Ventegra Premium Plus Formulary
Ventegra Premium Plus FormularyVentegra's Premium Plus drug formulary has been developed by a committee of physicians and pharmacists to ensurethe provision of safe, efficacious, and cost‐effective drug therapy. The committee meets on a quarterly basis to discussnew drugs and new prescribing information as it becomes available.This list of outpatient prescription drugs provides frequently prescribed medications and which copayment tier will applyto the medication. The following formulary reference is designed so that it features medications in generic and brandname drugs. The brand name products are listed in proper case ("Brand Name") and generic products are listed in lowercase ("generic name") in each drug category.TIERINGTier 0 ‐ ACA drugsTier 1 GenericTier 2 Preferred Brand Drug or*High‐cost GenericTier 3 Non‐Preferred DrugTier 4 Preferred Specialty DrugBENEFIT NOTESA Age EditG Gender EditPA Prior Authorization RequiredQL Quantity LimitST Step TherapyCoverage for some drugs may be limited to specific dosage forms and/or strengths. Clinical edits such as quantity limits,age and gender restrictions may apply to some medications. Since changes to the formulary may occur throughout theyear, medications listed on this formulary are subject to change. The listing of a medication on this formulary does notguarantee coverage. The excluded medications are not part of the member benefit. If you fill an excluded medication,you will pay the full retail price.You may contact a Customer Care representative to obtain current formulary status of a particular medication. Pleasereview your benefit plan documents for additional information regarding your pharmacy benefits and restrictions.Drug CategoryLabel NamePremium Plus BenefitFormulary Tier antsamphetamine‐dextroamphetamine cap eramphetamine‐dextroamphetamine tabamphetamine sulfate oral tablet 10 mgamphetamine sulfate oral tablet 5 mgarmodafinil tabatomoxetine capclonidine hcl er oral tablet extended release 12 hour 0.1 mgdexmethylphenidate hcl cap erdexmethylphenidate hcl oral tabletdextroamphetamine sol 5mg/5mldextroamphetamine sulfate er oral capsule extended release 24 hourdextroamphetamine sulfate oral tabletguanfacine hcl er oral tablet extended release 24 houPage a Premium Plus Formulary 2021
Drug CategoryLabel Namemethamphetamine hcl oral tabletmethylin chew tab 10mgmethylin chew tab 2.5mgmethylin chew tab 5mgmethylphenidate cap 10mg ermethylphenidate cap 15mg ermethylphenidate cap 20mg ermethylphenidate cap 30mg ermethylphenidate cap 40mg ermethylphenidate cap 50mg ermethylphenidate cap 60mg ermethylphenidate er capmethylphenidate hcl cap ermethylphenidate hcl oral tabletmethylphenidate hcl sa osm extended release 18 mgmethylphenidate hcl sa osm extended release 27 mgmethylphenidate hcl sa osm extended release 36 mgmethylphenidate hcl sa osm extended release 54 mgmethylphenidate hcl solnmethylphenidate hcl tab ermodafinil oral tabletPremium Plus BenefitFormulary Tier L; ST1QL1QL2*QL2*QL2*QL2*QL1QL1QL1QLAlkylating Agentstemozolomide cap 5mgtemozolomide cap 20 mgtemozolomide cap 100 mgtemozolomide cap 140 mgtemozolomide cap 180 mgtemozolomide cap 250 mg112*2*2*2*QLQLQLQLQLQLneomycin tabhumatin cap 250mg12*QLcelecoxib capcholine & magnesium salicylates liqdiclofenac potassium tabdiclofenac sodium tab delayed releaseetodolac capetodolac tabfenoprofen calcium oral tablet 600 mgflurbiprofen tabibuprofen chew tabibuprofen tabindomethacin capketorolac tromethamine tableflunomide tabmeloxicam capmeloxicam tab1111112*11111111QLAminoglycosidesAnalgesics ‐ Anti‐InflammatoryPage 2QLQLQLVentegra Premium Plus Formulary 2021
Drug CategoryLabel Namenabumetone tabnaproxen dr tabnaproxen tabpiroxicam capsulindac tabPremium Plus BenefitFormulary Tier Notes11111Analgesics ‐ Nonnarcoticaspirin chw 81mgaspirin tab 325mgaspirin tab 325mg ecaspirin tab 81mg ecbutalbital‐acetaminophen oral tablet 50‐300 mgbutalbital‐acetaminophen oral tablet 50‐325 mgbutalbital‐acetaminophen‐caffeine tabbutalbital‐aspirin‐caffeine capdiflunisal tabsalsalate tab00002*11111A; G; QLA; G; QLA; QLA; G; QLacetaminophen w/ codeine solnacetaminophen w/ codeine tabbuprenorphine hcl sl tabbuprenorphine hcl‐naloxone hcl sl film 2‐0.5mgbuprenorphine hcl‐naloxone hcl sl film 8‐2mgbuprenorphine hcl‐naloxone hcl sl film 12‐3mgbuprenorphine hcl‐naloxone hcl sl film 4‐1mgbuprenorphine hcl‐naloxone hcl sl tabbuprenorphine td patch weekly 7.5 mcg/hrbuprenorphine transdermal patch weekly 10 mcg/hrbuprenorphine transdermal patch weekly 15 mcg/hrbuprenorphine transdermal patch weekly 20 mcg/hrbuprenorphine transdermal patch weekly 5 mcg/hrbutalbital‐acetaminophen‐caff w/ cod capbutorphanol tartrate nasal solnCodeine Sulfate Tabcodeine sulfate tabfentanyl dis 87.5mcgfentanyl td patchfentanyl dis 37.5mcgfentanyl dis 62.5mcghydrocodone bitartrate tab erhydrocodone‐acetaminophen solnhydrocodone‐acetaminophen tabhydrocodone‐ibuprofen tabhydromorphone hcl tabhydromorphone hcl tablet er 24 hou 32 mgmethadone con 10mg/mlmethadone tabmethadone hcl oral solution 10 *QLQLQLQLQLQLQLQLQL; sics‐ OpioidPage 3Ventegra Premium Plus Formulary 2021
Drug CategoryLabel Namemethadone sol 5mg/5mlmorphine sul cap 40mg ermorphine sulfate oral solnmorphine sulfate tabmorphine sulfate tab eroxycodone hcl capOxycodone Hcl Tab Er 12Hr Deter 10 MgOxycodone Hcl Tab Er 12Hr Deter 20 MgOxycodone Hcl Tab Er 12Hr Deter 40 Mgoxycodone soloxycodone taboxycodone w/ acetaminophen tab 325 mgoxymorphone hcl tabtramadol‐acetaminophen tabtramadol hcl tabPremium Plus BenefitFormulary Tier Notes1QL1QL; ST11QL1QL1QL2QL; ST2QL; ST2QL; ne gel 1%(25mg)testosterone gel 1%(50mg)testosterone gel pump 1%testosterone pump transdermal gel 20.25 mg/act (1.62%)testosterone td soln 30 mg/acttestosterone transdermal gel 10 mg/act (2%)testosterone transdermal gel 20.25 mg/1.25gmtestosterone transdermal gel 40.5 mg/2.5gm (1.62%)112*2*2*2*2*2*hydrocortisone acetate supphydrocortisone acetate w/ pramoxine perianal creamhydrocortisone perianal cream111albendazole oral tab 200 mgivermectin tab 3mgpraziquantel 600mg tab2*12*isosorbide dinitrate tabisosorbide mononitrate er tabisosorbide tabnitro‐bid oint 2%nitroglycerin sublingual tabletnitroglycerin td patch 24hrranolazine oral tablet extended release 12 hour 500 mg1112112*alprazolam tabalprazolam tab erbuspirone tabchlordiazepoxide hcl capdiazepam tabhydroxyzine hcl tab111111QLQLQLQLQLQLQLQLAnorectal And Related ProductsAnthelminticsQLPA; QLAntianginal AgentsAntianxiety AgentsPage 4QLQLQLQLVentegra Premium Plus Formulary 2021
Drug CategoryLabel Namehydroxyzine hcl syruphydroxyzine pamoate caplorazepam tabPremium Plus BenefitFormulary Tier Notes111QLAntiarrhythmicsamiodarone hcl oral tabletdofetilide cap 125mcgdofetilide capflecainide tabmexiletine capMultaq Tablet 400 MgNorpace Cappropafenone hcl tabAntiasthmatic And Bronchodilator AgentsAdvair Hfaalbuterol sulfate hfa inhalation aerosol solutionalbuterol sulfate soln nebu 0.083%albuterol sypAnoro Elliptaarformoterol neb 15/2mlArnuity ElliptaAtrovent HfaBreo ElliptaBreztri Aerospherebudesonide susbudesonide sus 1mg/2mlBudesonide‐Formoterol Fumarate Dihyd Aerosol 160‐4.5 Mcg/ActBudesonide‐Formoterol Fumarate Dihyd Aerosol 80‐4.5 Mcg/ActCombivent Respimatcromolyn sol neb 20mg/2mlElixophylln Elixir 80 Mg/15MlFloventFlovent Hfafluticasone‐salmeterol inhalationfluticasone‐salmeterol inhalation aerosolformoterol neb 20/2mlIncruse Elliptaipratropium bromide inhal solnipratropium‐albuterol nebu soln 0.5‐2.5levalbuterol hcl soln nebmontelukast sodium chew tabmontelukast sodium oral granules packet 4 mgmontelukast sodium tab 10 mgProair HfaProair RespiclickQvar RedihalerSpiriva Cap HandihlrSpiriva Respimat Inhalation AerosolPage QLQLQLVentegra Premium Plus Formulary 2021
Drug CategoryLabel NameSpiriva Spray RespimatStioltoStriverdiSymbicortterbutaline sulfate tabtheophylline solntheophylline tab 600mg erTrelegy Elliptawixela inhub inhalation aerosolzafirlukast tab 10mgPremium Plus BenefitFormulary Tier Notes2QL2QL2QL2QL1112QL1QL1QLAnticoagulantsEliquis Oral Tabletenoxaparin injection solution 300 mg/3mlfondaparinux sodium subcutaneous solutionXarelto Oral TabletXarelto Starter Packwarfarin sodium tab212*221carbamazepine tabcarbamazepine xr tabclobazapam sus 2.5mg/mlclonazepam odt tabclonazepam oral tabletdivalproex tab drdivalproex tab ergabapentin oral capsulegabapentin oral soln 250 mg/5mlgabapentin tablamotrigine tablamotrigine tab er 24hrlevetiracetam tablevetiracetam tab eroxcarbazepin sus 300mg/5moxcarbazepine tabPeganone Tab 250Mgphenytoin sodium extended cappregabalin capprimidone tabrufinamide sus 40mg/mlrufinamide tabtiagabine tabtopiramate cap ertopiramate oral capsule sprinkletopiramate oral tabletVimpat SolVimpat Tabzonisamide vulsantsPage 6QLQLQLQLQLQLQLQLPAQLPA; QLPA; QLQLPAPAVentegra Premium Plus Formulary 2021
Drug CategoryLabel NamePremium Plus BenefitFormulary Tier NotesAntidepressantsamitriptyline hcl tabbupropion hcl tabbupropion hcl tab er 24hrbupropion tab srcitalopram hydrobromide tabdesipramine hcl tabdesvenlafaxine succinate tab er 24hrdoxepin hcl capduloxetine hcl enteric coated pellets capduloxetine hcl tab sr 24hr 100 mgescitalopram oxalate solnescitalopram tabFetzima Er CapsuleFetzima Titration Er Capsule 20 & 40 Mgfluoxetine capsulefluoxetine tabfluvoxamine tabfluvoxamine maleate capimipramine hcl tabNefazodone Hcl Oral Tablet 250 Mgmirtazapine orally disintegrating tabmirtazapine tabnortriptyline hcl capparoxetine hcl tabPexeva Tabsertraline hcl tabtrazodone hcl tabvenlafaxine tabvenlafaxine hcl ervenlafaxine hcl tabvenlafaxine tab 225mg erViibryd Oral TabletViibryd Starter Pack Oral Kit 10 & 20 Mg1111111111112211111211113111112*22acarbose tabBaqsimiBydureon BciseByettadiazoxide susp 50 mg/mlFarxiga TabFiasp FlextouchFiasp Penfill Subcutaneous Solution CartridgeFiasp Subcutaneous Solutionglimepiride tabglipizide er tabglipizide ; STQL; STAntidiabeticsPage 7QLQL; STQL; STQL; STVentegra Premium Plus Formulary 2021
Drug CategoryPage 8Label NamePremium Plus BenefitFormulary Tier Notesglipizide‐metformin hcl tab1Glucagen Inj Hypokit2QL2QLGlucagon Kit 1Mg2*QLglucagon kit 1mgglyburide tab1glyburide‐metformin tab1Glyxambi Tab2QL; STHumalog Inj 100/Ml2Humalog Junior Kwikpen Inj 100/Ml2Humalog Kwikpen Inj 100/Ml2Humalog Kwikpen Subcutaneous Solution Pen‐Injector 200 Unit/Ml2Humalog Mix Inj 50/502Humalog Mix Inj 50/50Kwp2Humalog Mix Inj 75/25Kwp2Humalog Mix 75/25 Subcutaneous Suspension (75‐25) 100 Unit/Ml2Humalog Subcutaneous Solution Cartridge 100 Unit/Ml2Humulin Inj 70/30Kwp2Humulin 70/302Humulin N Kwikpen2Humulin N Subcutaneous Suspension 100 Unit/Ml2Humulin R Inj U‐1002Humulin R Inj U‐500 Concentrated2Humulin R U‐500 Kwikpen22Humulin R U‐500 Kwikpeninsulin aspart flexpen subcutaneous solution pen‐injector 100 unit/ml1insulin aspart penfill subcutaneous solution cartridge 100 unit/ml1insulin aspart prot & aspart flexpen 70‐301insulin aspart prot & aspart subcutaneous susp (70‐30) 100 unit/ml1insulin aspart subcutaneous solution 100 unit/ml1insulin lisp inj junior1insulin lisp inj protamin11insulin lispro inj 100 unit/mlinsulin lispro subcutaneous solution pen‐injector 100 unit/ml1Invokamet Tab3QL; STInvokamet Xr Tab3QL; STInvokana Tab3QL; STJanumet Tab2QL; STJanumet Xr Tab2QL; STJanuvia Tab2QL; STJardiance Tab2QL; STKombiglyze Xr3QL; STLantus Inj 100/Ml2Lantus Inj Solostar2Levemir2Levemir Flextouch22LyumjevLyumjev Kwikpen2Ventegra Premium Plus Formulary 2021
Drug CategoryLabel Namemetformin hcl ermetformin hcl tabmetformin oral soln 500 mg/5mlmiglitol tabnateglinide tabNovolin 70/30Novolin 70/30 Flexpen RelionNovolin N Inj U‐100Novolin N Relion Subcutaneous Suspension 100 Unit/MlNovolin R Inj U‐100Novolin R Relion Inj U‐100Novolog 100 Unit/MlNovolog FlexpenNovolog Mix 70/30Novolog Mix 70/30 FlexpenNovolog Penfill Subcutaneous Solution Cartridge 100 Unit/MlOnglyza TabletOzempicpioglitazone hcl tabpioglitazone hcl‐glimepiride tabletpioglitazone hcl‐metformin hcl oral tabletQtern Tabrepaglinide tabRybelsus TabSoliquaSteglatro Oral TabletSymlinpenSynjardy TabSynjardy Xr TabToujeo Max SolostarToujeo SolostarTradjenta TabTresiba FlextouchTresiba Subcutaneous SolutionTrijardy Xr TabTrulicityVictozaXigduo Xr TabXultophyPremium Plus BenefitFormulary Tier Notes111QL2*ST1QL222222222223QL; ST2QL; ST1QL1QL1QL2QL; ST1QL2QL; ST2QL; ST3QL; ST22QL; ST2QL; ST223QL; ST222QL; ST2QL; ST2QL; ST2QL; ST2QL; STAntidiarrheal/Probiotic Agentsdiphenoxylate w/ atropine tabAntidotes And Specific Antagonistsdeferasirox tab 90 mgdeferasirox tab 360 mgdeferasirox tab for oral susp 125 mgdeferasirox tab for oral susp 250 mgdeferasirox tab for oral susp 500 mgPage 912*2*2*2*2*QLQLQLQLQLVentegra Premium Plus Formulary 2021
Drug CategoryLabel Namenaloxone prefilled syringe 2 mg/2mlnaltrexone tabNarcan SprPremium Plus BenefitFormulary Tier Notes1QL12QLAntiemeticsaprepitant cap 125mgaprepitant cap 40mgaprepitant cap 80mgaprepitant therapy pack 80 & 125 mgdoxylamine‐pyridoxine tab delayed release 10‐10 mgmeclizine hcl tabondansetron hcl oral solnondansetron tabondansetron tab odtscopolamine td patch 72hr 1 mg/3days2*2*2*2*2*11111fluconazole suspfluconazole tabgriseofulvin tab 250 mggriseofulvin tablet 125mgitraconazole oral solution 10 mg/mlitraconazole capketoconazole tabterbinafine tab 250mgvoriconazole susp 40 mg/mlvoriconazole tab112*2*2*1112*1cetirizine solcyproheptadine hcl syrupcyproheptadine hcl tabfexofenadine susp 30mg/5mllevocetirizine dihydrochloride tabpromethazine hcl syruppromethazine hcl tab1111111atorvastatin tab 10mgatorvastatin tab 20mgatorvastatin tab 40mgatorvastatin tab 80mgcholestyramine light powder packetscholestyramine powder packetscholine fenofibrate cap dr 1colesevelam hcl pak 3.75gmcolesevelam hcl tab 625mgcolestipol hcl granule packetscolestipol hcl granulescolestipol hcl tabezetimibe LAntihistaminesAntihyperlipidemicsPage 10A; QLA; QLA; QLA; QLQLQLVentegra Premium Plus Formulary 2021
Drug CategoryLabel Namefenofibrate micronized capfenofibrate tabfenofibrate tab 120 mgfenofibrate tab 40mgfluvastatin sodium er oral tablet extended release 24 hour 80 mggemfibrozil tablovastatin tabniacin tab eromega‐3‐acid cap 1gmPraluentpravastatin tabrosuvastatin tabsimvastatin tab 10 mgsimvastatin tab 20 mgsimvastatin tab 40 mgPremium Plus BenefitFormulary Tier Notes1QL1QL2*QL2*QL2*QL1QL1QL11QL2PA1QL0A; QL0A; QL0A; QL0A; QLAntihypertensivesaliskiren fumarate oral tabletamlodipine besylate‐benazepril hcl capamlodipine besylate‐olmesartan medoxomil tabamlodipine besylate‐valsartan tabamlodipine‐valsartan‐hctz tabletatenolol & chlorthalidone tabbenazepril & hydrochlorothiazide tabbenazepril hcl tabbisoprolol & hydrochlorothiazide tabcandesartan cilexetil tabcandesartan cilexetil‐hydrochlorothiazide tabcaptopril tabclonidine hcl tabdoxazosin mesylate tabenalapril maleate & hydrochlorothiazide tabenalapril maleate tabfosinopril sodium & hydrochlorothiazide tabfosinopril sodium tabguanfacine hcl tabhydralazine hcl oral tabletirbesartan tabirbesartan‐hydrochlorothiazide tablisinopril & hydrochlorothiazide tablisinopril tablosartan potassium & hydrochlorothiazide tablosartan potassium tabMethyldopa Tabmetoprolol & hydrochlorothiazide tabminoxidil tabmoexipril hcl tabolmesartan medoxomil tabPage QLQLQLQLVentegra Premium Plus Formulary 2021
Drug CategoryLabel Nameolmesartan medoxomil‐hydrochlorothiazide tabolmesartan‐amlodipine‐hydrochlorothiazide tabperindopril erbumine tabprazosin hcl capquinapril hcl tabquinapril‐hydrochlorothiazide tabramipril captelmisartan tabtelmisartan‐amlodipine tabtelmisartan‐hctz oral tablet 40‐12.5 mgtelmisartan‐hydrochlorothiazide tabterazosin hcl captrandolapril tabvalsartan tabvalsartan‐hydrochlorothiazide tabPremium Plus BenefitFormulary Tier ve Agents ‐ Misc.Cleocin Cap 300Mgclindamycin hcl capclindamycin soldapsone tablinezolid oral suslinezolid tabmetronidazole tabnitrofurantoin macrocrystalline capnitrofurantoin monohydrate macrocrystalline cappentamidine inh 300mgsulfamethoxazole‐trimethoprim suspsulfamethoxazole‐trimethoprim tabtinidazole tabtrimethoprim tabvancomycin proguanil hcl tabchloroquine phosphate tabhydroxychloroquine sulfate tabprimaquine phosphate oral tablet 26.3 mgAntimyasthenic/Cholinergic Agentspyridostigmine bromide tabAntimycobacterial Agentsethambutol hcl tabisoniazid tabpyrazinamide tab 500mgrifampin capAntineoplastics And Adjunctive Therapiesanastrozole tabbicalutamide tabcapecitabine oral tabletPage 121112*QLPAPA1112*1111QLVentegra Premium Plus Formulary 2021
Drug CategoryLabel Namecyclophosphamide oral capsule 25mgcyclophosphamide oral capsule 50mgexemestane tabhydroxyurea capimatinib mesylate tab 100mgimatinib mesylate tab 400mgletrozole tableucovorin calcium tableuprolide acetate injection 1mg/0.2megestrol acetate tabmegestrol oral sus 625mg/mlmelphalan tab 2mgmercaptopur tabmethotrexate tab 2.5 mgtamoxifen tab 10mgtamoxifen tab 20mgtoremifene tab 60mgAntiparkinson And Related Therapy Agentsamantadine hcl capamantadine tabbenztropine tabcarbidopa & levodopa tabentacapone tabpramipexole tabrasagiline tab 0.5mgrasagiline tab 1mgropinirole tabselegiline captrihexyphenidyl hcl tabAntipsychotics/Antimanic Agentsaripiprazole odt 15mgaripiprazole odt 10mgaripiprazole oral tabletasenapine maleate tabchlorpromazine hcl tabclozapine tabclozapine tab 200 mgclozapine tab 50 mgclozapine tab odtfluphenazine 10mgfluphenazine 1mgfluphenazine 2.5mgfluphenazine 5mghaloperidol tabLithium Carbonate Caplithium carbonate caplithium carbonate tabPage 13Premium Plus BenefitFormulary Tier Notes2*2*112*QL2*QL112*12*2*110A; G; QL0A; G; QL2*1111112*2*1112*2*12*112*2*12*2*2*2*1211QLQL; STQL; STQL; STQL; STQLQLQLQL; STVentegra Premium Plus Formulary 2021
Drug CategoryLabel Namelithium carbonate tab erloxapine succinate capolanzapine orally disintegrating tabolanzapine tabpaliperidone tabpaliperidone tab erperphenazine tabprochlorperazine maleate tabquetiapine fumarate tab erquetiapine tabrisperidone tabthioridazine hcl tabthiothixene captrifluoperazine hcl tabziprasidone hcl capPremium Plus BenefitFormulary Tier avir sulfate sol 20mg/mlabacavir sulfate‐lamivudine tababacavir sulfate‐lamivudine tab 600‐300 mgabacavir tabacyclovir capacyclovir tabAptivus CapAptivus Oral Solnatazanavir sulfate cap 150 mgatazanavir sulfate cap 200 mgatazanavir sulfate cap 300 mgCimduoCrixivan Capefavirenz cap 50 mgefavirenz cap 200 mgefavirenz tab 600mgefavirenz‐emtricitabine‐tenofovir df tab 600‐200‐300 mgefavirenz‐lamivudine‐tenofovir df tab 400‐300‐300 mgefavirenz‐lamivudine‐tenofovir df tab 600‐300‐300 mgemtricitabine cap 200mgemtricitabine‐tenofovir disoproxil fumarate tab 200‐300 mgentecavir oral tablet 0.5mg / 1mgetravirine tabEvotaz Tab 300‐150famciclovir tabInvirase Tab 500lamivudine tablopinavir‐ritonavir soln 400‐100 mg/5ml (80‐20 mg/ml)lopinavir‐ritonavir tab 200‐50 mgnevirapine oral suspension 50 mg/5mlnevirapine tabPage LQLQLQLQLQLQLQLPAQLQLQLQLVentegra Premium Plus Formulary 2021
Drug CategoryLabel NameNorvir Soloseltamivir phosphate oral capsuleoseltamivir suspRelenza Aer Diskhaleribavirin cap 200 mgrimantadine tab 100mgritonavir oral tablet 100 mgtenofovir tabvalacyclovir hcl tabViracept Tabzidovudine capzidovudine tabPremium Plus BenefitFormulary Tier Notes21QL1QL2QL112*11211Assorted Classesazathioprine oral tablet 50 mgmycophenolate sus x HibPneumovax 23Prevnar 13Trumenba000000000acebutolol hcl capatenolol tabbetaxolol hcl tabbisoprolol fumarate tabBystolic Oral Tabletcarvedilol cr capsule 10 mgcarvedilol cr capsule 20 mgcarvedilol cr capsule 40 mgcarvedilol cr capsule 80 mgcarvedilol tablabetalol hcl tabmetoprolol tabmetoprolol succinate tab ermetoprolol tartrate tabnadolol tabpindolol tabpropranolol hcl cap erpropranolol hcl tabPropranolol Solsotalol hcl tab111122*2*2*2*11111111121Bacterial VaccinesAAAAAAAAABeta BlockersQLQLQLQLQLCalcium Channel BlockersPage 15Ventegra Premium Plus Formulary 2021
Drug CategoryLabel Nameamlodipine besylate oral tabletdiltiazem cap erdiltiazem er tabdiltiazem tabfelodipine tab erisradipine capnicardipine hcl capnifedipine capnifedipine tab ernimodipine capnisoldipine tab erverapamil hcl cap erverapamil tabverapamil tab erPremium Plus BenefitFormulary Tier Notes11111111111111Cardiotonicsdigoxin sol 50mcg/mldigoxin tab2*1amlodipine besylate‐atorvastatin calcium tabsildenafil tabtadalafil tabtadalafil tab 20 mg (pah)vardenafil tab11111Ceclor Suscefaclor capcefadroxil capcefadroxil suscefdinir capcefdinir suscefixime oral capsule 400 mgcefpodoxime proxetil suspcefpodoxime tabcefprozil suscefprozil tabcephalexin capCephalexin Tabcephalexin suscefuroxime axetil tab3111112*11111211amethyst tabAnnovera Vaginal Ringaranelle tabavianeBalcoltra Oral Tablet 0.1‐20 Mg‐Mcg(21)briellyn oral tablet 0.4‐35 mg‐mcgcamilatab 0.35mg0000000Cardiovascular Agents ‐ Misc.QLG; QLG; QLQLG; QLCephalosporinsContraceptivesPage 16A; G; STA; GA; GA; GA; G; STA; GA; GVentegra Premium Plus Formulary 2021
Drug CategoryLabel Namecamrese lo oral tablet 0.1‐0.02 & 0.01 mgcamrese oral tablet 0.15‐0.03 &0.01 mgCaya Diaphragmcryselle‐28 tabdepo‐proveraDepo‐Sq Prov Inj 104drospirenone‐ethinyl estradiol‐levomefolate calciumdrospirenone‐ethinyl estrad‐levomefolate tabElla Oral Tablet 30 Mgeluryng vaginal ring 0.12‐0.015 mg/24hrFalessa KitFemcap Vaginal Devicegianvijolessajuneljunel fekaitlib fe oral tablet chewable 0.8‐25 mg‐mcgkariva tabKyleena Iudlevonorgestrel oral tablet 1.5 mglevora 0.15/30‐28Lo Loestrin Felomedia 24 tab femibelas 24 fe oral tablet chewable 1‐20 mg‐mcg(24)MirenaNataziaNexplanonnorethin‐eth estradiol‐fe oral tablet chewablenortrel 28 tabnortrel 7/7/7 tab 28 daysocellaOgestrel TabOmniflexParagardrivelsa oral tablet 42‐21‐21‐7 daysSkylaSlynd Oral Tablet 4 Mgsolia tab 0.15 mg‐30 mcgsprintec 28 tab 0.25 mg‐35 mcgtri‐legest fetrinessa lo oral tablet 0.18/0.215/0.25 mg‐25 mcgtrinessa tab 0.18‐35/0.215‐35/0.25‐35 mg‐mcgtrivora‐28Twirla Dis 120‐30velivet tab ��Seal Dpr Kitxulane transdermal patchPage 17Premium PlusFormulary 00BenefitNotesA; GA; GA; GA; GA; GA; GA; GA; GA; GA; G; STA; GA; GA; GA; GA; GA; G; STA; GA; GA; GA; GA; G; STA; GA; G; STA; GA; G; STA; GA; GA; GA; GA; GA; G; STA; GA; GA; G; STA; GA; G; STA; GA; GA; GA; G; STA; GA; GA; G; STA; GA; GA; GVentegra Premium Plus Formulary 2021
Drug CategoryLabel NamezoviaPremium Plus BenefitFormulary Tier Notes0A; GCorticosteroidsbudesonide capbudesonide oral tablet extended release 24 hour 9 mgdexamethasone 6 day oral tablet therapy pack 1.5 mg (21)dexamethasone elixirDexamethasone Tabdexamethasone tab 0.5 mgfludrocortisone acetate tabhydrocortisone tabmethylprednisolone tabmethylprednisolone tab therapy packprednisolone sodium phosphate sol 10mg/5mlprednisolone sodium phosphate sol 20mg/5mlprednisolone sodium phosph oral solnprednisolone solPrednisolone Sol 15Mg/5MlPrednisone Intensolprednisone oral tablet therapy pack 10 mgprednisone oral tablet therapy pack 5 mgprednisone pakprednisone tab12*2*12111112*2*11231111acetylcysteine inhal solnbenzonatate caphydrocode polst‐chlorphen polst er susp 10‐8 mg/5mlhydrocodone w/ homatropine syrupprometh/cod sol 6.25‐10promethazine sol dmpromethazine‐phenylephrine oral syrup 6.25‐5 mg/5mlpromethazine‐phenyleph‐codeine oral syrup 6.25‐5‐10 mg/5mlpseudoephed‐bromphen‐dm syrupsodium chloride soln nebuStahist Ad Tab 25‐60Mg1111112*2*112acitretin cap 10 mgacitretin cap 17.5mgacitretin cap 25 mgadapalene creamalclometasone dipropionate creamalclometasone dipropionate ointarzol silver nit applicators external miscellaneous 75‐25 %benzoyl peroxidebenzoyl peroxide‐erythromycin gelbetamethasone dipropionate augmented creambetamethasone dipropionate augmented ointbetamethasone dipropionate rmatologicalsPage 18QLQLQLVentegra Premium Plus Formulary 2021
Drug CategoryLabel Namebetamethasone dipropionate lotionbetamethasone dipropionate ointbetamethasone valerate creambetamethasone valerate lotionbetamethasone valerate ointcalcipotriene‐betamethasone dipropionate ointmentcalcipotriene‐betamethasone dipropionate susp 0.005‐0.064%ciclopirox olamine creamciclopirox solclindacin‐p external swab 1 %clindamycin lotionclindamycin phosphate external gel 1 %clindamycin phosphate‐benzoyl peroxide gelclindamycin solclobetasol creamclobetasol ointclobetasol solnclotrimazole creamclotrimazole w/ betamethasone creamdesonide creamdesonide gel 0.05%desoximetasone creamdesoximetasone cream 0.05%desoximetasone ointdesoximetasone oint 0.05%diclofenac geldiclofenac sodium solndiflorasone diacetate external ointment 0.05 %Drysol Sol 20%econazole nitrate creamerythromycin gelerythromycin solnfluocinolone acetonide creamfluocinolone acetonide ointfluocinonide creamfluocinonide emulsified base creamfluocinonide gelfluocinonide ointfluocinonide solnfluorouracil cream 5%flurandrenolide cream 0.05%flurandrenolide lotion 0.05%flurandrenolide ointment 0.05 %fluticasone propionate creamfluticasone propionate ointgentamicin creamgentamicin ointPage 19Premium Plus BenefitFormulary Tier 1111111112*12*1111Ventegra Premium Plus Formulary 2021
Drug CategoryLabel Namehalcinonide cre 0.1%halobetasol propionate creamhydrocortisone creamhydrocortisone ointimiquimod creamiodoquinol and hydrocortisone cream 1‐1.9%isotretinoin oral capsuleketoconazole creamketoconazole shampoolidocaine hcl creamlidocaine hcl external lotion 3 %lidocaine hcl solnlidocaine ointlidocaine padlidocaine‐prilocaine creamlocoid external lotion 0.1 %mafenide pak 5%Maxiflor Cream 0.05%metronidazole external gelmometasone furoate creammometasone furoate ointmometasone furoate solutionmupirocin calcium external cream 2 %mupirocin ointNaftifine Cre 1%naftifine gel 1%Naftin Gel 2%nystatin creamnystatin ointnystatin‐triamcinolone creamnystatin‐triamcinolone ointoxiconazole cre 1%permethrin creampimecrolimus cream 1%podofilox external solution 0.5 %Pramosone Oin 2.5%salicylic acid gel 6%salicylic acid‐cleanser external kit 6 % (lotion)selenium sulfide external shampoo 2.25 %selenium sulfide lotionselrx external shampoo 2.3 %silver sulfadiazine creamsulfacetamide sodium lotionsulfacetamide sodium w/ sulfur cleansing clothSulfamylon Cre 85Mg/Gmtacrolimus oin 0.03%tacrolimus oin 0.1%Page 20Premium Plus BenefitFormulary Tier 1112*12*A132*1112*11132*A2*AVentegra Premium Plus Formulary 2021
Drug CategoryLabel Nametavaborole sol 5%tretinoin creamtretinoin geltriamcinolone acetonide creamtriamcinolone acetonide lotiontriamcinolone acetonide ointtriamcinolone oin 0.05%urea 20 external lotion 20 %Premium Plus BenefitFormulary Tier Notes2*ST1A11112*1Diabetic SuppliesDexcom G6 ReceiverDexcom G6 SensorDexcom G6 TransmitterFreestyle Control Solution In Vitro LiquidFreestyle Freedom Lite Kit W/DeviceFreestyle Insulinx System KitFreestyle Insulinx Test Strips ‐ 100CtFreestyle Insulinx Test Strips ‐ 50CtFreestyle Lancets MiscellaneousFreestyle Libre 14 Day Reader DeviceFreestyle Libre 14 Day Sensor MiscellaneousFreestyle Libre Kit 2 SensorFreestyle Libre Mis 2 ReaderFreestyle Libre Reader DeviceFreestyle Libre Sensor System MiscellaneousFreestyle Lite DeviceFreestyle Lite Test Strips 100Freestyle Lite Test Strips 50CtFreestyle Precision Neo System Kit W/DeviceFreestyle Precision Neo Test In Vitro StripFreestyle Test Strips‐ 100CtFreestyle Test Strips‐ 50CtInsulin Pen NeedleInsulin SyringeInsulin Syringe/NeedleLancetsMedisense Mid Control In Vitro LiquidNovofine 32Gx6MmNovofine Autocover 30Gx8M MNovofine Pls Mis 32Gx4MmNovotwist 32Gx5Mm MiscPrecision Xtra Beta Ketone Test StripsPrecision Xtra DevicePrecision Xtra Test StripsRelion True Kit Met AirRelion True Test Metrix ‐ 100Relion True Tes Metrix ‐50Syringe / NeedlePage PAPAPAPAPAPAQLQLQLQLVentegra Premium Plus Formulary 2021
Drug CategoryLabel NameTrue Metrix Air Glucose Meter Kit W/DeviceTrue Metrix Blood Glucose Test Strip (100)True Metrix Blood Glucose Test Strip (50)True Metrix Meter Kit W/Devicetrueplus insulin syrg mis 0.3/29gtrueplus insulin syrg mis 0.3/30gtrueplus insulin syrg mis 0.3/31gtrueplus insulin syrg mis 0.5/28gtrueplus insulin syrg mis 0.5/29gtrueplus insulin syrg mis 0.5/30gtrueplus insulin syrg mis 0.5/31gtrueplus insulin syrg mis 1ml/28gtrueplus insulin syrg mis 1ml/29gtrueplus insulin syrg mis 1ml/30gtrueplus insulin syrg mis 1ml/31gtrueplus lancet mis 28gtrueplus lancet mis 30gtrueplus lancet mis 33gtrueplus pen needles mis 29gx12.7trueplus pen needles mis 31gx5mmtrueplus pen needles mis 31gx6mmtrueplus pen needles mis 31gx8mmtrueplus pen needles mis 32gx4mmPremium Plus BenefitFormulary Tier Notes2QL222QL1111111111111111111Digestive AidsCreon Oral CapsuleZenpep Oral Capsule22Diureticsacetazolamide capacetazolamide tabamiloride tabamiloride & hydrochlorothiazide tabbumetanide tabchlorthalidone tabethacrynic acid tab 25mgfurosemide oral solnfurosemide tabhydrochlorothiazide caphydrochlorothiazide tabindapamide tabmetolazone tabspironolactone & hydrochlorothiazide tabspironolactone tabtorsemid
Coverage for some drugs may be limited to specific dosage forms and/or strengths. Clinical edits such as quantity limits, . Advair Hfa 2QL albuterol sulfate hfa inhalation aerosol solution 1 QL albuterol sulfate
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MDwise Formulary Introduction – Hoosier Healthwise (HHW) HHW members must use MDwise network pharmacies to access their prescription drug benefit. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition Drugs in this formulary are grouped into categories depending on the type of medical
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Humulin N Kwikpen 2 Humulin N Subcutaneous Suspension 100 Unit/Ml 2 Humulin R Inj U‐100 2 Humulin R Inj U‐500 Concentrated 2 Humulin R U‐500 Kwikpen 2 Insulin Lisp Inj Junior 1 Insulin Lisp Inj Pro
Articulate with concept of Drug Formulary Understand the importance of drug formulary Describe how to read d rug formulary Understand the purpose of maintaining drug formulary Describe the concept of Current Index of Medical Specialties (CIMS) Know i mportance and u se of CIMS
Blue Cross Blue Shield of North Dakota Drug Formulary . January 2021 Please consider talking to your doctor about prescribing formulary medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The drug formulary is regularly updated.
inquiry-based instruction supported 5E learning cycle . In the instruction based on 5E learning cycle method, teaching and learning activities and lesson plans were designed to maximize students active involvement in the learning process. The topics included in the lesson plans were about the three units of fifth-grade sciences book; they included: hidden strangles (microbes, viruses, diseases .
