACA Drug
Non-Preferred Brand
Preferred Brand
Preferred Brand
PENLAC SOL 8%
PENNSAID SOL 1.5%
PENNSAID SOL 2%
PENNYROYAL OIL
PENTA/APAP TAB 25-650MG
KINRIX INJ
PENTAM 300 INJ 300MG
PENTASA CAP 250MG CR
PENTASA CAP 500MG CR
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
486
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PENTAZ/NALOX TAB 50-0.5MG
PENTOBARB POW SODIUM
PENTOSAN POW SODIUM
PENTOXIFYL POW
PENTOXIFYLLI TAB 400MG CR
1
2
2
2
1
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
PENTRAX GOLD SHA 4%
3
Non-Preferred Brand
PENTYLENE LIQ GLYCOL
PENTYLENETET CRY
PEPCID AC CHW 10MG
PEPCID AC CHW MAX ST
2
2
3
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
PEPCID AC TAB 10MG
3
Non-Preferred Brand
PEPCID AC TAB 20MG
3
Non-Preferred Brand
PEPCID CHW COMPLETE
3
Non-Preferred Brand
PEPCID SUS 40MG/5ML
3
Non-Preferred Brand
3
Non-Preferred Brand
2
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
PEPCID TAB 40MG
PEPPERMINT OIL
PEPPERMINT SOL SPIRIT
PEPSIN POW
PEPTO BISMOL TAB 262MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
487
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PEPTO-BISMOL CHW 262MG
PEPTO-BISMOL SUS 262/15ML
PEPTO-BISMOL SUS 525/15ML
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
PERCOCET TAB 10-325MG
3
Non-Preferred Brand
PERCOCET TAB 10-650MG
3
Non-Preferred Brand
PERCOCET TAB 2.5-325
3
Non-Preferred Brand
PERCOCET TAB 5-325MG
3
Non-Preferred Brand
PERCOCET TAB 7.5-325
3
Non-Preferred Brand
PERCOCET TAB 7.5-500
3
Non-Preferred Brand
3
Non-Preferred Brand
2
1
3
3
2
3
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
PERCODAN TAB
PERCOGESIC TAB 12.5-325
PERCOGESIC TAB XS
PERFECT IRON TAB 25MG
PERFLUORODEC LIQ
PERFOROMIST NEB 20MCG
PERGOLIDE POW MESYLATE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
488
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
PERIDEX SOL 0.12%
PERIDIN-C TAB
PERILLYL ALC POW 85%
PERINDOPRIL TAB 2MG
PERINDOPRIL TAB 4MG
PERINDOPRIL TAB 8MG
PERINEAL SOL WASH II
PERIO MED CON 0.63%
PERJETA INJ 420/14ML
PERLANE INJ 20MG/ML
Tier
Formulary Status
3
Non-Preferred Brand
-
-
3
1
1
1
3
1
3
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
-
-
PERLANE-L GEL 40MG/2ML
-
-
PERLANE-L INJ 20MG/ML
-
-
PERMETHRIN LIQ
PERMETHRIN POW
PERNOX LOT CLEANSER
PEROX SORE SOL MTH 1.5%
PEROX WIPES MIS 3%
PEROXYL GEL
PEROXYL SOL
PERPHEN/AMIT TAB 2-10MG
PERPHEN/AMIT TAB 2-25MG
PERPHEN/AMIT TAB 4-10MG
PERPHEN/AMIT TAB 4-25MG
PERPHEN/AMIT TAB 4-50MG
2
2
2
1
2
3
2
2
2
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
YES, Specialty Drug
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
489
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PERPHENAZINE POW
PERPHENAZINE TAB 16MG
PERPHENAZINE TAB 2MG
PERPHENAZINE TAB 4MG
PERPHENAZINE TAB 8MG
PERRY PRENAT CAP
3
1
1
1
1
-
Non-Preferred Brand
Generic
Generic
Generic
Generic
$0 Preventative Drug
PERSANTINE TAB 25MG
3
Non-Preferred Brand
PERSANTINE TAB 50MG
3
Non-Preferred Brand
PERSANTINE TAB 75MG
3
Non-Preferred Brand
3
3
2
2
2
3
1
2
2
2
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
PEXEVA TAB 10MG
3
Non-Preferred Brand
PEXEVA TAB 20MG
3
Non-Preferred Brand
PERSONAL BIO KIT
PERSONAL KIT SKIN CAR
PERUVIAN LIQ BALSAM
PERUVIAN MIS BALSAM
PERUVIAN POW BALSAM
PETN POW 20%
PETROLATUM GEL WHITE
PETROLATUM OIN
PETROLATUM OIN WHITE
PETROLATUM OIN YELLOW
PETROLEUM GEL
PEUCEDANUM SOL OSTRUTHI
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Maximum of 30
per 30 days
490
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PEXEVA TAB 30MG
3
Non-Preferred Brand
PEXEVA TAB 40MG
3
Non-Preferred Brand
2
2
2
3
3
2
1
1
3
1
2
1
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
Preferred Brand
Generic
-
-
PHENDIMETRAZ TAB 35MG
-
-
PHENELZINE POW SULFATE
PHENELZINE TAB 15MG
2
1
Preferred Brand
Generic
PHENERGAN INJ 25MG/ML
3
Non-Preferred Brand
PHENERGAN INJ 50MG/ML
3
Non-Preferred Brand
PHENERGAN SUP 50MG
PHENFLU CD TAB
PHENFLU CDX TAB
1
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
PFIZERPEN-G INJ 20MU
PFIZERPEN-G INJ 5MU
PHAZYME CAP 180MG
PHAZYME ULTR CAP 180MG
PHENABID DM TAB
PHENABID TAB 3.5-10MG
PHENADOZ SUP 12.5MG
PHENADOZ SUP 25MG
PHENAGIL CH TAB
PHENAZO TAB 200MG
PHENAZOPYRID POW HCL
PHENAZOPYRID TAB 100MG
PHENDIMETRAZ CAP 105MG ER
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Not a covered
benefit
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
491
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PHENFLU DM TAB
PHENINDIONE POW
PHENIRAMINE POW MALEATE
PHENOBARB ELX 20MG/5ML
PHENOBARB INJ 130MG/ML
PHENOBARB INJ 65MG/ML
PHENOBARB POW
PHENOBARB TAB 100MG
PHENOBARB TAB 15MG
PHENOBARB TAB 16.2MG
PHENOBARB TAB 30MG
PHENOBARB TAB 32.4MG
PHENOBARB TAB 60MG
PHENOBARB TAB 64.8MG
PHENOBARB TAB 97.2MG
PHENOL CRY
PHENOL EZ MIS
PHENOL LIQ
PHENOL LIQ
PHENOL RED POW
PHENOLPHTHAL POW YELLOW
PHENOLSULFON LIQ ACID
PHENOXYBENZA POW
PHENOXYETHAN LIQ
3
2
3
1
2
2
2
2
2
1
2
1
2
1
1
2
3
2
2
3
3
2
2
2
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
PHENTERMINE CAP 15MG
-
-
PHENTERMINE CAP 30MG
-
-
PHENTERMINE CAP 37.5MG
-
-
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
492
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PHENTERMINE POW
PHENTERMINE POW HCL
3
2
Non-Preferred Brand
Preferred Brand
PHENTERMINE TAB 37.5MG
-
-
3
2
2
3
3
3
2
3
2
2
2
2
3
2
2
3
2
3
3
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PHENYTEK CAP 200MG
3
Non-Preferred Brand
PHENYTEK CAP 300MG
3
Non-Preferred Brand
PHENYTOIN CHW 50MG
1
Generic
PHENTOL MESY INJ 5MG
PHENTOLAMINE INJ MESYLATE
PHENTOLAMINE POW MESYLATE
PHENYL LIQ ACETATE
PHENYL SALIC CRY
PHENYLACETYL POW
PHENYLADE TAB PHEBLOC
PHENYLALANIN PAK 50MG
PHENYLBUTAZ POW
PHENYLEPHRIN CRY
PHENYLEPHRIN POW HCL
PHENYLETHYL LIQ ALCOHOL
PHENYLETHYLA POW HCL
PHENYLHIST LIQ DH
PHENYLMERCUR POW ACETATE
PHENYLMERCUR POW BORATE
PHENYLMERCUR POW NITRATE
PHENYLPROPAN POW HCL
PHENYLTOLOXA POW CITRATE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
493
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
PHENYTOIN EX CAP 100MG
PHENYTOIN EX CAP 200MG
PHENYTOIN EX CAP 300MG
PHENYTOIN INJ 50MG/ML
PHENYTOIN POW
PHENYTOIN POW
PHENYTOIN SUS 100/4ML
PHILLIPS TAB 500MG
PHISOHEX LIQ 3%
PHLEXY-10 CAP
PHLEXY-VITS POW
PHOS CHOLINE CAP 65MG
PHOS FLUR SOL 0.044%
PHOSLO CAP 667MG
PHOSLYRA SOL
PHOS-NAK POW CONCENTR
PHOSPHA 250 TAB NEUTRAL
PHOSPHASAL TAB
PHOSPHATIDYL CAP 100MG
PHOSPHATIDYL POW 20%
PHOSPHATIDYL POW 40%
PHOSPHATIDYL POW 94%
PHOSPHATIDYL POW CHOLINE
PHOSPHOLINE SOL 0.125%OP
PHOSPHOR ACD SOL 85%
PHOSPHORUS POW PENTA CH
WDRx 2/23/15
Tier
Formulary Status
1
1
1
1
2
2
1
2
3
2
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
-
-
3
2
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
3
2
1
1
3
2
2
3
2
2
2
3
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
494
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PHOTOFRIN INJ 75MG
PHRENILIN CAP FORTE
PHTHALYLSULF POW
PHYS EZ USE KIT M-PRED
PHYSIOLYTE SOL
PHYSIOSOL SOL IRRIGAT
PHYSOS SALIC INJ 1MG/ML
PHYSOSTIGMIN CRY SALICYLA
PHYTIC ACID LIQ 50%
3
3
3
3
1
3
2
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
PHYTONADIONE INJ 1MG/0.5
-
-
2
Preferred Brand
3
Non-Preferred Brand
3
3
3
2
2
2
1
1
1
1
1
2
3
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Generic
PHYTONADIONE LIQ
PIC 200 CAP
PICATO GEL 0.015%
PICATO GEL 0.05%
PICROTOXIN POW
PILOCARPINE CRY HCL
PILOCARPINE POW HCL
PILOCARPINE POW NITRATE
PILOCARPINE SOL 1% OP
PILOCARPINE SOL 2% OP
PILOCARPINE SOL 4% OP
PILOCARPINE TAB 5MG
PILOCARPINE TAB 7.5MG
PILOPINE HS GEL 4% OP
PIMOBENDAN POW
PINDOLOL TAB 10MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Not a covered
benefit
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
495
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PINDOLOL TAB 5MG
PINE NEEDLE OIL
PINE NEEDLE OIL SIBERIAN
PINE OIL
PINE TAR LIQ
PINEAPPLE CHW EXTRACT
PINEAPPLE LIQ EXTRACT
PINENE POW L-ALPHA
PINNACAINE DRO 20% OTIC
PINWORM TAB MEDICINE
PIN-X CHW 250MG
1
2
3
2
2
3
2
2
3
3
2
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
PIOGLIT/GLIM TAB 30-2MG
1
Generic
PIOGLIT/GLIM TAB 30-4MG
1
Generic
PIOGLITA/MET TAB 15-500MG
1
Generic
PIOGLITA/MET TAB 15-850MG
1
Generic
PIOGLITAZONE TAB 15MG
1
Generic
PIOGLITAZONE TAB 30MG
1
Generic
PIOGLITAZONE TAB 45MG
1
Generic
PIPER/TAZOBA INJ 2-0.25GM
PIPER/TAZOBA INJ 3-0.375G
PIPER/TAZOBA INJ 36-4.5GM
PIPER/TAZOBA INJ 4-0.5GM
PIPERAZINE POW HEXAHYDR
PIPERINE POW
1
1
1
1
3
2
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 90
per 30 days
Maximum of 90
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
496
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PIPERONYL POW BUTOXIDE
PIRACETAM POW
PIROXICAM CAP 10MG
PIROXICAM CAP 20MG
PIROXICAM POW
3
2
1
1
2
Non-Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
PITOCIN INJ 10UNT/ML
3
Non-Preferred Brand
PITRESSIN INJ 20UNT/ML
3
Non-Preferred Brand
PKU EASY TAB MICROTAB
-
-
2
Preferred Brand
PLACEBO #00 CAP
PLAN B TAB 0.75MG
$0 Preventative Drug
PLAN B TAB 1.5MG
$0 Preventative Drug
PLANTAIN POW LEAF
3
Non-Preferred Brand
PLAQUENIL TAB 200MG
3
Non-Preferred Brand
2
2
2
2
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
PLAS ADAPT MIS 1ML
PLASMA-LYTE INJ -148
PLASMA-LYTE INJ 56/D5W
PLASMA-LYTE INJ -A
PLASMANATE INJ 5%
PLAST/PARIS POW DENTAL
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
497
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PLAVIX TAB 300MG
3
Non-Preferred Brand
PLAVIX TAB 75MG
3
Non-Preferred Brand
3
Non-Preferred Brand
PLETAL TAB 100MG
3
Non-Preferred Brand
PLETAL TAB 50MG
3
Non-Preferred Brand
3
3
3
3
3
3
2
2
2
2
-
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
$0 ACA Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
PLEGISOL SOL
PLEXION CLTH PAD 9.8-4.8%
PLEXION CRE 9.8-4.8%
PLEXION LIQ 9.8-4.8%
PLEXION LOT 9.8-4.8%
PLIAGEL GEL
PLIAGLIS CRE 7-7%
PLO MEDIFLO KIT KIT
PLO TRANSDER CRE
PLURONIC L64 LIQ
PLURONIC POW F127
OMNIFLEX DPR
PNV FE FUM TAB DOC/FA
PNV OB+DHA PAK
PNV PRENATAL TAB PLUS
PNV-DHA CAP
PNV-FIRST CAP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
-
498
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
PNV-OB/DHA PAK
PNV-OMEGA CAP
PNV-SELECT TAB
PNV-TOTAL CAP
PODIAPN CAP
PODOCON SOL 25%
PODOFILOX POW
PODOFILOX SOL 0.5%
PODOPHYLLUM POW RESIN
POISON IVY MIS WASH
POLAR FREEZE GEL 3.5-0.8%
POLIBAR ACB KIT 96%
POLIBAR PLUS SUS 105%
POLIBAR SUS 100%
POLICOSANOL CAP 10MG
POLIDENT GEL DENTU-GL
POLIGRIP MIS COMFORT
POLOCAINE INJ 1%
POLOCAINE INJ 2%
POLOCAINE INJ -MPF 1%
POLOCAINE INJ MPF 1.5%
POLOCAINE INJ -MPF 2%
POLOX GEL 20%
POLOX GEL 30%
POLOXITOL POW FREEDOM
POLY GLYCOL GRA 3350
POLY GLYCOL GRA 8000
POLY GLYCOL LIQ 1450
WDRx 2/23/15
Tier
Formulary Status
-
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
-
-
3
3
1
3
1
3
3
3
3
3
3
3
1
1
1
1
1
2
2
3
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Special Plan Edits
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
499
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
POLY GLYCOL MIS 1450
POLY GLYCOL POW 6000
POLY GLYCOL POW 8000
POLY HIST LIQ DHC
POLY HIST NC LIQ
POLY HIST TAB 7.5-10MG
2
3
2
3
3
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
POLY HIST TAB FORTE
3
Non-Preferred Brand
2
3
2
3
2
3
2
3
3
3
3
3
3
1
2
1
2
3
3
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
POLYCARBOPHI POW
POLYCOSE LIQ UNFLAVOR
POLYCOSE POW
POLYCOSE POW UNFLAVOR
POLYETH GLYC OIN 8000
POLYETHYLENE LIQ GLYCOL
POLYHEXAMETH LIQ 20% BIGU
POLY-HIST DM LIQ 5-25-10
POLY-HIST PD LIQ
POLYMAX DRSG PAD 4.5X4.5
POLYMEM DRS PAD 4"X12.5"
POLYMEM DRSG PAD 3.5X3.5
POLYMEM DRSG PAD 6.5X7.5
POLYMYXIN B INJ 500000
POLYMYXIN B POW SULFATE
POLYMYXIN B/ SOL TRIMETHP
POLYOX POW WSR-301
POLYOXYEHTYL MIS STRYL ET
POLYOXYETH40 LIQ SORB SEP
POLYOXYETHYL MIS STEARYL
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
500
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
POLYOXYL 40 POW STEARATE
POLYOXYPROPY LIQ STEARYL
POLYSORBATE LIQ 60
POLYSORBATE LIQ 80
POLYSORBATE SOL 20
POLYSORBATE SOL 40
2
3
2
2
2
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
POLYSPORIN OIN
3
Non-Preferred Brand
POLYSPORIN POW
POLYTAR BAR
POLYTAR SHA
POLYTETRAFLU POW
2
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
POLYTRIM SOL OP
3
Non-Preferred Brand
POLY-TUSSIN LIQ 10-9.375
POLY-TUSSIN LIQ DHC
POLY-TUSSIN SYP EX
POLY-TUSSIND LIQ 10-9.375
POLY-VENT DM TAB
POLY-VENT IR TAB 45-400MG
POLY-VENT IR TAB 60-380MG
POLY-VENT TAB PLUS
2
3
3
2
3
2
3
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
POLY-VI-FLOR CHW 0.25MG
-
-
POLY-VI-FLOR CHW 0.5MG
-
-
POLY-VI-FLOR CHW 1MG
-
-
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
501
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
POLY-VI-FLOR CHW W/IRON
-
-
POLY-VI-FLOR SUS /IRON
-
-
POLY-VI-FLOR SUS 0.25/ML
-
-
2
Preferred Brand
-
-
POLY-VI-SOL DRO /IRON
-
-
POLY-VITA DRO /IRON
-
-
3
3
3
3
3
1
3
3
3
2
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
2
2
1
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
POLYVINYL POW ALCOHOL
POLY-VI-SOL DRO
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
POMEGRANATE CAP 150MG
POMEGRANATE CAP 250MG
POMEGRANATE CAP EGCG-GRA
POMEGRANATE OIL 80%
POMEGRANATE POW EXTRACT
PONARIS SOL
PONAZURIL POW
PONSTEL CAP 250MG
POSTURE TAB
POSTURE-D TAB CALC/MAG
POT ACETATE CRY
POT ACETATE INJ 2MEQ/ML
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
-
-
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
502
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
POT ACETATE INJ 4MEQ/ML
POT AZELAOYL LIQ DIGLYCIN
POT BICARBON POW
POT BITARTRA POW
POT BROMIDE GRA
POT CARBONAT GRA
POT CHLORIDE CAP 10MEQ ER
POT CHLORIDE CAP 8MEQ ER
POT CHLORIDE GRA
POT CHLORIDE INJ 2MEQ/ML
POT CHLORIDE LIQ 10%
POT CHLORIDE LIQ 20%
POT CHLORIDE TAB 20MEQ ER
POT CHLORIDE TAB 25MEQ EF
POT CITRATE GRA
POT CITRATE TAB 1080MG
POT CITRATE TAB 1620MG
POT CITRATE TAB 540MG ER
POT GLUCONAT POW ANHYDROU
POT GLUCONAT TAB 2.5MEQ
POT GLUCONAT TAB 2MEQ
POT GLUCONAT TAB 550MG
POT GLUCONAT TAB 80MG
POT GUAIACOL POW SULFONAT
POT HYDROXID SOL 10%
POT HYDROXID SOL 20%
POT HYDROXID SOL 5%
POT HYDROXID SOL 50%
POT NITRATE GRA
1
3
2
2
2
2
1
1
2
1
1
1
2
1
2
1
1
1
2
1
1
1
3
3
2
2
3
2
2
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
503
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
POT NITRATE POW
POT PERCHLOR CRY
POT PERMANGT CRY
POT PERMANGT GRA
POT PHOSPHAT CRY MONOBASI
POT PHOSPHAT GRA DIBASIC
POT PHOSPHAT INJ 3MM/ML
POT PHOSPHAT POW DIBASIC
POT PHOSPHAT POW MONOBAS
POT SORBATE CRY
2
2
3
2
2
2
1
2
2
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
POTABA CAP 500MG
-
-
POTABA TAB 500MG
-
-
2
2
3
3
1
2
2
3
3
3
3
2
3
2
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
POTASH POW SULFURAT
POTASH SULFU MIS LUMP
POTASS & MAG CAP ASPARTAT
POTASSIM IOD TAB 32.5 MG
POTASSIMIN TAB 75MG
POTASSIUM CRY BROMIDE
POTASSIUM CRY IODIDE
POTASSIUM GL TAB ER 595MG
POTASSIUM GRA ACETATE
POTASSIUM GRA CHLORATE
POTASSIUM GRA DICHROMA
POTASSIUM GRA IODIDE
POTASSIUM HX POW
POTASSIUM MIS HYDROXID
POTASSIUM NA POW TARTRATE
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
504
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
POTASSIUM P- POW AMINOBEN
-
-
Not a covered
benefit
-
POTASSIUM POW ACETATE
POTASSIUM POW ASCORBAT
POTASSIUM POW ASPARTAT
POTASSIUM POW BENZOATE
POTASSIUM POW BROMIDE
POTASSIUM POW CHLORIDE
POTASSIUM POW CHROMATE
POTASSIUM POW CITRATE
POTASSIUM POW FLUORIDE
POTASSIUM POW IODIDE
POTASSIUM POW METABISU
POTASSIUM POW OXALATE
POTASSIUM POW PHOSPHAT
POTASSIUM POW SORBATE
POTASSIUM POW SULFATE
POTASSIUM POW THIOCYAN
POTASSIUM SOL HYDROXID
2
3
2
3
2
2
3
2
3
2
2
3
3
2
2
3
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
POTASSIUM TAB 75MG
3
Non-Preferred Brand
POTASSIUM TAB 95MG
POTASSIUM TAB 99MG
POTIGA TAB 200MG
POTIGA TAB 300MG
POTIGA TAB 400MG
POTIGA TAB 50MG
POULTRY MEAL POW
3
1
2
2
2
2
3
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
505
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
POVIDONE IOD OIN 10%
POVIDONE POW
POVIDONE POW IODINE
POVIDONE/IOD GEL 10%
POVIDONE-IOD GEL 1%
POVIDONE-IOD MIS 10%
POVIDONE-IOD MIS 7.5%
POVIDONE-IOD SOL 0.75%
POVIDONE-IOD SOL 1%
POWDER SCENT LIQ FRAGRANC
PPG-2-MYRIST LIQ ETHER PR
PR CREAM KIT
PR NATAL 400 PAK
PR NATAL 400 PAK EC
PR NATAL 430 PAK
PR NATAL 430 PAK EC
PRACAMAC OIL BASE
PRADAXA CAP 150MG
PRADAXA CAP 75MG
PRALIDOXIME INJ 600/2ML
PRALIDOXIME POW CHLORIDE
PRAMEGEL GEL 1%
PRAMIPEXOLE TAB 0.125MG
PRAMIPEXOLE TAB 0.25MG
PRAMIPEXOLE TAB 0.5MG
PRAMIPEXOLE TAB 0.75MG
PRAMIPEXOLE TAB 1.5MG
PRAMIPEXOLE TAB 1MG
PRAMOSONE CRE 1%
1
2
2
2
3
3
3
3
3
3
3
2
2
2
2
3
2
1
1
1
1
1
1
1
2
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
506
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
2
2
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
1
2
1
Generic
Preferred Brand
Generic
PRANDIMET TAB 1-500MG
2
Preferred Brand
PRANDIMET TAB 2-500MG
2
Preferred Brand
PRANDIN TAB 0.5MG
3
Non-Preferred Brand
Maximum of90per
30 days
PRANDIN TAB 1MG
3
Non-Preferred Brand
Maximum of90per
30 days
PRANDIN TAB 2MG
3
Non-Preferred Brand
Maximum
of240per 30 days
PRASCION FC PAD 10-5%
PRASCION RA CRE 10-5%
1
1
Generic
Generic
PRAVACHOL TAB 20MG
3
Non-Preferred Brand
PRAMOSONE CRE 1-2.5%
PRAMOSONE E CRE 1-2.5%
PRAMOSONE LOT 1%
PRAMOSONE LOT 2.5%
PRAMOSONE OIN 1%
PRAMOSONE OIN 2.5%
PRAMOTIC DRO 1-0.1%
PRAMOXINE AER 1%
PRAMOXINE POW HCL
PRAMOXINE-HC DRO AQ OTIC
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 90
per 30 days
Maximum of 150
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
507
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PRAVACHOL TAB 40MG
3
Non-Preferred Brand
PRAVACHOL TAB 80MG
3
Non-Preferred Brand
PRAVASTATIN TAB 10MG
PRAVASTATIN TAB 20MG
PRAVASTATIN TAB 40MG
PRAVASTATIN TAB 80MG
PRAZIQUANTEL CRY
PRAZIQUANTEL POW
PRAZOLAMINE PAK
PRAZOSIN HCL CAP 1MG
PRAZOSIN HCL CAP 2MG
PRAZOSIN HCL CAP 5MG
PREB-2 PAK
2
2
3
1
1
1
3
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
PRECEDEX INJ 100MCG
3
Non-Preferred Brand
PRECEDEX INJ 200/50ML
PRECEDEX INJ 400/100
3
3
Non-Preferred Brand
Non-Preferred Brand
PRECOSE TAB 100MG
3
Non-Preferred Brand
PRECOSE TAB 25MG
3
Non-Preferred Brand
PRECOSE TAB 50MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
508
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PRED MILD SUS 0.12% OP
PRED SOD PHO SOL 1% OP
PRED SOD PHO SOL 5MG/5ML
PRED-G S.O.P OIN OP
PRED-G SUS OP
PREDNICARBAT CRE 0.1%
PREDNICARBAT OIN 0.1%
PREDNISOLONE POW
PREDNISOLONE POW ACETATE
PREDNISOLONE POW ANHYDROU
PREDNISOLONE POW SOD PHOS
PREDNISOLONE SOL 15MG/5ML
PREDNISOLONE SOL 15MG/5ML
PREDNISOLONE SOL 25MG/5ML
PREDNISOLONE SUS 1% OP
PREDNISONE CON 5MG/ML
PREDNISONE POW
PREDNISONE SOL 5MG/5ML
PREDNISONE TAB 10MG
PREDNISONE TAB 1MG
PREDNISONE TAB 2.5MG
PREDNISONE TAB 20MG
PREDNISONE TAB 50MG
PREDNISONE TAB 5MG
PREFERA OB MIS + DHA
PREFERA OB TAB
PREFERAOB CAP ONE
2
2
1
3
3
1
1
2
2
3
2
1
1
2
1
2
2
2
1
1
1
1
2
1
-
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Generic
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
3
Non-Preferred Brand
PREFEST TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
Maximum of 30
per 30 days
509
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PREFOL-DHA CAP
PRE-FOLIC TAB 1-100MG
PREGABALIN POW
PREGNENOLONE POW
PREGNENOLONE POW MICRONIZ
PREGNITUDE PAK 2000-200
PRELIEF TAB
PRELIEVE PMS TAB 20MG
3
3
2
2
2
2
3
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
PREMARIN INJ 25MG
2
Preferred Brand
PREMARIN TAB 0.3MG
2
Preferred Brand
PREMARIN TAB 0.45MG
2
Preferred Brand
PREMARIN TAB 0.625MG
2
Preferred Brand
PREMARIN TAB 0.9MG
2
Preferred Brand
PREMARIN TAB 1.25MG
2
Preferred Brand
3
1
Non-Preferred Brand
Generic
2
Preferred Brand
PREMPRO TAB .625-2.5
2
Preferred Brand
PREMPRO TAB 0.3-1.5
2
Preferred Brand
PREMPRO TAB 0.45-1.5
2
Preferred Brand
PRELONE SYP 15MG/5ML
PREMARIN VAG CRE 0.625MG
PREMASOL SOL 6%
PREMPHASE TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
510
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
PREMPRO TAB 0.625-5
PRENA1 CAP QUATREFO
PRENA1 CHW
PRENA1 CHW QUATREFO
PRENA1 PEARL CAP
PRENA1 PLUS MIS QUATREFO
PRENAISSANCE CAP
PRENAISSANCE CAP BALANCE
PRENAISSANCE MIS HARMONY
PRENAISSANCE TAB NEXT
PRENAT MULTI CAP +DHA
PRENATA CHW 29-1MG
PRENATABS FA TAB
PRENATAL 1 CAP
PRENATAL 19 CHW 29-1MG
PRENATAL 19 TAB 29-1MG
PRENATAL CAP FORMULA
PRENATAL CAP OMEGA-3
PRENATAL FRM TAB A-FREE
PRENATAL MIS COMPLEAT
PRENATAL MUL CAP +DHA
PRENATAL ONE TAB DAILY
PRENATAL TAB
PRENATAL TAB COMPLETE
PRE-NATAL TAB FORMULA
PRENATAL TAB FORMULA
PRENATAL TAB PLUS DHA
PRENATAL+DHA MIS
WDRx 2/23/15
Tier
Formulary Status
Special Plan Edits
2
Preferred Brand
Maximum of 30
per 30 days
-
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
511
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PRENATAL-U CAP
PRENATE AM TAB 1MG
PRENATE CAP ENHANCE
PRENATE CAP ESSENT
PRENATE CAP ESSENTIA
PRENATE CAP PIXIE
PRENATE CAP RESTORE
PRENATE CHW 0.6-0.4
PRENATE DHA CAP
PRENATE MINI CAP
PRENATE STAR TAB 20-1MG
PRENEXA CAP
ORTHO COIL DPR KIT 100
ORTHO COIL DPR KIT 105
ORTHO COIL DPR KIT 50
ORTH FLAT DPR KIT 55
ORTHO FLAT DPR KIT 60
-
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
PREPARATIO H CRE TOTABLE
3
Non-Preferred Brand
PREPARATIO H GEL
3
Non-Preferred Brand
PREPARATION CRE H
2
Preferred Brand
PREPARATION OIN H
3
Non-Preferred Brand
PREPARATION SUP H
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
512
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PRE-PEN INJ
PREPIDIL GEL 0.5MG/3G
PREPOPIK PAK
PREQUE 10 TAB
PRETZ SOL
PREVACARE CRE PER/PRO
PREVACARE GEL ANTIMICR
PREVACARE SPR SKIN CAR
PREVACID 24H CAP 15MG DR
3
3
3
2
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
PREVACID CAP 15MG DR
3
Non-Preferred Brand
PREVACID CAP 30MG DR
3
Non-Preferred Brand
PREVACID TAB 15MG STB
PREVACID TAB 30MG STB
PREVAGEN CAP 10MG
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PREVDNT 5000 PST 1.1%
3
Non-Preferred Brand
PREVIDENT CRE 5000 PLS
3
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
PREVIDENT GEL 1.1%
PREVIDENT PST 5000 SEN
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
513
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
PREVIDENT SOL RINSE
Tier
Formulary Status
3
Non-Preferred Brand
-
$0 ACA Drug
3
Non-Preferred Brand
3
2
3
3
3
3
3
3
3
2
2
2
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
PRILOSEC CAP 10MG
3
Non-Preferred Brand
PRILOSEC CAP 20MG
3
Non-Preferred Brand
PRILOSEC CAP 40MG
3
Non-Preferred Brand
2
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ORTHO FLAT DPR KIT 65
PREVPAC MIS
PREZISTA SUS 100MG/ML
PREZISTA TAB 150MG
PREZISTA TAB 400MG
PREZISTA TAB 600MG
PREZISTA TAB 75MG
PREZISTA TAB 800MG
PRIALT INJ 100MCG
PRIALT INJ 25MCG/ML
PRIALT INJ 500MCG
PRIFTIN TAB 150MG
PRILOCAINE POW
PRILOCAINE POW HCL
PRILOSEC OTC TAB 20MG
PRILOSEC POW 10MG
PRILOSEC POW 2.5MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
514
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PRIMAQUINE POW PHOSPHAT
PRIMAQUINE TAB 26.3MG
PRIMATENE TAB 12.5-200
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
PRIMAXIN IV INJ 250MG
3
Non-Preferred Brand
PRIMAXIN IV INJ 500MG
3
Non-Preferred Brand
2
1
1
3
3
3
3
3
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PRINIVIL TAB 10MG
3
Non-Preferred Brand
PRINIVIL TAB 20MG
3
Non-Preferred Brand
PRINIVIL TAB 5MG
3
Non-Preferred Brand
3
Non-Preferred Brand
PRIMIDONE POW
PRIMIDONE TAB 250MG
PRIMIDONE TAB 50MG
PRIMLEV TAB 10-300MG
PRIMLEV TAB 5-300MG
PRIMLEV TAB 7.5-300
PRIMROSE OIL CAP CRANBERR
PRIMSOL SOL 50MG/5ML
PRISMASOL SOL 0/0/1.2
PRISTIQ TAB 100MG
WDRx 2/23/15
2
Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Step Therapy
Required,
Maximum of 30
per 30 days
515
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
2
Preferred Brand
Maximum of 30
per 30 days
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
2
Preferred Brand
-
-
2
1
1
3
3
2
2
2
2
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
PROCARDIA XL TAB 30MG CR
3
Non-Preferred Brand
PROCARDIA XL TAB 60MG CR
3
Non-Preferred Brand
PRISTIQ TAB 50MG
PRIVIGEN INJ 10GRAMS
PRIVIGEN INJ 20GRAMS
PRIVIGEN INJ 40GRAMS
PRIVIGEN INJ 5 GRAMS
PRO NUTRIENT CAP OMEGA3
PRO:12 AER MOUSSE
PROAIR HFA AER
PROBARIMIN CHW QT
PROBE COVER MIS THERMOM
PROBEN/COLCH TAB 500-0.5
PROBENECID TAB 500MG
PROBIOTIC TAB
PROBUCOL POW
PROCAINAMIDE INJ 100MG/ML
PROCAINAMIDE INJ 500MG/ML
PROCAINAMIDE POW
PROCAINE HCL CRY
PROCARDIA CAP 10MG
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Maximum of 17
gm per 30 days
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
516
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PROCARDIA XL TAB 90MG CR
3
Non-Preferred Brand
PROCENTRA SOL 5MG/5ML
PRO-CEPTION MIS
PRO-CHLO LIQ
PROCHLORPER INJ 10MG/2ML
PROCHLORPER POW MALEATE
PROCHLORPER TAB 10MG
PROCHLORPER TAB 5MG
PROCHLORPERA POW EDISYLAT
PRO-CLEAR AC SYP
PROCOMYCIN CRE
PROCORT CRE
PROCRIT INJ 10000/ML
PROCRIT INJ 2000/ML
PROCRIT INJ 20000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 40000/ML
2
3
2
1
2
1
1
2
3
3
3
3
3
3
3
3
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PROCTOCORT CRE 1%
3
Non-Preferred Brand
PROCTOCORT SUP 30MG
3
Non-Preferred Brand
PROCTOFOAM AER HC 1%
PROCTOFOAM AER NS 1%
PROCTO-PAK CRE 1%
PROCYSBI CAP 25MG
2
2
1
3
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA after 25
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
517
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PROCYSBI CAP 75MG
PRODERM AER
PRODIGY MIS 29GX1/2"
PROFE CAP 180MG
PROFERRIN ES TAB 12 MG
PROFERRIN- TAB FORTE
PROFILNINE INJ 1000UNIT
PROFILNINE INJ 1500UNIT
PROFILNINE INJ 500UNIT
PROFLAVINE POW HEMISULF
PROGESTERONE CAP 100MG
PROGESTERONE CAP 200MG
PROGESTERONE INJ 50MG/ML
PROGESTERONE POW
PROGESTERONE POW MICRONIZ
PROGESTERONE POW MILLED
PROGESTERONE SUP VGS 100
PROGESTERONE SUP VGS 200
PROGESTERONE SUP VGS 25
PROGESTERONE SUP VGS 400
PROGESTERONE SUP VGS 50
PROGLYCEM SUS 50MG/ML
3
2
2
2
3
3
3
3
3
1
1
1
2
2
3
3
3
3
3
3
2
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
PROGRAF CAP 0.5MG
3
Non-Preferred Brand
PROGRAF CAP 1MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
518
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
PROGRAF CAP 5MG
Tier
Formulary Status
3
Non-Preferred Brand
2
2
2
3
3
3
3
3
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
PROMAZINE POW HCL
PROMENSIL TAB
PROMETH/COD SYP 6.25-10
PROMETHAZINE CRY HCL
PROMETHAZINE INJ 25MG/ML
PROMETHAZINE INJ 50MG/ML
PROMETHAZINE POW HCL
PROMETHAZINE SOL 6.25/5ML
PROMETHAZINE SYP DM
PROMETHAZINE TAB 12.5MG
PROMETHAZINE TAB 25MG
PROMETHAZINE TAB 50MG
2
3
1
2
1
1
2
1
1
1
1
1
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
PROMETRIUM CAP 100MG
3
Non-Preferred Brand
PROGRAF INJ 5MG/ML
PROHANCE INJ 279.3/ML
PROLENSA SOL 0.07%
PROLEUKIN INJ 22MU
PROLIA SOL 60MG/ML
PROLINE POW
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
PROMAR CAP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
519
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PROMETRIUM CAP 200MG
3
Non-Preferred Brand
PROMISEB KIT COMPLETE
PRONTO AER 0.4%
3
3
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
PRONUTRIENTS TAB SUPER B
-
-
PROPA PH ACN GEL MASK N/O
3
Non-Preferred Brand
PROPA PH ACN LOT MAX STR
PROPA PH ACN LOT OILY SKN
3
3
Non-Preferred Brand
Non-Preferred Brand
PROPA PH ACN PAD MAX ST
3
Non-Preferred Brand
PROPAFENONE CAP 225MG ER
PROPAFENONE CAP 325MG ER
PROPAFENONE CAP 425MG SR
PROPAFENONE TAB 150MG
PROPAFENONE TAB 225MG
PROPAFENONE TAB 300MG
PROPANEDIOL LIQ
PROPANTHELIN POW BROMIDE
PROPANTHELIN TAB 15MG
PROPARACAINE POW HCL
1
1
1
1
1
1
3
2
3
2
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
PRONTO KIT
PRONTO SHA 0.33-4%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
520
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
PROPECIA TAB 1MG
PROPIONIC LIQ ACID
PROPOFOL INJ 10MG/ML
PROPOLIS POW
PROPRAN/HCTZ TAB 40/25
PROPRAN/HCTZ TAB 80/25
PROPRANOLOL CAP 120MG ER
PROPRANOLOL CAP 160MG ER
PROPRANOLOL CAP 60MG ER
PROPRANOLOL CAP 80MG ER
PROPRANOLOL INJ 1MG/ML
PROPRANOLOL POW HCL
PROPRANOLOL SOL 20MG/5ML
PROPRANOLOL SOL 40MG/5ML
PROPRANOLOL TAB 10MG
PROPRANOLOL TAB 20MG
PROPRANOLOL TAB 40MG
PROPRANOLOL TAB 60MG
PROPRANOLOL TAB 80MG
PROPYL POW GALLATE
PROPYL SOL ALCOHOL
PROPYLENE GL BEA MONOSTEA
PROPYLENE GL SOL
PROPYLENE LIQ CARBONAT
PROPYLENE LIQ GLYCOL
PROPYLTHIOUR POW
PROPYLTHIOUR TAB 50MG
PROPYPARABEN POW
WDRx 2/23/15
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
-
Not a covered
benefit
-
3
1
3
2
2
2
3
2
2
3
2
2
1
2
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Penalty applied if Brand Selected
over Generic
-
521
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ORTHO FLAT DPR KIT 70
PRO-RED AC SYP
PRO-RED AC SYP 5-1-9/5
3
3
$0 ACA Drug
Non-Preferred Brand
Non-Preferred Brand
PROSCAR TAB 5MG
3
Non-Preferred Brand
PROSED/DS TAB
3
Non-Preferred Brand
PROSHIELD AER FOAM/SPR
PROSOL INJ 20%
PROSTAGLAND POW E2
PROSTAPRO CAP 320MG
PROSTASCINT KIT
PRO-STAT 101 LIQ
PROSTATE SR CAP
PROSTATONIN CAP
3
2
3
3
3
1
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
PROSTIGMIN INJ 0.5MG/ML
3
Non-Preferred Brand
PROSTIGMIN TAB 15MG
PROSTIN E2 SUP 20MG
2
3
Preferred Brand
Non-Preferred Brand
PROSTIN VR INJ 500MCG
3
Non-Preferred Brand
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
PROTECTBONE WAF
-
-
PROTECTIRON TAB
3
Non-Preferred Brand
PROTAMINE POW SULFATE
PROTAMINE SU SOL 10MG/ML
PROTECT SKIN PAD BARRIER
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
522
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PROTECTNATAL TAB
PROTEIN CHW 500MG
PROTEIN POW 80%
PROTEIN POW VANILLA
PROTEIN TAB 975MG
PROTEINEX LIQ
3
2
2
2
2
$0 Preventative Drug
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
PROTEO ENZYM TAB EC
3
Non-Preferred Brand
-
-
PROTEXIN SYP
-
-
PROTIRELIN POW
2
Preferred Brand
PROTONIX INJ 40MG
3
Non-Preferred Brand
3
Non-Preferred Brand
PROTONIX TAB 20MG
3
Non-Preferred Brand
PROTONIX TAB 40MG
3
Non-Preferred Brand
2
2
2
1
1
3
2
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
PROTEOLIN DS TAB
PROTONIX PAK
PROTOPAM CHL INJ 1GM
PROTOPIC OIN 0.03%
PROTOPIC OIN 0.1%
PROTRIPTYLIN TAB 10MG
PROTRIPTYLIN TAB 5MG
PROVENGE INJ
PROVENT MIS STARTER
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
Limited Distribution
523
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PROVENT SR MIS
2
Preferred Brand
PROVERA TAB 10MG
3
Non-Preferred Brand
PROVERA TAB 2.5MG
3
Non-Preferred Brand
PROVERA TAB 5MG
3
Non-Preferred Brand
PROVIDA OB CAP
PROVIEW KIT
2
$0 Preventative Drug
Preferred Brand
PROVIGIL TAB 100MG
3
Non-Preferred Brand
PA Required
PROVIGIL TAB 200MG
3
Non-Preferred Brand
PA Required
3
3
Non-Preferred Brand
Non-Preferred Brand
PROZAC CAP 10MG
3
Non-Preferred Brand
PROZAC CAP 20MG
3
Non-Preferred Brand
PROZAC CAP 40MG
3
Non-Preferred Brand
3
Non-Preferred Brand
2
Preferred Brand
PROVOCHOLINE SOL 100MG
PROXEED PAK
PROZAC WEEKL CAP 90MG
PRUDOXIN CRE 5%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
524
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PSEUDOEPHED POW
PSORIASIN GEL 1.25%
PSORIASIN LIQ 3%
2
3
1
Preferred Brand
Non-Preferred Brand
Generic
PSORIASIN OIN 2%
3
Non-Preferred Brand
3
Non-Preferred Brand
PSYLLIUM POW 100%
PSYLLIUM POW HUSK
PTS PANELS TES KETONE
PULMICORT INH 180MCG
PULMICORT INH 90MCG
1
2
3
-
Generic
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
PULMICORT SUS 0.25MG/2
3
Non-Preferred Brand
PULMICORT SUS 0.5MG/2
3
Non-Preferred Brand
ORTHO FLAT DPR KIT 75
PULMOPHYLLIN PAK
PULMOSAL NEB 7%
PULMOZYME SOL 1MG/ML
PUMICE POW
PUMICE POW FLOUR
PUMPKIN SEED POW
PUR-ABSORB LIQ 5MG/20ML
3
1
3
3
2
3
3
$0 ACA Drug
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
-
$0 Preventative Drug
PSORIASIS LIQ
PURALOR CHW
PUREFE OB CAP PLUS
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Not a covered
benefit
-
-
-
-
525
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
PURE-GAR TAB 350MG
Tier
Formulary Status
3
Non-Preferred Brand
PURELL CLEAN MIS WIPES
PURELL HAND AER SANITIZR
3
1
Non-Preferred Brand
Generic
PURELL HAND LIQ SANITIZR
3
Non-Preferred Brand
PURELL HAND SPR SANITIZR
PUREVIT DUAL CAP FE PLUS
3
1
Non-Preferred Brand
Generic
PURINETHOL TAB 50MG
3
Non-Preferred Brand
PURIXAN SUS 20MG/ML
PX MEDICATED OIN CHESTRUB
PX ULTRA STR OIN RUB
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
PX VITAMIN A CAP 8000UNIT
-
-
3
Non-Preferred Brand
2
Preferred Brand
2
1
3
Preferred Brand
Generic
Non-Preferred Brand
PYGEUM BARK POW
PYLERA CAP
PYRANTEL POW PAMOATE
PYRAZINAMIDE TAB 500MG
PYRE/PIPERON LIQ
PYRIDIUM TAB 100MG
3
Non-Preferred Brand
PYRIDIUM TAB 200MG
3
Non-Preferred Brand
1
2
Generic
Preferred Brand
PYRIDOSTIGM TAB 60MG
PYRIDOSTIGMI POW BROMIDE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Not a covered
benefit
-
-
Maximum of 120
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
526
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
PYRIDOXAL-5- POW PHOSPHAT
2
Preferred Brand
PYRIDOXINE INJ 100MG/ML
-
-
PYRIDOXINE POW HCL
-
-
PYRIDOXINE TAB 25MG
-
-
3
1
2
1
2
2
3
2
3
2
2
1
3
3
1
1
1
3
Non-Preferred Brand
Generic
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
QSYMIA CAP 11.25-69
-
-
QSYMIA CAP 15-92MG
-
-
PYRIDOXINE/ CAP MINERALS
PYRIL D SUS 16-5MG/5
PYRIL DM SUS
PYRILAMIN/PE TAB 25-10MG
PYRILAMINE POW MALEATE
PYRIMETHAMIN POW
PYROGALL ACD OIN
PYROGALLOL CRY
PYRROLIDINON LIQ 1-METHYL
PYRUVIC ACID LIQ
PYRUVIC ACID POW
QC NATURAL POW VEGETABL
Q-GEL CAP 15MG
QH LIQ 100MG/ML
QNAPRIL/HCTZ TAB 10-12.5
QNAPRIL/HCTZ TAB 20-12.5
QNAPRIL/HCTZ TAB 20-25MG
QNASL AER 80MCG
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
527
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
QSYMIA CAP 3.75-23
-
-
QSYMIA CAP 7.5-46MG
-
-
Q-TABS TAB 1MG
-
-
QUADRAMET INJ
2
Preferred Brand
3
Non-Preferred Brand
2
2
3
3
3
3
3
3
$0 Preventative Drug
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
QUALAQUIN CAP 324MG
QUARTETTE TAB
QUATERNIUM- POW 15
QUAZEPAM TAB 15MG
QUDEXY XR CAP 100/24HR
QUDEXY XR CAP 150/24HR
QUDEXY XR CAP 200/24HR
QUDEXY XR CAP 25/24HR
QUDEXY XR CAP 50/24HR
QUELICIN INJ -1000
QUELICIN INJ 20MG/ML
3
Non-Preferred Brand
QUERCETIN POW DIHYDRAT
2
Preferred Brand
-
-
QUERCETIN TAB 250MG
-
-
QUERCITIN POW
QUETIAPINE TAB 100MG
QUETIAPINE TAB 200MG
QUETIAPINE TAB 25MG
3
1
1
1
Non-Preferred Brand
Generic
Generic
Generic
QUERCETIN TAB
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
-
-
-
-
528
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
QUETIAPINE TAB 300MG
QUETIAPINE TAB 400MG
QUETIAPINE TAB 50MG
1
1
1
Generic
Generic
Generic
QUFLORA PED CHW 0.25MG
-
-
QUFLORA PED CHW 0.5MG
-
-
QUFLORA PED CHW 1MG
-
-
QUFLORA PED DRO 0.25MG
-
-
QUFLORA PED DRO 0.5MG/ML
-
-
QUILLIVANT SUS XR
QUINACRINE POW
QUINAPRIL TAB 10MG
QUINAPRIL TAB 20MG
QUINAPRIL TAB 40MG
QUINAPRIL TAB 5MG
QUINIDINE CRY SULFATE
QUINIDINE GL INJ 80MG/ML
QUINIDINE GL TAB 324MG CR
QUINIDINE POW SULFATE
QUINIDINE SU TAB 300MG
QUINIDINE SU TAB 300MG ER
QUININE HCL CRY
QUININE POW SULFATE
QUININE SULF CAP 324MG
QUININE SULF POW DIHYDRAT
QUINIZARIN POW GREEN SS
2
2
1
1
1
1
2
2
1
3
1
2
2
3
1
2
2
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
PA after 25
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
-
-
-
-
-
-
529
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
QUINZYME TAB 90MG
QUTENZA KIT 8% 1-PCH
ORTHO FLAT DPR KIT 80
ORTHO FLAT DPR KIT 85
RA ACNE MAX PAD 2%
RA ADVANCED LOT HEALING
RA ALOE VERA GEL LIDOCAIN
RA B-12 LOZ 1000MCG
RA BANDAGES MIS 3/4"
RA CA/BORON TAB
RA CALAMINE SUS 8-8%
RA COL-RITE CAP 50MG
RA EXFOLIATI OIN
RA FISH OIL CAP 1400MG
RA GARLIC CAP 580MG
RA GARLIC TAB 600MG
RA HAND SOAP LIQ REFILL
RA KRILL OIL CAP
RA LAXATIVE TAB EX ST
RA LOT
RA LUTEIN CAP 20MG
RA LYCOPENE CAP 15MG
RA MELATONIN SUB 1MG
RA MELATONIN TAB 10MG
RA OATMEAL LOT MOISTURI
RA OYS SHL/D TAB 250MG
3
3
2
1
2
3
1
3
2
1
1
3
3
2
3
3
1
2
3
3
3
2
3
2
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
RA SACCHARIN TAB 15MG
-
-
RA SAW PALM CAP 80MG
1
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
530
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
RA SELENIUM TAB 50MCG
RA SENNA CAP 8.6MG
RA STAY AWAK TAB 100MG
RA STERILE DRO
RA THROAT LOZ CHERRY
RA TRIPLE AER ANTIBIOT
RA TURMERIC CAP 500MG
1
1
3
1
1
3
1
Generic
Generic
Non-Preferred Brand
Generic
Generic
Non-Preferred Brand
Generic
RA VIT B-6 TAB 200MG TR
-
-
RA VITAMIN C CHW 300MG
-
-
2
Preferred Brand
RABEPRAZOLE TAB 20MG
1
Generic
RACEPINEPHRI POW HCL
RADIOGARDASE CAP 0.5GM
2
3
Preferred Brand
Non-Preferred Brand
2
Preferred Brand
RALOXIFENE TAB 60MG
1
Generic
RAMIPRIL CAP 1.25MG
RAMIPRIL CAP 10MG
RAMIPRIL CAP 2.5MG
RAMIPRIL CAP 5MG
1
1
1
1
Generic
Generic
Generic
Generic
RANEXA TAB 1000MG
2
Preferred Brand
RANEXA TAB 500MG
2
Preferred Brand
RANITIDINE CAP 150MG
RANITIDINE CAP 300MG
1
1
Generic
Generic
RABAVERT INJ
RAGWITEK SUB
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
Maximum of 30
per 30 days
May be subject to
Quantity Level
Limits
Maximum of 30
per 30 days
Maximum of 60
per 30 days
Maximum of 60
per 30 days
531
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
1
1
1
2
1
1
2
2
2
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
RAPAMUNE TAB 0.5MG
3
Non-Preferred Brand
RAPAMUNE TAB 1MG
RAPAMUNE TAB 2MG
RAPESEED OIL
RAPID B-12 SPR
RAPPORT VTD KIT
RASH + SKIN OIN 16-57%
RASH AWAY AER
RASH RELIEF SPR 20-25%
RASH-N-ALL OIN
RASPBERRY SYP
RASUVO INJ 10MG
RASUVO INJ 12.5MG
RASUVO INJ 15MG
RASUVO INJ 17.5MG
RASUVO INJ 22.5MG
RASUVO INJ 25MG
RASUVO INJ 27.5MG
2
2
3
3
2
3
3
3
2
2
3
3
3
3
3
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
RANITIDINE INJ 150/6ML
RANITIDINE INJ 25MG/ML
RANITIDINE INJ 50MG/2ML
RANITIDINE POW HCL
RANITIDINE SYP 150/10ML
RANITIDINE TAB 300MG
RAPAFLO CAP 4MG
RAPAFLO CAP 8MG
RAPAMUNE SOL 1MG/ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
532
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
RASUVO INJ 30MG
RASUVO INJ 7.5MG
RAUWOLFIA POW SERPENTI
RAVICTI LIQ 1.1GM/ML
RAYOS TAB 1MG
RAYOS TAB 2MG
RAYOS TAB 5MG
3
3
2
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
RAZADYNE ER CAP 16MG
3
Non-Preferred Brand
RAZADYNE ER CAP 24MG
3
Non-Preferred Brand
RAZADYNE ER CAP 8MG
3
Non-Preferred Brand
RAZADYNE SOL 4MG/ML
3
Non-Preferred Brand
RAZADYNE TAB 12MG
3
Non-Preferred Brand
RAZADYNE TAB 4MG
3
Non-Preferred Brand
RAZADYNE TAB 8MG
3
Non-Preferred Brand
RE 10 WASH LIQ 10%
REA LO 40 CRE 40%
REACH KIDS PST 0.15%
READI-CAT 2 SUS 2.1%
1
1
3
3
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Drug Name
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
533
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
READI-CAT 2 SUS APPLE
READI-CAT 2 SUS BERRY
READI-CAT SUS 1.3%
REA-LO CRE 30%
REA-LO LOT 15%
REALROOT GIN CAP 200MG
REAPHIRM CAP
REBETOL CAP 200MG
REBETOL SOL 40MG/ML
REBIF INJ 22/0.5
REBIF INJ 44/0.5
REBIF REBIDO SOL TITRATN
RECLAST INJ 5/100ML
RECOMBINATE INJ
RECOMBINATE INJ
RECOMBINATE INJ 220-400
RECOMBINATE INJ 401-800
RECOMBINATE INJ 801-1240
ORTHO FLAT DPR KIT 90
ORTHO FLAT DPR KIT 95
PEDIARIX INJ 0.5ML
RECOTHROM SOL 20000UNT
RECOTHROM SOL 5000UNIT
RECTAL THERM MIS
RECTIV OIN 0.4%
RED YEAST CAP 600MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Tier
Formulary Status
3
3
3
2
3
3
-
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
-
3
Non-Preferred Brand
YES, Specialty Drug
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
3
Non-Preferred Brand
YES, Specialty Drug
3
3
3
3
3
3
3
2
2
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
PA Required
PA Required
PA Required
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
534
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
3
1
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Generic
-
-
REFRESH CELL DRO 1% OP
REFRESH DRO OP
REFRESH DRO RELIEF
REFRESH LIQU DRO 1% OP
2
2
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
REFRESH OPTI DRO 0.5-0.9%
3
Non-Preferred Brand
REFRESH PLUS DRO 0.5% OP
REFRESH SOL OPTIVE
2
2
Preferred Brand
Preferred Brand
REFRESH TEAR DRO 0.5% OP
3
Non-Preferred Brand
REGENECARE GEL
REGENECARE SPR HA
3
3
Non-Preferred Brand
Non-Preferred Brand
REGIMEX TAB 25MG
-
-
REGLAN TAB 10MG
3
Non-Preferred Brand
REGLAN TAB 5MG
3
Non-Preferred Brand
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
RED YEAST POW RICE
RED YEAST TAB 600MG
REDICHEW CHW RX
REFENESEN TAB CHST CNG
REFISSA CRE 0.05%
REGONOL INJ 5MG/ML
REGRANEX GEL 0.01%
REJUVENESS MIS 10X20CM
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
535
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
3
3
2
3
3
2
3
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
RELPAX TAB 20MG
2
Preferred Brand
RELPAX TAB 40MG
2
Preferred Brand
REMBRANDT PST CANKER
REMBRANDT PST DEEP WHT
REMEDY CLEAN LIQ 0.12%
REMEDY CLEAN LOT 1.5%
REMEDY PST CALAZIME
REMEDY SKIN CRE REPAIR
3
3
2
2
2
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
REMERON SLTB TAB 15MG
3
Non-Preferred Brand
REMERON SLTB TAB 30MG
3
Non-Preferred Brand
REMERON SLTB TAB 45MG
3
Non-Preferred Brand
RELAGARD GEL
RELAMINE TAB
RELAX TAB 50MG
RELENZA AER DISKHALE
RELENZA MIS DISKHALE
RELHIST CHW
RELI GLUCOSE LIQ SHOT
RELION A1C TES
RELISTOR INJ 12/0.6ML
RELISTOR INJ 8/0.4ML
RELISTOR KIT 12/0.6ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 12
per 30 days
Maximum of 12
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
536
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
REMERON TAB 15MG
3
Non-Preferred Brand
REMERON TAB 30MG
3
Non-Preferred Brand
REMERON TAB 45MG
3
Non-Preferred Brand
REMESENSE MIS
REMEVEN CRE 50%
REMICADE INJ 100MG
3
1
3
Non-Preferred Brand
Generic
Non-Preferred Brand
REMIFEMIN TAB 20MG
3
Non-Preferred Brand
3
3
3
3
3
2
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
RENATABS TAB
-
-
RENAX TAB 2.5MG
-
-
RENOVA CRE 0.02%
-
-
3
Non-Preferred Brand
REMODULIN INJ 10MG/ML
REMODULIN INJ 1MG/ML
REMODULIN INJ 2.5MG/ML
REMODULIN INJ 5MG/ML
REMOVE ADHES MIS WIPES
RENACIDIN SOL IRR
RENAGEL TAB 400MG
RENAGEL TAB 800MG
RENATABS MIS IRON
RENOVAGE LIQ
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
-
-
537
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
RENU 1 STEP TAB ENZ CLEA
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
REOPRO INJ 2MG/ML
3
2
2
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
REPAGLINIDE TAB 0.5MG
1
Generic
REPAGLINIDE TAB 1MG
1
Generic
REPAGLINIDE TAB 2MG
1
Generic
3
2
-
Non-Preferred Brand
Preferred Brand
$0 ACA Drug
$0 ACA Drug
REPREXAIN TAB 2.5-200
3
Non-Preferred Brand
REPREXAIN TAB 5-200MG
3
Non-Preferred Brand
REPRONEX INJ 75UNIT
3
Non-Preferred Brand
REQUIP TAB 0.25MG
3
Non-Preferred Brand
REQUIP TAB 0.5MG
3
Non-Preferred Brand
REQUIP TAB 1MG
3
Non-Preferred Brand
REPHRESH KIT BALANCE
REPLENS GEL VAG
REPLESTA NX WAF 14000UNT
REPLESTA WAF 50000UNT
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 90
per 30 days
Maximum of 90
per 30 days
Maximum of 240
per 30 days
-
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
538
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
REQUIP TAB 2MG
3
Non-Preferred Brand
REQUIP TAB 3MG
3
Non-Preferred Brand
REQUIP TAB 4MG
3
Non-Preferred Brand
REQUIP TAB 5MG
3
Non-Preferred Brand
REQUIP XL TAB 12MG
3
Non-Preferred Brand
Maximum of 60
per 30 days
REQUIP XL TAB 2MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
REQUIP XL TAB 4MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
REQUIP XL TAB 6MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
REQUIP XL TAB 8MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
2
2
2
3
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
RESCON TAB 2-60MG
RESCON-DM SYP
RESCON-GG LIQ
RESCON-MX TAB
RESCRIPTOR TAB 100 MG
RESCRIPTOR TAB 200MG
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
539
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
RESCULA SOL 0.15%
RESECTISOL SOL 5%
RESERPINE POW
RESERPINE TAB 0.1MG
RESERPINE TAB 0.25MG
RESINOL OIN
RESORCINOL CRY
RESORCINOL POW
RESOURCE LIQ WATER
RESOURCE THI POW CANS
RESOURCE THI POW PACKET
RESPA C&C IR TAB
RESPA-BR TAB 11MG
RESPAIRE-30 CAP
RESPERATE KIT 1.0
RESTASIS EMU 0.05%
RESTONE CAP 3-100MG
RESTORA RX CAP 60-1.25
RESTORE CLNS LIQ MOISTURI
RESTORE CONT PAD 8"X12"
RESTORE CRE BARRIER
RESTORE DUO PAD 2"X4"
RESTORE FOAM PAD 2.5"X2.5
RESTORE HEEL PAD 4.7"X7.5
RESTORE ODOR PAD 6"X10"
RESTORE TRIO PAD 4"X5"
3
2
2
2
2
2
2
2
3
2
3
3
3
3
3
2
1
3
3
3
3
3
3
3
3
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
RESTORIL CAP 15MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
540
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
RESTORIL CAP 22.5MG
3
Non-Preferred Brand
RESTORIL CAP 30MG
3
Non-Preferred Brand
RESTORIL CAP 7.5MG
3
Non-Preferred Brand
RESTYLANE-L INJ 10/0.5ML
-
-
RESVERATROL CAP 250MG
RESVERATROL CAP 50MG
RESVERATROL POW
RESVERATROL TAB PLUS
RETAINE MGD EMU 0.5-0.5%
RETAVASE INJ
RETAVASE INJ HALF-KIT
3
3
2
3
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
RETIN-A CRE 0.025%
3
Non-Preferred Brand
PA after 25
RETIN-A CRE 0.05%
3
Non-Preferred Brand
PA after 25
RETIN-A CRE 0.1%
3
Non-Preferred Brand
PA after 25
RETIN-A GEL 0.01%
3
Non-Preferred Brand
PA after 25
RETIN-A GEL 0.025%
3
Non-Preferred Brand
PA after 25
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
541
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Generic Available. Brand copay + the
difference between the brand and the
generic.
RETIN-A MICR GEL 0.04%
3
Non-Preferred Brand
PA after 25
RETIN-A MICR GEL 0.08%
3
Non-Preferred Brand
PA after 25
RETIN-A MICR GEL 0.1%
3
Non-Preferred Brand
PA after 25
2
3
3
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PA after 25
RETROVIR CAP 100MG
3
Non-Preferred Brand
YES, Specialty Drug
RETROVIR INJ 10MG/ML
3
Non-Preferred Brand
YES, Specialty Drug
RETROVIR SYP 50MG/5ML
3
Non-Preferred Brand
YES, Specialty Drug
3
Non-Preferred Brand
PA Required
YES, Specialty Drug
3
Non-Preferred Brand
PA Required
YES, Specialty Drug
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
RETINOIC ACD POW
RETINOL FILM OIL MOLECULR
RETINOL POW
RETISERT IMP 0.59MG
RETRE-GEL GEL
RETROBUL NDL MIS 25GX1.5"
REVATIO INJ
REVATIO TAB 20MG
REVEAL COLON TES DISEASE
REVEAL CUP MIS 12 PANEL
REVEAL DNA KIT PATERNIT
REVEAL GET KIT PREGNANT
REVEAL URINA TES INFECTIO
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
542
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
REVIA TAB 50MG
Tier
Formulary Status
3
Non-Preferred Brand
REVINA OIN
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 2.5MG
REVLIMID CAP 20MG
REVLIMID CAP 25MG
REVLIMID CAP 5MG
REVONTO INJ 20MG
REYATAZ CAP 100MG
REYATAZ CAP 150MG
REYATAZ CAP 200MG
REYATAZ CAP 300MG
REZAMID LOT
REZIRA SOL 60-5/5ML
REZYST SB CHW 250MG
R-GENE 10 INJ 10%
RHEUMATREX TAB 2.5MG
RHINARIS GEL 0.2%
RHINARIS SPR 0.2%
1
3
3
3
3
3
3
1
2
3
3
3
3
3
3
2
3
2
2
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
RHINOCORT SUS AQUA
3
Non-Preferred Brand
2
3
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
RHINOFLEX TAB 50-650MG
RHIZINATE 3X CHW 400-50MG
RHODIOLA CAP 300MG
RHOPHYLAC INJ 1500/2ML
RHUBARB EXT
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 8.6
gm per 30 days
YES, Specialty Drug
543
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
RIASTAP SOL 1GM
RIAX AER 5.5%
RIAX AER 9.5%
RIBASPHERE CAP 200MG
RIBATAB PAK 1000/DAY
RIBATAB TAB 1200/DAY
RIBATAB TAB 800/DAY
RIBAVIRIN POW
RIBO-5-PHOSP POW SODIUM
3
3
3
3
3
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
RIBOFLAVIN CAP 100MG
-
-
RIBOFLAVIN CAP 50MG
-
-
2
Preferred Brand
-
-
3
3
3
3
3
3
3
3
2
2
1
2
2
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Generic
RIBOFLAVIN POW
RIBOFLAVIN TAB 400MG
RIBOSE (D) POW
RICE BRAN OIL
RICE PROTEIN POW
RICOLA CHRY LOZ HERB SF
RICOLA CHRY LOZ HNY HERB
RICOLA LEMON LOZ MINT
RICOLA LMN LOZ MNT HERB
RICOLA LOZ
RID AER
RID COMPLETE KIT LICE
RID ESS LICE KIT 0.33-4%
RID LIQ
RIDAURA CAP 3MG
RIFABUTIN CAP 150MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
544
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
RIFADIN CAP 150MG
3
Non-Preferred Brand
RIFADIN CAP 300MG
3
Non-Preferred Brand
RIFADIN INJ 600 MG
3
Non-Preferred Brand
RIFAMATE CAP
RIFAMPIN CAP 150MG
RIFAMPIN CAP 300MG
RIFAMPIN INJ 600 MG
RIFAMPIN POW
RIFATER TAB
RIFAXIMIN POW
3
1
1
1
2
3
3
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
RILUTEK TAB 50MG
3
Non-Preferred Brand
1
2
1
3
3
1
1
Generic
Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
2
Preferred Brand
RISEDRONATE TAB 150MG
1
Generic
RISPERDAL INJ 12.5MG
2
Preferred Brand
RILUZOLE TAB 50MG
RI-MAG PLUS SUS
RIMANTADINE TAB 100MG
RIMANTALIST PAK
RIMSO-50 SOL 50%
RINGERS INJ
RINGERS IRR SOL
RIOMET SOL
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 750
mL per 30 days
Maximum of 1 per
30 days
545
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
RISPERDAL M TAB 0.5MG
3
Non-Preferred Brand
RISPERDAL M TAB 1MG
3
Non-Preferred Brand
RISPERDAL M TAB 2MG
3
Non-Preferred Brand
RISPERDAL M TAB 3MG
3
Non-Preferred Brand
RISPERDAL M TAB 4MG
3
Non-Preferred Brand
RISPERDAL SOL 1MG/ML
3
Non-Preferred Brand
RISPERDAL TAB 0.25MG
3
Non-Preferred Brand
RISPERDAL TAB 0.5MG
3
Non-Preferred Brand
RISPERDAL TAB 1MG
3
Non-Preferred Brand
RISPERDAL TAB 2MG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
546
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
3
Non-Preferred Brand
RISPERDAL TAB 4MG
3
Non-Preferred Brand
1
1
1
1
1
1
1
1
1
1
1
1
1
3
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
PA after 25
RITALIN LA CAP 20MG
3
Non-Preferred Brand
PA after 25
RITALIN LA CAP 30MG
3
Non-Preferred Brand
PA after 25
RITALIN LA CAP 40MG
3
Non-Preferred Brand
PA after 25
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
RISPERDAL TAB 3MG
RISPERIDONE SOL 1MG/ML
RISPERIDONE TAB 0.25 ODT
RISPERIDONE TAB 0.25MG
RISPERIDONE TAB 0.5MG
RISPERIDONE TAB 0.5MG OD
RISPERIDONE TAB 1MG
RISPERIDONE TAB 1MG ODT
RISPERIDONE TAB 2MG
RISPERIDONE TAB 2MG ODT
RISPERIDONE TAB 3MG
RISPERIDONE TAB 3MG ODT
RISPERIDONE TAB 4MG
RISPERIDONE TAB 4MG ODT
RITALIN LA CAP 10MG
Medication must be filled
through US Specialty Care
Pharmacy
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
547
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
RITALIN TAB 10MG
3
Non-Preferred Brand
PA after 25
RITALIN TAB 20MG
3
Non-Preferred Brand
PA after 25
3
Non-Preferred Brand
PA after 25
3
Non-Preferred Brand
PA after 25
RITUXAN INJ 100MG
RIVASTIGMINE CAP 1.5MG
RIVASTIGMINE CAP 3MG
RIVASTIGMINE CAP 4.5MG
RIVASTIGMINE CAP 6MG
RIXUBIS INJ 1000UNIT
RIXUBIS INJ 2000UNIT
RIXUBIS INJ 250 UNIT
RIXUBIS INJ 3000UNIT
RIXUBIS INJ 500UNIT
3
1
1
1
1
3
3
3
3
3
Non-Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
RIZATRIPTAN TAB 10MG
1
Generic
1
Generic
1
Generic
1
Generic
3
2
Non-Preferred Brand
Preferred Brand
RITALIN TAB 20MG SR
RITALIN TAB 5MG
RIZATRIPTAN TAB 10MG ODT
RIZATRIPTAN TAB 5MG
RIZATRIPTAN TAB 5MG ODT
RNA POW
ROBATHOL OIL
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Maximum of 12
per 30 days
Maximum of 12
per 30 days
Maximum of 12
per 30 days
Maximum of 12
per 30 days
548
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ROBAXIN INJ 100MG/ML
2
Preferred Brand
ROBAXIN TAB 500MG
3
Non-Preferred Brand
ROBAXIN-750 TAB 750MG
3
Non-Preferred Brand
ROBINUL FORT TAB 2MG
3
Non-Preferred Brand
3
Non-Preferred Brand
ROBITUS NGHT LIQ 12.5-30
3
Non-Preferred Brand
ROBITUSSIN CAP COUGHGEL
3
Non-Preferred Brand
ROBITUSSIN LIQ CF
ROBITUSSIN LIQ CGH/CLD
2
2
Preferred Brand
Preferred Brand
ROBITUSSIN LIQ CGH/CONG
3
Non-Preferred Brand
ROBITUSSIN LIQ NIGHT TM
2
Preferred Brand
ROBITUSSIN LIQ TO GO CF
3
Non-Preferred Brand
ROBITUSSIN MIS DAY/NGHT
ROBITUSSIN SYP 7.5/5ML
3
1
Non-Preferred Brand
Generic
ROBITUSSIN SYP CHST CNG
3
Non-Preferred Brand
2
Preferred Brand
ROBINUL TAB 1MG
ROBITUSSN DM SYP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
549
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ROCALTROL CAP 0.25MCG
3
Non-Preferred Brand
ROCALTROL CAP 0.5MCG
3
Non-Preferred Brand
ROCALTROL SOL 1MCG/ML
3
Non-Preferred Brand
ROCEPHIN INJ 1GM
3
Non-Preferred Brand
ROCEPHIN INJ 500MG
3
Non-Preferred Brand
2
1
1
Preferred Brand
Generic
Generic
-
-
-
-
ROGAINE SOL 2% WOMEN
-
-
ROGAINE X-S SOL 5% MEN
-
-
RONIDAZOLE POW
ROPINIROLE TAB 0.25MG
ROPINIROLE TAB 0.5MG
3
1
1
Non-Preferred Brand
Generic
Generic
ROPINIROLE TAB 12MG ER
1
Generic
1
Generic
ROCK CANDY CRY
ROCURONIUM INJ 100MG/10
ROCURONIUM INJ 10MG/ML
ROGAINE MENS AER 5%
ROGAINE MENS AER EXTRA ST
ROPINIROLE TAB 1MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
-
-
-
-
-
-
-
-
Maximum of 60
per 30 days
550
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
1
Generic
1
Generic
1
1
Generic
Generic
1
Generic
1
Generic
ROPINIROLE TAB 6MG ER
1
Generic
ROPINIROLE TAB 8MG ER
1
Generic
ROPIVACAINE INJ 10MG/ML
ROPIVACAINE INJ 5MG/ML
ROPIVACAINE POW HCL
ROSANIL KIT
ROSE BENGAL POW B
ROSE BENGAL TES 1.3MG
ROSE GLO TES 1.5MG
ROSE OIL
ROSE WATER LIQ
ROSEMARY OIL
ROSIN LUMP MIS
ROSIN LUMP MIS CLEAR
ROSIN POW
ROSIN POW DILUENT
PENTACEL INJ
PRENTIF MIS 22MM
1
1
2
3
2
3
3
2
2
2
2
3
2
3
-
Generic
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
ROPINIROLE TAB 2MG
ROPINIROLE TAB 2MG ER
ROPINIROLE TAB 3MG
ROPINIROLE TAB 4MG
ROPINIROLE TAB 4MG ER
ROPINIROLE TAB 5MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
551
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
ROWASA KIT 4GM
3
Non-Preferred Brand
ROXICET SOL 5-325/5
3
Non-Preferred Brand
ROXICODONE TAB 15MG
3
Non-Preferred Brand
ROXICODONE TAB 30MG
3
Non-Preferred Brand
ROXICODONE TAB 5MG
3
Non-Preferred Brand
ROYAL JELLY CAP 200MG
ROYAL JELLY CAP 500MG
ROYAL JELLY/ POW HDA
3
1
3
Non-Preferred Brand
Generic
Non-Preferred Brand
2
Preferred Brand
1
3
3
3
2
2
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
-
-
RYANODEX INJ 250MG
3
Non-Preferred Brand
RYBIX ODT TAB 50MG
3
Non-Preferred Brand
RYCONTUSS LIQ 5-2-10/5
RYDEX G TAB 38.5-398
3
2
Non-Preferred Brand
Preferred Brand
ROZEREM TAB 8MG
RSPBRRY KETO CAP 100MG
RUBIDIUM POW CHLORIDE
RUCONEST INJ 2100UNIT
RU-HIST-D LIQ 30-10/5
RU-HIST-D TAB 30-10MG
RUTIN POW
RUTIN TAB 50MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Step Therapy
Required
Limited Distribution
Not a covered
benefit
-
-
Maximum of 120
per 30 days
552
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
2
Preferred Brand
Preferred Brand
RYTHMOL SR CAP 225MG
3
Non-Preferred Brand
RYTHMOL SR CAP 325MG
3
Non-Preferred Brand
RYTHMOL SR CAP 425MG
3
Non-Preferred Brand
RYTHMOL TAB 150MG
3
Non-Preferred Brand
RYTHMOL TAB 225MG
3
Non-Preferred Brand
S.S.S. TONIC LIQ
-
-
2
3
3
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
-
-
SACCHARIN POW SODIUM
-
-
SAFE TUSSIN LIQ PM
SAFE WASH SOL
SAFETYGLIDE MIS 27GX5/8"
SAFETYGLIDE MIS 27GX5/8"
SAFFLOWER OIL
3
2
2
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
RYDEX LIQ
RYMED TAB 2-10MG
S2 NEB 2.25%
SABRIL POW 500MG
SABRIL TAB 500MG
SACCHARIN CRY CALCIUM
SACCHARIN POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Limited Distribution
Limited Distribution
Not a covered
benefit
Not a covered
benefit
-
-
-
-
553
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SAFFLOWER/B6 CAP 1150-12
SAFTY NEEDLE MIS 21GX1"
SAFTY NEEDLE MIS 21GX5/8"
SAFTY NEEDLE MIS 23GX5/8"
SAFYRAL TAB
SAGE LEAF POW
SAIZEN INJ 5MG
SAIZEN INJ 8.8MG
3
3
3
3
2
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
SAKRIN SOL 12%
-
-
SALAC AER 2%
SALACYN CRE 6%
SALACYN LOT 6%
3
1
1
Non-Preferred Brand
Generic
Generic
SALAGEN TAB 5MG
3
Non-Preferred Brand
SALAGEN TAB 7.5MG
3
Non-Preferred Brand
SALEX CREAM KIT 6%
3
Non-Preferred Brand
SALEX LOTION KIT 6%
3
Non-Preferred Brand
3
Non-Preferred Brand
3
2
1
Non-Preferred Brand
Preferred Brand
Generic
SALEX SHA 6%
SALICYLAMIDE POW
SALICYLIC AC AER 6%
SALICYLIC AC GEL 6%
WDRx 2/23/15
Special Plan Edits
PA Required
PA Required
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
-
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
554
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SALICYLIC AC KIT 6%
SALICYLIC AC KIT 6% LOTN
SALICYLIC AC LIQ 26%
SALICYLIC AC LIQ 27.5%
SALICYLIC AC SHA 6%
SALICYLIC AER 6%
SALICYLIC CRY ACID
SALICYLIC POW ACID
SALINE PAK 2300-700
SALINE WOUND LIQ 0.13%
SALINE WOUND SPR WASH
SALINE/PHENO SOL
SALKERA AER 6%
SALMON CAP 200MG
1
1
2
1
1
1
2
2
1
1
3
3
3
3
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
SALMON OIL CAP 1000MG
-
-
3
2
3
3
2
3
2
2
1
1
2
3
1
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
Generic
SALONPAS AER MASSAGE
SALONPAS GEL
SALONPAS GEL PAD
SALONPAS JET SPR PAIN REL
SALONPAS PAD
SALONPAS PAD ARTHRITI
SALONPAS-HOT PAD
SALSALATE POW
SALSALATE TAB 500MG
SALSALATE TAB 750MG
SALVAX AER 6%
SALVAX DUO KIT PLUS
SAM-E SUPER TAB 400MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
555
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SAM-E TAB 200MG
SAM-G.L.A. CAP
SAMOLINIC CAP
SAMSCA TAB 15MG
SAMSCA TAB 30MG
SANARE SCAR CRE THERAPY
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
2
2
Preferred Brand
Preferred Brand
SANDIMMUNE CAP 100MG
3
Non-Preferred Brand
SANDIMMUNE CAP 25MG
3
Non-Preferred Brand
SANDIMMUNE INJ 50MG/ML
3
Non-Preferred Brand
SANDIMMUNE SOL 100MG/ML
2
Preferred Brand
SANDOSTATIN INJ 1000MCG
3
Non-Preferred Brand
YES, Specialty Drug
SANDOSTATIN INJ 100MCG
3
Non-Preferred Brand
YES, Specialty Drug
SANCTURA TAB 20MG
SANCTURA XR CAP 60MG
SANCUSO DIS 3.1MG
SANDALWOOD OIL FRAGRANC
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
556
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
SANDOSTATIN INJ 200MCG
3
Non-Preferred Brand
YES, Specialty Drug
SANDOSTATIN INJ 500MCG
3
Non-Preferred Brand
YES, Specialty Drug
SANDOSTATIN INJ 50MCG/ML
3
Non-Preferred Brand
YES, Specialty Drug
SANDOSTATIN KIT LAR 10MG
SANDOSTATIN KIT LAR 20MG
SANDOSTATIN KIT LAR 30MG
SANTYL OIN 250/GM
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
SAPHRIS SUB 10MG
3
Non-Preferred Brand
SAPHRIS SUB 5MG
3
Non-Preferred Brand
2
3
3
3
3
2
3
2
2
3
2
2
2
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
SAPONIN POW FOOD GRD
SARAFEM TAB 10MG
SARAFEM TAB 20MG
SARAPIN INJ
SARDOETTES MIS
SARNA LOT
SARSAPARILLA POW ROOT
SASSAFRAS OIL
SASTID BAR 3-5%
SAUGELLA LIQ WASH
SAVELLA MIS TITR PAK
SAVELLA TAB 100MG
SAVELLA TAB 12.5MG
SAVELLA TAB 25MG
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum o f60
per 30 days
Maximum of 60
per 30 days
557
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SAVELLA TAB 50MG
SAVENTARO CAP 20MG
SAW PALMETTO CAP
SAW PALMETTO CAP 1000MG
SAW PALMETTO CAP 160-100
SAW PALMETTO CAP 450MG
SAW PALMETTO CAP 500MG
SAW PALMETTO CAP 540MG
SAW PALMETTO CAP COMPLEX
SAW PALMETTO CAP EXTRACT
SAW PALMETTO EXT
SAW PALMETTO POW
SAW PALMETTO TAB 160MG
SAYMAN OIN SALVE
SB FIB LAX POW 33%
SB-NORM STL TAB FORMULA
SCALACORT DK KIT
SCALACORT LOT 2%
SCAR TREATMT MIS 38X69MM
SCARLET RED POW
SCHIRMER TEA TES STRIPS
SCHISANDRA CAP 50MG
SCHOLLS COOL LOT PEPPERMT
SCLEROSOL AER INTRAPLE
2
3
2
1
2
1
1
3
3
1
3
2
3
3
1
3
3
1
3
2
3
3
3
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
SCOOBY-DOO CHW
SCOPOLAMINE INJ 0.4MG/ML
SCOPOLAMINE POW HBR
SCOT-TUSSIN LIQ DIBTS/CF
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
558
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SCOT-TUSSIN LIQ ORIGINAL
3
Non-Preferred Brand
SCOT-TUSSIN LIQ SENIOR
2
Preferred Brand
SCULPTRA INJ 367.5MG
-
-
SCYTERA AER 2%
SE BPO 7-5.5 KIT WASH KIT
SE BPO CLOTH MIS 3%
SE BPO CLOTH MIS 6%
SE BPO CLOTH MIS 9%
2
2
1
1
1
Preferred Brand
Preferred Brand
Generic
Generic
Generic
SE PLUS PROT TAB 200MCG
3
Non-Preferred Brand
SE-100 CAP 100MCG
SEA BOND WAF
SEA-BAND MIS ADULT
SEALS BOTTLE MIS /VIALS
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
SEASONIQUE TAB
SEBASORB LOT
SEB-PREV LOT 10%
SEBULEX SHA
SECONAL CAP 100MG
SECREFLO INJ 16MCG
SECRETIN- POW MANNITOL
WDRx 2/23/15
$0 Preventative Drug
2
3
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
2
3
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
559
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SECTRAL CAP 200MG
3
Non-Preferred Brand
SECTRAL CAP 400MG
3
Non-Preferred Brand
SECURA CLEAN SPR 0.13%
SECURA CRE 30.6%
SECURA KIT STARTER
SECURI-T MIS BARRIER
SELECT-OB+ PAK DHA
SELEGILINE CAP 5MG
SELEGILINE POW HCL
SELEGILINE TAB 5MG
SELENICAPS CAP 200
SELENIMIN TAB 125MCG
SELENIOUS POW ACID
SELENIUM CHE POW 0.2%
SELENIUM INJ 40MCG/ML
SELENIUM POW MONOCHLO
SELENIUM POW SULFIDE
SELENIUM POW YEAST
SELENIUM SUL LOT 2.5%
SELENIUM TAB 100MCG
SELENIUM TAB 200MCG
2
2
3
3
1
2
1
1
3
3
3
2
3
2
2
1
1
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
SELENIUM-E CAP 50-400
-
-
SELRX SHA 2.3%
SELSUN BLUE SHA 1%
3
2
Non-Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
-
-
-
-
560
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
SELSUN SHA 2.5%
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
SEMPREX-D CAP 8-60MG
SENEXON LIQ 8.8MG/5
SENIOR MOMEN CAP 150-50MG
SENNA EXT
SENNA LEAVES MIS
SENNA POW
SENNA PROMPT CAP 9-500MG
SENNA SYP
SENNA TAB 187MG
SENOKOT 2GO TAB 8.6MG
SENOKOT S TAB 8.6-50MG
SENOKOT XTRA TAB 17.2MG
SENS EYES TAB ENZYME
SENSI-CARE OIN 49-15%
SENSIPAR TAB 30MG
SENSIPAR TAB 60MG
SENSIPAR TAB 90MG
SENSODYNE PST MAX MINT
SENSORCAINE INJ -MPF/EPI
SENTRALOPRAM PAK AM-10
SENTRAMODAFI PAK AM-100
SENTRAVIL PM PAK -25
SEPICALM VG LIQ
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
3
3
3
1
3
3
3
3
3
2
2
2
2
2
3
2
2
2
2
2
2
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
561
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Maximum of 1
INHALER per 30
days
SEREVENT DIS AER 50MCG
2
Preferred Brand
SERMORELIN POW ACETATE
2
Preferred Brand
SEROQUEL TAB 100MG
3
Non-Preferred Brand
SEROQUEL TAB 200MG
3
Non-Preferred Brand
SEROQUEL TAB 25MG
3
Non-Preferred Brand
SEROQUEL TAB 300MG
3
Non-Preferred Brand
SEROQUEL TAB 400MG
3
Non-Preferred Brand
SEROQUEL TAB 50MG
3
Non-Preferred Brand
2
2
2
2
2
3
3
3
2
-
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
$0 Preventative Drug
SEROQUEL XR TAB 150MG
SEROQUEL XR TAB 200MG
SEROQUEL XR TAB 300MG
SEROQUEL XR TAB 400MG
SEROQUEL XR TAB 50MG
SEROSTIM INJ 4MG
SEROSTIM INJ 5MG
SEROSTIM INJ 6MG
SEROTONIN POW HCL
SERTRALINE CON 20MG/ML
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
PA Required
Limited Distribution
Limited Distribution
Limited Distribution
-
562
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SERTRALINE POW
SERTRALINE TAB 100MG
SERTRALINE TAB 25MG
SERTRALINE TAB 50MG
SESAME OIL
SE-TAN DHA CAP
SEVOFLURANE SOL
SFROWASA ENE 4GM
SHARK CARTIL CAP 500MG
SHARK CARTIL CAP 675MG
SHARK CARTIL CAP 740MG
SHARK CARTIL CAP 750MG
SHARK POW CARTLG
SHAVEGRASS POW
SHEA BUTTER MIS
SHITAKE POW MUSHROOM
2
2
1
3
1
3
1
1
2
3
2
3
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
SHOHLS SOL MODIFIED
3
Non-Preferred Brand
2
3
2
3
3
3
3
3
2
Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
SHOWER FRESH LIQ FRAGRANC
SHOWER TAB
PRENTIF MIS 25MM
SIB GINSENG POW
SIBERN ROOT TAB 500MG
SIDEKICK KIT SYSTEM
SIGNIFOR INJ 0.3MG/ML
SIGNIFOR INJ 0.6MG/ML
SIGNIFOR INJ 0.9MG/ML
SILDENAFIL POW CITRATE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
563
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
3
Non-Preferred Brand
SILENOR TAB 3MG
3
Non-Preferred Brand
SILENOR TAB 6MG
3
Non-Preferred Brand
PA Required
Step Therapy
Required
Step Therapy
Required
2
3
3
3
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
2
2
2
2
2
2
2
1
2
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
SIMCOR TAB 1000-20
2
Preferred Brand
SIMCOR TAB 1000-40
2
Preferred Brand
SIMCOR TAB 500-20MG
2
Preferred Brand
SILDENAFIL TAB 20MG
SILICA GEL
SILICA GRA FINE
SILICNE BLND PST CUSTOM
SILICON POW
SILICON POW DIOXIDE
SILVADENE CRE 1%
SILVER CRY NITRATE
SILVER NITRA OIN 10%
SILVER NITRA SOL 0.5%
SILVER NITRA SOL 10%
SILVER NITRA SOL 25%
SILVER NITRA SOL 50%
SILVER PROTE POW MILD
SILVER SULFA CRE 1%
SILVER SULFA POW
SILYMARIN CAP
SIMBRINZA SUS 1-0.2%
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 60
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
564
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SIMCOR TAB 500-40MG
2
Preferred Brand
SIMCOR TAB 750-20MG
2
Preferred Brand
SIMETHICONE LIQ
SIMPLE SYP
SIMPLY COUGH SYP 5MG/5ML
SIMPLY SALIN AER 0.9%
SIMPLYTHICK GEL
SIMPONI ARIA SOL 50MG/4ML
SIMPONI INJ 100MG/ML
SIMPONI INJ 50/0.5ML
SIMULECT INJ 10MG
SIMULECT INJ 20MG
SIMVASTATIN POW
SIMVASTATIN TAB 10MG
SIMVASTATIN TAB 20MG
SIMVASTATIN TAB 40MG
SIMVASTATIN TAB 5MG
SIMVASTATIN TAB 80MG
SINADRIN PE TAB 2-10-650
SINCALIDE IN POW MANNITOL
2
2
1
3
2
3
3
3
2
2
2
3
3
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
SINEMET CR TAB 25-100MG
3
Non-Preferred Brand
SINEMET CR TAB 50-200MG
3
Non-Preferred Brand
3
Non-Preferred Brand
SINEMET TAB 10-100MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30
per 30 days
Maximum of 60
per 30 days
PA Required
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
565
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
SINEMET TAB 25-100MG
3
Non-Preferred Brand
SINEMET TAB 25-250MG
3
Non-Preferred Brand
SINEX DT/NT MIS SINUS RE
3
Non-Preferred Brand
SINGULAIR CHW 4MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
SINGULAIR CHW 5MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
SINGULAIR GRA 4MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
SINGULAIR TAB 10MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
3
Non-Preferred Brand
SINUCLEANSE KIT NETI POT
3
Non-Preferred Brand
SINUCLEANSE PAK REFILL
3
Non-Preferred Brand
SINUFLO KIT RDYRINSE
SINUGATOR KIT NASL WSH
SINUS WASH CRY SALT
SINUS WASH KIT NETI POT
SINUS-MAX MIS DAY/NGHT
3
2
3
2
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
SINOGRAFIN INJ
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
566
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
SINUSTAR MIS NEBULIZE
SIROLIMUS POW
SIROLIMUS TAB 0.5MG
SIRTURO TAB 100MG
SITAVIG TAB 50MG
SITOSTEROL POW 40%
SITZMARKS CAP
SIVEXTRO INJ 200MG
SIVEXTRO TAB 200MG
SKEETER STIK LIQ 5-1%
SKELAXIN TAB 800MG
SKIN PROTECT CRE 12%
SKIN SCRUB KIT PREP TRY
SKIN SHIELD LIQ
SKIN SOFT LIQ FRAGRANC
SKLICE LOT 0.5%
Tier
Formulary Status
3
2
1
2
3
3
3
2
3
3
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
3
3
3
3
SLEEP SOUNDL LIQ 3.5/2ML
SLEEP-N-HEEL KIT
SLOANS LINIM LIQ 0.025-47
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Medical ONLY
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
SLO-NIACIN TAB 500MG CR
-
-
SLO-NIACIN TAB 750MG CR
-
-
SLOW FE TAB 142MG
SLOW FE TAB 160MG CR
SLOW IRON TAB 160MG CR
2
2
1
Preferred Brand
Preferred Brand
Generic
SKYLA IUD 13.5MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
-
-
-
-
567
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SLOW IRON TAB 50MG
SLOW REL FE TAB 140MG CR
SLOW REL FE TAB 143MG CR
SLOW RELEASE TAB 143MG
SLOW RELEASE TAB 47.5MG
SLOW-MAG TAB
1
2
2
2
1
2
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
SM B-COMPLEX TAB /VIT C
-
-
SM CORAL CAL TAB 1000MG
SM COTTON MIS SQUARES
SM GARLIC TAB 150MG
SM GLUCO/MSM TAB 750-750
SM GREEN TEA TAB 1000MG
SM ONE DAILY MIS PRENATAL
SM VAPORIZER LIQ INHALANT
SMZ/TMP DS TAB 800-160
SMZ-TMP INJ 400-80/5
SMZ-TMP SUS
SMZ-TMP TAB 400-80MG
SOD ACETATE INJ 2MEQ/ML
SOD ACETATE INJ 4MEQ/ML
SOD ACETATE POW ANHYDR
SOD ACETATE POW TRIHYDRA
SOD ALGINATE POW
3
2
2
3
3
2
1
2
1
1
1
1
2
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
SOD ASCORBAT GRA
-
-
SOD BENZOATE POW
SOD BICARB INJ 4.2%
SOD BICARB INJ 7.5%
2
1
1
Preferred Brand
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
-
-
-
-
Not a covered
benefit
568
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SOD BICARB INJ 8.4%
SOD BISULFIT GRA
SOD BROMIDE GRA
SOD CARBONAT POW ANHYDROU
SOD CARBONAT POW MONOHYDR
SOD CHLORATE POW
SOD CHLORIDE GRA
SOD CHLORIDE INJ 0.45%
SOD CHLORIDE INJ 0.9%
SOD CHLORIDE INJ 0.9%BACT
SOD CHLORIDE INJ 2.5/ML
SOD CHLORIDE INJ 3%
SOD CHLORIDE INJ 5%
SOD CHLORIDE NEB 0.9%
SOD CHLORIDE TAB 1000MG
SOD CITRATE CRY
SOD CITRATE POW DIHYDRAT
1
2
2
2
3
3
2
1
1
1
1
1
1
1
1
2
2
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
2
2
2
2
2
2
2
2
Preferred Brand
$0 ACA Drug
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
SOD DIURIL INJ 500MG
SOD EDECRIN INJ 50MG
SOD FLUORIDE DRO 0.5MG/ML
SOD FLUORIDE POW
SOD FLUORIDE TAB 0.5MG F
SOD FLUORIDE TAB 1MG F
SOD IODIDE GRA
SOD IODIDE POW
SOD LACTATE INJ 5MEQ/ML
SOD LACTATE SOL 60%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
569
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SOD LAURYL POW SULFATE
SOD METABISU GRA
SOD METABISU POW
SOD METABISU POW USP/NF
SOD NITRITE GRA
SOD NITRITE INJ 30MG/ML
SOD PERBORAT CRY
SOD PERBORAT GRA
SOD PERBORAT POW PURIFIED
SOD PHOS DIB CRY HEPTAHYD
SOD PHOSPHAT CRY DIBASIC
SOD PHOSPHAT CRY TRIBASIC
SOD PHOSPHAT GRA DIBASIC
SOD PHOSPHAT GRA MONOBAS
SOD PHOSPHAT INJ 3MM/ML
SOD POLY SUL SUS 30/120ML
SOD PROPION POW
2
2
2
3
2
3
2
2
2
2
3
2
2
2
1
1
2
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
-
-
3
2
3
2
2
3
2
2
1
1
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
SOD SACCHARI GRA
SOD SALICYLA CRY
SOD SALICYLA POW
SOD SELENATE POW DECAHYDR
SOD SILICATE SOL
SOD SILICATE SOL 40%
SOD STARCH POW GLYCOLAT
SOD STEARATE POW
SOD STEARYL POW FUMARATE
SOD SUL/SULF AER 10-5%
SOD SUL/SULF CRE 10-2%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
570
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SOD SUL/SULF EMU 10-5%
SOD SUL/SULF GEL 10-5%
SOD SUL/SULF KIT
SOD SUL/SULF LIQ 10-2%
SOD SUL/SULF LIQ 9-4.5%
SOD SUL/SULF LIQ WASH
SOD SUL/SULF LOT 10-5%
SOD SUL/SULF PAD 10-4%
SOD SUL/SULF SUS 10-5%
SOD SUL/SULF SUS 8-4%
SOD SULFACET GEL 10%
SOD SULFACET PAD 10%
SOD SULFACET SHA 10%
SOD SULFACET SOL 10% OP
SOD SULFATE GRA
SOD SULFATE POW
SOD SULFIDE POW HYDRATE
SOD SULFITE POW ANHYDROU
SOD TETR SUL SOL 27%
SOD THIOSULF INJ 10%
SOD THIOSULF INJ 25%
SOD TUNGSTAT POW DIHYDRAT
SOD VALPROAT POW
SODIUM BICAR TAB 10GR
SODIUM BICAR TAB 325MG
SODIUM BORAT POW
SODIUM BUTYR POW
SODIUM CHLOR INJ 0.9%
SODIUM CHLOR NEB 10%
2
3
1
1
1
1
1
1
2
1
1
2
1
1
3
2
3
2
2
2
1
3
2
1
1
2
2
2
1
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
571
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SODIUM CITRA GRA DIHYDRAT
SODIUM FORMA POW SULFOXYL
SODIUM LAURE LIQ SULFATE
SODIUM LIQ PIDOLATE
SODIUM MIS CHLORITE
SODIUM MIS HYDROXID
SODIUM MOLYB POW DIHYDRAT
SODIUM NITRA GRA
SODIUM POLYS POW SULFONAT
SODIUM POW BICARBON
SODIUM POW BICARBON
SODIUM POW BISULFAT
SODIUM POW CAPRATE
SODIUM POW CAPYRLAT
SODIUM POW CHLORIDE
SODIUM POW DICHLORO
SODIUM POW GLUCONAT
SODIUM POW NITRATE
SODIUM POW OLEATE
SODIUM POW R-LIPOAT
SODIUM POW SELENITE
SODIUM POW SUCCINAT
SODIUM SULFA LIQ 10% WASH
SODIUM TARTR POW DIHYDRAT
SODIUM TETRA POW SULFATE
SOD-K TAB
2
3
2
2
2
2
3
3
3
2
2
3
2
2
2
2
2
2
2
2
2
2
2
3
2
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
SOLARAZE GEL 3% W/W
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
572
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
SOLARCAINE AER 20%
Tier
Formulary Status
3
Non-Preferred Brand
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
SOLODYN TAB 105MG
2
Preferred Brand
SOLODYN TAB 115MG
2
Preferred Brand
SOLODYN TAB 55MG
2
Preferred Brand
SOLODYN TAB 65MG
2
Preferred Brand
SOLODYN TAB 80MG
2
Preferred Brand
SOLTAMOX SOL 10MG/5ML
SOLTICE OIN QUICK-RU
SOLU-CORTEF INJ 1000MG
SOLU-CORTEF INJ 100MG
SOLU-CORTEF INJ 250MG
SOLU-CORTEF INJ 500MG
3
3
2
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
SOLU-MEDROL INJ 125MG
3
Non-Preferred Brand
SOLU-MEDROL INJ 1GM
3
Non-Preferred Brand
SOLU-MEDROL INJ 2GM
2
Preferred Brand
SOLARCAINE AER ALOE VER
SOLARCAINE LOT
SOLASODINE POW
SOLEDUM CAP 100MG
SOLESTA INJ 50-15ML
SOLIRIS INJ 10MG/ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
573
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SOLU-MEDROL INJ 40MG
3
Non-Preferred Brand
SOLU-MEDROL INJ 500MG
3
Non-Preferred Brand
SOLU-SILK LIQ PROTEIN
3
Non-Preferred Brand
3
Non-Preferred Brand
SOMATROPIN POW
SOMATULINE INJ 120/.5ML
SOMATULINE INJ 60/0.2ML
SOMATULINE INJ 90/0.3ML
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
3
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
SOMBRA COOL GEL 6%
3
Non-Preferred Brand
3
3
Non-Preferred Brand
Non-Preferred Brand
SONATA CAP 10MG
3
Non-Preferred Brand
SONATA CAP 5MG
3
Non-Preferred Brand
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
SOMA TAB 350MG
SOMBRA NATUR GEL PAIN REL
SOMNICIN CAP
SOOTHE DRO 0.6-0.6%
SORBIC ACID POW
SORBITAN LIQ MONOLAUR
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Limited Distribution
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
574
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SORBITAN LIQ MONOOLEA
SORBITAN LIQ SESQUIOL
SORBITAN LIQ TRIOLEAT
SORBITAN MIS MONOSTEA
SORBITAN POW MONOPALM
SORBITOL MIS LOLLIPOP
SORBITOL POW
SORBITOL SOL
SORBITOL SOL 3% IRR
SORBITOL SOL 3.3% IRR
SORBITOL SOL 70%
SORBITOL SOL 70%
SORBITOL-MAN SOL
SORBUTUSS NR LIQ
SORE THROAT LOZ REL POPS
SORE THROAT LOZ RELIEF
SORE THROAT MIS
SORE THROAT SPR
2
3
3
3
3
2
2
3
3
3
2
2
3
2
2
1
1
1
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
SORIATANE CAP 10MG
3
Non-Preferred Brand
SORIATANE CAP 17.5MG
3
Non-Preferred Brand
SORIATANE CAP 25MG
3
Non-Preferred Brand
SORILUX AER 0.005%
SORINE TAB 120MG
SORINE TAB 160MG
3
1
1
Non-Preferred Brand
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
575
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SORINE TAB 240MG
SORINE TAB 80MG
SOTALOL AF TAB 120MG
SOTALOL AF TAB 160MG
SOTALOL AF TAB 80MG
SOTALOL HCL INJ 150/10ML
SOTRADECOL INJ 1%
SOTRADECOL INJ 3%
SOVALDI TAB 400MG
SOY ISOFLAVO CAP
SOY ISOFLAVO CAP 50MG
SOY ISOFLAVO CAP 750MG
SOY ISOFLAVO POW 40%
SOY ISOFLAVO TAB 40MG
SOY ISOLFLAV CAP 55MG
SOY MENOPAUS TAB 55MG
SOYABEAN POW CASEIN
SOYBEAN OIL
SPAN 80 LIQ
SPEARMINT OIL
SPECTRACEF TAB 200MG
SPECTRACEF TAB 400MG
SPEEDEGEL GEL
SPG SUPPOSI- MIS BASE
SPIKE OIL DARK
SPINAL NEEDL MIS 14GX2"
SPINAL NEEDL MIS 17GX3.5"
SPINAL NEEDL MIS 18GX1.5"
SPINAL NEEDL MIS 18GX2.5"
1
1
1
1
1
2
2
2
3
3
3
3
3
1
3
3
3
2
3
2
3
3
2
2
3
3
3
3
2
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
PA Required
YES, Specialty Drug
Penalty applied if Brand Selected
over Generic
576
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SPINAL NEEDL MIS 19GX3"
SPINAL NEEDL MIS 19GX3.5"
SPINAL NEEDL MIS 20GX1.5"
SPINAL NEEDL MIS 20GX2"
SPINAL NEEDL MIS 20GX2.5"
SPINAL NEEDL MIS 20GX3"
SPINAL NEEDL MIS 20GX4"
SPINAL NEEDL MIS 20GX6"
SPINAL NEEDL MIS 22GX2"
SPINAL NEEDL MIS 22GX3.5"
SPINAL NEEDL MIS 22GX5"
SPINAL NEEDL MIS 22GX7"
SPINAL NEEDL MIS 23GX3.5"
SPINAL NEEDL MIS 24GX3.5"
SPINAL NEEDL MIS 25GX1"
SPINAL NEEDL MIS 25GX1.5"
SPINAL NEEDL MIS 25GX2"
SPINAL NEEDL MIS 25GX3"
SPINAL NEEDL MIS 25GX4-11
SPINAL NEEDL MIS 27GX1.5"
SPINAL NEEDL MIS 27GX3.5"
SPINAL NEEDL MIS 27GX4-11
SPINAL NEEDL MIS 29GX3.5"
SPINAL NEEDL MIS 29GX4-11
SPINOSAD SUS 0.9%
2
2
3
3
2
2
3
3
3
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
SPIRIVA CAP HANDIHLR
2
Preferred Brand
SPIRONO/HCTZ TAB 25/25
-
$0 Preventative Drug
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 30 (1
BOX) per 30 days
577
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
3
3
3
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
SPORANOX CAP 100MG
3
Non-Preferred Brand
SPORANOX SOL 10MG/ML
SPORTS RUB OIN INTENSE
SPRAYZOIN SPR
SPRIX SPR 15.75MG
2
2
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
3
3
3
3
3
3
2
2
2
2
1
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
SPIRONOLACT POW
SPIRONOLACT TAB 100MG
SPIRONOLACT TAB 25MG
SPIRONOLACT TAB 50MG
SPIRULINA POW
SPIRULINA TAB 500MG
SPONGE STICK MIS /PVP
SPROAM LIQ 0.1%
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
SPS SUS 15GM/60
SQUALANE LIQ
SQUALANE OIL
SQUARIC ACID POW
SQUARIC ACID POW DI-N-BUT
SS SINADRIN TAB 4-10-650
SSKI SOL 1GM/ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
578
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SSS 10-4 AER 10-4%
ST JOHN WORT TAB 150MG
ST JOHNS POW WORT
ST JOHNS WRT CAP 1000MG
ST JOHNS WRT CAP 300MG
ST JOHNS WRT CAP 450MG
3
3
2
3
1
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
ST JOSEPH CHW 75MG ADU
3
Non-Preferred Brand
2
Preferred Brand
STAFLEX TAB 55-500MG
3
Non-Preferred Brand
STAHIST AD LIQ
STAHIST AD TAB 25-60MG
3
2
Non-Preferred Brand
Preferred Brand
STALEVO 100 TAB
3
Non-Preferred Brand
STALEVO 125 TAB
3
Non-Preferred Brand
STALEVO 150 TAB
3
Non-Preferred Brand
STALEVO 200 TAB
3
Non-Preferred Brand
STALEVO 50 TAB
3
Non-Preferred Brand
STALEVO 75 TAB
3
Non-Preferred Brand
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ST-37 LIQ
STANBACK AF POW 950MG
STANBACK POW HEADACHE
STANNIC CHLO POW PENTAHYD
STANNOUS CRY CHLORIDE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 240
per 30 days
Maximum of 240
per 30 days
Maximum of 240
per 30 days
Maximum of 180
per 30 days
Maximum of 240
per 30 days
Maximum of 240
per 30 days
579
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
STARLIX TAB 120MG
3
Non-Preferred Brand
STARLIX TAB 60MG
3
Non-Preferred Brand
3
3
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
STANNOUS LIQ FLUORIDE
STANNOUS POW FLUORIDE
STANOZOLOL POW
STATUSS LIQ GREEN
STAVUDINE CAP 15MG
STAVUDINE CAP 20MG
STAVUDINE CAP 30MG
STAVUDINE CAP 40MG
STAVUDINE SOL 1MG/ML
STAVZOR CAP 125MG
STAVZOR CAP 250MG
STAVZOR CAP 500MG
STAXYN TAB 10MG
STAY COOL TAB 30MG
STAYBELITE POW ESTER 5
STEAM MIS INHALER
STEARIC ACID MIS
STEARIC ACID POW
STEARYL MIS ALCOHOL
STEARYL POW ALCOHOL
STELARA INJ 45MG/0.5
STELARA INJ 90MG/ML
STENDRA TAB 100MG
STENDRA TAB 200MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
PA Required
PA Required
10 per 30 days
10 per 30 days
580
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
STENDRA TAB 50MG
STEP 2 SOL 8%
STERIL TALC SUS 5GM
STERIL WATER INJ
STERIL WATER INJ
STERILE DILU SOL EPOPROS
STERILE DILU SOL FLOLAN
STERILE LUBR DRO 0.7%
STERILID AER
STERI-TAMP MIS SEAL/BAG
STERI-TAMP MIS SEAL/SYG
STEVIA POW 100MG
STEVIA POW EXTRACT
STEVIA POW EXTRACT
STEVIOL GLYC POW 95%
STEVIOSIDE EXT 15%
STEVIOSIDE POW 90%
STIMATE SOL 1.5MG/ML
STIMEX NEEDL MIS 22GX4.25
STIMEX NEEDL MIS 22X2-1/8
STIMULEN LOT
STINGING POW NETTLE
STING-KILL MIS
STING-KILL PAD
STIVARGA TAB 40MG
STOPAIN GEL 6%
STOPAIN LIQ 8%
STOPAIN SPR 6%
STORAX GUM
3
3
3
1
1
1
2
3
2
3
3
3
2
2
2
2
2
3
3
3
3
2
3
3
3
1
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
10 per 30 days
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Limited Distribution
581
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
STRATTERA CAP 100MG
STRATTERA CAP 10MG
STRATTERA CAP 18MG
STRATTERA CAP 25MG
STRATTERA CAP 40MG
STRATTERA CAP 60MG
STRATTERA CAP 80MG
STRAZEPAM PAK
STREPTOMYCIN INJ 1GM
STREPTOMYCIN POW SULFATE
STRIANT MIS 30MG
STRIBILD TAB
STRIDEX ESSE PAD 1%
2
2
2
2
2
2
2
3
2
2
3
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
STRI-DEX PAD SENS SKI
3
Non-Preferred Brand
STRIVERDI AER RESPIMAT
3
Non-Preferred Brand
STROMECTOL TAB 3MG
STRONTIUM CRY CHLORIDE
STRONTIUM CRY NITRATE
STRONTIUM POW CHLORIDE
2
2
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
-
-
3
2
2
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
STROVITE FOR SYP
STRYCHNINE POW SULFATE
STUART ONE CAP
STUART PRENA PAK + DHA
STYPTOCAINE LIQ 46%
SUBLIMAZE INJ 0.05MG/1
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
Not a covered
benefit
-
-
-
-
582
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SUBOXONE MIS 12-3MG
SUBOXONE MIS 2-0.5MG
SUBOXONE MIS 4-1MG
SUBOXONE MIS 8-2MG
SUBOXONE SUB 2-0.5MG
2
2
2
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
SUBOXONE SUB 8-2MG
3
Non-Preferred Brand
SUBSYS SPR 100MCG
SUBSYS SPR 1200MCG
SUBSYS SPR 1600MCG
SUBSYS SPR 200MCG
SUBSYS SPR 400MCG
SUBSYS SPR 600MCG
SUBSYS SPR 800MCG
SUCCINIC ACD CRY
SUCCINYLCHOL POW CHLORIDE
SUCCINYLSULF POW THIAZOLE
SUCLEAR KIT
SUCRAID SOL 8500/ML
SUCRALFATE POW
SUCRALFATE TAB 1GM
SUCROSE CRY
SUCROSE OCTA CRY ACETATE
SUCROSE POW
SUDAFD NASAL TAB DECONGES
SUDAFED 24HR TAB 240MG
3
3
3
3
3
3
3
2
2
3
2
2
2
1
2
2
2
2
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
SUDAFED CHLD LIQ 15MG/5ML
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
PA Required
Generic Available. Brand copay + the
difference between the brand and the
generic.
583
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SUDAFED CONG TAB 30MG
3
Non-Preferred Brand
SUDAFED PE PAK COLD
3
Non-Preferred Brand
3
3
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
SUDAFED PE TAB CLD/CGH
3
Non-Preferred Brand
SUDAFED TRPL TAB ACTION
SUFENTA INJ 50MCG/ML
SUFENTA INJ 50MCG/ML
SUFENTA INJ 50MCG/ML
SUFENTANIL INJ 100/2ML
SUFENTANIL INJ 250/5ML
SUFENTANIL INJ 50MCG/ML
SUFENTANIL POW CITRATE
2
2
2
2
1
1
1
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Preferred Brand
SULAR TAB 17MG
3
Non-Preferred Brand
SULAR TAB 34MG
3
Non-Preferred Brand
SULAR TAB 8.5MG
3
Non-Preferred Brand
SULF LIME SOL
3
Non-Preferred Brand
SUDAFED PE PAK DAY&NGHT
SUDAFED PE SOL CHILDREN
SUDAFED PE TAB 10MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
584
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
SULF/PRED NA SOL OP
SULFACET SOD OIN 10% OP
SULFACET SOD POW
SULFACETAMID LOT 10%
SULFACETAMID POW
SULFADIAZINE POW
SULFADIAZINE POW SODIUM
SULFADIAZINE TAB 500MG
SULFADIMETHO POW
SULFADOXINE POW
SULFAGUANIDI POW
SULFAMERAZIN POW
SULFAMETHAZ POW
SULFAMETHOX POW
SULFAMYLON CRE 85MG/GM
SULFAMYLON PAK 5%
SULFANILAMID POW
SULFAPYRIDIN POW
SULFAQUINOXA POW 98%
SULFASALAZIN POW
SULFASALAZIN TAB 500MG
SULFASALAZIN TAB 500MG DR
SULFATHIAZOL POW
SULFISOXIZOL CRY
SULFOAM SHA 2%
SULFO-LO BAR 5%
SULFO-LO LOT 6%
WDRx 2/23/15
Tier
Formulary Status
1
2
2
1
2
2
2
2
3
3
3
2
3
2
2
Generic
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
2
2
3
2
1
1
2
2
3
1
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
585
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SULFOSALICYL POW DIHYDRAT
SULFUR BAR 10%
SULFUR POW
SULFURIC ACD SOL
SULINDAC POW
SULINDAC TAB 150MG
SULINDAC TAB 200MG
SULPHAN BLUE POW
SULPIRIDE POW
SUMA ROOT POW
2
3
2
2
2
1
1
3
3
3
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
SUMADAN WASH LIQ 9-4.5%
3
Non-Preferred Brand
SUMADAN XLT KIT 9-4.5%
3
Non-Preferred Brand
SUMATRIPTAN INJ 4MG/0.5
1
Generic
SUMATRIPTAN INJ 4MG/0.5
1
Generic
SUMATRIPTAN INJ 6MG/0.5
1
Generic
SUMATRIPTAN INJ 6MG/0.5
1
Generic
SUMATRIPTAN INJ 6MG/0.5
1
Generic
SUMADAN KIT
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
586
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
May be subject to
Quantity Level
Limits
SUMATRIPTAN INJ 6MG/0.5
1
Generic
SUMATRIPTAN POW
SUMATRIPTAN POW SUCCINAT
2
2
Preferred Brand
Preferred Brand
SUMATRIPTAN SPR 20MG/ACT
2
Preferred Brand
SUMATRIPTAN SPR 5MG/ACT
2
Preferred Brand
SUMATRIPTAN TAB 100MG
1
Generic
SUMATRIPTAN TAB 25MG
1
Generic
SUMATRIPTAN TAB 50MG
1
Generic
SUMAVEL DOSE INJ 6MG/0.5
2
Preferred Brand
3
Non-Preferred Brand
SUMAXIN PAD 10-4%
3
Non-Preferred Brand
SUMAXIN TS SUS 8-4%
3
Non-Preferred Brand
SUMAXIN WASH LIQ 9-4%
3
Non-Preferred Brand
SUMMERS EVE LIQ WASH
2
Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
SUMAXIN CP KIT
SUMMERS EVE POW FEMININE
SUNFLOWER OIL SEED
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Maximum of 12
units per 30 days
Maximum of 12
units per 30 days
Maximum of 12
units per 30 days
Maximum of 12
units per 30 days
Maximum of 12
units per 30 days
May be subject to
Quantity Level
Limits
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
587
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SUPAC TAB
SUPARTZ INJ 25/2.5ML
3
3
Non-Preferred Brand
Non-Preferred Brand
SUPER D3 CAP COMPLEX
-
-
3
3
3
3
2
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
-
-
-
-
2
3
3
3
3
3
3
3
3
3
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
SUPER E CRE
SUPER E HAND LOT /BODY
SUPER E OIN
SUPER TWIN CAP EPA/DHA
SUPEROXIDE POW DISMUTAS
SUPEROXIDE SOL DISMUTAS
SUPERVITE EC TAB
SUPLEVIT LIQ
SUPPOSIBASE POW F
SUPPOSIBLEND MIS
SUPPRELIN LA KIT 50MG
SUPPRESS A DRO 5-1-10
SUPR CRANBRY CAP URINARY
SUPRANE INH
SUPRAX CAP 400MG
SUPRAX CHW 100MG
SUPRAX CHW 200MG
SUPRAX SUS 100/5ML
SUPRAX SUS 200/5ML
SUPRAX SUS 500/5ML
SUPRAX TAB 400MG
SUPRENZA TAB 15MG
WDRx 2/23/15
Special Plan Edits
PA Required
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
-
-
-
-
-
-
Limited Distribution
Not a covered
benefit
-
-
588
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SUPRENZA TAB 30MG
-
-
SUPRENZA TAB 37.5MG
-
-
3
3
2
2
2
2
3
3
3
3
3
3
2
3
3
3
3
3
3
3
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
2
2
Preferred Brand
Preferred Brand
SUPREP BOWEL SOL PREP
SUPRESS DM DRO 5-50/ML
SUPRESS-PE DRO PEDIATRI
SURESTEP PRO KIT LINEARIT
SURESTEP PRO TES LOW CON
SURESTEP PRO TES NORM CON
SURE-T INFUS MIS SET 18"
SURFAXIN SUS 30MG/ML
SURG BLADES MIS SIZE 10
SURMONTIL CAP 100MG
SURMONTIL CAP 25MG
SURMONTIL CAP 50MG
SURVANTA INH
SUSPENDOL-S LIQ
SUSTIVA CAP 200MG
SUSTIVA CAP 50MG
SUSTIVA TAB 600MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 37.5MG
SUTENT CAP 50MG
SUTTAR-2 SYP
SWEEN 24 CRE
SWEEN 24 CRE 6%
WDRx 2/23/15
Special Plan Edits
Not a covered
benefit
Not a covered
benefit
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
-
-
-
-
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
589
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
-
-
Drug Name
Tier
Formulary Status
SWEEN PREP SOL W/DABBER
2
Preferred Brand
-
-
SWIM EAR LIQ 95% OTIC
SYLATRON KIT 296MCG
SYLATRON KIT 296MCG
SYLATRON KIT 444MCG
SYLATRON KIT 444MCG
SYLATRON KIT 888MCG
SYLATRON KIT 888MCG
SYLVANT SOL 100MG
SYLVANT SOL 400MG
SYMAX DUOTAB TAB
2
3
3
3
3
3
3
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
SYMBICORT AER 160-4.5
2
Preferred Brand
SYMBICORT AER 80-4.5
2
Preferred Brand
SYMBYAX CAP 12-25MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
SYMBYAX CAP 12-50MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
SYMBYAX CAP 3-25MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
SYMBYAX CAP 6-25MG
3
Non-Preferred Brand
Maximum of 30
per 30 days
SWEETA SOL
WDRx 2/23/15
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
YES, Specialty Drug
YES, Specialty Drug
Maximum of
10.2gm per 30
days
Maximum of
10.2gm per 30
days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
590
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Formulary Status
Special Plan Edits
3
Non-Preferred Brand
Maximum of 30
per 30 days
2
2
3
3
3
2
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
SYNAGEX CAP 1.25MG
-
-
SYNAGIS INJ 100MG/ML
SYNAGIS INJ 50MG
SYN-AKE LIQ
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
SYNALAR CRE 0.025%
3
Non-Preferred Brand
SYNALAR OIN 0.025%
3
Non-Preferred Brand
SYNALAR SOL 0.01%
3
Non-Preferred Brand
3
3
3
3
2
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
SYMBYAX CAP 6-50MG
SYMLINPEN 60 INJ 1000MCG
SYMLNPEN 120 INJ 1000MCG
SYMPATH NDL MIS 18GX6"
SYMPATH NDL MIS 19GX5"
SYMPATH NDL MIS 20GX5"
SYMPT-X G.I. POW RAP RLS
SYMPT-X POW
SYNALAR TS KIT 0.01%
SYNALGOS-DC CAP
SYNAREL SOL 2MG/ML
SYNERA DIS 70-70MG
SYNERCID INJ 500MG
SYNRIBO INJ 3.5MG
WDRx 2/23/15
Tier
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
Not a covered
benefit
PA Required
PA Required
-
-
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
PA Required
YES, Specialty Drug
591
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
SYNTHROID TAB 100MCG
3
Non-Preferred Brand
SYNTHROID TAB 112MCG
3
Non-Preferred Brand
SYNTHROID TAB 125MCG
3
Non-Preferred Brand
SYNTHROID TAB 137MCG
3
Non-Preferred Brand
SYNTHROID TAB 150MCG
3
Non-Preferred Brand
SYNTHROID TAB 175MCG
3
Non-Preferred Brand
SYNTHROID TAB 200MCG
3
Non-Preferred Brand
SYNTHROID TAB 25MCG
3
Non-Preferred Brand
SYNTHROID TAB 300MCG
3
Non-Preferred Brand
SYNTHROID TAB 50MCG
3
Non-Preferred Brand
SYNTHROID TAB 75MCG
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
592
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
SYNTHROID TAB 88MCG
Tier
Formulary Status
3
Non-Preferred Brand
3
3
3
2
3
2
2
2
3
2
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
TACLONEX SUS
TACROLIMUS POW
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TAGAMET HB TAB 200MG
TAGITOL V SUS 40%
TALC POW
TALWIN INJ 30MG/ML
2
2
3
3
2
3
2
2
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
TAMBOCOR TAB 100MG
3
Non-Preferred Brand
SYNVISC INJ 8MG/ML
SYNVISC ONE INJ 8MG/ML
SYPRINE CAP 250MG
SYRSPEND SF SUS
SYRSPEND SF SUS ALKA
SYSTANE BAL SOL RESTOR
SYSTANE CAP 500MG
SYSTANE GEL DRO 0.4-0.3%
SYSTANE LIQ DRO 0.4-0.3%
SYSTANE PF SOL
SYSTANE ULTR SOL
T.R.U.E. TES
TABLOID TAB 40MG
TACLONEX OIN
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
593
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TAMBOCOR TAB 150MG
3
Non-Preferred Brand
TAMBOCOR TAB 50MG
3
Non-Preferred Brand
2
2
2
2
2
1
1
1
3
3
3
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
TANDEM PLUS CAP
3
Non-Preferred Brand
TANGERINE OIL
TANNIC ACID POW
TANZEUM INJ 30MG
TANZEUM INJ 50MG
2
2
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
TAPAZOLE TAB 10MG
3
Non-Preferred Brand
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
TAMOXIFEN POW CITRATE
TAMOXIFEN TAB 10MG
TAMOXIFEN TAB 20MG
TAMSULOSIN CAP 0.4MG
TANAC GEL
TANAC LIQ
TANAC LIQ ROLL-ON
TANDEM CAP
TANDEM F CAP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
Generic Available. Brand copay + the
difference between the brand and the
generic.
594
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
TAPAZOLE TAB 5MG
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TARCEVA TAB 25MG
TARGETD ACNE CRE 2.5%
TARGRETIN CAP 75MG
TARGRETIN GEL 1%
TARKA TAB 1-240 CR
TARKA TAB 2-180 CR
TARKA TAB 2-240 CR
TARKA TAB 4-240 CR
TARON FORTE CAP
TARON-BC MIS
TARON-C DHA CAP
TARON-PREX CAP
TARSUM SHA
TARTARIC ACD GRA
TARTARIC ACD POW
TARTRAZINE POW
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TASMAR TAB 100MG
TAURINE CAP 500MG
TAURINE LIQ
TAURINE POW
TAVIST TAB 1.34MG
WDRx 2/23/15
Tier
Formulary Status
3
Non-Preferred Brand
3
3
3
1
3
3
2
2
2
2
2
2
2
2
3
3
3
3
1
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
-
-
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
595
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TAXOTERE INJ 20MG/ML
TAXOTERE INJ 80MG/4ML
TAZAROTENE POW
TAZICEF INJ 1GM
TAZICEF INJ 1GM/50ML
TAZICEF INJ 2GM
TAZORAC CRE 0.05%
TAZORAC CRE 0.1%
TAZORAC GEL 0.05%
TAZORAC GEL 0.1%
TB SYRINGE MIS 0.5/28G
TBC AER
TEA COCYL SOL GLUTAMNE
TEA LAURYL LIQ SULFATE
TEA TREE OIL
TEA TREE OIL 100%
3
3
3
1
3
1
2
2
2
2
2
1
3
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
PA after 25
PA after 25
PA after 25
PA after 25
TEARS AGAIN CAP HYDRATE
-
-
Not a covered
benefit
-
TEARS AGAIN GEL NGHT/DAY
TEARS NATURA OIN PM
TECFIDERA CAP 120MG
TECFIDERA CAP 240MG
TECFIDERA MIS STARTER
TEFLARO INJ 400MG
TEFLARO INJ 600MG
TEGADERM ADH PAD 2.75"X3"
TEGADERM ADH PAD 2-3/4"
TEGADERM ADH PAD 4"X4.5"
TEGADERM ADH PAD 5.5"X5.5
3
2
3
3
3
2
2
3
3
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
PA Required
PA Required
PA Required
Limited Distribution
Limited Distribution
Limited Distribution
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
-
596
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TEGRETOL SUS 100/5ML
3
Non-Preferred Brand
TEGRETOL TAB 200MG
3
Non-Preferred Brand
TEGRETOL-XR TAB 100MG
2
Preferred Brand
TEGRETOL-XR TAB 200MG
3
Non-Preferred Brand
TEGRETOL-XR TAB 400MG
3
Non-Preferred Brand
TEKAMLO TAB 150-10MG
2
Preferred Brand
TEKAMLO TAB 150-5MG
2
Preferred Brand
TEKAMLO TAB 300-10MG
2
Preferred Brand
TEKAMLO TAB 300-5MG
2
Preferred Brand
TEKTURNA HCT TAB 150-12.5
2
Preferred Brand
TEKTURNA HCT TAB 150-25MG
2
Preferred Brand
TEKTURNA HCT TAB 300-12.5
2
Preferred Brand
TEKTURNA HCT TAB 300-25MG
2
Preferred Brand
TEKTURNA TAB 150MG
2
Preferred Brand
TEKTURNA TAB 300MG
2
Preferred Brand
TELFA ISLAND PAD 2X3-3/4"
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
Maximum of 30
per 30 days
597
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
TELFA NON-AD PAD 6"X3"
TELFA PLUS PAD 6"X7"
Tier
Formulary Status
3
3
Non-Preferred Brand
Non-Preferred Brand
TELMIS/AMLOD TAB 40-10MG
1
Generic
TELMIS/AMLOD TAB 40-5MG
1
Generic
TELMIS/AMLOD TAB 80-10MG
1
Generic
TELMIS/AMLOD TAB 80-5MG
1
Generic
TELMISA/HCTZ TAB 40-12.5
1
Generic
TELMISA/HCTZ TAB 80-12.5
1
Generic
TELMISA/HCTZ TAB 80-25MG
1
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 60
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
598
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
TELMISARTAN TAB 20MG
1
Generic
TELMISARTAN TAB 40MG
1
Generic
TELMISARTAN TAB 80MG
1
Generic
TEMAZEPAM CAP 15MG
TEMAZEPAM CAP 22.5MG
TEMAZEPAM CAP 30MG
TEMAZEPAM CAP 7.5MG
1
1
1
1
Generic
Generic
Generic
Generic
TEMODAR CAP 100MG
3
Non-Preferred Brand
YES, Specialty Drug
TEMODAR CAP 140MG
3
Non-Preferred Brand
YES, Specialty Drug
TEMODAR CAP 180MG
3
Non-Preferred Brand
YES, Specialty Drug
TEMODAR CAP 20MG
3
Non-Preferred Brand
YES, Specialty Drug
TEMODAR CAP 250MG
3
Non-Preferred Brand
YES, Specialty Drug
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
599
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
TEMODAR CAP 5MG
3
Non-Preferred Brand
YES, Specialty Drug
TEMODAR INJ 100MG
3
Non-Preferred Brand
YES, Specialty Drug
TEMOVATE CRE 0.05%
3
Non-Preferred Brand
3
Non-Preferred Brand
TEMOVATE GEL 0.05%
3
Non-Preferred Brand
TEMOVATE OIN 0.05%
3
Non-Preferred Brand
TEMOVATE SOL 0.05%
3
Non-Preferred Brand
3
3
3
3
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
TEMOVATE E CRE 0.05%EML
TEMOZOLOMIDE CAP 100MG
TEMOZOLOMIDE CAP 140MG
TEMOZOLOMIDE CAP 180MG
TEMOZOLOMIDE CAP 20MG
TEMOZOLOMIDE CAP 250MG
TEMOZOLOMIDE CAP 5MG
TENDER 1 KIT 31"
TENDER 1 KIT INFUSION
TENEX TAB 1MG
WDRx 2/23/15
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
600
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
TENEX TAB 2MG
Tier
Formulary Status
3
Non-Preferred Brand
3
Non-Preferred Brand
TENORETIC TAB 100
3
Non-Preferred Brand
TENORETIC TAB 50
3
Non-Preferred Brand
TENORMIN TAB 100MG
3
Non-Preferred Brand
TENORMIN TAB 25MG
3
Non-Preferred Brand
TENORMIN TAB 50MG
3
Non-Preferred Brand
TERAZOL 3 CRE 0.8%
3
Non-Preferred Brand
TERAZOL 3 SUP 80MG
3
Non-Preferred Brand
TERAZOL 7 CRE 0.4%
3
Non-Preferred Brand
TERAZOSIN CAP 10MG
TERAZOSIN CAP 1MG
TERAZOSIN CAP 2MG
TERAZOSIN CAP 5MG
TERAZOSIN POW HCL
1
1
1
1
3
Generic
Generic
Generic
Generic
Non-Preferred Brand
TENIPOSIDE INJ 50MG/5ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
601
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TERBINAFINE POW HCL
TERBINAFINE TAB 250MG
TERBINEX KIT
TERBUTALINE INJ 1MG/ML
TERBUTALINE POW SULFATE
TERBUTALINE TAB 2.5MG
TERBUTALINE TAB 5MG
TERCONAZOLE CRE 0.4%
TERCONAZOLE CRE 0.8%
TERCONAZOLE SUP 80MG
TEROCIN DIS 4-4%
TEROCIN LOT
TERPIN HYDR POW MONOHYDR
TERSASEPTIC LIQ
TERSI FOAM AER 2.25%
TERUMO SYRIN MIS
2
1
3
1
2
1
1
1
1
1
3
2
2
2
3
2
Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
TESSALON PER CAP 100MG
3
Non-Preferred Brand
3
1
1
1
2
2
3
2
2
2
Non-Preferred Brand
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
TESTOPEL MIS PELLETS
TESTOST CYP INJ 100MG/ML
TESTOST CYP INJ 200MG/ML
TESTOST ENAN INJ 200MG/ML
TESTOST PROP POW
TESTOSTERONE CRY YAM
TESTOSTERONE GEL 10MG/ACT
TESTOSTERONE POW
TESTOSTERONE POW CYPIONAT
TESTOSTERONE POW ENANTHAT
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
602
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TESTOSTERONE POW MICRONIZ
PRENTIF MIS 28MM
PRENTIF MIS 31MM
TETRACAINE INJ 1%
TETRACAINE POW
TETRACAINE POW HCL
TETRACYCLINE CAP 250MG
TETRACYCLINE CAP 500MG
TETRACYCLINE POW
TETRACYCLINE POW
TETRAHYDROBI POW DIHCL
TETRAHYDROZ POW
2
2
2
2
2
2
2
2
2
2
Preferred Brand
$0 ACA Drug
$0 ACA Drug
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
TEVETEN HCT TAB 600-12.5
3
Non-Preferred Brand
TEVETEN HCT TAB 600-25MG
3
Non-Preferred Brand
TEVETEN TAB 400MG
3
Non-Preferred Brand
TEVETEN TAB 600MG
3
Non-Preferred Brand
3
3
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
TEV-TROPIN INJ 5MG
TEXACORT SOL 2.5%
TGQ 15DM/5PE SYP H/2CPM
WDRx 2/23/15
Special Plan Edits
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
Step Therapy
Required,
Maximum of 30
per 30 days
PA Required
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
-
603
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TGQ 30/ SYP 150/15
TGQ 30/PSE/3 SYP BRM/15DM
TGT THROAT LOZ DROPS
THALLOUS CL INJ TL 201
THALOMID CAP 100MG
THALOMID CAP 150MG
THALOMID CAP 200MG
THALOMID CAP 50MG
THAM INJ 30MEQ
THEANINE POW
THEO-24 CAP 100MG CR
THEO-24 CAP 200MG CR
THEO-24 CAP 300MG CR
THEO-24 CAP 400MG ER
THEOBROMINE POW
THEOCHRON TAB 100MG CR
THEOCHRON TAB 200MG CR
THEOCHRON TAB 300MG CR
THEOPHYL/D5W INJ 0.8MG/ML
THEOPHYL/D5W INJ 1.6MG/ML
THEOPHYLLINE POW ACETIC
THEOPHYLLINE POW ANHYDROU
THEOPHYLLINE SOL 80/15ML
THEOPHYLLINE TAB 400MG ER
THEOPHYLLINE TAB 450MG ER
THEOPHYLLINE TAB 600MG ER
THERA TEARS CAP NUTR
THERABENZAPR PAK -60
THERABENZAPR PAK -90-5
2
2
1
2
3
3
3
3
3
2
2
3
2
2
3
3
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
Limited Distribution
Limited Distribution
Limited Distribution
604
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
THERACODEINE PAK -300
THERACODOPHE PAK -750
THERACODOPHN PAK -325
THERACODOPHN PAK -650
THERACODOPHN PAK -LOW-90
THERACOF PLS LIQ CGH/COLD
THERACRAN CAP 650MG
THERACRAN HP CHW 50MG
THERACYS INJ
THERA-D TAB 4000UNIT
THERAFELDAMI PAK
THERAFLU CLD MIS CGH DAY
3
3
3
3
3
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Non-Preferred Brand
Non-Preferred Brand
THERAFLU CLD PAK /SORE TH
3
Non-Preferred Brand
THERAFLU FLU POW CHST CON
THERAFLU LIQ WARM RLF
THERAFLU PAK COLD/CGH
THERAFLU POW MAX-D
THERAFLU SEV PAK COLD/CGH
THERAFLU SEV POW COLD/CGH
THERAFLU SEV POW COLD/CGH
THERAFLU SEV TAB COLD DT
THERAGUAZE PAD
THERANATAL MIS COMPLETE
THERANATAL PAK OVAVITE
THERAPENTIN PAK -60
3
3
3
3
3
2
2
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
3
Non-Preferred Brand
THERAPLEX T SHA 1%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
YES, Specialty Drug
-
Penalty applied if Brand Selected
over Generic
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
-
Generic Available. Brand copay + the
difference between the brand and the
generic.
605
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
-
-
Not a covered
benefit
-
-
3
3
3
3
2
2
2
3
2
2
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
-
-
-
-
-
-
-
-
-
-
-
-
THIAMINE POW MONONITR
-
-
-
-
THICK & EASY POW
THICK-AID LIQ
THICKENUP POW CLEAR
THICK-IT #2 POW
THICK-IT POW ORIGINAL
THICK-IT POW ORIGINAL
THIK & CLEAR PAK HONEY
THIK & CLEAR POW
THIMEROSAL POW
1
2
2
2
2
2
3
3
3
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Drug Name
THERA-PLUS LIQ
THERAPROFEN PAK -60
THERAPROFEN PAK 800MG
THERAPROXEN PAK 500MG
THERAPROXEN PAK -60
THERASEAL LOT 1%
THERATEARS GEL 1%
THERATEARS SOL OP
THERATRAMADO PAK -60
THERMOTABS TAB
THIABENDAZOL POW
THIACETAZONE POW
THIAMINE CAP 50MG
THIAMINE HCL INJ 100MG/ML
THIAMINE HCL POW
WDRx 2/23/15
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Penalty applied if Brand Selected
over Generic
606
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
THIOGLYCOLAT POW CALCIUM
THIOGUANINE POW
THIOLA TAB 100MG
THIORIDAZINE POW HCL
THIORIDAZINE TAB 100MG
THIORIDAZINE TAB 10MG
THIORIDAZINE TAB 25MG
THIORIDAZINE TAB 50MG
THIOSALICYLI POW SODIUM
THIOSULFATE CRY SODIUM
THIOSULFATE POW SODIUM
THIOTEPA POW
THIOTHIXENE CAP 10MG
THIOTHIXENE CAP 1MG
THIOTHIXENE CAP 2MG
THIOTHIXENE CAP 5MG
THIOTHIXENE POW
THIOUREA POW
THREONINE POW
THROAT DROPS LOZ 2MG
THROMBAT III INJ 1000UNIT
THROMBAT III INJ 500UNIT
THROMBI-GEL PAD 10
THROMBIN KIT 5000UNIT
THROMBIN-JMI KIT 20000UNT
THROMBIN-JMI SOL 20000UNT
THROMBIN-JMI SOL 5000UNIT
THROMBI-PAD PAD 3"X3"
THROMBOGEN KIT 10000UNT
2
2
3
2
1
1
1
1
3
3
2
2
1
1
1
1
3
3
2
2
3
3
3
3
3
3
3
3
3
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
607
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
THROMBOGEN SOL 10000UNT
THROMBOGEN SOL 1000UNIT
THYME OIL
THYMINE POW
THYMOGLOBULN INJ 25MG
THYMOL CRY
THYMOL POW IODIDE
THYMUS TAB 200MG
THYROGEN INJ 1.1MG
THYROID 3X POW PORCINE
THYROID POW
THYROLAR-1 TAB 60MG
THYROLAR-1/2 TAB 30MG
THYROLAR-1/4 TAB 15MG
THYROLAR-2 TAB 120MG
THYROLAR-3 TAB 180MG
THYROSAFE TAB 65MG
THYROSHIELD SOL 65MG/ML
TIAGABINE TAB 2MG
TIAGABINE TAB 4MG
3
3
3
3
2
2
2
3
3
2
2
3
3
3
3
3
2
2
1
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
TIAZAC CAP 120MG/24
3
Non-Preferred Brand
TIAZAC CAP 180MG/24
3
Non-Preferred Brand
TIAZAC CAP 240MG/24
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
608
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TIAZAC CAP 300MG/24
3
Non-Preferred Brand
TIAZAC CAP 360MG/24
3
Non-Preferred Brand
TIAZAC CAP 420MG/24
3
Non-Preferred Brand
3
Non-Preferred Brand
TICLOPIDINE TAB 250MG
1
Generic
TIELLE PAD
TIELLE PAD 2.75X3.5
TIELLE PAD 5-7/8X7
TIELLE PAD 7"X7"
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
TIGAN CAP 300MG
3
Non-Preferred Brand
TIGAN INJ 100MG/ML
3
Non-Preferred Brand
3
3
2
3
3
3
2
3
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
TICE BCG INJ
TIGER BALM CRE 10%-11%
TIGER BALM CRE ARTHRITI
TIGER BALM CRE MUSCLE
TIGER BALM DIS PAIN REL
TIGER BALM LIQ LINIMENT
TIGER BALM OIN 11%-11%
TIGER BALM PAD LARGE
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Maximum of 60
per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
609
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TIKOSYN CAP 500MCG
TILIA FE TAB
TIMENTIN INJ 3.1GM
TIMENTIN INJ 3.1GM
TIMENTIN INJ 31GM
TIMOLOL GEL SOL 0.25% OP
TIMOLOL GEL SOL 0.5% OP
TIMOLOL MAL SOL 0.25% OP
TIMOLOL MAL SOL 0.5% OP
TIMOLOL MAL TAB 10MG
TIMOLOL MAL TAB 20MG
TIMOLOL MAL TAB 5MG
TIMOLOL POW MALEATE
TIMONACIC POW
TIMOPTIC OCU SOL 0.25% OP
TIMOPTIC OCU SOL 0.5% OP
3
2
2
2
1
1
1
1
2
2
2
2
3
3
3
Non-Preferred Brand
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
TIMOPTIC SOL 0.25% OP
3
Non-Preferred Brand
TIMOPTIC SOL 0.5% OP
3
Non-Preferred Brand
TIMOPTIC-XE SOL 0.25% OP
3
Non-Preferred Brand
TIMOPTIC-XE SOL 0.5% OP
3
Non-Preferred Brand
TINACTIN AER 1%
TINACTIN AER DEODORAN
2
3
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
610
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TINACTIN CRE 1%
3
Non-Preferred Brand
TINACTIN POW 1%
2
Preferred Brand
TINACTIN POW AER 1%
3
Non-Preferred Brand
TINDAMAX TAB 250MG
3
Non-Preferred Brand
TINDAMAX TAB 500MG
3
Non-Preferred Brand
TINEACIDE CRE
TINIDAZOLE POW
TINIDAZOLE TAB 250MG
TINIDAZOLE TAB 500MG
TINOGARD TL LIQ
TIROSINT CAP 100MCG
TIROSINT CAP 112MCG
TIROSINT CAP 125MCG
TIROSINT CAP 137MCG
TIROSINT CAP 13MCG
TIROSINT CAP 150MCG
TIROSINT CAP 25MCG
TIROSINT CAP 50MCG
TIROSINT CAP 75MCG
TIROSINT CAP 88MCG
TITAN DIOXID PST
TITANIUM DIO LIQ 30%
3
2
1
1
3
3
3
3
3
3
3
3
3
3
3
3
2
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
611
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
TITANIUM POW DIOXIDE
TITRALAC CHW PLUS
TIVICAY TAB 50MG
TITZANIDINE CAP 2MG
Tier
Formulary Status
2
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
YES, Specialty Drug
Maximum of 120
per 30 days
May be subject to
Quantity Level
Limits
Maximum of 120
per 30 days
1
Generic
TIZANIDINE CAP 4MG
1
Generic
TIZANIDINE CAP 6MG
1
Generic
3
2
1
1
Non-Preferred Brand
Preferred Brand
Generic
Generic
-
-
1
1
Generic
$0 Preventative Drug
Generic
TL-FLUORIVIT CHW
-
-
TL-FOL 500 TAB
TL-HIST PD LIQ 1-7.5MG
TNKASE KIT 50MG
1
1
3
Generic
Generic
Non-Preferred Brand
3
Non-Preferred Brand
Limited Distribution
3
1
2
2
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Limited Distribution
TIZANIDINE KIT COMFORT
TIZANIDINE POW HCL
TIZANIDINE TAB 2MG
TIZANIDINE TAB 4MG
TL G-FOL OS TAB
TL UREA LOT 45%
TL-CARE DHA CAP 27-1-500
TL-DMX SYP 5-200MG
TOBI NEB 300/5ML
TOBI PODHALR CAP 28MG
TOBRA/DEXAME SUS 0.3-0.1%
TOBRA/NACL INJ 80/0.9
TOBRADEX OIN 0.3-0.1%
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
612
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TOBRADEX ST SUS 0.3-0.05
2
Preferred Brand
TOBRADEX SUS 0.3-0.1%
3
Non-Preferred Brand
TOBRAMYCIN INJ 1.2/30ML
TOBRAMYCIN INJ 1.2GM
TOBRAMYCIN INJ 10MG/ML
TOBRAMYCIN INJ 40MG/ML
TOBRAMYCIN INJ 40MG/ML
TOBRAMYCIN NEB 300/5ML
TOBRAMYCIN POW
TOBRAMYCIN POW SULFATE
TOBRAMYCIN SOL 0.3% OP
TOBREX OIN 0.3% OP
1
1
1
1
1
3
2
2
1
3
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
3
Non-Preferred Brand
2
2
3
-
Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 ACA Drug
TOFRANIL TAB 10MG
3
Non-Preferred Brand
TOFRANIL TAB 25MG
3
Non-Preferred Brand
TOFRANIL TAB 50MG
3
Non-Preferred Brand
TOBREX SOL 0.3% OP
TOCOPHEROL LIQ ALPHA
TOCOPHERYL POW PEG 1000
TOCOTRIENOL SUS 50%
PRENTIF MIS FITTING
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
613
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TOFRANIL-PM CAP 100MG
3
Non-Preferred Brand
TOFRANIL-PM CAP 125MG
3
Non-Preferred Brand
TOFRANIL-PM CAP 150MG
3
Non-Preferred Brand
TOFRANIL-PM CAP 75MG
3
Non-Preferred Brand
TOLAZAMIDE TAB 250MG
TOLAZAMIDE TAB 500MG
TOLAZOLINE POW HCL
TOLBUTAMIDE TAB 500MG
TOLMETIN SOD CAP 400MG
TOLMETIN SOD TAB 200MG
TOLMETIN SOD TAB 600MG
TOLNAFTATE POW
1
2
2
2
1
2
2
2
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Generic
Preferred Brand
Preferred Brand
Preferred Brand
TOLTERODINE CAP 2MG ER
1
Generic
TOLTERODINE CAP 4MG ER
1
Generic
TOLTERODINE TAB 1MG
TOLTERODINE TAB 2MG
TOLTRAZURIL POW
TOLU BALSAM MIS MASS
TOLU BALSAM TIN
1
1
3
3
3
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
614
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TOLUENE LIQ
TOLUIDINE POW BLUE O
TOOMEY SYRIN MIS 70ML
TOOTHACHE GUM
TOOTHETTE MIS UNTREATE
3
2
2
3
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
TOPAMAX SPR CAP 15MG
3
Non-Preferred Brand
TOPAMAX SPR CAP 25MG
3
Non-Preferred Brand
TOPAMAX TAB 100MG
3
Non-Preferred Brand
TOPAMAX TAB 200MG
3
Non-Preferred Brand
TOPAMAX TAB 25MG
3
Non-Preferred Brand
TOPAMAX TAB 50MG
3
Non-Preferred Brand
TOPICAINE 5 GEL 5%
TOPICAINE GEL 4%
3
2
Non-Preferred Brand
Preferred Brand
TOPICORT CRE 0.25%
3
Non-Preferred Brand
TOPICORT GEL 0.05%
3
Non-Preferred Brand
TOPICORT OIN 0.05%
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
615
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
TOPICORT OIN 0.25%
Tier
Formulary Status
3
Non-Preferred Brand
TOPICORT SPR 0.25%
TOPIRAGEN TAB 100MG
TOPIRAGEN TAB 200MG
TOPIRAGEN TAB 25MG
TOPIRAGEN TAB 50MG
TOPIRAMATE CAP 15MG
TOPIRAMATE CAP 25MG
TOPIRAMATE POW
TOPOTECAN INJ 4MG
TOPOTECAN INJ 4MG/4ML
3
1
1
1
1
1
1
2
3
3
Non-Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
TOPROL XL TAB 100MG
3
Non-Preferred Brand
TOPROL XL TAB 200MG
3
Non-Preferred Brand
TOPROL XL TAB 25MG
3
Non-Preferred Brand
TOPROL XL TAB 50MG
3
Non-Preferred Brand
3
2
3
1
1
1
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
TORISEL SOL 25MG/ML
TORSEMIDE INJ 20MG/2ML
TORSEMIDE INJ 50MG/5ML
TORSEMIDE TAB 100MG
TORSEMIDE TAB 10MG
TORSEMIDE TAB 20MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
616
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
1
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
TOVIAZ TAB 4MG
2
Preferred Brand
TOVIAZ TAB 8MG
2
Preferred Brand
3
2
3
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
2
Preferred Brand
TRAIMINIC SOL CONGEST
TRAMADL/APAP TAB 37.5-325
TRAMADOL CRE 5%
TRAMADOL CRE 8% KIT
TRAMADOL HCL CAP 150MG ER
TRAMADOL HCL POW
TRAMADOL HCL TAB 100MG ER
3
1
3
3
3
2
1
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
TRAMADOL HCL TAB 100MG ER
1
Generic
TRAMADOL HCL TAB 200MG ER
1
Generic
TRAMADOL HCL TAB 200MG ER
1
Generic
TORSEMIDE TAB 5MG
TOTAL BODY AER 0.13%
TOTECT INJ 500MG
TOXIN CONTRL TAB
TRACE ELEM 4 INJ PED
TRACHEOSTOMY KIT TRAY
TRACLEER TAB 125MG
TRACLEER TAB 62.5MG
TRADJENTA TAB 5MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
PA Required
PA Required
May be subject to
Quantity Level
Limits
Limited Distribution
Limited Distribution
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
617
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TRAMADOL HCL TAB 300MG ER
1
Generic
TRAMADOL HCL TAB 300MG ER
1
Generic
1
Generic
TRANDATE TAB 100MG
3
Non-Preferred Brand
TRANDATE TAB 200MG
3
Non-Preferred Brand
TRANDATE TAB 300MG
3
Non-Preferred Brand
TRANDOLAPRIL TAB 1MG
TRANDOLAPRIL TAB 2MG
TRANDOLAPRIL TAB 4MG
TRANEX ACID INJ 100MG/ML
1
1
1
1
Generic
Generic
Generic
Generic
TRANEX ACID TAB 650MG
1
Generic
2
2
1
2
Preferred Brand
Preferred Brand
Generic
Preferred Brand
TRANXENE T TAB 15MG
3
Non-Preferred Brand
TRANXENE T TAB 3.75MG
3
Non-Preferred Brand
TRAMADOL HCL TAB 50MG
TRANEXAMIC POW ACID
TRANILAST POW
TRANQUILITY KIT ASSORTED
TRANSDERM-SC DIS 1.5MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
May be subject to
Quantity Level
Limits
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
618
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TRANXENE T TAB 7.5MG
3
Non-Preferred Brand
TRANYLCYPROM TAB 10MG
TRAUMEEL OIN
TRAUMEEL X PAK
TRAVATAN Z DRO 0.004%
TRAVOPROST DRO 0.004%
TRAZAMINE PAK 50MG
TRAZODONE POW
TRAZODONE TAB 100MG
TRAZODONE TAB 150MG
TRAZODONE TAB 300MG
TRAZODONE TAB 50MG
TREAGAN OTIC DRO
TREANDA INJ 100MG
TREANDA INJ 25MG
TRECATOR TAB 250MG
TREHALOSE POW DIHYDRAT
TRELSTAR DEP INJ 3.75MG
TRELSTAR LA INJ 11.25MG
TRELSTAR MIX INJ 22.5MG
1
2
3
2
2
3
2
3
3
3
3
3
3
3
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
TRENTAL TAB 400MG CR
3
Non-Preferred Brand
TREPADICLOFE PAK 25MG
TREPOXICAM PAK 7.5MG
TRETINOIN CAP 10MG
TRETINOIN CRE 0.05%
TRETINOIN CRE 0.1%
3
3
1
1
1
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA after 25
PA after 25
619
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TRETINOIN EM CRE 0.05%
-
-
TRETINOIN GEL 0.01%
TRETINOIN GEL 0.04%
TRETINOIN GEL 0.1%
TRETIN-X CRE 0.0375%
TRETIN-X CRE 0.075%
TRETIN-X CRE KIT 0.025%
TRETIN-X CRE KIT 0.05%
TRETIN-X CRE KIT 0.1%
TRETIN-X GEL KIT 0.01%
TRETIN-X GEL KIT 0.025%
TRETTEN INJ
TREXALL TAB 10MG
TREXALL TAB 15MG
TREXALL TAB 5MG
TREXALL TAB 7.5MG
TREXBROM LIQ 10-4-25
1
1
1
3
3
3
3
3
3
3
3
2
2
2
2
2
Generic
Generic
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
TREXIMET TAB 85-500MG
2
Preferred Brand
2
2
3
2
1
1
1
1
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Generic
Generic
TREZIX CAP
TRIACETIN LIQ
TRIACTIN SOL CHST CON
TRIAD WOUND PST DRESSING
TRIAMCINOLON CRE 0.025%
TRIAMCINOLON CRE 0.1%
TRIAMCINOLON CRE 0.5%
TRIAMCINOLON LOT 0.025%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
PA after 25
YES, Specialty Drug
May be subject to
Quantity Level
Limits
620
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TRIAMCINOLON LOT 0.1%
TRIAMCINOLON OIN 0.025%
TRIAMCINOLON OIN 0.1%
TRIAMCINOLON OIN 0.5%
TRIAMCINOLON POW
TRIAMCINOLON POW ACETONID
TRIAMCINOLON POW DIACETAT
TRIAMCINOLON POW HEXACETO
TRIAMCINOLON SPR 55MCG/AC
TRIAMIN FLU/ SYP CGH/FVR
TRIAMINIC LIQ
TRIAMINIC LIQ CHST/NAS
1
1
1
2
2
2
2
3
1
3
3
2
Generic
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
3
2
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
TRIAMINIC NT LIQ COLD/CGH
3
Non-Preferred Brand
TRIAMINIC NT MIS COLD/CGH
TRIAMINIC SOL
TRIAMINIC SOL COLD/CGH
TRIAMINIC SYP CGH/SORE
TRIAMINIC SYP CHILD
TRIAMINIC SYP CHST/NSL
TRIAMINIC SYP COLD/ALL
TRIAMINIC SYP COLD/CGH
3
3
2
2
2
2
2
3
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
TRIAMINIC LIQ COUGH
TRIAMINIC MIS CGH/COLD
TRIAMINIC MIS COLD/CGH
TRIAMINIC MIS COUGH
TRIAMINIC MIS GRAPE
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
621
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
2
2
1
1
Preferred Brand
$0 Preventative Drug
$0 ACA Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Generic
Generic
TRIBENZOR20- TAB 5-12.5MG
2
Preferred Brand
TRIBENZOR40- TAB 10-12.5
2
Preferred Brand
TRIBENZOR40- TAB 10-25MG
2
Preferred Brand
TRIBENZOR40- TAB 5-12.5MG
2
Preferred Brand
TRIBENZOR40- TAB 5-25MG
2
Preferred Brand
TRICARE PRE CAP 27-1-500
TRI-CHLOR LIQ 80%
TRICHLORETHY LIQ
TRICHLORMETH POW
TRICHLOROACE CRY ACID
TRICHLOROACE POW ACID
TRICHLOROFON POW
TRICHOPHYTON INJ 1:200
2
3
2
2
2
3
3
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
TRIAMINIC-D SYP
TRIAMT/HCTZ CAP 37.5-25
PROQUAD INJ
TRIAMT/HCTZ TAB 37.5-25
TRIAMTERENE POW
TRIANEX OIN 0.05%
TRIAZOLAM TAB 0.125MG
TRIAZOLAM TAB 0.25MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
622
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
2
1
2
3
3
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
TRICOR TAB 145MG
3
Non-Preferred Brand
TRICOR TAB 48MG
3
Non-Preferred Brand
3
3
1
1
1
1
3
2
1
3
1
1
1
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
Generic
$0 Preventative Drug
Non-Preferred Brand
Generic
Generic
Generic
3
Non-Preferred Brand
TRICHOPHYTON INJ 1:500
TRICITRASOL CON
TRICITRATES SOL
TRICLOSAN POW
TRICODE AR LIQ
TRICODE GF LIQ
TRIESENCE INJ 40MG/ML
TRIETHANOLAM LIQ SALICYLT
TRIFLUOPERAZ TAB 10MG
TRIFLUOPERAZ TAB 1MG
TRIFLUOPERAZ TAB 2MG
TRIFLUOPERAZ TAB 5MG
TRIFLUOROACE LIQ ACID
TRIFLURIDINE POW
TRIFLURIDINE SOL 1% OP
TRIGLIDE TAB 50MG
TRIGOSAMINE TAB MAX STR
TRIHEXYPHEN ELX 0.4MG/ML
TRIHEXYPHEN TAB 2MG
TRIHEXYPHEN TAB 5MG
TRILEPTAL SUS 300MG/5M
WDRx 2/23/15
Special Plan Edits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
623
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TRILEPTAL TAB 150MG
3
Non-Preferred Brand
TRILEPTAL TAB 300MG
3
Non-Preferred Brand
TRILEPTAL TAB 600MG
3
Non-Preferred Brand
TRILIPIX CAP 135MG
3
Non-Preferred Brand
TRILIPIX CAP 45MG
3
Non-Preferred Brand
TRILOSTANE POW
2
Preferred Brand
TRI-LUMA CRE
-
-
2
3
1
1
2
2
1
3
1
1
1
3
2
Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Preferred Brand
Generic
Non-Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Preferred Brand
TRIMEPRAZINE POW TARTRATE
TRIMETHLGLYC CAP 500MG
TRIMETHOBENZ CAP 300MG
TRIMETHOBENZ INJ 100MG/ML
TRIMETHOBENZ POW HCL
TRIMETHOPRIM POW
TRIMETHOPRIM TAB 100MG
TRIMETHYLAMI POW HCL
TRIMIPRAMINE CAP 100MG
TRIMIPRAMINE CAP 25MG
TRIMIPRAMINE CAP 50MG
TRIMIPRAMINE POW MALEATE
TRIMO-SAN GEL
WDRx 2/23/15
Special Plan Edits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
624
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TRINATAL RX TAB 1
TRINATE TAB
-
$0 Preventative Drug
$0 Preventative Drug
TRI-NORINYL TAB 28
-
$0 Preventative Drug
3
Non-Preferred Brand
TRIOXSALEN POW
QVAR AER 40MCG
TRIPELENNAMI POW
TRIPLE DYE LIQ
TRIPLE FLEX TAB
TRIPLE FLEX TAB 50+
TRIPLE OMEGA CAP COMPLEX
TRIPLE PASTE OIN 12.8%
TRIPROLIDINE CRY
TRIS AMINO POW METHANE
TRIS HCL POW
TRISENOX SOL 10MG/10M
TRISPEC DMX LIQ 10-187/5
TRISPEC PSE DRO PEDIATRC
TRISPEC PSE LIQ
TRITON X-100 LIQ
TRITON X-45 LIQ
TRIUMEQ TAB
TRIVEEN-TEN TAB
2
2
3
3
3
3
2
2
3
3
3
3
3
2
2
3
3
-
Preferred Brand
$0 Preventative Drug
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
TRI-VI-FLOR SUS 0.25/ML
-
-
TRIOSTAT INJ 10MCG/ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
YES, Specialty Drug
Not a covered
benefit
625
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TRI-VI-FLOR SUS 0.5MG/ML
-
-
-
-
TRI-VIT/FE DRO /FL 0.25
-
-
TRI-VIT/FL DRO 0.5MG
-
-
TRIXAICIN CRE 0.025%
2
Preferred Brand
3
Non-Preferred Brand
3
3
2
2
3
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
$0 ACA Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
-
-
2
2
2
2
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
TRI-VI-SOL SOL
TRIZIVIR TAB
TROCAL COUGH LOZ 7.5MG
TROCHE BASE POW
TROCHIBASE MIS
TROCHIBASE S MIS
ROTARIX SUS
TROKENDI XR CAP 100MG
TROKENDI XR CAP 200MG
TROKENDI XR CAP 25MG
TROKENDI XR CAP 50MG
TROLAMINE LIQ
TROMBONEX CAP
TROMETHAMINE POW
TRONOLANE CRE 1-5%
TROPHAMINE INJ 6%
TROPICAMIDE POW
TROPOLONE POW
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
626
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
May be subject to
Quantity Level
Limits
TROSPIUM CHL CAP 60MG ER
1
Generic
TROSPIUM CL TAB 20MG
TRUEPLUS CHW GLUCOSE
TRUEPLUS GEL GLUCOSE
TRU-MICIN LOT 10%
1
3
3
1
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
3
Non-Preferred Brand
TRUTICAL CAP COMPLEX
TRUVADA TAB
TRYMINE CG LIQ 225-7.5
TRYPAN BLUE POW
TRYPSIN POW
TUCKS FAST SPR REL 1%
TUCKS OIN
TUCKS OIN 1%
TUCKS SUP 51%
TUDORZA PRES AER 400/ACT
TUMS CHW 500MG
TUMS E-X CHW 750MG
3
3
1
2
2
3
2
3
2
2
2
2
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
TUMS LASTING CHW 500MG
3
Non-Preferred Brand
TUMS ULTRA CHW 1000MG
TUNGSTEN POW CHLORIDE
TURPENTINE LIQ
TURPENTINE LIQ SPIRITS
TURPENTINE OIL
2
3
3
2
2
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
TRUSOPT SOL 2% OP
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
627
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TURPENTINE SOL SPIRITS
TUSNEL C SYP
TUSNEL CAP
TUSNEL LIQ
TUSNEL PED DRO 7.5-50
TUSNEL-DM DRO PEDIATRC
TUSSAFEX-A LIQ 6-2-15/5
TUSSICAPS CAP 10-8MG
TUSSICAPS CAP 5-4MG
2
1
2
3
2
3
3
2
2
Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
TUSSIONEX SUS EXT-REL
3
Non-Preferred Brand
TUSSI-PRES LIQ PE PED
TUSSI-PRES LIQ PEDIATRC
TUSSLIN LIQ
SHUR-SEAL GEL 2%
TWO-STEP KIT 0.13-10%
1
2
1
3
Generic
Preferred Brand
Generic
$0 ACA Drug
Non-Preferred Brand
TWYNSTA TAB 40-10MG
3
Non-Preferred Brand
TWYNSTA TAB 40-5MG
3
Non-Preferred Brand
TWYNSTA TAB 80-10MG
3
Non-Preferred Brand
TWYNSTA TAB 80-5MG
3
Non-Preferred Brand
TYGACIL INJ 50MG
TYKERB TAB 250MG
2
3
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
628
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
TYLENOL 8 HR TAB 650MG
Tier
Formulary Status
3
Non-Preferred Brand
TYLENOL ALLE PAK MULTI-SY
3
Non-Preferred Brand
TYLENOL ALLE TAB MULTI-SY
3
Non-Preferred Brand
TYLENOL CGH PAK SORE THR
TYLENOL CHES LIQ CONGEST
3
3
Non-Preferred Brand
Non-Preferred Brand
TYLENOL CHES TAB CONGEST
3
Non-Preferred Brand
TYLENOL CHLD SUS 160/5ML
3
Non-Preferred Brand
TYLENOL CHLD SUS CLD/CGH
3
Non-Preferred Brand
TYLENOL CHLD SUS PLUS C/A
3
Non-Preferred Brand
TYLENOL CHLD SUS PLUS CLD
2
Preferred Brand
TYLENOL CHLD SUS PLUS FLU
3
Non-Preferred Brand
TYLENOL CHLD SUS STUFFY
3
Non-Preferred Brand
TYLENOL CHLD SYP COLD/CGH
3
Non-Preferred Brand
TYLENOL COLD LIQ MULTI-S
3
Non-Preferred Brand
TYLENOL COLD LIQ RELIEF
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
629
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
TYLENOL COLD TAB
Tier
Formulary Status
3
Non-Preferred Brand
TYLENOL COLD TAB HEAD CON
3
Non-Preferred Brand
TYLENOL COLD TAB MULTI-S
TYLENOL COLD TAB SEV CONG
2
2
Preferred Brand
Preferred Brand
TYLENOL DAY PAK & NIGHT
3
Non-Preferred Brand
TYLENOL GO CHW EXTRA ST
3
Non-Preferred Brand
TYLENOL INF DRO 80/0.8ML
3
Non-Preferred Brand
TYLENOL JR TAB 160MG
3
Non-Preferred Brand
TYLENOL LIQ 1000/30
2
Preferred Brand
TYLENOL LIQ 167MG/5
3
Non-Preferred Brand
TYLENOL PM LIQ EX ST
3
Non-Preferred Brand
TYLENOL PM TAB 25-500MG
3
Non-Preferred Brand
TYLENOL SINU MIS DAY/NITE
3
Non-Preferred Brand
TYLENOL SINU PAK CNG/PAIN
3
Non-Preferred Brand
TYLENOL SINU TAB CNG/PAIN
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
630
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
TYLENOL TAB 325MG
3
Non-Preferred Brand
TYLENOL TAB 500MG
3
Non-Preferred Brand
TYLENOL/COD TAB #3
3
Non-Preferred Brand
TYLENOL/COD TAB #4
3
Non-Preferred Brand
3
3
2
3
2
3
3
3
3
3
1
2
2
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
-
-
-
-
TYLOSIN POW TARTRATE
TYLOXAPOL LIQ
TYPHIM VI INJ
TYRAMINE HCL POW
TYROSINE PAK 1000MG
TYSABRI INJ 300/15ML
TYVASO REFIL SOL 0.6MG/ML
TYZEKA TAB 600MG
TYZINE PED DRO 0.05%
TYZINE SOL 0.1%
UBIQUINOL CAP 100MG
UBIQUINOL POW
UBIQUINOL POW 30%
UBQH CAP 50MG
UCERIS TAB 9MG
UDAMIN SP TAB
UDAMIN TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
Limited Distribution
Limited Distribution
YES, Specialty Drug
Not a covered
benefit
Not a covered
benefit
631
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
3
2
2
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
2
2
2
$0 Preventative Drug
$0 Preventative Drug
Preferred Brand
Preferred Brand
Preferred Brand
-
-
ULTRA MIDE LOT 25%
ULTRA OMEGA CAP 952MG
2
3
Preferred Brand
Non-Preferred Brand
ULTRACET TAB 37.5-325
3
Non-Preferred Brand
ULTRACIN LOT
ULTRAFOAM MIS 2X6.25X7
ULTRAFOAM MIS 8X12.5X1
ULTRAFOAM MIS 8X12.5X3
ULTRAFOAM MIS 8X25X1
ULTRAFOAM MIS 8X6.25X1
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
ULTRAM ER TAB 100MG
3
Non-Preferred Brand
ULTRAM ER TAB 200MG
3
Non-Preferred Brand
ULCEREASE SOL
ULESFIA LOT 5%
ULORIC TAB 40MG
ULORIC TAB 80MG
ULTANE SOL
ULTIMATE OB MIS DHA
ULTIMATECARE CAP ONE NF
ULTIVA INJ 1MG
ULTIVA INJ 2MG
ULTIVA INJ 5MG
ULTRA MAN TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
632
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
ULTRAM ER TAB 300MG
Tier
Formulary Status
3
Non-Preferred Brand
3
Non-Preferred Brand
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
ULTRAVATE KIT PAC
3
Non-Preferred Brand
ULTRAVATE OIN 0.05%
3
Non-Preferred Brand
ULTRAVIST INJ 150MG/ML
ULTRAVIST INJ 240MG/ML
ULTRAVIST INJ 300MG/ML
ULTRAVIST INJ 370MG/ML
ULTRESA CAP 13800UNT
ULTRESA CAP 20700UNT
ULTRESA CAP 23000UNT
UMECTA EMU
UMECTA MOUSS AER 40%
3
3
3
3
3
3
3
3
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
UMECTA NAIL SUS FILM
3
Non-Preferred Brand
ULTRAM TAB 50MG
ULTRASAL-ER SOL 28.5%
ULTRASONE CRE
ULTRATHON LOT REPELLNT
ULTRAVATE CRE 0.05%
ULTRAVATE KIT
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
633
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
3
3
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
UNASYN INJ 15GM
3
Non-Preferred Brand
UNASYN INJ 3GM
3
Non-Preferred Brand
2
3
3
2
2
-
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
$0 Preventative Drug
UMECTA PD EMU 40-0.3%
UMECTA PD SUS 40-0.3%
UNASYN INJ 1.5GM
UNASYN INJ 1.5GM PB
UNDECYLENIC LIQ ACID
UNDELENIC TIN
UNGUENTINE OIN
UNIBASE CRE
UNIFIBER POW
UNIFINE PNTP MIS 31GX6MM
UNIRETIC TAB 15-12.5
3
Non-Preferred Brand
UNIRETIC TAB 15-25MG
3
Non-Preferred Brand
UNIRETIC TAB 7.5-12.5
3
Non-Preferred Brand
UNISOM SLEEP CAP 50MG
2
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
634
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
UNISOM SLEEP TAB 25MG
Tier
Formulary Status
3
Non-Preferred Brand
UNISOM TAB 25MG
3
Non-Preferred Brand
UNISOM TAB PM PAIN
3
Non-Preferred Brand
UNIVASC TAB 15MG
3
Non-Preferred Brand
UNIVASC TAB 7.5MG
3
Non-Preferred Brand
UNIVERSAL GEL WATER
UNIVERSAL PH TES
UNIVERT TAB 32MG
URAMAXIN AER 20%
3
3
1
3
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
URAMAXIN CRE 45%
3
Non-Preferred Brand
URAMAXIN GEL 45%
3
Non-Preferred Brand
URAMAXIN GT KIT 45%
3
Non-Preferred Brand
URAMAXIN LOT 45%
3
Non-Preferred Brand
UREA 40% SUS NAIL
UREA BEA
UREA CRE 39%
UREA CRE 45%
UREA EMU 50%
1
2
1
1
1
Generic
Preferred Brand
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
635
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
UREA HYDRATI AER 35%
UREA NAIL GEL 45%
UREA NAIL KIT
UREA NAIL MIS 50%
UREA POW
1
1
2
2
2
Generic
Generic
Preferred Brand
Preferred Brand
Preferred Brand
URECHOLINE TAB 10MG
3
Non-Preferred Brand
URECHOLINE TAB 25MG
3
Non-Preferred Brand
URECHOLINE TAB 50MG
3
Non-Preferred Brand
URECHOLINE TAB 5MG
3
Non-Preferred Brand
1
2
3
1
3
2
3
2
3
3
2
Generic
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
URELLE TAB
URETRON D/S TAB
URGENTQR POW
URIBEL CAP 118MG
URIC ACID POW
URIDINE POW
URINARY TRAC CAP HEALTH
URINARY TRAC TES INFECTIO
URIN-TEK KIT
URIPLEX TAB 500MG
URO MAG CAP 140MG
UROCIT-K 10 TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
636
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
UROCIT-K 15 TAB
3
Non-Preferred Brand
UROCIT-K 5 TAB
3
Non-Preferred Brand
UROGESIC- TAB BLUE
URO-MAG CAP 140MG
UROQID #2 TAB
2
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
UROXATRAL TAB 10MG
3
Non-Preferred Brand
URSO 250 TAB 250MG
3
Non-Preferred Brand
URSO FORTE TAB 500MG
3
Non-Preferred Brand
URSODIOL CAP 300MG
URSODIOL POW
URSODIOL TAB 250MG
URSODIOL TAB 500MG
URYL TAB
USNIC ACID POW
USTELL CAP
UTI HOME TES TEST
UTI RELIEF TAB 97.2MG
UTI-STAT LIQ
UTOPIC CRE 41%
UVA URSI EXT LEAF
UVA URSI POW LEAF
1
2
1
1
1
3
1
3
1
2
3
2
3
Generic
Preferred Brand
Generic
Generic
Generic
Non-Preferred Brand
Generic
Non-Preferred Brand
Generic
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
637
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
UVADEX INJ 20MCG/ML
VAGICAINE CRE 20-3%
VAGICREAM CRE 5-0.13%
VAGIFEM TAB 10MCG
VAGISIL CRE
VAGISIL FEM LOT MOISTURI
VAGISIL MS CRE 20-3%
VAGISIL MS MIS 1%
VAGISIL YEAS SUP CONTROL
VAGISTAT-1 OIN 6.5% VAG
VAGNL INFECT KIT SCREEN
VALACYCLOVIR POW HCL
VALACYCLOVIR TAB 1GM
VALACYCLOVIR TAB 500MG
VALCHLOR GEL 0.016%
VALCYTE SOL 50MG/ML
VALCYTE TAB 450MG
VALERIAN CAP 250MG
VALERIAN CAP 500MG
VALERIAN CAP COMPLEX
VALERIAN CAP PLUS
VALERIAN EXT ROOT
VALERIAN POW ROOT
VALERIAN RT CAP 100MG
VALERIAN RT CAP 166.67MG
VALERIAN RT CAP 530MG
WDRx 2/23/15
Tier
Formulary Status
3
1
2
2
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
3
Non-Preferred Brand
3
2
Non-Preferred Brand
Preferred Brand
3
Non-Preferred Brand
3
2
3
2
1
1
3
2
2
3
1
3
3
3
2
3
3
1
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Generic
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
638
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VALERIAN TIN ROOT
VALINE 1000 POW
VALINE PAK 50MG
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
VALIUM TAB 10MG
3
Non-Preferred Brand
VALIUM TAB 2MG
3
Non-Preferred Brand
VALIUM TAB 5MG
3
Non-Preferred Brand
1
1
1
2
1
1
1
1
1
1
1
1
1
3
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Non-Preferred Brand
3
Non-Preferred Brand
VALPROATE INJ 100MG/ML
VALPROIC ACD CAP 250MG
VALPROIC ACD SOL 250/5ML
VALPROIC ACI LIQ
VALSART/HCTZ TAB 160-12.5
VALSART/HCTZ TAB 160-25MG
VALSART/HCTZ TAB 320-12.5
VALSART/HCTZ TAB 320-25MG
VALSART/HCTZ TAB 80-12.5
VALSARTAN TAB 160MG
VALSARTAN TAB 320MG
VALSARTAN TAB 40MG
VALSARTAN TAB 80MG
VALSTAR SOL 40MG/ML
VALTREX TAB 1GM
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
639
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
VALTREX TAB 500MG
Tier
Formulary Status
3
Non-Preferred Brand
VANACHOL CAP
VANACOF APE LIQ
VANACOF CD LIQ
VANACOF DM LIQ
VANACOF DX LIQ
VANACOF G LIQ
VANACOF GPE LIQ
VANACOF LIQ
VANACOF-8 LIQ 25-50/15
VANADIUM CAP 7.5MG
VANADIUM POW
VANADYL CRY SULFATE
VANAHIST PD LIQ 0.625MG
VANATAB DX TAB
3
3
3
3
2
2
3
2
3
3
2
2
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
VANCOCIN HCL CAP 125MG
3
Non-Preferred Brand
VANCOCIN HCL CAP 250MG
3
Non-Preferred Brand
VANCOMYC/DEX INJ 1GM
VANCOMYC/DEX INJ 500MG
VANCOMYC/DEX INJ 750MG
VANCOMYCIN CAP 125MG
VANCOMYCIN CAP 250MG
VANCOMYCIN INJ 1 GM
VANCOMYCIN INJ 10GM
2
2
3
1
1
1
1
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
640
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VANCOMYCIN INJ 500MG
VANCOMYCIN INJ 5GM
VANCOMYCIN INJ 750MG
VANCOMYCIN POW
VANCOMYCN 25 SOL 25MG/ML
VANCOMYCN 50 SOL 50MG/ML
VANILLIN LIQ
VANIPLY OIN 1%
VANIQA CRE 13.9%
1
1
2
2
3
3
3
2
3
Generic
Generic
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
VANOXIDE-HC LOT 5-0.5%
VANQUISH TAB
VANTAS KIT 50MG
VAPODROPS LOZ 1.7MG
VAPODROPS LOZ 3.3MG
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
VAPOINHALER INH VICKS
3
Non-Preferred Brand
VAPOR PATCH DIS
VAPRISOL INJ
TET/DIP TOX INJ 2-2 LF
TODAY SPONGE MIS
VARIBAR PST PUDDING
VARIBAR THIN SUS LIQUID
VARITHENA AER 10MG/ML
TROJAN MIS NATULAMB
VARIZIG INJ 125UNIT
3
3
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 ACA Drug
Preferred Brand
VANOS CRE 0.1%
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
641
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VASCAZEN CAP 1GM
-
-
VASCEPA CAP 1GM
2
Preferred Brand
VASERETIC TAB 10-25MG
3
Non-Preferred Brand
VASOCLEAR A SOL OP
VASOCLEAR SOL 0.02% OP
3
3
Non-Preferred Brand
Non-Preferred Brand
VASOFLEX D1 TAB 900-100
-
-
VASOHA TAB
VASOPRESSIN INJ 10/0.5ML
3
1
Non-Preferred Brand
Generic
VASOTEC TAB 10MG
3
Non-Preferred Brand
VASOTEC TAB 2.5MG
3
Non-Preferred Brand
VASOTEC TAB 20MG
3
Non-Preferred Brand
VASOTEC TAB 5MG
3
Non-Preferred Brand
VAYACOG CAP
-
-
VAYARIN CAP
-
-
VAYAROL CAP
-
-
-
$0 ACA Drug
TWINRIX INJ
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
May be subject to
Quantity Level
Limits
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
642
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VAQTA INJ 25/0.5ML
VCKS DAYQUIL LIQ MUCUS DM
VECAMYL TAB 2.5MG
VECTIBIX INJ 100MG
VECTIBIX INJ 400MG
VECTICAL OIN 3MCG/GM
VECURONIUM INJ 10MG
VECURONIUM INJ 20MG
VEEGUM MIS LUMP
VEINERECT CAP
VELCADE INJ 3.5MG
VELETRI INJ 0.5MG
VELETRI INJ 1.5MG
VELPHORO CHW 500MG
VELTIN GEL
1
3
3
3
3
1
1
2
3
3
3
3
3
3
$0 ACA Drug
Generic
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
3
3
1
1
1
1
2
1
1
1
1
2
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
Generic
Generic
Generic
Generic
Preferred Brand
VENALIV TAB
VENASTAT CAP 300MG
VENELEX OIN
VENLAFAXINE CAP 150MG ER
VENLAFAXINE CAP 37.5 ER
VENLAFAXINE CAP 75MG ER
VENLAFAXINE TAB 100MG
VENLAFAXINE TAB 225MG ER
VENLAFAXINE TAB 25MG
VENLAFAXINE TAB 37.5MG
VENLAFAXINE TAB 50MG
VENLAFAXINE TAB 75MG
VENOFER INJ 20MG/ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
Limited Distribution
Limited Distribution
PA after 25
Not a covered
benefit
643
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VENOMIL MIX INJ VESPID
VENTAVIS SOL 10MCG/ML
VENTAVIS SOL 20MCG/ML
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
VERAMYST SPR 27.5MCG
2
Preferred Brand
VERAPAMIL CAP 100MG ER
VERAPAMIL CAP 120MG ER
VERAPAMIL CAP 180MG ER
VERAPAMIL CAP 200MG ER
VERAPAMIL CAP 240MG ER
VERAPAMIL CAP 300MG ER
VERAPAMIL CAP 360MG SR
VERAPAMIL INJ 2.5MG/ML
VERAPAMIL POW
VERAPAMIL TAB 120MG
VERAPAMIL TAB 120MG ER
VERAPAMIL TAB 180MG CR
VERAPAMIL TAB 240MG CR
VERAPAMIL TAB 40MG
VERAPAMIL TAB 80MG
VERDESO AER 0.05%
VEREGEN OIN 15%
3
3
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
VERELAN CAP 120MG SR
3
Non-Preferred Brand
3
Non-Preferred Brand
VERELAN CAP 180MG
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Limited Distribution
Limited Distribution
May be subject to
Quantity Level
Limits
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
644
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VERELAN CAP 240MG SR
3
Non-Preferred Brand
VERELAN CAP 360MG SR
3
Non-Preferred Brand
VERELAN PM CAP 100MG
3
Non-Preferred Brand
VERELAN PM CAP 200MG
3
Non-Preferred Brand
VERELAN PM CAP 300MG
3
Non-Preferred Brand
VERIPRED 20 SOL 20MG/5ML
VERSABASE AER
VERSABASE CRE
VERSABASE GEL
VERSABASE LOT
VERSABASE SHA
VERSACLOZ SUS 50MG/ML
VERSIVA XC PAD
VERSIVA XC PAD 8" X 7"
VERTIGOX OIL
2
2
2
2
2
2
3
2
3
3
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
VESICARE TAB 10MG
2
Preferred Brand
VESICARE TAB 5MG
2
Preferred Brand
VEXA PAD 2-4-30%
3
Non-Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
645
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VEXOL SUS 1% OP
3
Non-Preferred Brand
VFEND IV INJ 200MG
3
Non-Preferred Brand
VFEND SUS 40MG/ML
3
Non-Preferred Brand
VFEND TAB 200MG
3
Non-Preferred Brand
VFEND TAB 50MG
3
Non-Preferred Brand
VH VAGINAL SUP PREBIOTI
3
Non-Preferred Brand
VIACTIV CHW CARAMEL
3
Non-Preferred Brand
-
-
VIAGRA TAB 100MG
VIAGRA TAB 25MG
VIAGRA TAB 50MG
VIASORB PAD 6"X10"
VIASPAN SOL
VIBATIV INJ 250MG
VIBATIV INJ 750MG
2
2
2
2
3
2
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
VIBRAMYCIN CAP 100MG
3
Non-Preferred Brand
3
Non-Preferred Brand
VIACTIV MULT CHW VITAMIN
VIBRAMYCIN SUS 25MG/5ML
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
10 per 30 days
10 per 30 days
10 per 30 days
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
646
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VIBRAMYCIN SYP 50MG/5ML
VIBURCOL SUP
VICECTIN GB TAB 325-25MG
VICKS DAYQUI LIQ COUGH
VICKS NATURE LIQ COLD/FLU
VICKS NATURE LIQ CONGEST
VICKS NYQUIL LIQ CHILDREN
VICKS NYQUIL TAB SEVERE
VICKS VAPO LIQ STEAM
3
3
3
2
3
3
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
VICOPROFEN TAB 7.5-200
3
Non-Preferred Brand
VICTOZA INJ 18MG/3ML
2
Preferred Brand
VICTRELIS CAP 200MG
VIDARABINE POW
3
2
Non-Preferred Brand
Preferred Brand
VIDAZA INJ 100MG
3
Non-Preferred Brand
YES, Specialty Drug
VIDEX EC CAP 125MG
3
Non-Preferred Brand
YES, Specialty Drug
VIDEX EC CAP 200MG
3
Non-Preferred Brand
YES, Specialty Drug
VIDEX EC CAP 250MG
3
Non-Preferred Brand
YES, Specialty Drug
VIDEX EC CAP 400MG
3
Non-Preferred Brand
YES, Specialty Drug
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required and
Quantity Level
Limits
PA Required
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
647
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VIDEX SOL 2GM
VIDEX SOL 4GM
VIGAMOX DRO 0.5%
VIIBRYD KIT
3
3
2
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
VIIBRYD TAB 10MG
2
Preferred Brand
VIIBRYD TAB 20MG
2
Preferred Brand
VIIBRYD TAB 40MG
2
Preferred Brand
-
-
VIMAR/IRON SYP FORTE
-
-
VIMIZIM INJ 5MG/5ML
3
Non-Preferred Brand
VIMOVO TAB 375-20MG
3
Non-Preferred Brand
VIMOVO TAB 500-20MG
3
Non-Preferred Brand
VIMPAT INJ 200MG/20
VIMPAT SOL 10MG/ML
2
2
Preferred Brand
Preferred Brand
VIMPAT TAB 100MG
2
Preferred Brand
VIMPAT TAB 150MG
2
Preferred Brand
VIMAR SYP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Not a covered
benefit
Not a covered
benefit
Limited Distribution
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
648
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
VIMPAT TAB 200MG
2
Preferred Brand
VIMPAT TAB 50MG
2
Preferred Brand
3
3
3
3
3
3
2
2
2
3
3
3
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
3
Non-Preferred Brand
YES, Speciatly Drug
3
3
Non-Preferred Brand
Non-Preferred Brand
YES, Speciatly Drug
YES, Speciatly Drug
VINACAL TAB
VINATE AZ EX TAB
VINATE CAL TAB
VINATE DHA CAP
VINATE IC CAP
VINATE M TAB
VINATE PN TAB CARE
VINBLASTINE INJ 10MG
VINBLASTINE INJ 1MG/ML
VINCAMINE POW
VINCASAR PFS INJ 1MG/ML
VINORELBINE INJ 10MG/ML
VINORELBINE INJ 10MG/ML
VINPOCETINE POW
VIOKACE TAB
VIOKACE TAB
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
VIRAMUNE SUS 50MG/5ML
VIRAMUNE TAB 200MG
VIRAMUNE XR TAB 100MG
VIRAMUNE XR TAB 400MG
WDRx 2/23/15
Penalty applied if Brand Selected
over Generic
YES, Speciatly Drug
YES, Speciatly Drug
YES, Specialty Drug
YES, Speciatly Drug
YES, Speciatly Drug
YES, Speciatly Drug
YES, Speciatly Drug
YES, Speciatly Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
649
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VIRASAL LIQ 27.5%
3
Non-Preferred Brand
VIRAZOLE INH 6GM
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
VIROPTIC SOL 1% OP
3
Non-Preferred Brand
3
Non-Preferred Brand
3
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
VISINE ADV DRO RELIEF
3
Non-Preferred Brand
VISINE DRO TOTALITY
3
Non-Preferred Brand
3
Non-Preferred Brand
VISINE MAX SOL RELIEF
3
Non-Preferred Brand
VISINE PURE DRO TEARS
3
Non-Preferred Brand
VISINE SOL 0.05% OP
3
Non-Preferred Brand
VIROXYN LIQ
VIRT-BAL DHA MIS
VIRTPREX CAP
VISCOAT SOL
VISINE EXTRA SOL 0.05% OP
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
YES, Speciatly Drug
YES, Speciatly Drug
YES, Speciatly Drug
YES, Speciatly Drug
YES, Speciatly Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
650
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
2
3
3
2
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
VISTARIL CAP 25MG
3
Non-Preferred Brand
VISTARIL CAP 50MG
3
Non-Preferred Brand
VISTIDE INJ 75MG/ML
3
Non-Preferred Brand
-
-
3
Non-Preferred Brand
VISINE TEARS DRO
VISINE-LR SOL 0.025%
VISIONBLUE SOL 0.06%
VISIPAQUE INJ 270MG/ML
VISIPAQUE INJ 320MG/ML
VI-STRESS TAB
VISUDYNE INJ 15MG
VIT A FISH CAP 7500UNIT
-
-
VIT A WRINKL GEL TREATMNT
VIT C/QUERCE CAP CITRUS
3
3
Non-Preferred Brand
Non-Preferred Brand
VIT D3/VIT C CAP 1000-500
-
-
VIT E & A OIL BEAUTY
VIT E & C LOT BEAUTY
VIT E & D OIL BEAUTY
VIT E & K OIL SKIN OIL
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
VITABALL GUM
-
-
VITA-C CRY
-
-
3
Non-Preferred Brand
VITA-CALCIUM WAF
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Limited Distribution
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
651
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VITACRAVES CHW +OMEGA-3
-
-
-
-
-
$0 Preventative Drug
-
-
-
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
VITAL-D RX TAB
-
-
VITALETS CHW
-
-
VITAMAX CHW
-
-
2
3
2
3
$0 Preventative Drug
$0 Preventative Drug
$0 ACA Drug
Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
-
-
VITAMIN A TAB 10000UNT
-
-
VITAMIN A TAB 15000UNT
-
-
VITAMIN A TAB 8000UNIT
-
-
VITADYE LOT 5%
VITAFOL CAP ULTRA
VITAFOL TAB
VITAFOL-NANO TAB
VITAFOL-OB PAK +DHA
VITAFOL-PLUS CAP
VITAMEDMD CAP ONE RX
VITAMEDMD MIS PLUS RX
VITAMELTS D TAB 1000 IU
VITAMIN A BEA ACETATE
VITAMIN A GRA ACETATE
VITAMIN A LIQ PALMITAT
VITAMIN A POW ACETATE
VITAMIN A TAB
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
652
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
-
-
Not a covered
benefit
3
3
Non-Preferred Brand
Non-Preferred Brand
-
-
3
3
1
3
3
1
1
Non-Preferred Brand
Non-Preferred Brand
Generic
Non-Preferred Brand
Non-Preferred Brand
Generic
Generic
-
-
1
Generic
VITAMIN C CAP 500MG
-
-
VITAMIN C CHW 1000MG
-
-
VITAMIN C CHW 500MG
-
-
VITAMIN C CHW GUMMIE
-
-
VITAMIN C CHW ROSE HIP
-
-
-
-
-
-
-
-
VITAMIN A&D TAB
VITAMIN B 12 LOZ 100MCG
VITAMIN B 12 LOZ 250MCG
VITAMIN B-1 TAB 50MG
VITAMIN B12 DRO 3000/ML
VITAMIN B-12 LIQ 1000MCG
VITAMIN B-12 LOZ 500MCG
VITAMIN B-12 LOZ 50MCG
VITAMIN B-12 SUB 6000MCG
VITAMIN B-12 TAB 1000MCG
VITAMIN B-12 TAB 1500 LA
VITAMIN B-2 TAB 25MG
VITAMIN C + TAB ECHINACE
VITAMIN C LIQ
VITAMIN C LIQ 500/5ML
VITAMIN C SOL
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
653
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VITAMIN C SYP 500/5ML
-
-
VITAMIN C TAB 100MG
-
-
VITAMIN C&D3 CAP /ROSE HI
-
-
VITAMIN C/ CAP ECHINACE
VITAMIN D KIT TEST
VITAMIN D TAB 400
3
3
2
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
VITAMIN D2 TAB 2000UNIT
-
-
VITAMIN D2 TAB 400UNIT
-
-
VITAMIN D3 CAP 10000UNT
VITAMIN D3 CAP 4000UNIT
VITAMIN D3 CAP 400UNIT
VITAMIN D3 CHW 2000UNIT
VITAMIN D3 LIQ
VITAMIN D3 LIQ 1000UNIT
VITAMIN D3 LIQ 1200UNIT
VITAMIN D3 POW
VITAMIN D3 SPR 1000UNIT
VITAMIN D3 TAB 3000UNIT
VITAMIN D3 TAB 50000UNT
VITAMIN E GEL MOISTURZ
VITAMIN E LIQ
VITAMIN E LIQ ACETATE
VITAMIN E OIL 24000UNT
2
2
3
1
2
2
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
Preferred Brand
$0 ACA Drug
$0 ACA Drug
Preferred Brand
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
Non-Preferred Brand
Generic
Preferred Brand
Preferred Brand
VITAMIN E POW ACETATE
-
-
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
654
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VITAMIN E POW SUCCINAT
3
Non-Preferred Brand
VITAMIN E TAB 100UNIT
-
-
VITAMIN E TAB 200UNIT
-
-
VITAMIN K1 INJ 10MG/ML
-
-
2
Preferred Brand
-
-
VITAPEARL CAP
-
$0 Preventative Drug
VITA-PLUS H CAP
-
-
VITA-PREN TAB
VITA-RAY CRE
2
$0 Preventative Drug
Preferred Brand
VITA-RESPA TAB
-
-
1
3
3
Generic
Non-Preferred Brand
Non-Preferred Brand
-
-
VITRASE INJ 200/ML
VITRON-C TAB 65-125
VITUZ SOL 5-4MG
VIVA CT CHW 28-1MG
VIVA DHA CAP
VIVA DROPS DRO 1%
3
2
3
3
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
Non-Preferred Brand
VIVACTIL TAB 10MG
3
Non-Preferred Brand
VITAMIN K-1 POW
VITAMIN K2 CAP 100MCG
VITEC LOT
VITEYES CAP ESSNTLS
VITEYES CAP OMEGA-3
VITONIC LIQ
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
655
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VIVACTIL TAB 5MG
3
Non-Preferred Brand
VIVARIN TAB 200MG
2
Preferred Brand
VIVELLE-DOT DIS 0.025MG
2
Preferred Brand
VIVELLE-DOT DIS 0.0375MG
3
Non-Preferred Brand
VIVITROL INJ 380MG
VIVOTIF BERN CAP EC
VOLTAREN GEL 1%
3
2
2
Non-Preferred Brand
Preferred Brand
Preferred Brand
VOLTAREN-XR TAB 100MG
3
Non-Preferred Brand
3
3
2
3
3
2
1
2
1
1
1
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Generic
Preferred Brand
Generic
Generic
Generic
3
Non-Preferred Brand
VOLUMEN SUS 0.1%
VOLUMEX INJ 25/ML
VOLUVEN INJ 6%/NACL
VOPAC CRE 10-2%
VOPAC GB CRE 5-2-5%
VORAXAZE INJ 1000UNIT
VORICONAZOLE INJ 200MG
VORICONAZOLE POW
VORICONAZOLE SUS 40MG/ML
VORICONAZOLE TAB 200MG
VORICONAZOLE TAB 50MG
VOSOL HC SOL OTIC
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
YES, Specialty Drug
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
656
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
VOSPIRE ER TAB 4MG
3
Non-Preferred Brand
VOSPIRE ER TAB 8MG
3
Non-Preferred Brand
VOTRIENT TAB 200MG
VP-CH PLUS CAP
VP-ERA OB PAK PLUS
VP-HEME ONE CAP
VP-PNV-DHA CAP
3
-
Non-Preferred Brand
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
$0 Preventative Drug
VP-PRECIP CAP
-
-
VPRIV INJ 400UNIT
3
Non-Preferred Brand
VSL#3 PAK
-
-
VUSION OIN
VYTONE CRE 1-1.9%
3
3
Non-Preferred Brand
Non-Preferred Brand
VYTORIN TAB 10-10MG
2
Preferred Brand
VYTORIN TAB 10-20MG
2
Preferred Brand
VYTORIN TAB 10-40MG
2
Preferred Brand
VYTORIN TAB 10-80MG
2
Preferred Brand
VYVANSE CAP 20MG
VYVANSE CAP 30MG
2
2
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Limited Distribution
Not a covered
benefit
Limited Distribution
Not a covered
benefit
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
PA after 25
PA after 25
657
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
Special Plan Edits
2
2
2
2
3
1
2
-
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Generic
Preferred Brand
$0 Preventative Drug
PA after 25
PA after 25
PA after 25
PA after 25
3
Non-Preferred Brand
3
3
3
3
3
3
3
1
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Generic
WELCHOL PAK 3.75GM
2
Preferred Brand
WELCHOL TAB 625MG
2
Preferred Brand
3
Non-Preferred Brand
3
Non-Preferred Brand
VYVANSE CAP 40MG
VYVANSE CAP 50MG
VYVANSE CAP 60MG
VYVANSE CAP 70MG
WAL-DRYL-D TAB 25-60MG
WAL-SOM TAB 25MG
WAL-TUSSIN CHW 7.5MG
WARFARIN POW SODIUM
WART OFF SOL 17%
WASABI CAP 100MG
WASP VENOM INJ 1000MCG
WASP VENOM INJ 1300MCG
WASP VENOM INJ 550MCG
WASP VENOM KIT 100MCG
WATER PILL TAB /POTASS
WAX FOR MIS BRACES
WEE CARE SUS 15/1.25
WELLBUTRIN TAB 100MG
WELLBUTRIN TAB 100MG SR
WDRx 2/23/15
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
May be subject to
Quantity Level
Limits
May be subject to
Quantity Level
Limits
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
658
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
WELLBUTRIN TAB 150MG SR
3
Non-Preferred Brand
WELLBUTRIN TAB 200MG SR
3
Non-Preferred Brand
3
Non-Preferred Brand
WELLBUTRIN TAB XL 150MG
3
Non-Preferred Brand
WELLBUTRIN TAB XL 300MG
3
Non-Preferred Brand
WELLNESS ESS KIT AI
-
-
WESTCORT OIN 0.2%
3
Non-Preferred Brand
3
3
3
3
3
3
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
-
-
2
3
3
3
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
WELLBUTRIN TAB 75MG
WESTHROID-P TAB 130MG
WESTHROID-P TAB 16.25MG
WESTHROID-P TAB 32.5MG
WESTHROID-P TAB 48.75MG
WESTHROID-P TAB 65MG
WESTHROID-P TAB 97.5MG
WHEAT GERM OIL
WHEY PROTEIN POW ISOLATE
WHITE HORNET KIT 100MCG
WHITE HORNET SOL 1000MCG
WHITE KIDNEY POW BEAN EXT
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
Generic Available. Brand copay + the
difference between the brand and the
generic.
Not a covered
benefit
659
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
WHITE WILLOW POW BARK
VAQTA INJ 50 UNT/ML
WIDE-SEAL DPR KIT 60
WIDE-SEAL DPR KIT 65
WIDE-SEAL DPR KIT 70
WIDE-SEAL DPR KIT 75
WIDE-SEAL DPR KIT 80
WIDE-SEAL DPR KIT 85
WIDE-SEAL DPR KIT 90
WILATE INJ
WILATE INJ
WILD CHERRY POW BARK
WILD YAM CAP 100MG
WILD YAM EXT
WINGED SPONG MIS /PVP SCR
WINRHO SDF INJ 15000UNT
WINRHO SDF INJ 1500UNIT
WINRHO SDF INJ 2500UNIT
WINRHO SDF INJ 5000UNIT
WINTERGREEN OIL
WITCH HAZEL EXT
WITCH HAZEL LIQ
WITCH HAZEL SOL 86%
WITEPSOL H15 MIS
WITEPSOL MIS
WOMENS WATR TAB BALANCE
WP THYROID TAB 113.75MG
WP THYROID TAB 81.25MG
WYMZYA FE CHW 0.4MG-35
3
3
3
3
3
3
3
3
3
3
3
2
2
2
2
2
2
3
3
3
Non-Preferred Brand
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
$0 ACA Drug
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
Non-Preferred Brand
$0 Preventative Drug
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
YES, Specialty Drug
660
Colorado Health OP Formulary
***Please note this list is not all inclusive and is subject to change***
**Brand name drugs may move to non-formulary status if a generic
version becomes available during the year**
Drug Name
Tier
Formulary Status
XALATAN SOL 0.005%
3
Non-Preferred Brand
XALKORI CAP 200MG
XALKORI CAP 250MG
3
3
Non-Preferred Brand
Non-Preferred Brand
XANAX TAB 0.25MG
3
Non-Preferred Brand
XANAX TAB 0.5MG
3
Non-Preferred Brand
XANAX TAB 1MG
3
Non-Preferred Brand
XANAX TAB 2MG
3
Non-Preferred Brand
XANAX XR TAB 0.5MG
3
Non-Preferred Brand
XANAX XR TAB 1MG
3
Non-Preferred Brand
XANAX XR TAB 2MG
3
Non-Preferred Brand
XANAX XR TAB 3MG
3
Non-Preferred Brand
XANTHAN GUM POW
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
2
2
2
2
Preferred Brand
Preferred Brand
Preferred Brand
Preferred Brand
WDRx 2/23/15
Special Plan Edits
Medication must be filled
through US Specialty Care
Pharmacy
Penalty applied if Brand Selected
over Generic
Generic Available. Brand copay + the
difference between the brand and the
generic.
PA Required
PA Required
Limited Distribution
Limited Distribution
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between the brand and the
generic.
Generic Available. Brand copay + the
difference between