Post on 29-Sep-2018
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Formulario completo del 2016
Lista de medicamentos cubiertos
IMPORTANTE LEER: ESTE DOCUMENTO CONTIENE
INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS
EN ESTE PLAN
Formulary ID: 00016484, Version: 12
Este formulario se actualizó el 03/23/2016. Para obtener información más reciente o si
tiene preguntas, llame a Servicios al miembro de Denver Health Medical Plan, Inc.
al 1-877-956-2111. Los usuarios de TTY deben llamar al 711.
Nuestro horario de atención es de 8 a. m. a 8 p. m., los siete días de la
semana, o puede visitar www.denverhealthmedicalplan.org.
Nota para aquellos que ya son miembros:
Este formulario presenta cambios respecto del año pasado. Sírvase revisar
este documento para asegurarse de que todavía contenga los
medicamentos que usted toma. El Formulario puede cambiar en cualquier momento. Usted recibirá un aviso cuando sea necesario.
Esta información está disponible de manera gratuita en otros idiomas. Para obtener más información, llame a
nuestro departamento de Servicios al miembro al 303-602-2111 o al número gratuito 1-877-956-2111. Los
usuarios de TTY deben llamar al 711. Nuestro horario de atención es de 8 a. m. a 8 p. m. los siete días de la
semana.
This information is available for free in other languages. Please contact our Member Services department at
303-602-2111 or toll free at 1-877-956-2111 for more information. TTY users should call 711. Our hours of
operation are from 8 a.m. - 8 p.m. seven days a week.
Denver Health Medical Plan, Inc. es un plan HMO aprobado por Medicare y tiene un contrato con el
Colorado Medicaid Program. La inscripción en Denver Health Medical Plan, Inc. depende de la renovación
del contrato. H5608_1085 CF16_001_SP accepted
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Cuando en esta lista de medicamentos (formulario) figuran los términos “nosotros”, “a nosotros” o
“nuestro”, se hace referencia a Denver Health Medical Plan, Inc. Donde dice “plan” o “nuestro plan”,
significa Medicare Choice HMO SNP.
Este documento incluye una lista parcial de los medicamentos (formulario) de nuestro plan que está
en vigencia desde el April 01, 2016. Para obtener el formulario actualizado, comuníquese con nosotros.
Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario,
aparece en las páginas de portada y contraportada.
En general, usted debe utilizar farmacias de la red para utilizar su beneficio de medicamentos
recetados. Los beneficios, la lista de medicamentos, la red de farmacias, y/o los copagos/coseguro
pueden cambiar el 01 de enero 2017, y de vez en cuando durante el año.
¿Qué es el Formulario completo de Denver Health Medical Plan, Inc.?
Un formulario es una lista de medicamentos cubiertos seleccionados por nosotros en colaboración con un
equipo de proveedores de atención médica, que representa los tratamientos recetados que se consideran parte
necesaria de un programa de tratamiento de calidad. En general, cubriremos los medicamentos incluidos en
nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la receta se presente en
una farmacia de la red de Denver Health Medical Plan, Inc. y se sigan otras reglas del plan. Para obtener más
información sobre cómo obtener sus medicamentos recetados, revise su Evidencia de cobertura.
¿Puede el Formulario (lista de medicamentos) modificarse?
En general, si usted está tomando un medicamento de nuestro formulario del 2016 que estaba cubierto a
principios del año, no vamos a interrumpir ni a reducir la cobertura del medicamento durante el año de
cobertura 2016, excepto cuando un medicamento genérico nuevo y menos costoso esté disponible o se
publique nueva información adversa sobre la seguridad o eficacia de un medicamento. Otros tipos de
cambios en el formulario, tales como eliminar un medicamento de nuestro formulario, no afectarán a los
miembros que actualmente están tomando el medicamento. Permanecerá disponible al mismo costo
compartido durante el resto del año de cobertura para aquellos miembros que lo toman. Consideramos que es
importante que usted tenga acceso continuo durante el resto del año de cobertura a los medicamentos del
formulario que estaban disponibles cuando eligió nuestro plan, excepto por los casos en los que usted pudiera
ahorrar dinero adicional o nosotros podamos garantizar su seguridad.
Si eliminamos medicamentos de nuestro formulario o añadimos requisitos de autorización previa, límites
de cantidad o restricciones de terapia escalonada para un medicamento, debemos notificar a los miembros
afectados acerca del cambio al menos 60 días antes de que el cambio entre en vigencia o en el momento en
que el miembro solicite una renovación del medicamento, momento en el cual el miembro recibirá un
suministro para 60 días del medicamento. Si la Administración de Medicamentos y Alimentos considera
que un medicamento en nuestro formulario no es seguro o si el fabricante del medicamento retira el
medicamento del mercado, retiraremos inmediatamente el medicamento de nuestro formulario y
notificaremos a los miembros que toman el medicamento. El formulario adjunto tiene vigencia a partir del
April 01, 2016. Para obtener información actualizada sobre los medicamentos que cubrimos, comuníquese
con nosotros. Nuestra información de contacto aparece en las páginas de portada y contraportada.
Los futuros cambios en el formulario se le enviarán con su Explicación mensual de Beneficios de la Parte D.
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Si la Administración de Medicamentos y Alimentos considera que un medicamento en nuestro formulario no
es seguro o el fabricante del medicamento retira el medicamento del mercado, los miembros afectados
recibirán una notificación aparte. En nuestro sitio web, encontrará una lista de los futuros cambios que se
realizarán en el Formulario.
¿Cómo uso el Formulario?
Hay dos maneras de encontrar un medicamento en el formulario:
Afección médica
El formulario comienza en la página 13. Los medicamentos en este formulario están agrupados en
categorías que dependen del tipo de afección médica para la que se usan como tratamiento. Por ejemplo,
los medicamentos utilizados para tratar una afección cardíaca aparecen bajo la categoría “Agentes
cardiovasculares”. Si usted sabe para qué se usa su medicamento, busque el nombre de la categoría en la
lista que comienza en la página 13. Luego busque su medicamento en esa categoría.
Lista en orden alfabético
Si no sabe con certeza en qué categoría buscar, deberá buscar su medicamento en el Índice que comienza
en la página I-1. El Índice ofrece una lista en orden alfabético de todos los medicamentos incluidos en
este documento. Tanto los medicamentos de marca como los genéricos aparecen en el Índice. Busque en
el Índice y encuentre su medicamento. Junto a su medicamento, verá el número de página donde puede
encontrar información sobre la cobertura. Vaya a la página indicada en el Índice y busque el nombre de
su medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
Nuestro plan cubre tanto medicamentos de marca como genéricos. Un medicamento genérico está
aprobado por la FDA porque se considera que tiene los mismos ingredientes activos que el medicamento
de marca. En general, los medicamentos genéricos tienen un costo menor que los de marca.
¿Hay alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Estos requisitos
y límites pueden ser los siguientes:
Autorización previa: nuestro plan exige que usted o su médico obtengan una autorización previa
para obtener ciertos medicamentos. Esto significa que usted tendrá que obtener nuestra aprobación
antes de adquirir sus medicamentos recetados. Si usted no obtiene la aprobación, es posible que no
cubramos el medicamento.
Límites de cantidad: para ciertos medicamentos, limitamos la cantidad del medicamento que
cubriremos. Por ejemplo, nuestro plan ofrece 90 cápsulas por receta para LYRICA. Esto puede ser
además del suministro estándar de un mes o tres meses.
Terapia escalonada: en algunos casos, requerimos que para tratar su afección de salud, pruebe
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ciertos medicamentos primero antes de que aprobemos otro medicamento para tratar esa afección. Por
ejemplo, si el medicamento A y el medicamento B tratan su afección de salud, es posible que no
cubramos el medicamento B, a menos que usted pruebe el medicamento A primero. Si el medicamento
A no funciona para usted, cubriremos el Medicamento B.
Para averiguar si su medicamento tiene otros requisitos o límites adicionales, puede consultar el formulario
que comienza en la página 13. También puede visitar nuestro sitio web para obtener más información sobre
las restricciones que se aplican a un medicamento específico. Hemos publicado en línea documentos que
explican nuestras restricciones de autorización previa y de terapia escalonada. También puede solicitarnos
que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última vez que
actualizamos el formulario, aparece en las páginas de portada y contraportada.
Puede solicitarnos que hagamos una excepción a esas restricciones o límites o pedirnos una lista de otros
medicamentos similares para tratar su afección médica. Consulte la sección “¿Cómo puedo solicitar una
excepción respecto del formulario de Denver Health Medical Plan?” en la parte inferior de esta página
para obtener información sobre cómo solicitar una excepción.
¿Qué pasa si mi medicamento no figura en el Formulario?
Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), usted debe primero
comunicarse con Servicios al miembro y averiguar si su medicamento está cubierto.
Si usted se entera de que nuestro plan no cubre su medicamento, usted tiene dos opciones:
Puede solicitar a Servicios al miembro una lista de medicamentos similares que cubramos. Cuando
reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté
cubierto por nuestro plan.
Puede pedirnos que hagamos una excepción y que cubramos su medicamento. Consulte la
información que figura más abajo sobre cómo solicitar una excepción.
¿Cómo puedo solicitar una excepción respecto del formulario de Denver Health Medical
Plan, Inc.?
Puede pedirnos que hagamos una excepción respecto de nuestras reglas de cobertura. Hay varios tipos de
excepciones que usted puede solicitarnos que hagamos.
Puede pedirnos que cubramos un medicamento aunque no esté en nuestro formulario. Si
aprobamos su pedido, cubriremos este medicamento a un nivel de costo compartido
predeterminado, y usted no podrá solicitarnos que le proporcionemos el medicamento a un nivel
de costo compartido menor.
Puede pedirnos que anulemos las restricciones o los límites de cobertura de su medicamento. Por
ejemplo, para ciertos medicamentos, nuestro plan limita la cantidad de medicamento que cubriremos.
Si su medicamento tiene un límite de cantidad, usted puede pedirnos que anulemos el límite y
cubramos una cantidad mayor.
Generalmente, solo aprobaremos su solicitud de excepción si los medicamentos alternativos incluidos en el
formulario del plan, el medicamento con el nivel más bajo de costo compartido o las restricciones
adicionales de utilización no resultaran tan eficaces para tratar su afección o le causaran efectos de salud
adversos.
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Usted debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para obtener una
excepción respecto del formulario o de la restricción de utilización. Cuando usted solicita una excepción
respecto del formulario o de la restricción de utilización, debe presentar una declaración del
proveedor o médico, que respalde su solicitud. En general, debemos tomar una decisión dentro de las 72
horas de recibir la declaración de respaldo de su médico. Usted puede solicitar una excepción acelerada
(rápida) si usted o su médico creen que su salud podría verse seriamente afectada si espera las 72 horas que
lleva tomar la decisión. Si se le concede su petición de acelerar la decisión, debemos darle una decisión
a más tardar 24 horas después de recibir la declaración de respaldo de su médico u otro proveedor.
¿Qué debo hacer antes de que pueda hablar con mi médico acerca de cambiar mis
medicamentos o solicitar una excepción?
Como miembro nuevo o continuo en nuestro plan, usted puede tomar medicamentos que no están en nuestro
formulario. O bien, usted puede tomar un medicamento que está en nuestro formulario pero su capacidad
para obtenerlo es limitada. Por ejemplo, es posible que necesite una autorización previa de nuestra parte antes
de poder obtener su medicamento con receta. Usted debe hablar con su médico para decidir si debe cambiar
por otro medicamento apropiado que cubrimos o solicitar una excepción al formulario de modo que cubramos
el medicamento que toma. Mientras hable con su médico para determinar el curso de acción correcto para
usted, es posible que cubramos su medicamento en ciertos casos durante los primeros 90 días que usted sea
miembro de nuestro plan.
Por cada uno de sus medicamentos que no esté en nuestro formulario o si su capacidad para obtener sus
medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que usted tenga una
receta escrita por menos días) cuando vaya a una farmacia de la red. Después de su primer suministro para
30 días, no pagaremos por estos medicamentos, incluso si usted ha sido miembro del plan por menos de
90 días.
Si usted es residente de un centro de atención a largo plazo, permitiremos la renovación de su medicamento
recetado hasta que le hayamos proporcionado un suministro de transición para 91 días, coherente con el
incremento de dispensación, (a menos que tenga una receta escrita para menos días). Cubriremos más de una
renovación de estos medicamentos durante los primeros 90 días que usted sea miembro de nuestro plan. Si
necesita un medicamento que no está en nuestro formulario o si su capacidad para obtener sus medicamentos
es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de
emergencia para 31 días de ese medicamento (a menos usted tiene una receta escrita menos días) mientras
solicita una excepción al formulario.
Si experimenta un cambio en el nivel de atención, por ejemplo, se le interna en un centro de atención a
largo plazo o se le da el alta de este, y se encuentra fuera de sus primeros 90 días de cobertura, Denver
Health Medical Plan, Inc. proporcionará un suministro por única vez un los medicamentos de la Parte D
que no están en el formulario, como se describió anteriormente.
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Para obtener más información
Para obtener información más detallada sobre la cobertura de medicamentos recetados que ofrece nuestro
plan, consulte su Evidencia de cobertura y otros materiales del plan.
Si tiene preguntas sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto
con la fecha de la última vez que actualizamos el formulario, aparece en las páginas de portada y
contraportada.
Si tiene preguntas generales sobre la cobertura de Medicare para medicamentos recetados, puede llamar a
Medicare al 1-800- MEDICARE (1-800-633-4227) las 24 horas del día, los 7 días de la semana. Los
usuarios de TTY deben llamar al 1-877-486-2048. O bien, visite http://www.medicare.gov.
Formulario de Denver Health Medical Plan, Inc.
El formulario completo que comienza en la página 13 proporciona información sobre la cobertura de los
medicamentos cubiertos por nuestro plan. Si tiene inconvenientes para encontrar su medicamento en la
lista, consulte el Índice que comienza en la página I-1.
La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca están en
mayúsculas (por ejemplo, ADVAIR DISKUS) y los medicamentos genéricos aparecen en letra cursiva en
minúsculas con un nombre de medicamento de marca de referencia que aparece junto al nombre genérico del
fármaco (por ejemplo, amoxicilina (Amoxil)). Los medicamentos genéricos en cursiva con nombres de marca
de referencia entre paréntesis indican que sólo el medicamento genérico está en el formulario.
Durante la etapa inicial de su cobertura, su costo compartido será de 25% cuando obtenga un
medicamento recetado de la Parte D en una farmacia de la red. Si usted califica para recibir un
subsidio por bajos ingresos, su costo compartido por bajos ingresos dependerá del tipo de
medicamento que reciba. Si recibe un medicamento genérico, incluso un medicamento de marca que se
considere genérico, usted tendrá que pagar $0, $1.20 o $2.95, dependiendo de su nivel de subsidio.
Para medicamentos de marca y todos los demás, usted tendrá que pagar $ 0, $3.60 o $7.40,
dependiendo de su nivel de subsidio. Para obtener más información sobre sus responsabilidades de costo
compartido, consulte el Capítulo 6 de su Evidencia de cobertura.
La información en la columna de Requisitos/Límites le indica si Denver Health Medical Plan, Inc. tiene
algún requisito especial para la cobertura de su medicamento.
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Las siguientes abreviaturas pueden encontrarse en el cuerpo de este
documento.
ABREVIATURAS SOBRE NOTAS DE COBERTURA
ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
Restricciones sobre la Administración de la Utilización de Servicios
PA
Restricción de
autorización previa
previa
Usted (o su médico) tiene la obligación de obtener
autorización previa de Denver Health Medical Plan
(DHMP), Inc. antes de obtener el medicamento de su receta.
Sin autorización previa, Denver Health Medical Plan Inc. no
puede cubrir este medicamento.
PA BvD
Restricción de
autorización previa para
una determinación de
Parte B frente a Parte D
Este medicamento puede ser elegible para el pago bajo la
Parte B o la Parte D de Medicare. Usted (o su médico) tiene
la obligación de obtener una autorización previa de Denver
Health Medical Plan, Inc. para determinar que este
medicamento esté cubierto por la Parte D de Medicare antes
de obtener el medicamento indicado en su receta. Sin
autorización previa, Denver Health Medical Plan Inc. no
puede cubrir este medicamento.
PA-HRM
Restricción de
autorización previa
para medicamentos
de alto riesgo
Este medicamento ha sido considerado por CMS como
potencialmente perjudicial y, por lo tanto, como
medicamento de alto riesgo para los beneficiarios de
Medicare de 65 años o más. Los miembros de 65 años o
más tienen la obligación de obtener una autorización previa
de Denver Health Medical Plan, Inc. antes de obtener el
medicamento de su receta. Sin autorización previa, Denver
Health Medical Plan Inc. no puede cubrir este
medicamento.
PA NSO
Restricción de
autorización previa
para nuevos
miembros solamente
Si usted es un miembro nuevo o si usted no ha tomado este
medicamento antes, usted (o su médico) tiene la obligación
de obtener una autorización previa de Denver Health
Medical Plan, Inc. antes de obtener el medicamento que
figura en su receta. Sin aprobación previa, DHMP no
cubrirá este medicamento.
QL
Restricción de límite
de cantidad
Denver Health Medical Plan, Inc. establece un límite de
cobertura respecto de la cantidad de este medicamento por
receta o dentro de un marco de tiempo específico.
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ST
Restricción de terapia
escalonada
Antes de que Denver Health Medical Plan, Inc. proporcione
cobertura para este medicamento, usted debe primero probar
otro(s) medicamento(s) para el tratamiento de su afección
médica. Este medicamento sólo será cubierto si otro(s)
fármaco(s) no funciona(n) para usted.
LA
Medicamento de acceso
limitado
Es posible que este medicamento recetado sólo esté
disponible en algunas farmacias. Para obtener más
información, consulte su Directorio de farmacias o llame a
Servicios al miembro al 1-877-956-2111, de 8 a. m. a 8 p. m.
los siete días de la semana. Los usuarios de TTY deben
llamar al 711.
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ABREVIATURAS DE DOSIS Y PRESENTACIÓN
ABREVIATURA DESCRIPCIÓN
adh. patch parche adhesivo
aer br act aerosol, activado por aliento
aer pow aerosol, polvo
aer pow ba polvo aerosol, activado por aliento
aer refill repuesto de aerosol
aer w/adap aerosol con adaptador
ampul ampolla
blkbaginj inyección en bolsas a granel
cap dr mp cápsula, multifásica de liberación prolongada
cap ds pk cápsula, paquete de dosis
cap er 12h cápsula, 12 horas liberación prolongada
cap er 24h cápsula, 24 horas liberación prolongada
cap er deg cápsula, liberación prolongada degradable
cap er pel cápsula, pellets liberación prolongada
cap mphase cápsula, multifásica
cap.sa 24h cápsula, 24 horas liberación sostenida
cap.sr 12h cápsula, 12 horas liberación sostenida
cap.sr 24h cápsula, 24 horas liberación sostenida
cap24h pct cápsula, 24 horas pellets de inicio controlado
cap24h pel cápsula, 24 horas pellets liberación sostenida
cap sprink cápsula, esparcir
cap sr pel cápsula pellets liberación sostenida
cap w/dev cápsula con dispositivo
capsule dr cápsula, liberación retardada
capsule er cápsula, liberación prolongada
capsule sa cápsula, acción sostenida
cmb cappad combinación: cápsula, almohadilla
cmb ont fm combinación: ungüento, espuma
cmb ont lt combinación: ungüento, loción
cmb tabpad combinación: comprimido, almohadilla
combo. pkg paquete combinado
cpmp 12hr cápsula, 12 horas multifásica
cpmp 24hr cápsula, 24 horas multifásica
cpmp 30-70 cápsula, multifásica, 30%-70%
cpmp 50-50 cápsula, multifásica, 50%-50%
cream(g), cream(gm) crema (gramos)
cream(ml) crema (mililitros)
cream/appl crema con aplicador
cream, er (g) crema, liberación prolongada (gramos)
cream pack crema, paquete
dehp fr bg bolsa sin di(2-etilhexil) ftalato
dis needle aguja desechable
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ABREVIATURA DESCRIPCIÓN
disk w/dev disco con dispositivo para inhalación
disp syrin jeringa desechable
drops susp gotas, suspensión
drps hpvis gotas, hiperviscosas
emul adhes adhesivo emulsión
emul packt paquete de emulsión
emulsn(g) emulsión (gramos)
foam/appl. espuma con aplicador
froz.piggy accesorio congelado
g gramo
gel/pf app gel con aplicador precargado
gel (gm) gel (gramos)
gel (ml) gel (mililitros)
gel md pmp gel en bomba con dosis medida
gel w/appl gel con aplicador
gel w/pump gel con bomba
gran pack paquete de gránulos
hfa aer ad adaptador para aerosol hfahidrofluoroalcano
infus. btl frasco para infusión
insuln pen pluma de insulina
ip soln solución intraperitoneal
irrig soln solución de irrigación
iv soln. solución intravenosa
jel jalea
jelly/app jalea con aplicador
jel/pf app jalea con aplicador precargado
kit cl&crm kit: limpiador y crema
kt crm le kit: crema, loción emoliente
kt lotn ce kit: loción, crema emoliente
kt oint le kit: ungüento, loción emoliente
lotion, er loción, liberación prolongada
lozenge hd pastillas con soporte
m.ht patch parche de calor con medicamento
ma buc tab comprimidos bucales mucoadhesivos
mcg microgramo
med. pad almohadilla con medicamento
med. swab hisopo con medicamento
med. tape cinta adhesiva con medicamento
mg miligramo
ml mililitro
muc er 12h sistema mucoadhesivo, 12 horas liberación prolongada
ndl fr inj aguja para inyección
nl fm susp suspensión para cubierta de uñas
oint. (g), oint.(gm) ungüento (gramos)
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ABREVIATURA DESCRIPCIÓN
oral conc concentrado oral
oral susp suspensión oral
paste (g) pasta (gramos)
patch td24 parche, 24 horas transdérmico
patch td72 parche, 72 horas transdérmico
patch tdsw parche, 2 veces por semana transdérmico
patch tdwk parche, 1 vez por semana transdérmico
pca syring jeringa analgésica controlada por paciente
pca vial vial analgésico controlado por paciente
pellet(ea) pellet (cada uno)
pen ij kit kit con pluma para inyección
pen injctr pluma para inyección
pggybk btl frasco accesorio
plast. bag bolsa plástica
powd pack paquete de polvo
sol md pmp solución con bomba multidosis
sol w/appl solución con aplicador
sol/pf app solución con aplicador precargado
sol-gel solución, formadora de gel
soln recon solución, reconstituida
soln(gram) solución (gramos)
spray susp atomizador, suspensión
spray/pump atomizador con bomba
stick(ea) varilla (cada una)
supp.rect supositorio, rectal
supp.vag supositorio, vaginal
suppos. supositorio
sus er 24h suspensión, 24 horas liberación prolongada
sus er rec suspensión, reconstituida de liberación prolongada
sus mc rec suspensión, microcápsula reconstituida
suspdr pkt suspensión, paquete de liberación retardada
susp recon suspensión, reconstituida
syringekit kit de jeringa
tab chew comprimido, masticable
tab er 12h comprimido, 12 horas liberación prolongada
tab er 24h comprimido, 24 horas liberación prolongada
tab er prt comprimido, partículas de liberación prolongada
tab er seq comprimido, efectos de liberación prolongada de liberación prolongada tab disper comprimido, dispersable
tab ds pk comprimido, paquete de dosis
tab er 24 comprimido, 24 horas liberación prolongada
tab mphase comprimido, multifásico
tab part comprimido, partículas
tab rap dr comprimido, liberación retardada de desintegración rápida
12
ABREVIATURA DESCRIPCIÓN
tab rapdis comprimido, desintegración rápida
tab subl comprimido, sublingual
tab.sr 12h comprimido, 12 horas liberación sostenida
tab.sr 24h comprimido, 24 horas liberación sostenida
tabergr24hr comprimido, 24 horas liberación prolongada gradual
tablet dr comprimido, liberación retardada
tablet, er comprimido, liberación prolongada
tablet eff comprimido, efervescente
tablet sa comprimido, acción sostenida
tablet sol comprimido, soluble
tb er dspk comprimido, paquete de dosis de liberación prolongada
tb mp dspk comprimido, paquete de dosis multifásica
tb rd dspk comprimido, paquete de dosis de desintegración rápida
tbdspk 3mo comprimido, paquete de dosis de 3 meses
tbmp 12hr comprimido, 12 horas multifásico
tbmp 24hr comprimido, 24 horas multifásico
u unidad
vag ring anillo vaginal
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
13
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen-codeine 120 mg-12 mg/5
ml solution
(Acetaminophen with
Codeine)
1 QL (2700 per 30 days)
acetaminophen-codeine oral solution 300
mg-30 mg /12.5 ml
(Acetaminophen with
Codeine)
1 QL (2700 per 30 days)
acetaminophen-codeine oral tablet 300-15
mg, 300-30 mg
(Tylenol-Codeine No.3) 1 QL (360 per 30 days)
acetaminophen-codeine oral tablet 300-60
mg
(Tylenol-Codeine No.3) 1 QL (180 per 30 days)
ALLZITAL 1
BELBUCA 1 ST; QL (60 per 30 days)
buprenorphine hcl injection syringe (Buprenorphine HCl) 1
butalb-acetaminophen-caffeine oral
capsule 50-325-40 mg
(Esgic) 1 PA-HRM; QL (180 per
30 days)
butalbital-acetaminop-caf-cod (Fioricet with Codeine) 1 PA-HRM; QL (180 per
30 days)
butalbital-acetaminophen oral tablet 50-
325 mg
(Tencon) 1 PA-HRM; QL (180 per
30 days)
butalbital-acetaminophen-caff oral
capsule 50-325-40 mg
(Esgic) 1 PA-HRM; QL (180 per
30 days)
butalbital-acetaminophen-caff oral tablet
50-325-40 mg
(Esgic) 1 PA-HRM; QL (180 per
30 days)
butalbital-aspirin-caffeine oral capsule (Fiorinal) 1 PA-HRM; QL (180 per
30 days)
BUTRANS 1 QL (4 per 28 days)
codeine sulfate oral tablet (Codeine Sulfate) 1 QL (180 per 30 days)
codeine-butalbital-asa-caffein oral
capsule 30-50-325-40 mg
(Fiorinal with Codeine
#3)
1 PA-HRM; QL (180 per
30 days)
fentanyl (Duragesic) 1 PA; QL (10 per 30 days)
fentanyl citrate (Actiq) 1 PA; QL (120 per 30
days)
hydrocodone-acetaminophen oral solution
10-325 mg/15 ml(15 ml), 2.5-167 mg/5 ml,
7.5-325 mg/15 ml
(Hycet) 1 QL (2700 per 30 days)
hydrocodone-acetaminophen oral tablet
10-300 mg, 5-300 mg, 7.5-300 mg
(Norco) 1 (includes Vicodin,
Vicodin ES and Vicodin
HP); QL (390 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
14
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
hydrocodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
(Norco) 1 QL (360 per 30 days)
hydrocodone-ibuprofen (Ibudone) 1 QL (150 per 30 days)
hydromorphone (pf) injection solution 10
mg/ml
(Dilaudid-HP) 1
hydromorphone (pf) injection solution 4
mg/ml
(Dilaudid) 1
hydromorphone injection solution (Hydromorphone HCl) 1
hydromorphone injection syringe 2 mg/ml (Hydromorphone HCl) 1
hydromorphone oral liquid (Dilaudid) 1 QL (1200 per 30 days)
hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) 1 QL (180 per 30 days)
hydromorphone oral tablet 8 mg (Dilaudid) 1 QL (240 per 30 days)
LAZANDA 1 PA; QL (30 per 30 days)
methadone hcl oral tablet,soluble 40 mg (Diskets) 1 QL (90 per 30 days)
methadone injection (Methadone HCl) 1
methadone oral solution (Methadone HCl) 1 QL (1800 per 30 days)
methadone oral tablet (Diskets) 1 QL (360 per 30 days)
morphine (pf) in 0.9 % nacl intravenous pt
controlled analgesia syring 50 mg/25 ml
(2 mg/ml)
(Morphine Sulfate/0.9%
Nacl/PF)
1
morphine 10 mg/ml carpuject (Morphine Sulfate) 1
morphine 2 mg/ml carpuject (Morphine Sulfate) 1
morphine 4 mg/ml carpuject (Morphine Sulfate) 1
morphine 8 mg/ml syringe (Morphine Sulfate) 1
morphine concentrate oral solution (Morphine Sulfate) 1 QL (200 per 30 days)
morphine concentrate oral syringe (Morphine Sulfate) 1
morphine in dextrose 5 % injection pt
controlled analgesia syring
(Morphine
Sulfate/D5W)
1
morphine injection solution 15 mg/ml, 8
mg/ml
(Morphine Sulfate) 1
morphine injection syringe 10 mg/ml (Morphine Sulfate) 1
morphine intramuscular (Morphine Sulfate) 1
morphine intravenous cartridge 15 mg/ml (Morphine Sulfate) 1
morphine intravenous solution 25 mg/ml,
50 mg/ml
(Morphine Sulfate) 1
morphine intravenous syringe (Morphine Sulfate) 1
morphine oral solution 10 mg/5 ml (Morphine Sulfate) 1 QL (700 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
15
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
morphine oral solution 20 mg/5 ml (Morphine Sulfate) 1 QL (300 per 30 days)
MORPHINE ORAL TABLET 1 QL (180 per 30 days)
morphine oral tablet extended release 100
mg, 30 mg, 60 mg
(MS Contin) 1 QL (120 per 30 days)
morphine oral tablet extended release 15
mg, 200 mg
(MS Contin) 1 QL (180 per 30 days)
morphine rectal (Morphine Sulfate) 1
NUCYNTA 1 QL (181 per 30 days)
NUCYNTA ER 1 QL (60 per 30 days)
oxycodone hcl-acetaminophen oral
solution 5-325 mg/5 ml
(Oxycodone
HCl/Acetaminophen)
1 QL (1800 per 30 days)
oxycodone hcl-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
(Xolox) 1 QL (360 per 30 days)
oxycodone hcl-aspirin (Percodan) 1 QL (360 per 30 days)
oxycodone oral concentrate (Oxycodone HCl) 1 QL (180 per 30 days)
oxycodone oral solution (Oxycodone HCl) 1 QL (1300 per 30 days)
oxycodone oral tablet (Roxicodone) 1 QL (180 per 30 days)
oxycodone-acetaminophen oral tablet 10-
325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
(Xolox) 1 QL (360 per 30 days)
oxycodone-acetaminophen oral tablet 10-
650 mg
(Xolox) 1 QL (180 per 30 days)
oxycodone-acetaminophen oral tablet 7.5-
500 mg
(Xolox) 1 QL (240 per 30 days)
oxycodone-aspirin (Percodan) 1 QL (360 per 30 days)
OXYCONTIN ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG, 15 MG,
20 MG, 30 MG, 40 MG, 60 MG
1 QL (60 per 30 days)
OXYCONTIN ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 80 MG
1 QL (120 per 30 days)
oxymorphone oral tablet (Opana) 1 QL (180 per 30 days)
oxymorphone oral tablet extended release
12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
(Opana ER) 1 QL (60 per 30 days)
oxymorphone oral tablet extended release
12 hr 30 mg, 40 mg
(Opana ER) 1 QL (120 per 30 days)
tramadol oral tablet (Ultram) 1 QL (240 per 30 days)
tramadol-acetaminophen (Ultracet) 1 QL (240 per 30 days)
xylon 10 (Ibudone) 1 QL (150 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
16
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
Nonsteroidal Anti-Inflammatory
Agents
CALDOLOR INTRAVENOUS RECON
SOLN 400 MG/4 ML (100 MG/ML)
1
celecoxib (Celebrex) 1 QL (60 per 30 days)
choline,magnesium salicylate (Choline Sal/Mag
Salicylate)
1
diclofenac potassium (Diclofenac Potassium) 1
diclofenac sodium oral tablet extended
release 24 hr
(Voltaren-XR) 1
diclofenac sodium oral tablet,delayed
release (dr/ec)
(Diclofenac Sodium) 1
diclofenac sodium topical gel (Solaraze) 1
diclofenac-misoprostol (Arthrotec 50) 1
diflunisal (Diflunisal) 1
etodolac (Etodolac) 1
fenoprofen oral tablet (Fenoprofen Calcium) 1
FLECTOR 1 PA
flurbiprofen (Flurbiprofen) 1
ibuprofen oral suspension (Ibuprofen) 1
ibuprofen oral tablet 400 mg, 600 mg, 800
mg
(Ibuprofen) 1
indomethacin oral capsule 25 mg (Indomethacin) 1 PA-HRM; QL (240 per
30 days)
indomethacin oral capsule 50 mg (Indomethacin) 1 PA-HRM; QL (120 per
30 days)
indomethacin oral capsule, extended
release
(Indomethacin) 1 PA-HRM; QL (60 per 30
days)
indomethacin sodium (Indomethacin Sodium) 1 PA-HRM
ketoprofen oral capsule (Ketoprofen) 1
ketoprofen oral capsule,ext rel. pellets 24
hr 200 mg
(Ketoprofen) 1
ketorolac oral (Ketorolac
Tromethamine)
1 QL (20 per 30 days)
mefenamic acid (Ponstel) 1
meloxicam (Mobic) 1
nabumetone (Nabumetone) 1
naproxen oral suspension (Naprosyn) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
17
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
naproxen oral tablet (Naprosyn) 1
naproxen oral tablet,delayed release
(dr/ec)
(Ec-Naprosyn) 1
naproxen sodium oral tablet 275 mg, 550
mg
(Anaprox) 1
piroxicam (Feldene) 1
salsalate (Salsalate) 1
sulindac oral (Sulindac) 1
tolmetin (Tolmetin Sodium) 1
VOLTAREN TOPICAL 1
Anesthetics
Local Anesthetics
glydo (Lidocaine HCl) 1
lidocaine (pf) injection solution 15 mg/ml
(1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)
(Xylocaine-MPF) 1 (PA for ESRD Only)
lidocaine 2% viscous soln 2 % (Xylocaine) 1
lidocaine hcl injection solution 10 mg/ml
(1 %), 20 mg/ml (2 %)
(Xylocaine) 1 (PA for ESRD Only)
lidocaine hcl laryngotracheal (Xylocaine) 1
lidocaine hcl mucous membrane gel (Lidocaine HCl) 1
lidocaine hcl mucous membrane jelly in
applicator
(Lidocaine HCl) 1
lidocaine hcl mucous membrane solution (Xylocaine) 1
lidocaine hcl urethral (Lidocaine HCl) 1
lidocaine topical adhesive
patch,medicated
(Lidoderm) 1 PA
lidocaine topical ointment (Lidocaine) 1 (PA for ESRD Only)
lidocaine-prilocaine topical cream (EMLA) 1 (PA for ESRD Only)
lidocaine-prilocaine topical kit (Relador Pak) 1 (PA for ESRD Only)
RELADOR PAK 1 (PA for ESRD Only)
Anti-Addiction/Substance Abuse
Treatment Agents
Anti-Addiction/Substance Abuse
Treatment Agents
acamprosate (Acamprosate Calcium) 1
buprenorphine hcl sublingual (Buprenorphine HCl) 1 PA; QL (90 per 30 days)
buprenorphine-naloxone (Buprenorphine
HCl/Naloxone HCl)
1 PA; QL (90 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
18
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
bupropion hcl sr 150 mg tablet f/c (Zyban) 1
CHANTIX 1 QL (168 per 84 days)
CHANTIX CONTINUING MONTH
BOX
1 QL (168 per 84 days)
CHANTIX STARTING MONTH BOX 1 QL (53 per 28 days)
disulfiram (Antabuse) 1
naloxone (Naloxone HCl) 1
naltrexone oral (Revia) 1
NICOTROL 1 QL (1008 per 90 days)
ZUBSOLV 1 PA; QL (90 per 30 days)
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet (Xanax) 1 QL (120 per 30 days)
chlordiazepoxide hcl (Chlordiazepoxide HCl) 1 QL (120 per 30 days)
clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) 1 QL (90 per 30 days)
clonazepam oral tablet 2 mg (Klonopin) 1 QL (300 per 30 days)
clonazepam oral tablet,disintegrating
0.125 mg, 0.25 mg, 0.5 mg, 1 mg
(Clonazepam) 1 QL (90 per 30 days)
clonazepam oral tablet,disintegrating 2
mg
(Clonazepam) 1 QL (300 per 30 days)
clorazepate dipotassium oral tablet 15 mg (Tranxene T-Tab) 1 QL (120 per 30 days)
clorazepate dipotassium oral tablet 3.75
mg, 7.5 mg
(Tranxene T-Tab) 1 QL (60 per 30 days)
diazepam injection solution 1 QL (10 per 28 days)
diazepam intensol (Diazepam) 1 QL (1200 per 30 days)
diazepam oral solution 5 mg/5 ml (1
mg/ml)
(Diazepam) 1 QL (1200 per 30 days)
diazepam oral tablet (Valium) 1 QL (120 per 30 days)
diazepam rectal (Diastat) 1
lorazepam oral tablet (Ativan) 1 QL (90 per 30 days)
ONFI ORAL SUSPENSION 1 PA NSO; QL (480 per 30
days)
Antibacterials
Aminoglycosides
BETHKIS 1 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
19
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
gentamicin in nacl (iso-osm) intravenous
piggyback 100 mg/100 ml, 100 mg/50 ml,
60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml,
80 mg/50 ml, 90 mg/100 ml
(Gentamicin In Nacl,
Iso-Osm)
1
gentamicin injection solution 40 mg/ml (Gentamicin Sulfate) 1
gentamicin ped 20 mg/2 ml vial
25's,pedi,latex-free
(Gentamicin Sulfate/PF) 1
gentamicin sulfate (pf) intravenous
solution 80 mg/8 ml
(Gentamicin Sulfate/PF) 1
neomycin (Neomycin Sulfate) 1
streptomycin intramuscular (Streptomycin Sulfate) 1
TOBI PODHALER INHALATION
CAPSULE, W/INHALATION DEVICE
1 QL (224 per 28 days)
tobramycin in 0.225 % nacl (Tobi) 1 PA BvD
tobramycin in 0.9 % nacl (Tobramycin/Sodium
Chloride)
1
tobramycin sulfate injection solution (Tobramycin Sulfate) 1
Antibacterials, Miscellaneous
bacitracin intramuscular (Bacitracin) 1
chloramphenicol sod succinate (Chloramphenicol Sod
Succ)
1
clindamycin 75 mg/5 ml soln (Cleocin Palmitate) 1
clindamycin hcl (Cleocin HCl) 1
clindamycin in 5 % dextrose (Cleocin Phosphate In
D5w)
1
clindamycin ph 9 g/60 ml vial bulk vial (Cleocin Phosphate) 1
clindamycin phosphate intravenous
solution 600 mg/4 ml
(Cleocin Phosphate) 1
colistin (colistimethate na) (Coly-Mycin M
Parenteral)
1
CUBICIN 1
linezolid (Zyvox) 1
methenamine hippurate (Hiprex) 1
methenamine mandelate (Methenamine
Mandelate)
1
metronidazole in nacl (iso-os) (Metronidazole/Sodium
Chloride)
1
metronidazole oral (Flagyl) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
20
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
nitrofurantoin macrocrystal oral capsule
100 mg, 25 mg
(Macrodantin/Macrobid) 1 PA-HRM; QL (120 per
30 days)
nitrofurantoin macrocrystal oral capsule
50 mg
(Macrodantin/Macrobid) 1 PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs); QL
(120 per 30 days)
nitrofurantoin monohyd/m-cryst (Macrobid) 1 PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs); QL
(120 per 30 days)
polymyxin b sulfate (Polymyxin B Sulfate) 1
SYNERCID 1
trimethoprim (Trimethoprim) 1
vancomycin hcl 1g/200 ml bag (Vancomycin
HCl/D5W)
1
vancomycin intravenous recon soln 1,000
mg, 10 gram, 750 mg
(Vancomycin HCl) 1
vancomycin intravenous recon soln 500
mg
(Vancomycin
HCl/D5W)
1
vancomycin oral (Vancocin HCl) 1
XIFAXAN ORAL TABLET 200 MG 1 PA; QL (9 per 30 days)
XIFAXAN ORAL TABLET 550 MG 1 PA
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION
1
Cephalosporins
cefaclor oral capsule (Cefaclor) 1
cefaclor oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
(Cefaclor) 1
cefadroxil oral capsule (Cefadroxil) 1
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500 mg/5 ml
(Cefadroxil) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
21
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
cefadroxil oral tablet (Cefadroxil) 1
CEFAZOLIN IN DEXTROSE (ISO-OS)
INTRAVENOUS PIGGYBACK 1
GRAM/50 ML
1
cefazolin in dextrose (iso-os) intravenous
piggyback 2 gram/50 ml
(Cefazolin
Sodium/Dextrose, Iso)
1
cefazolin injection recon soln 1 gram, 10
gram, 100 gram, 300 g, 500 mg
(Cefazolin Sodium) 1
cefdinir (Cefdinir) 1
cefditoren pivoxil (Spectracef) 1
cefepime (Maxipime) 1
CEFEPIME 2 GM INJECTION 1
CEFEPIME IN DEXTROSE 5 % 1
cefotaxime (Claforan) 1
cefoxitin (Cefoxitin Sodium) 1
cefoxitin in dextrose, iso-osm intravenous
piggyback 2 gram/50 ml
(Cefoxitin
Sodium/Dextrose, Iso)
1
cefpodoxime (Cefpodoxime Proxetil) 1
cefprozil (Cefprozil) 1
ceftazidime injection recon soln 2 gram, 6
gram
(Fortaz) 1
ceftibuten (Cedax) 1
ceftriaxone 1 gm piggyback 50ml
galaxycontainer
(Ceftriaxone
Na/Dextrose, Iso)
1
ceftriaxone 1 gm vial 10's, fliptop,l/f (Rocephin) 1
CEFTRIAXONE 2 GM PIGGYBACK
50ML GALAXYCONTAINER
1
ceftriaxone injection recon soln 10 gram,
250 mg, 500 mg
(Rocephin) 1
ceftriaxone intravenous recon soln 1 gram (Ceftriaxone
Na/Dextrose, Iso)
1
CEFTRIAXONE INTRAVENOUS
RECON SOLN 2 GRAM
1
cefuroxime axetil oral tablet (Ceftin) 1
cefuroxime sodium injection recon soln
1.5 gram, 750 mg
(Zinacef) 1
cefuroxime sodium intravenous (Zinacef) 1
cephalexin oral capsule (Keflex) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
22
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
cephalexin oral suspension for
reconstitution
(Cephalexin) 1
cephalexin oral tablet (Cephalexin) 1
MEFOXIN IN DEXTROSE (ISO-OSM) 1
SUPRAX ORAL TABLET,CHEWABLE 1
TEFLARO 1
Macrolides
azithromycin (Zithromax) 1
clarithromycin oral suspension for
reconstitution
(Biaxin) 1
clarithromycin oral tablet (Biaxin) 1
clarithromycin oral tablet extended
release 24 hr
(Clarithromycin) 1
DIFICID 1 QL (20 per 10 days)
ERYTHROCIN 1
erythromycin base oral tablet,delayed
release (dr/ec) 250 mg, 500 mg
(Erythromycin Base) 1
ERYTHROMYCIN BASE ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
1
erythromycin ethylsuccinate oral
suspension for reconstitution 200 mg/5 ml
(Eryped 200) 1
erythromycin ethylsuccinate oral tablet (Erythromycin
Ethylsuccinate)
1
erythromycin oral capsule,delayed
release(dr/ec)
(Erythromycin Base) 1
erythromycin oral tablet (Erythromycin Base) 1
erythromycin stearate oral tablet 250 mg (Erythromycin Stearate) 1
Miscellaneous B-Lactam
Antibiotics
aztreonam injection recon soln 1 gram (Azactam) 1
CAYSTON 1 LA
imipenem-cilastatin (Primaxin) 1
INVANZ INJECTION 1
meropenem intravenous recon soln 500
mg
(Merrem) 1
meropenem iv 1 gm vial outer, latex-free (Merrem) 1
Penicillins
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
23
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
amoxicillin oral capsule (Amoxicillin) 1
amoxicillin oral suspension for
reconstitution
(Amoxicillin) 1
amoxicillin oral tablet (Amoxicillin) 1
amoxicillin oral tablet,chewable 125 mg,
250 mg
(Amoxicillin) 1
amoxicillin-pot clavulanate oral
suspension for reconstitution
(Augmentin) 1
amoxicillin-pot clavulanate oral tablet (Augmentin) 1
amoxicillin-pot clavulanate oral tablet
extended release 12 hr
(Augmentin XR) 1
amoxicillin-pot clavulanate oral
tablet,chewable
(Amoxicillin/Potassium
Clav)
1
ampicillin (Ampicillin Trihydrate) 1
ampicillin 2 gm vial 10's, latex-free (Ampicillin Sodium) 1
ampicillin sodium injection recon soln 1
gram, 10 gram, 125 mg
(Ampicillin Sodium) 1
ampicillin sodium intravenous recon soln
2 gram
(Ampicillin Sodium) 1
ampicillin-sulbactam 1.5 gm vl p/f, latex-
free
1
ampicillin-sulbactam injection recon soln
15 gram
(Unasyn) 1
ampicillin-sulbactam injection recon soln
3 gram
1
ampicillin-sulbactam intravenous recon
soln 1.5 gram
1
BICILLIN C-R 1
BICILLIN L-A 1
dicloxacillin (Dicloxacillin Sodium) 1
nafcillin 2 gm vial sterile, latex-free (Nafcillin Sodium) 1
nafcillin injection recon soln 1 gram, 10
gram
(Nafcillin Sodium) 1
nafcillin intravenous recon soln 2 gram (Nafcillin Sodium) 1
oxacillin 1 gm add-vantage vl add-
vantage, inner
(Oxacillin Sodium) 1
oxacillin in dextrose(iso-osm) (Oxacillin
Sodium/Dextrose, Iso)
1
oxacillin injection recon soln 10 gram (Oxacillin Sodium) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
24
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
oxacillin intravenous recon soln 2 gram (Oxacillin Sodium) 1
penicillin g pot in dextrose (Pen G Pot/Dextrose-
Water)
1
penicillin g potassium injection recon soln
20 million unit, 5 million unit
(Penicillin G Potassium) 1
penicillin g procaine (Penicillin G Procaine) 1
penicillin gk 20 million unit (Penicillin G Potassium) 1
penicillin v potassium (Penicillin V Potassium) 1
piperacillin-tazobactam intravenous recon
soln 2.25 gram, 3.375 gram, 4.5 gram
(Zosyn) 1
piperacil-tazobact 40.5 gram p/f,
pharmacy bulk
(Zosyn) 1
Quinolones
ciprofloxacin (Cipro) 1
ciprofloxacin 200 mg/20 ml vl sdv,latex-
free
(Ciprofloxacin Lactate) 1
ciprofloxacin hcl oral (Cipro) 1
ciprofloxacin in 5 % dextrose intravenous
piggyback 200 mg/100 ml
(Cipro I.V.) 1
ciprofloxacin lactate intravenous solution
400 mg/40 ml
(Ciprofloxacin Lactate) 1
ciprofloxacn-d5w 400 mg/200 ml
p/f,latex/f, in d5w
(Cipro I.V.) 1
levofloxacin in d5w intravenous piggyback
500 mg/100 ml
(Levaquin) 1
levofloxacin intravenous (Levofloxacin) 1
levofloxacin oral (Levaquin) 1
levofloxacin-d5w 750 mg/150 ml
24's,outer, p/f
(Levaquin) 1
moxifloxacin (Avelox) 1
ofloxacin oral tablet 400 mg (Ofloxacin) 1
Sulfonamides
sulfadiazine oral (Sulfadiazine) 1
sulfamethoxazole-trimethoprim
intravenous
(Sulfamethoxazole/Trim
ethoprim)
1
sulfamethoxazole-trimethoprim oral
suspension
(Sulfamethoxazole/Trim
ethoprim)
1
sulfamethoxazole-trimethoprim oral tablet (Bactrim) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
25
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
sulfasalazine dr 500 mg tab (Azulfidine) 1
sulfasalazine oral tablet (Azulfidine) 1
sulfatrim (Sulfamethoxazole/Trim
ethoprim)
1
sulfazine ec (Azulfidine) 1
Tetracyclines
doxy 100 vial 10's, p/f 100 mg (Doxycycline Hyclate) 1
doxycycline hyclate 100 mg cap (Morgidox) 1
doxycycline hyclate 100 mg tab f/c (Doryx) 1
doxycycline hyclate intravenous (Doxycycline Hyclate) 1
doxycycline hyclate oral capsule 100 mg (Adoxa) 1
doxycycline hyclate oral capsule 50 mg (Morgidox) 1
doxycycline hyclate oral tablet 100 mg, 50
mg
(Avidoxy) 1
doxycycline hyclate oral tablet 20 mg (Doryx) 1
doxycycline mono 100 mg cap (Adoxa) 1
doxycycline mono 100 mg tablet f/c (Avidoxy) 1
doxycycline mono 50 mg tablet (Avidoxy) 1
doxycycline monohydrate oral capsule 150
mg, 50 mg, 75 mg
(Adoxa) 1
doxycycline monohydrate oral suspension
for reconstitution
(Vibramycin) 1
doxycycline monohydrate oral tablet 150
mg, 75 mg
(Avidoxy) 1
minocycline oral capsule (Minocin) 1
minocycline oral tablet (Minocycline HCl) 1
tetracycline (Tetracycline HCl) 1
TYGACIL 1
Anticancer Agents
Anticancer Agents
ABRAXANE 1
ADCETRIS 1 PA NSO; QL (4 per 21
days)
adrucil 2,500 mg/50 ml vial outer, latex-
free 2.5 gram/50 ml
(Fluorouracil) 1 PA BvD
AFINITOR DISPERZ 1 PA NSO; QL (112 per 28
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
26
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
AFINITOR ORAL TABLET 10 MG 1 PA NSO; QL (56 per 28
days)
AFINITOR ORAL TABLET 2.5 MG, 5
MG, 7.5 MG
1 PA NSO; QL (28 per 28
days)
ALECENSA 1 PA NSO; QL (240 per 30
days)
ALIMTA INTRAVENOUS RECON
SOLN 500 MG
1
anastrozole (Arimidex) 1
AVASTIN 1 PA NSO
azacitidine (Vidaza) 1
BELEODAQ 1 PA NSO
BENDEKA 1 PA NSO
bexarotene (Targretin) 1 PA NSO; QL (420 per 30
days)
bicalutamide (Casodex) 1
bleomycin injection recon soln 30 unit (Bleomycin Sulfate) 1 PA BvD
bleomycin sulfate 15 unit vial latex-free (Bleomycin Sulfate) 1 PA BvD
BLINCYTO 1 PA NSO; QL (140 per
365 days)
BOSULIF ORAL TABLET 100 MG 1 PA NSO; QL (120 per 30
days)
BOSULIF ORAL TABLET 500 MG 1 PA NSO; QL (30 per 30
days)
CAPRELSA ORAL TABLET 100 MG 1 PA NSO; QL (60 per 30
days)
CAPRELSA ORAL TABLET 300 MG 1 PA NSO; QL (30 per 30
days)
COMETRIQ 1 PA NSO; QL (112 per 28
days)
COTELLIC 1 PA NSO; LA; QL (63
per 28 days)
cyclophosphamide intravenous recon soln
2 gram
(Cyclophosphamide) 1 PA BvD
CYCLOPHOSPHAMIDE ORAL
CAPSULE
1 PA BvD; ST
cyclophosphamide oral tablet (Cyclophosphamide) 1 PA BvD; ST
CYRAMZA 1 PA NSO
dactinomycin (Dactinomycin) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
27
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
DARZALEX 1 PA NSO; LA
decitabine (Dacogen) 1
doxorubicin hcl intravenous recon soln 10
mg, 20 mg, 50 mg
(Doxorubicin HCl) 1 PA BvD
doxorubicin hcl intravenous solution 10
mg/5 ml
(Doxorubicin HCl) 1 PA BvD
doxorubicin hcl peg-liposomal intravenous
suspension 2 mg/ml
(Doxil) 1 PA BvD
doxorubicin, peg-liposomal (Doxil) 1 PA BvD
DROXIA 1
ELIGARD SUBCUTANEOUS SYRINGE
22.5 MG (3 MONTH)
1 QL (1 per 84 days)
ELIGARD SUBCUTANEOUS SYRINGE
30 MG (4 MONTH)
1 QL (1 per 112 days)
ELIGARD SUBCUTANEOUS SYRINGE
45 MG (6 MONTH)
1 QL (1 per 168 days)
ELIGARD SUBCUTANEOUS SYRINGE
7.5 MG (1 MONTH)
1
EMCYT 1
EMPLICITI 1 PA NSO
ERIVEDGE 1 PA NSO; QL (30 per 30
days)
ETOPOPHOS 1
etoposide intravenous (Etoposide) 1
exemestane (Aromasin) 1
FARESTON 1
FARYDAK 1 PA NSO
FASLODEX 1
floxuridine (Floxuridine) 1 PA BvD
fluorouracil 5,000 mg/100 ml latex-free (Fluorouracil) 1 PA BvD
fluorouracil intravenous solution 2.5
gram/50 ml, 500 mg/10 ml
(Fluorouracil) 1 PA BvD
flutamide (Flutamide) 1
GAZYVA 1 PA NSO
GILOTRIF 1 PA NSO; QL (30 per 30
days)
GLEEVEC ORAL TABLET 100 MG 1 PA NSO; QL (90 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
28
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
GLEEVEC ORAL TABLET 400 MG 1 PA NSO; QL (60 per 30
days)
GLEOSTINE ORAL CAPSULE 10 MG,
100 MG, 40 MG
1
HERCEPTIN 1 PA NSO
HEXALEN 1
hydroxyurea (Hydrea) 1
IBRANCE 1 PA NSO; QL (21 per 28
days)
ICLUSIG ORAL TABLET 15 MG 1 PA NSO; QL (60 per 30
days)
ICLUSIG ORAL TABLET 45 MG 1 PA NSO; QL (30 per 30
days)
ifosfamide 1 gm/20 ml vial sd polymer vial (Ifex) 1 PA BvD
ifosfamide intravenous recon soln 1 gram (Ifex) 1 PA BvD
ifosfamide-mesna (Ifosfamide/Mesna) 1 PA BvD
IMBRUVICA 1 PA NSO
IMLYGIC INJECTION SUSPENSION
10EXP6 (1 MILLION) PFU/ML
1 PA NSO; QL (4 per 365
days)
IMLYGIC INJECTION SUSPENSION
10EXP8 (100 MILLION) PFU/ML
1 PA NSO; QL (8 per 28
days)
INLYTA ORAL TABLET 1 MG 1 PA NSO; QL (180 per 30
days)
INLYTA ORAL TABLET 5 MG 1 PA NSO; QL (60 per 30
days)
IRESSA 1 PA NSO; QL (60 per 30
days)
IXEMPRA 15 MG KIT WITH DILUENT 1
IXEMPRA INTRAVENOUS RECON
SOLN 45 MG
1
JAKAFI 1 PA NSO; QL (60 per 30
days)
KEYTRUDA 100 MG/4 ML VIAL
LATEX-FREE,P/F,INNER
1 PA NSO
KEYTRUDA INTRAVENOUS RECON
SOLN
1 PA NSO
KYPROLIS 1 PA NSO; QL (6 per 28
days)
LENVIMA 1 PA NSO
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
29
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
letrozole (Femara) 1
LEUKERAN 1
leuprolide subcutaneous kit (Leuprolide Acetate) 1
lomustine (Lomustine) 1
LONSURF ORAL TABLET 15-6.14 MG 1 PA NSO; QL (100 per 28
days)
LONSURF ORAL TABLET 20-8.19 MG 1 PA NSO; QL (80 per 28
days)
LUPRON DEPOT 1
LUPRON DEPOT (3 MONTH) 1 QL (1 per 84 days)
LUPRON DEPOT (4 MONTH) 1 QL (1 per 84 days)
LUPRON DEPOT (6 MONTH) 1 QL (1 per 168 days)
LYNPARZA 1 PA NSO; QL (480 per 30
days)
LYSODREN 1
MATULANE 1
megestrol oral tablet (Megestrol Acetate) 1
MEKINIST ORAL TABLET 0.5 MG 1 PA NSO; QL (90 per 30
days)
MEKINIST ORAL TABLET 2 MG 1 PA NSO; QL (30 per 30
days)
mercaptopurine (Mercaptopurine) 1
methotrexate 50 mg/2 ml vial latex-free,
5's, mdv
(Methotrexate Sodium) 1 PA BvD
methotrexate sodium (pf) injection recon
soln
(Methotrexate
Sodium/PF)
1 PA BvD
methotrexate sodium (pf) injection
solution
(Methotrexate Sodium) 1 PA BvD
methotrexate sodium oral (Methotrexate Sodium) 1 PA BvD; ST
mitoxantrone (Mitoxantrone HCl) 1
NEXAVAR 1 PA NSO; QL (120 per 30
days)
NILANDRON 1
NINLARO 1 PA NSO; QL (3 per 28
days)
ODOMZO 1 PA NSO; LA
ONCASPAR 1 PA NSO
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
30
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
OPDIVO INTRAVENOUS SOLUTION
40 MG/4 ML
1 PA NSO
POMALYST 1 PA NSO; QL (21 per 28
days)
PORTRAZZA 1 PA NSO; QL (100 per 21
days)
PROLEUKIN 1
PURIXAN 1
REVLIMID 1 PA NSO; LA
RITUXAN 1 PA NSO
SOLTAMOX 1
SPRYCEL ORAL TABLET 100 MG, 140
MG, 50 MG, 70 MG, 80 MG
1 PA NSO; QL (30 per 30
days)
SPRYCEL ORAL TABLET 20 MG 1 PA NSO; QL (60 per 30
days)
STIVARGA 1 PA NSO; QL (84 per 28
days)
SUTENT 1 PA NSO; QL (30 per 30
days)
SYLVANT 1 PA NSO
SYNRIBO 1 PA NSO; QL (28 per 28
days)
TABLOID 1
TAFINLAR 1 PA NSO; QL (120 per 30
days)
TAGRISSO 1 PA NSO; LA; QL (30
per 30 days)
tamoxifen (Tamoxifen Citrate) 1
TARCEVA ORAL TABLET 100 MG, 25
MG
1 PA NSO; QL (60 per 30
days)
TARCEVA ORAL TABLET 150 MG 1 PA NSO; QL (90 per 30
days)
TARGRETIN ORAL 1 PA NSO; QL (420 per 30
days)
TARGRETIN TOPICAL 1 PA NSO; QL (60 per 28
days)
TASIGNA 1 PA NSO; QL (112 per 28
days)
TEMODAR INTRAVENOUS 1 PA NSO; (vial only)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
31
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
thiotepa (Thiotepa) 1
toposar (Etoposide) 1
TREANDA 25 MG VIAL 1
TREANDA INTRAVENOUS RECON
SOLN 100 MG
1
TREANDA INTRAVENOUS
SOLUTION
1
TRELSTAR 22.5 MG SYRINGE WITH
MIXJECT
1 QL (1 per 168 days)
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION
1 QL (1 per 168 days)
TRELSTAR INTRAMUSCULAR
SYRINGE 11.25 MG/2 ML
1 QL (1 per 84 days)
TRELSTAR INTRAMUSCULAR
SYRINGE 3.75 MG/2 ML
1
tretinoin (chemotherapy) (Tretinoin) 1 (capsule: 10mg)
TREXALL 1 PA BvD; ST
TYKERB 1
UNITUXIN 1 PA NSO
VALSTAR 1
VELCADE 1 PA NSO
vinorelbine intravenous solution 50 mg/5
ml
(Navelbine) 1
VOTRIENT 1 PA NSO; QL (120 per 30
days)
XALKORI 1 PA NSO; QL (60 per 30
days)
XTANDI 1 PA NSO; QL (120 per 30
days)
YERVOY INTRAVENOUS SOLUTION
50 MG/10 ML (5 MG/ML)
1 PA NSO
YONDELIS 1 PA NSO
ZELBORAF 1 PA NSO; QL (240 per 30
days)
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
1 QL (1 per 84 days)
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
1 QL (1 per 28 days)
ZOLINZA 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
32
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
ZYDELIG 1 PA NSO; QL (60 per 30
days)
ZYKADIA 1 PA NSO; QL (140 per 28
days)
ZYTIGA 1 PA NSO; QL (120 per 30
days)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine injection solution 0.4 mg/ml (Atropine Sulfate) 1
atropine injection syringe 0.05 mg/ml, 0.1
mg/ml
(Atropine Sulfate) 1
propantheline (Propantheline Bromide) 1
STIOLTO RESPIMAT 1 QL (4 per 28 days)
Anticonvulsants
Anticonvulsants
APTIOM 1 ST
BANZEL 1 ST
carbamazepine oral capsule, er
multiphase 12 hr
(Carbatrol) 1
carbamazepine oral suspension 100 mg/5
ml
(Tegretol) 1
carbamazepine oral tablet extended
release 12 hr
(Tegretol XR) 1
carbamazepine oral tablet,chewable (Carbamazepine) 1
CELONTIN ORAL CAPSULE 300 MG 1
DILANTIN 1
divalproex oral capsule, sprinkle (Depakote Sprinkle) 1
divalproex oral tablet extended release 24
hr
(Depakote ER) 1
divalproex oral tablet,delayed release
(dr/ec)
(Depakote) 1
ethosuximide (Zarontin) 1
felbamate (Felbatol) 1
fosphenytoin 500 mg pe/10 ml
10's,sdv,latex-free
(Cerebyx) 1
fosphenytoin injection solution 100 mg
pe/2 ml
(Cerebyx) 1
FYCOMPA ORAL TABLET 1 ST
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
33
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
gabapentin oral capsule (Neurontin) 1
gabapentin oral solution 250 mg/5 ml (Neurontin) 1
gabapentin oral tablet 600 mg, 800 mg (Neurontin) 1
GABITRIL ORAL TABLET 12 MG, 16
MG
1
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2 MG
1
lamotrigine oral tablet (Lamictal) 1
lamotrigine oral tablet extended release
24hr
(Lamictal XR) 1
lamotrigine oral tablet, chewable
dispersible
(Lamictal) 1
lamotrigine oral tablets,dose pack 25 mg
(35)
(Lamictal (Blue)) 1
levetiracetam intravenous (Keppra) 1
levetiracetam oral solution 100 mg/ml (Keppra) 1
levetiracetam oral tablet (Keppra) 1
levetiracetam oral tablet extended release
24 hr
(Keppra XR) 1
LYRICA ORAL CAPSULE 1 QL (90 per 30 days)
LYRICA ORAL SOLUTION 1 QL (900 per 30 days)
oxcarbazepine (Trileptal) 1
OXTELLAR XR 1 ST
PEGANONE 1
phenobarbital oral elixir (Phenobarbital) 1 QL (1500 per 30 days)
phenobarbital oral tablet 100 mg, 15 mg,
16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2
mg
(Phenobarbital) 1 QL (90 per 30 days)
phenobarbital oral tablet 30 mg (Phenobarbital) 1 QL (200 per 30 days)
phenobarbital sodium injection solution (Phenobarbital Sodium) 1 QL (2 per 30 days)
phenytoin oral suspension 125 mg/5 ml (Dilantin-125) 1
phenytoin oral tablet,chewable (Dilantin) 1
phenytoin sodium (Phenytoin Sodium) 1
phenytoin sodium extended (Dilantin) 1
POTIGA ORAL TABLET 200 MG, 300
MG, 400 MG
1 QL (90 per 30 days)
POTIGA ORAL TABLET 50 MG 1 QL (270 per 30 days)
primidone (Mysoline) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
34
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
SABRIL 1
tiagabine (Gabitril) 1
topiramate (Topamax) 1
topiramate oral capsule, sprinkle (Topamax) 1
topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) 1
TROKENDI XR 1 ST
valproate sodium (Depacon) 1
valproic acid (Depakene) 1
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
(Depakene) 1
VIMPAT INTRAVENOUS 1 QL (200 per 5 days)
VIMPAT ORAL SOLUTION 1 QL (1200 per 30 days)
VIMPAT ORAL TABLET 1 QL (60 per 30 days)
zonisamide (Zonegran) 1
Antidementia Agents
Antidementia Agents
donepezil oral tablet (Aricept) 1 QL (30 per 30 days)
donepezil oral tablet,disintegrating (Donepezil HCl) 1 QL (30 per 30 days)
EXELON TRANSDERMAL 1 QL (30 per 30 days)
galantamine oral capsule,ext rel. pellets
24 hr
(Razadyne ER) 1 QL (30 per 30 days)
galantamine oral solution (Galantamine Hbr) 1 QL (200 per 30 days)
galantamine oral tablet (Razadyne) 1 QL (60 per 30 days)
memantine oral solution (Namenda) 1 QL (360 per 30 days)
memantine oral tablet (Namenda) 1 QL (60 per 30 days)
memantine oral tablets,dose pack (Namenda) 1 QL (49 per 28 days)
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE PACK
1 QL (28 per 28 days)
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
1 QL (30 per 30 days)
NAMZARIC 1
rivastigmine (Exelon) 1 QL (30 per 30 days)
rivastigmine tartrate (Exelon) 1 QL (60 per 30 days)
Antidepressants
Antidepressants
amitriptyline (Amitriptyline HCl) 1 PA NSO-HRM
amoxapine (Amoxapine) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
35
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
BRINTELLIX 1 ST
bupropion hcl oral tablet (Wellbutrin) 1
bupropion hcl oral tablet extended release
, 150 mg
(Wellbutrin SR) 1
bupropion hcl oral tablet extended release
24 hr
(Wellbutrin XL) 1
citalopram oral solution (Citalopram
Hydrobromide)
1
citalopram oral tablet (Celexa) 1 QL (30 per 30 days)
clomipramine (Anafranil) 1 PA NSO-HRM
desipramine oral (Norpramin) 1
doxepin oral (Doxepin HCl) 1 PA NSO-HRM
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
(Duloxetine) 1 (Cymbalta); QL (60 per
30 days)
duloxetine oral capsule,delayed
release(dr/ec) 30 mg
(Duloxetine) 1 (Cymbalta); QL (30 per
30 days)
duloxetine oral capsule,delayed
release(dr/ec) 40 mg
(Duloxetine) 1 (Irenka); QL (30 per 30
days)
EMSAM 1 QL (30 per 30 days)
escitalopram oxalate (Lexapro) 1
FETZIMA 1 ST
fluoxetine oral capsule (Prozac) 1
fluoxetine oral capsule,delayed
release(dr/ec)
(Prozac Weekly) 1
fluoxetine oral solution (Fluoxetine HCl) 1
fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) 1
fluvoxamine (Fluvoxamine Maleate) 1
imipramine hcl (Tofranil) 1 PA NSO-HRM
imipramine pamoate (Tofranil-Pm) 1 PA NSO-HRM
maprotiline (Maprotiline HCl) 1
MARPLAN 1
mirtazapine (Remeron) 1
nefazodone (Nefazodone HCl) 1
nortriptyline oral capsule (Pamelor) 1
nortriptyline oral solution (Nortriptyline HCl) 1
olanzapine-fluoxetine (Symbyax) 1
paroxetine hcl oral tablet (Paxil) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
36
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
paroxetine hcl oral tablet extended release
24 hr
(Paxil CR) 1
PAXIL ORAL SUSPENSION 1
perphenazine-amitriptyline (Perphenazine/Amitripty
line HCl)
1 PA NSO-HRM
phenelzine (Nardil) 1
PRISTIQ 1 ST ; QL (30 per 30 days)
protriptyline (Protriptyline HCl) 1
sertraline (Zoloft) 1
SILENOR 1 QL (30 per 30 days)
SURMONTIL 1 PA NSO-HRM
tranylcypromine (Parnate) 1
trazodone (Trazodone HCl) 1
trimipramine (Trimipramine Maleate) 1 PA NSO-HRM
venlafaxine oral capsule,extended release
24hr
(Effexor XR) 1
venlafaxine oral tablet (Venlafaxine HCl) 1
venlafaxine oral tablet extended release
24hr 150 mg, 37.5 mg, 75 mg
(Venlafaxine HCl) 1
VIIBRYD 1
Antidiabetic Agents
Antidiabetic Agents,
Miscellaneous
acarbose (Precose) 1 QL (90 per 30 days)
CYCLOSET 1 QL (180 per 30 days)
GLYXAMBI 1 ST; QL (30 per 30 days)
INVOKAMET ORAL TABLET 150-
1,000 MG, 150-500 MG, 50-1,000 MG
1 ST; QL (60 per 30 days)
INVOKAMET ORAL TABLET 50-500
MG
1 ST; QL (120 per 30
days)
INVOKANA ORAL TABLET 100 MG 1 ST; QL (60 per 30 days)
INVOKANA ORAL TABLET 300 MG 1 ST; QL (30 per 30 days)
JANUMET 1
JANUMET XR 1
JANUVIA 1
JARDIANCE 1 ST; QL (30 per 30 days)
JENTADUETO 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
37
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
KORLYM 1 PA; QL (112 per 28
days)
metformin oral tablet 1,000 mg (Glucophage) 1 QL (60 per 30 days)
metformin oral tablet 500 mg (Glucophage) 1 QL (150 per 30 days)
metformin oral tablet 850 mg (Glucophage) 1 QL (90 per 30 days)
metformin oral tablet extended release 24
hr 500 mg
(Glucophage XR) 1 QL (120 per 30 days)
metformin oral tablet extended release 24
hr 750 mg
(Glucophage XR) 1 QL (90 per 30 days)
metformin oral tablet extended release
24hr 1,000 mg
(Fortamet) 1 QL (60 per 30 days)
nateglinide (Starlix) 1 QL (90 per 30 days)
pioglitazone (Actos) 1 QL (30 per 30 days)
pioglitazone-glimepiride (Duetact) 1 QL (30 per 30 days)
pioglitazone-metformin (Actoplus Met) 1 QL (90 per 30 days)
PRANDIMET 1 QL (150 per 30 days)
repaglinide (Prandin) 1 QL (240 per 30 days)
repaglinide-metformin (Prandimet) 1 QL (150 per 30 days)
SYMLINPEN 120 1 PA; QL (10.8 per 28
days)
SYMLINPEN 60 1 PA; QL (6 per 28 days)
SYNJARDY 1 ST; QL (60 per 30 days)
TRADJENTA 1
TRULICITY 1
VICTOZA 3-PAK 1
Insulins
HUMULIN R U-500
(CONCENTRATED)
1 QL (40 per 28 days)
LANTUS 1
LANTUS SOLOSTAR 1
NOVOLIN 70/30 1 QL (40 per 28 days)
NOVOLIN N 1 QL (40 per 28 days)
NOVOLIN R 1 QL (40 per 28 days)
NOVOLOG 1 QL (40 per 28 days)
NOVOLOG FLEXPEN 1 QL (30 per 28 days)
NOVOLOG MIX 70-30 1 QL (40 per 28 days)
NOVOLOG MIX 70-30 FLEXPEN 1 QL (30 per 28 days)
NOVOLOG PENFILL 1 QL (30 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
38
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
TOUJEO SOLOSTAR 1
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg (Amaryl) 1 QL (30 per 30 days)
glimepiride oral tablet 4 mg (Amaryl) 1 QL (60 per 30 days)
glipizide oral tablet 10 mg (Glucotrol) 1 QL (120 per 30 days)
glipizide oral tablet 5 mg (Glucotrol) 1 QL (60 per 30 days)
glipizide oral tablet extended release 24hr
10 mg
(Glucotrol XL) 1 QL (60 per 30 days)
glipizide oral tablet extended release 24hr
2.5 mg, 5 mg
(Glucotrol XL) 1 QL (30 per 30 days)
glipizide-metformin oral tablet 2.5-250 mg (Glipizide/Metformin
HCl)
1 QL (240 per 30 days)
glipizide-metformin oral tablet 2.5-500
mg, 5-500 mg
(Glipizide/Metformin
HCl)
1 QL (120 per 30 days)
glyburide micronized oral tablet 1.5 mg (Glynase) 1 PA-HRM; QL (400 per
30 days)
glyburide micronized oral tablet 3 mg (Glynase) 1 PA-HRM; QL (180 per
30 days)
glyburide micronized oral tablet 6 mg (Glynase) 1 PA-HRM; QL (120 per
30 days)
glyburide oral tablet 1.25 mg (Glyburide) 1 PA-HRM; QL (280 per
30 days)
glyburide oral tablet 2.5 mg (Glyburide) 1 PA-HRM; QL (240 per
30 days)
glyburide oral tablet 5 mg (Glyburide) 1 PA-HRM; QL (120 per
30 days)
glyburide-metformin oral tablet 1.25-250
mg
(Glucovance) 1 PA-HRM; QL (240 per
30 days)
glyburide-metformin oral tablet 2.5-500
mg, 5-500 mg
(Glucovance) 1 PA-HRM; QL (120 per
30 days)
tolazamide oral tablet 250 mg (Tolazamide) 1 QL (120 per 30 days)
tolazamide oral tablet 500 mg (Tolazamide) 1 QL (60 per 30 days)
tolbutamide (Tolbutamide) 1 QL (180 per 30 days)
Antifungals
Antifungals
ABELCET 1 PA BvD
AMBISOME 1 PA BvD
amphotericin b (Amphotericin B) 1 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
39
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
CANCIDAS 1
ciclopirox topical cream (Ciclodan) 1
ciclopirox topical gel (Loprox) 1
ciclopirox topical shampoo (Loprox) 1
ciclopirox topical solution (Penlac) 1
ciclopirox topical suspension (Ciclopirox Olamine) 1
ciclopirox-ure-camph-menth-euc (Ciclodan) 1
clotrimazole mucous membrane (Clotrimazole) 1
clotrimazole topical (Clotrimazole) 1
clotrimazole-betamethasone topical cream (Lotrisone) 1
clotrimazole-betamethasone topical lotion (Clotrimazole/Betameth
asone Dip)
1
econazole topical (Econazole Nitrate) 1
fluconazole (Diflucan) 1
fluconazole in dextrose(iso-o) intravenous
piggyback 400 mg/200 ml
(Fluconazole In
Nacl,Iso-Osm)
1
fluconazole-nacl 400 mg/200 ml latex-free,
outer
(Fluconazole In
Nacl,Iso-Osm)
1
flucytosine (Ancobon) 1
griseofulvin microsize oral tablet (Grifulvin V) 1
itraconazole (Sporanox) 1
ketoconazole oral (Ketoconazole) 1
ketoconazole topical cream (Ketoconazole) 1
ketoconazole topical shampoo (Nizoral) 1
miconazole nitrate vaginal suppository
200 mg
(Miconazole Nitrate) 1
NOXAFIL ORAL 1
NYSTATIN (BULK) POWDER 1
BILLION UNIT, 10 BILLION UNIT
1
nystatin oral suspension (Nystatin) 1
nystatin oral tablet (Nystatin) 1
nystatin topical (Nystatin) 1
nystatin topical powder 100,000 unit/gram (Nystatin) 1
nystatin-triamcinolone (Nystatin/Triamcin) 1
terbinafine hcl oral (Lamisil) 1
voriconazole intravenous (Vfend IV) 1
voriconazole oral (Vfend) 1
Antihistamines
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
40
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
Antihistamines
cyproheptadine (Cyproheptadine HCl) 1
diphenhydramine hcl injection solution 50
mg/ml
(Diphenhydramine HCl) 1
levocetirizine (Xyzal) 1
promethazine oral syrup (Promethazine HCl) 1 PA-HRM
Anti-Infectives (Skin And Mucous
Membrane)
Anti-Infectives (Skin And
Mucous Membrane)
AVC VAGINAL 1
clindamycin phosphate vaginal (Cleocin) 1
metronidazole vaginal (Metrogel-Vaginal) 1
terconazole vaginal cream (Terazol 7) 1
terconazole vaginal suppository (Terconazole) 1
Antimigraine Agents
Antimigraine Agents
dihydroergotamine injection (D.H.E.45) 1 QL (30 per 28 days)
dihydroergotamine nasal (Migranal) 1 QL (8 per 28 days)
ERGOMAR 1 QL (40 per 28 days)
naratriptan (Amerge) 1 QL (18 per 28 days)
rizatriptan oral tablet (Maxalt) 1 QL (18 per 28 days)
rizatriptan oral tablet,disintegrating (Maxalt Mlt) 1 QL (18 per 28 days)
sumatriptan (Imitrex) 1 QL (12 per 28 days)
sumatriptan 4 mg/0.5 ml inject latex-free (Sumatriptan Succinate) 1 QL (4 per 28 days)
sumatriptan 4 mg/0.5 ml refill (Imitrex) 1 QL (4 per 28 days)
sumatriptan 6 mg/0.5 ml refill latex-free (Imitrex) 1 QL (4 per 28 days)
sumatriptan succinate oral (Imitrex) 1 QL (18 per 28 days)
sumatriptan succinate subcutaneous
cartridge 4 mg/0.5 ml
(Sumatriptan Succinate) 1 QL (4 per 28 days)
sumatriptan succinate subcutaneous pen
injector 6 mg/0.5 ml
(Imitrex) 1 QL (4 per 28 days)
sumatriptan succinate subcutaneous pen
injector 6 mg/0.5 ml (auto-injector)
(Sumatriptan Succinate) 1 QL (4 per 28 days)
sumatriptan succinate subcutaneous
solution
(Imitrex) 1 QL (4 per 28 days)
zolmitriptan oral tablet (Zomig) 1 QL (12 per 28 days)
zolmitriptan oral tablet,disintegrating (Zomig Zmt) 1 QL (12 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
41
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
Antimycobacterials
Antimycobacterials
CAPASTAT 1
dapsone (Dapsone) 1
ethambutol (Myambutol) 1
isoniazid oral (Isoniazid) 1
PASER 1
PRIFTIN 1
pyrazinamide (Pyrazinamide) 1
rifabutin (Mycobutin) 1
rifampin intravenous (Rifadin) 1
rifampin oral (Rifadin) 1
RIFATER 1
SIRTURO 1 PA; QL (188 per 168
days)
TRECATOR 1
Antinausea Agents
Antinausea Agents
AKYNZEO 1 PA BvD
dimenhydrinate injection solution (Dimenhydrinate) 1
dronabinol (Marinol) 1
EMEND INTRAVENOUS 1 QL (2 per 28 days)
EMEND ORAL CAPSULE 125 MG, 80
MG
1 PA BvD
EMEND ORAL CAPSULE 40 MG 1
EMEND ORAL CAPSULE,DOSE PACK 1 PA BvD
granisetron (pf) intravenous solution 100
mcg/ml
(Granisetron HCl/PF) 1
granisetron hcl intravenous solution 1
mg/ml (1 ml)
(Granisetron HCl) 1
granisetron hcl oral (Granisetron HCl) 1 PA BvD
meclizine oral tablet 12.5 mg, 25 mg (Antivert) 1
ondansetron (Zofran Odt) 1 PA BvD
ondansetron hcl (pf) (Ondansetron HCl/PF) 1
ondansetron hcl oral (Zofran) 1 PA BvD
prochlorperazine (Compazine) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
42
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
prochlorperazine edisylate injection
solution 10 mg/2 ml (5 mg/ml)
(Prochlorperazine
Edisylate)
1
prochlorperazine maleate oral (Compazine) 1
promethazine hcl (Phenergan) 1 PA-HRM
promethazine oral tablet (Promethazine HCl) 1 PA-HRM
promethazine rectal (Phenergan) 1 PA-HRM
TRANSDERM-SCOP 1 QL (10 per 30 days)
Antiparasite Agents
Antiparasite Agents
ALBENZA 1
ALINIA 1
atovaquone (Mepron) 1
atovaquone-proguanil (Malarone) 1
chloroquine phosphate oral (Chloroquine Phosphate) 1
COARTEM 1
DARAPRIM 1
hydroxychloroquine oral (Plaquenil) 1
ivermectin oral (Stromectol) 1
mefloquine (Mefloquine HCl) 1
NEBUPENT 1 PA BvD
paromomycin (Paromomycin Sulfate) 1
PENTAM 1
PRIMAQUINE 1 QL (90 per 30 days)
quinine sulfate (Qualaquin) 1 PA; QL (42 per 7 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl (Amantadine HCl) 1
APOKYN 1 QL (60 per 30 days)
AZILECT 1
benztropine oral (Benztropine Mesylate) 1 PA-HRM
bromocriptine (Parlodel) 1
cabergoline (Cabergoline) 1
carbidopa (Lodosyn) 1
carbidopa-levodopa oral tablet (Sinemet CR) 1
carbidopa-levodopa oral tablet extended
release
(Sinemet CR) 1
carbidopa-levodopa-entacapone (Stalevo 50) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
43
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
entacapone (Comtan) 1
NEUPRO 1 ST; QL (30 per 30 days)
pramipexole oral tablet (Mirapex) 1
ropinirole oral tablet (Requip) 1
ropinirole oral tablet extended release 24
hr
(Requip XL) 1
selegiline hcl oral capsule (Eldepryl) 1
selegiline hcl oral tablet (Selegiline HCl) 1
trihexyphenidyl (Trihexyphenidyl HCl) 1 PA-HRM
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10 MG
1 QL (90 per 30 days)
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 300 MG
1
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON 400 MG
1 QL (1 per 28 days)
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING
1 QL (1 per 28 days)
aripiprazole oral solution (Abilify) 1 QL (900 per 30 days)
aripiprazole oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
(Abilify) 1 QL (30 per 30 days)
aripiprazole oral tablet 2 mg (Abilify) 1 QL (60 per 30 days)
aripiprazole oral tablet,disintegrating 10
mg
(Abilify Discmelt) 1 QL (90 per 30 days)
aripiprazole oral tablet,disintegrating 15
mg
(Abilify Discmelt) 1 QL (60 per 30 days)
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 441 MG/1.6 ML
1 QL (1.6 per 28 days)
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 662 MG/2.4 ML
1 QL (2.4 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
44
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING 882 MG/3.2 ML
1 QL (3.2 per 28 days)
chlorpromazine (Chlorpromazine HCl) 1
clozapine oral tablet 100 mg (Clozaril) 1 QL (270 per 30 days)
clozapine oral tablet 200 mg (Clozaril) 1 QL (135 per 30 days)
clozapine oral tablet 25 mg, 50 mg (Clozaril) 1 QL (90 per 30 days)
clozapine oral tablet,disintegrating (Fazaclo) 1 ST
FANAPT ORAL TABLET 1 ST ; QL (60 per 30 days)
FANAPT ORAL TABLETS,DOSE
PACK
1 ST ; QL (8 per 28 days)
fluphenazine decanoate (Fluphenazine
Decanoate)
1
fluphenazine hcl (Fluphenazine HCl) 1
GEODON INTRAMUSCULAR 1 QL (6 per 28 days)
haloperidol (Haloperidol) 1
haloperidol decanoate intramuscular
solution 100 mg/ml
(Haloperidol Decanoate) 1
haloperidol decanoate intramuscular
solution 50 mg/ml
(Haldol Decanoate 50) 1
haloperidol lactate (Haloperidol Lactate) 1
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 1.5 MG, 3 MG, 9 MG
1 QL (30 per 30 days)
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 6 MG
1 QL (60 per 30 days)
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 117
MG/0.75 ML
1 QL (0.75 per 28 days)
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 156
MG/ML
1 QL (1 per 28 days)
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 234
MG/1.5 ML
1 QL (1.5 per 28 days)
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 39
MG/0.25 ML
1 QL (0.25 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
45
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 78
MG/0.5 ML
1 QL (0.5 per 28 days)
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 273 MG/0.875 ML
1 QL (0.875 per 84 days)
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 410 MG/1.315 ML
1 QL (1.315 per 84 days)
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 546 MG/1.75 ML
1 QL (1.75 per 84 days)
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 819 MG/2.625 ML
1 QL (2.625 per 84 days)
LATUDA 1
loxapine succinate (Loxapine Succinate) 1
molindone oral tablet 10 mg (Moban) 1 QL (240 per 30 days)
molindone oral tablet 25 mg (Moban) 1 QL (270 per 30 days)
molindone oral tablet 5 mg (Moban) 1 QL (120 per 30 days)
olanzapine intramuscular (Zyprexa) 1 QL (30 per 30 days)
olanzapine oral tablet (Zyprexa) 1 QL (30 per 30 days)
olanzapine oral tablet,disintegrating 10
mg, 15 mg, 5 mg
(Zyprexa Zydis) 1 QL (30 per 30 days)
olanzapine oral tablet,disintegrating 20
mg
(Zyprexa Zydis) 1 QL (31 per 30 days)
ORAP 1
paliperidone oral tablet extended release
24hr 1.5 mg, 3 mg, 9 mg
(Invega) 1 QL (30 per 30 days)
paliperidone oral tablet extended release
24hr 6 mg
(Invega) 1 QL (60 per 30 days)
perphenazine (Perphenazine) 1
pimozide (Orap) 1
quetiapine (Seroquel) 1 QL (90 per 30 days)
REXULTI ORAL TABLET 0.25 MG 1 QL (120 per 30 days)
REXULTI ORAL TABLET 0.5 MG 1 QL (60 per 30 days)
REXULTI ORAL TABLET 1 MG, 2 MG,
3 MG, 4 MG
1 QL (30 per 30 days)
RISPERDAL CONSTA 1 QL (4 per 28 days)
risperidone oral solution (Risperdal) 1 QL (480 per 30 days)
risperidone oral tablet (Risperdal) 1 QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
46
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
risperidone oral tablet,disintegrating 0.25
mg, 0.5 mg, 1 mg, 2 mg
(Risperdal M-Tab) 1 QL (60 per 30 days)
risperidone oral tablet,disintegrating 3
mg, 4 mg
(Risperdal M-Tab) 1 QL (120 per 30 days)
SAPHRIS (BLACK CHERRY) 1 ST ; QL (60 per 30 days)
thioridazine (Thioridazine HCl) 1 PA NSO-HRM
thiothixene (Thiothixene) 1
trifluoperazine (Trifluoperazine HCl) 1
VERSACLOZ 1 ST ; QL (540 per 30
days)
VRAYLAR ORAL CAPSULE 1 ST ; QL (30 per 30 days)
VRAYLAR ORAL CAPSULE,DOSE
PACK
1 ST ; QL (7 per 30 days)
ziprasidone hcl (Geodon) 1 QL (60 per 30 days)
ZYPREXA RELPREVV 405 MG VL KIT
W/ DILUENT, OUTER
1
ZYPREXA RELPREVV
INTRAMUSCULAR SUSPENSION FOR
RECONSTITUTION 210 MG
1
Antivirals (Systemic)
Antiretrovirals
abacavir (Ziagen) 1
abacavir-lamivudine-zidovudine (Trizivir) 1
APTIVUS 1
ATRIPLA 1
COMPLERA 1
CRIXIVAN ORAL CAPSULE 200 MG,
400 MG
1
didanosine (Videx EC) 1
EDURANT 1
EMTRIVA 1
EPIVIR HBV ORAL SOLUTION 1
EPZICOM 1
EVOTAZ 1
FUZEON SUBCUTANEOUS RECON
SOLN
1
GENVOYA 1
INTELENCE 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
47
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
INVIRASE 1
ISENTRESS 1
KALETRA 1
lamivudine (Epivir) 1
lamivudine-zidovudine (Combivir) 1
LEXIVA 1
nevirapine oral suspension (Viramune) 1
nevirapine oral tablet (Viramune) 1
nevirapine oral tablet extended release 24
hr
(Viramune XR) 1
NORVIR 1
PREZCOBIX 1
PREZISTA 1
RESCRIPTOR 1
RETROVIR INTRAVENOUS 1
REYATAZ ORAL CAPSULE 150 MG,
200 MG, 300 MG
1
REYATAZ ORAL POWDER IN
PACKET
1
SELZENTRY 1
stavudine (Zerit) 1
STRIBILD 1
SUSTIVA 1
TIVICAY 1
TRIUMEQ 1
TRUVADA 1
VIDEX 2 GRAM PEDIATRIC 1
VIDEX 4 GM PEDIATRIC SOLN 1
VIRACEPT ORAL TABLET 1
VIRAMUNE XR ORAL TABLET
EXTENDED RELEASE 24 HR 100 MG
1
VIREAD 1
VITEKTA 1
ZIAGEN ORAL SOLUTION 1
zidovudine oral capsule (Retrovir) 1
zidovudine oral syrup (Retrovir) 1
zidovudine oral tablet (Zidovudine) 1
Antivirals, Miscellaneous
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
48
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
foscarnet (Foscavir) 1 PA BvD
RELENZA DISKHALER 1
rimantadine (Flumadine) 1
SYNAGIS 100 MG/1 ML VIAL 1
SYNAGIS INTRAMUSCULAR
SOLUTION 50 MG/0.5 ML
1
TAMIFLU ORAL CAPSULE 30 MG 1 QL (84 per 180 days)
TAMIFLU ORAL CAPSULE 45 MG 1 QL (48 per 180 days)
TAMIFLU ORAL CAPSULE 75 MG 1 QL (42 per 180 days)
TAMIFLU ORAL SUSPENSION FOR
RECONSTITUTION
1 QL (540 per 180 days)
Hcv Antivirals
DAKLINZA 1 PA; QL (28 per 28 days)
HARVONI 1 PA; QL (30 per 30 days)
OLYSIO 1 PA; QL (28 per 28 days)
SOVALDI 1 PA; QL (28 per 28 days)
TECHNIVIE 1 PA; QL (56 per 28 days)
VIEKIRA PAK 1 PA; QL (112 per 28
days)
ZEPATIER 1 PA; QL (30 per 30 days)
Interferons
INTRON A 10 MILLION UNIT/ML 1 PA NSO
INTRON A INJECTION RECON SOLN 1 PA NSO
INTRON A INJECTION SOLUTION 6
MILLION UNIT/ML
1 PA NSO
PEGASYS 1 PA
PEGASYS PROCLICK 1 PA
PEGINTRON 1 PA
SYLATRON 1 PA NSO; QL (4 per 28
days)
Nucleosides And Nucleotides
acyclovir oral capsule (Zovirax) 1
acyclovir oral suspension 200 mg/5 ml (Zovirax) 1
acyclovir oral tablet (Zovirax) 1
acyclovir sodium intravenous solution (Acyclovir Sodium) 1 PA BvD
adefovir (Hepsera) 1
entecavir (Baraclude) 1
famciclovir (Famvir) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
49
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
ganciclovir sodium (Cytovene) 1 PA BvD
ribavirin oral capsule 200 mg (Rebetol) 1
ribavirin oral tablet 200 mg, 400 mg, 600
mg
(Copegus) 1
TYZEKA 1
valacyclovir (Valtrex) 1
valganciclovir (Valcyte) 1
VIRAZOLE 1 PA BvD
Blood Products/Modifiers/Volume
Expanders
Anticoagulants
CEPROTIN (BLUE BAR) 1
ELIQUIS 1
enoxaparin subcutaneous solution (Lovenox) 1 QL (36 per 30 days)
enoxaparin subcutaneous syringe 100
mg/ml
(Lovenox) 1 QL (36 per 30 days)
enoxaparin subcutaneous syringe 120
mg/0.8 ml, 80 mg/0.8 ml
(Lovenox) 1 QL (27.2 per 30 days)
enoxaparin subcutaneous syringe 150
mg/ml
(Lovenox) 1 QL (34 per 30 days)
enoxaparin subcutaneous syringe 30
mg/0.3 ml
(Lovenox) 1 QL (18 per 30 days)
enoxaparin subcutaneous syringe 40
mg/0.4 ml
(Lovenox) 1 QL (13.6 per 30 days)
enoxaparin subcutaneous syringe 60
mg/0.6 ml
(Lovenox) 1 QL (20.4 per 30 days)
fondaparinux subcutaneous syringe 10
mg/0.8 ml
(Arixtra) 1 QL (24 per 30 days)
fondaparinux subcutaneous syringe 2.5
mg/0.5 ml
(Arixtra) 1 QL (15 per 30 days)
fondaparinux subcutaneous syringe 5
mg/0.4 ml
(Arixtra) 1 QL (12 per 30 days)
fondaparinux subcutaneous syringe 7.5
mg/0.6 ml
(Arixtra) 1 QL (18 per 30 days)
heparin (porcine) in 5 % dex intravenous
parenteral solution 12,500 unit/250 ml,
20,000 unit/500 ml (40 unit/ml), 25,000
unit/500 ml (50 unit/ml)
(Heparin
Sodium,Porcine/D5W)
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
50
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
heparin (porcine) in 5 % dex intravenous
parenteral solution 25,000 unit/250
ml(100 unit/ml)
(Heparin Sod,Pork In
0.45% NaCl)
1
heparin (porcine) in nacl (pf) intravenous
parenteral solution 1,000 unit/500 ml
(Heparin
Sodium,Porcine/Ns/PF)
1
heparin (porcine) injection solution 1,000
unit/ml, 20,000 unit/ml, 5,000 unit/ml
(Heparin
Sodium,Porcine)
1 (PA for ESRD Only)
heparin (porcine) injection solution
10,000 unit/ml
(Heparin
Sodium,Porcine)
1
heparin sodium,porcine-pf intravenous
syringe 10 unit/ml
(Monoject Prefill
Advanced)
1
heparin, porcine (pf) injection solution
5,000 unit/0.5 ml
(Heparin
Sodium,Porcine/PF)
1 (PA for ESRD Only)
heparin, porcine (pf) injection syringe (Monoject Prefill
Advanced)
1 (PA for ESRD Only)
heparin, porcine (pf) intravenous syringe (Monoject Prefill
Advanced)
1
heparin-0.45% nacl 25,000 units/250 ml
(100 units/ml) bag latex-free, inner
(Heparin Sod,Pork In
0.45% NaCl)
1
heparin-d5w 25,000 units/250 ml (100
units/ml) bag excel container
(Heparin
Sodium,Porcine/D5W)
1
IPRIVASK 1 PA; QL (24 per 28 days)
jantoven (Coumadin) 1
PRADAXA 1 ST; QL (60 per 30 days)
warfarin (Coumadin) 1
XARELTO 1
Blood Formation Modifiers
CINRYZE 1 PA
EPOGEN 10,000 UNITS/ML VIAL SDV,
P/F, OUTER
1 PA; QL (12 per 28 days)
EPOGEN INJECTION SOLUTION 2,000
UNIT/ML, 20,000 UNIT/2 ML, 20,000
UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML
1 PA; QL (12 per 28 days)
GRANIX 1
LEUKINE INJECTION RECON SOLN 1
MIRCERA 1 PA; QL (0.6 per 28 days)
MOZOBIL 1
NEULASTA 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
51
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
NEUMEGA 1
NEUPOGEN 1
PROCRIT 10,000 UNITS/ML VIAL 4'S,
MDV, OUTER
1 PA; QL (12 per 28 days)
PROCRIT INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
20,000 UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML
1 PA; QL (12 per 28 days)
PROCRIT INJECTION SOLUTION
40,000 UNIT/ML
1 PA; QL (6 per 28 days)
PROMACTA 1 PA; QL (30 per 30 days)
ZARXIO 1
Hematologic Agents,
Miscellaneous
aminocaproic acid oral (Aminocaproic Acid) 1
anagrelide (Agrylin) 1
protamine (Protamine Sulfate) 1 (PA for ESRD Only)
tranexamic acid intravenous (Tranexamic Acid) 1
tranexamic acid oral (Lysteda) 1 QL (30 per 30 days)
Platelet-Aggregation Inhibitors
AGGRENOX 1 QL (60 per 30 days)
aspirin-dipyridamole (Aggrenox) 1
BRILINTA 1
cilostazol (Pletal) 1
clopidogrel (Plavix) 1
EFFIENT 1 QL (30 per 30 days)
pentoxifylline (Pentoxifylline) 1
Volume Expanders
ALBUKED-25 1
ALBUKED-5 1
ALBUMIN, HUMAN 20 % 1
ALBUMIN, HUMAN 25 % 1
ALBUMIN, HUMAN 5 % 1
ALBUMINAR 25 % 1
ALBUMINAR 5 % 1
ALBURX (HUMAN) 5 % 1
ALBUTEIN 25 % 1
ALBUTEIN 5 % 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
52
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
BUMINATE 25 % 1
BUMINATE 5 % 1
FLEXBUMIN 25 % 1
FLEXBUMIN 5 % 1
KEDBUMIN 1
PLASBUMIN 25 % 1
PLASBUMIN 5 % 1
Caloric Agents
Caloric Agents
AMINO ACIDS 15 % 1 PA BvD
AMINOSYN 10 % 1 PA BvD
AMINOSYN 3.5 % 1 PA BvD
AMINOSYN 7 % 1 PA BvD
AMINOSYN 7 % WITH
ELECTROLYTES
1 PA BvD
AMINOSYN 8.5 % 1 PA BvD
AMINOSYN 8.5 %-ELECTROLYTES 1 PA BvD
AMINOSYN II 10 % 1 PA BvD
AMINOSYN II 15 % 1 PA BvD
AMINOSYN II 7 % 1 PA BvD
AMINOSYN II 8.5 % 1 PA BvD
AMINOSYN II 8.5 %-ELECTROLYTES 1 PA BvD
AMINOSYN M 3.5 % 1 PA BvD
AMINOSYN-HBC 7% 1 PA BvD
AMINOSYN-PF 10 % 1 PA BvD
AMINOSYN-PF 7 % (SULFITE-FREE) 1 PA BvD
AMINOSYN-RF 5.2 % 1 PA BvD
CLINIMIX 5%/D15W SULFITE FREE 1 PA BvD
CLINIMIX 5%/D25W SULFITE-FREE 1 PA BvD
CLINIMIX 2.75%/D5W SULFIT FREE 1 PA BvD
CLINIMIX 4.25%/D10W SULF FREE 1 PA BvD
CLINIMIX 4.25%/D5W SULFIT FREE 1 PA BvD
CLINIMIX 4.25%-D20W SULF-FREE 1 PA BvD
CLINIMIX 4.25%-D25W SULF-FREE 1 PA BvD
CLINIMIX 5%-D20W(SULFITE-FREE) 1 PA BvD
CLINIMIX E 2.75%/D10W SUL FREE 1 PA BvD
CLINIMIX E 2.75%/D5W SULF FREE 1 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
53
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
CLINIMIX E 4.25%/D10W SUL FREE 1 PA BvD
CLINIMIX E 4.25%/D25W SUL FREE 1 PA BvD
CLINIMIX E 4.25%/D5W SULF FREE 1 PA BvD
CLINIMIX E 5%/D15W SULFIT FREE 1 PA BvD
CLINIMIX E 5%/D20W SULFIT FREE 1 PA BvD
CLINIMIX E 5%/D25W SULFIT FREE 1 PA BvD
CLINISOL SF 15 % 1 PA BvD
cysteine (l-cysteine) intravenous solution (Cysteine HCl) 1 PA BvD
dextrose 10 % in water (d10w) (Dextrose 10 % in
Water)
1 PA BvD
dextrose 20 % in water (d20w) (Dextrose 20 % in
Water)
1 PA BvD
dextrose 25 % in water (d25w) (Dextrose 25 % in
Water)
1 PA BvD
dextrose 40 % in water (d40w) (Dextrose 40 % in
Water)
1 PA BvD
dextrose 5 % in ringers (Dextrose 5% In
Ringers)
1
dextrose 5 % in water (d5w) intravenous
parenteral solution
(Dextrose 5 % in Water) 1
dextrose 50 % in water (d50w) (Dextrose 50 % in
Water)
1 PA BvD
dextrose 70 % in water (d70w) (Dextrose 70 % in
Water)
1 PA BvD
FREAMINE HBC 6.9 % 1 PA BvD
FREAMINE III 10 % 1 PA BvD
HEPATAMINE 8% 1 PA BvD
HEPATASOL 8 % 1 PA BvD
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
1 PA BvD
KABIVEN 1 PA BvD
LIPOSYN II 1 PA BvD
LIPOSYN III 1 PA BvD
NEPHRAMINE 5.4 % 1 PA BvD
NUTRILIPID 1 PA BvD
PERIKABIVEN 1 PA BvD
PREMASOL 10 % 1 PA BvD
PREMASOL 6 % 1 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
54
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
PROCALAMINE 3% 1 PA BvD
PROSOL 20 % 1 PA BvD
TRAVASOL 10 % 1 PA BvD
TROPHAMINE 10 % 1 PA BvD
TROPHAMINE 6% 1 PA BvD
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet (Catapres) 1
clonidine hcl-chlorthalidone (Clonidine
HCl/Chlorthalidone)
1
clonidine transdermal patch weekly 0.1
mg/24 hr, 0.2 mg/24 hr
(Catapres-Tts 1) 1 QL (4 per 28 days)
clonidine transdermal patch weekly 0.3
mg/24 hr
(Catapres-Tts 1) 1 QL (8 per 28 days)
doxazosin (Cardura) 1
guanfacine oral tablet (Tenex) 1 PA-HRM
midodrine (Midodrine HCl) 1
NORTHERA 1 PA; QL (180 per 30
days)
phenylephrine hcl injection (Vazculep) 1
prazosin oral (Minipress) 1
Angiotensin Ii Receptor
Antagonists
BENICAR 1
BENICAR HCT 1
candesartan (Atacand) 1
candesartan-hydrochlorothiazid (Atacand HCT) 1
ENTRESTO 1 PA; QL (60 per 30 days)
irbesartan (Avapro) 1
irbesartan-hydrochlorothiazide (Avalide) 1
losartan (Cozaar) 1
losartan-hydrochlorothiazide (Hyzaar) 1
telmisartan (Micardis) 1
telmisartan-hydrochlorothiazid (Micardis HCT) 1
TRIBENZOR 1 ST
valsartan (Diovan) 1
valsartan-hydrochlorothiazide (Diovan HCT) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
55
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
Angiotensin-Converting Enzyme
Inhibitors
benazepril (Lotensin) 1
benazepril-hydrochlorothiazide (Lotensin HCT) 1
captopril (Captopril) 1
captopril-hydrochlorothiazide (Captopril/Hydrochlorot
hiazide)
1
enalapril maleate (Vasotec) 1
enalaprilat intravenous solution (Enalaprilat Dihydrate) 1
enalapril-hydrochlorothiazide (Vaseretic) 1
fosinopril (Fosinopril Sodium) 1
fosinopril-hydrochlorothiazide (Fosinopril/Hydrochloro
thiazide)
1
lisinopril (Zestril) 1
lisinopril-hydrochlorothiazide (Zestoretic) 1
moexipril (Moexipril HCl) 1
moexipril-hydrochlorothiazide (Moexipril/Hydrochlorot
hiazide)
1
perindopril erbumine (Aceon) 1
quinapril (Accupril) 1
quinapril-hydrochlorothiazide (Accuretic) 1
ramipril (Altace) 1
trandolapril (Mavik) 1
Antiarrhythmic Agents
amiodarone hcl oral tablet 100 mg, 200
mg, 400 mg
(Cordarone) 1
amiodarone oral (Cordarone) 1
disopyramide phosphate oral capsule (Norpace) 1
flecainide (Tambocor) 1
lidocaine (pf) intravenous syringe 50 mg/5
ml (1 %)
(Lidocaine HCl/PF) 1
lidocaine in 5 % dextrose (pf) intravenous
parenteral solution 8 mg/ml (0.8 %)
(Lidocaine
HCl/D5w/PF)
1
mexiletine (Mexiletine HCl) 1
MULTAQ 1
procainamide injection (Procainamide HCl) 1
propafenone oral capsule,extended release
12 hr
(Rythmol SR) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
56
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
propafenone oral tablet (Rythmol) 1
quinidine gluconate oral (Quinidine Gluconate) 1
quinidine sulfate (Quinidine Sulfate) 1
TIKOSYN 1
Beta-Adrenergic Blocking Agents
acebutolol (Sectral) 1
atenolol (Tenormin) 1
atenolol-chlorthalidone (Tenoretic 50) 1
betaxolol oral (Kerlone) 1
bisoprolol fumarate (Zebeta) 1
bisoprolol-hydrochlorothiazide (Ziac) 1
BYSTOLIC 1
carvedilol (Coreg) 1
esmolol intravenous solution (Esmolol HCl) 1 PA BvD
labetalol intravenous solution (Labetalol HCl) 1
labetalol oral (Trandate) 1
metoprolol succinate (Toprol XL) 1
metoprolol ta-hydrochlorothiaz (Lopressor HCT) 1
metoprolol tartrate intravenous solution (Lopressor) 1
metoprolol tartrate oral tablet 100 mg, 25
mg, 50 mg
(Lopressor) 1
nadolol (Corgard) 1
pindolol (Pindolol) 1
propranolol intravenous (Propranolol HCl) 1
propranolol oral capsule,extended release
24 hr
(Inderal LA) 1
propranolol oral solution (Propranolol HCl) 1
propranolol oral tablet (Propranolol HCl) 1
propranolol-hydrochlorothiazid (Propranolol/Hydrochlor
othiazid)
1
sotalol 120 mg tablet (Betapace) 1
sotalol hcl oral tablet 120 mg, 160 mg,
240 mg, 80 mg
(Betapace) 1
sotalol oral tablet 160 mg, 240 mg, 80 mg (Betapace) 1
timolol maleate oral (Timolol Maleate) 1
Calcium-Channel Blocking
Agents
cartia xt (Cardizem CD) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
57
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
diltiazem 24hr er 180 mg cap (Cardizem CD) 1
diltiazem 24hr er 360 mg cap once a day
dosage
(Cardizem CD) 1
diltiazem hcl intravenous (Cardizem CD) 1
diltiazem hcl oral capsule, extended
release 180 mg, 360 mg, 420 mg
(Cardizem CD) 1
diltiazem hcl oral capsule,extended
release 12 hr
(Cardizem CD) 1
diltiazem hcl oral capsule,extended
release 24hr 120 mg, 240 mg, 300 mg
(Cardizem CD) 1
diltiazem hcl oral tablet (Cardizem CD) 1
diltiazem hcl oral tablet extended release
24 hr
(Cardizem LA) 1
dilt-xr (Cardizem CD) 1
matzim la (Cardizem CD) 1
taztia xt (Cardizem CD) 1
verapamil intravenous syringe (Verapamil HCl) 1
verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) 1
verapamil oral capsule,ext rel. pellets 24
hr
(Verelan) 1
verapamil oral tablet (Calan) 1
verapamil oral tablet extended release (Calan SR) 1
Cardiovascular Agents,
Miscellaneous
CORLANOR 1 ST
DEMSER 1
digitek oral tablet 125 mcg (Lanoxin) 1 PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per 30
days)
digitek oral tablet 250 mcg (Lanoxin) 1 PA-HRM; QL (30 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
58
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
digox 125 mcg tablet 125 mcg (Lanoxin) 1 PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per 30
days)
digox 250 mcg tablet 250 mcg (Lanoxin) 1 PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per 30
days)
digoxin 0.25 mg/ml syringe (Digoxin) 1 PA-HRM
digoxin injection solution (Digoxin) 1 PA-HRM
DIGOXIN ORAL SOLUTION 50
MCG/ML
1 PA-HRM; QL (300 per
30 days)
digoxin oral tablet (Lanoxin) 1 PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per 30
days)
dobutamine in d5w intravenous parenteral
solution 1,000 mg/250 ml (4,000 mcg/ml),
250 mg/250 ml (1 mg/ml), 500 mg/250 ml
(2,000 mcg/ml)
(Dobutamine HCl/D5W) 1 PA BvD
dobutamine intravenous solution 250
mg/20 ml (12.5 mg/ml)
(Dobutamine HCl) 1 PA BvD
dopamine in 5 % dextrose intravenous
solution 200 mg/250 ml (800 mcg/ml), 400
mg/250 ml (1,600 mcg/ml), 800 mg/250 ml
(3,200 mcg/ml)
(Dopamine HCl/D5W) 1 PA BvD
dopamine intravenous solution 200 mg/5
ml (40 mg/ml), 800 mg/10 ml (80 mg/ml),
800 mg/5 ml (160 mg/ml)
(Dopamine HCl) 1 PA BvD
ephedrine sulfate injection solution (Ephedrine Sulfate) 1
epinephrine hcl (pf) intravenous (Epinephrine HCl/PF) 1
epinephrine injection auto-injector (Adrenaclick) 1
epinephrine injection solution 1 mg/ml (1
ml)
(Epinephrine) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
59
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
epinephrine injection syringe 0.1 mg/ml (Epinephrine) 1
EPIPEN 2-PAK 1
EPIPEN JR 2-PAK 1
ethamolin (Ethanolamine Oleate) 1
FIRAZYR 1
hydralazine (Hydralazine HCl) 1
LANOXIN ORAL TABLET 187.5 MCG,
62.5 MCG
1 PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per 30
days)
milrinone (Milrinone Lactate) 1 PA BvD
milrinone in 5 % dextrose intravenous
piggyback 40 mg/200 ml (200 mcg/ml)
(Milrinone
Lactate/D5W)
1 PA BvD
norepinephrine bitartrate (Levophed Bitartrate) 1 PA BvD
papaverine injection solution (Papaverine HCl) 1 PA
papaverine oral (Papaverine HCl) 1 PA
RANEXA 1
Dihydropyridines
amlodipine (Norvasc) 1
amlodipine-benazepril (Lotrel) 1
amlodipine-valsartan (Exforge) 1
amlodipine-valsartan-hcthiazid (Exforge HCT) 1
AZOR 1 ST
CLEVIPREX INTRAVENOUS
EMULSION 50 MG/100 ML
1
felodipine (Felodipine) 1
isradipine (Isradipine) 1
nicardipine oral (Nicardipine HCl) 1
nifedipine er 30 mg tablet f/c (Adalat CC) 1
nifedipine oral tablet extended release
24hr 30 mg
(Adalat CC) 1
nifedipine oral tablet extended release
24hr 60 mg, 90 mg
(Procardia XL) 1
nifedipine oral tablet extended release 30
mg, 60 mg
(Adalat CC) 1
Diuretics
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
60
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
amiloride oral (Midamor) 1
amiloride-hydrochlorothiazide (Amiloride/Hydrochloro
thiazide)
1
bumetanide (Bumetanide) 1
chlorothiazide (Chlorothiazide) 1
chlorothiazide sodium (Sodium Diuril) 1
chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) 1
DYRENIUM 1
furosemide injection (Furosemide) 1
furosemide oral solution 10 mg/ml, 40
mg/5 ml
(Furosemide) 1
furosemide oral tablet (Lasix) 1
hydrochlorothiazide oral capsule (Microzide) 1
hydrochlorothiazide oral tablet (Hydrochlorothiazide) 1
indapamide (Indapamide) 1
methyclothiazide (Methyclothiazide) 1
metolazone (Zaroxolyn) 1
torsemide oral (Demadex) 1
triamterene-hydrochlorothiazid oral
capsule
(Dyazide) 1
triamterene-hydrochlorothiazid oral tablet (Maxzide) 1
Dyslipidemics
amlodipine-atorvastatin (Caduet) 1
atorvastatin (Lipitor) 1
cholestyramine packet (Questran) 1
cholestyramine-aspartame oral powder 4
gram
(Cholestyramine/Asparta
me)
1
cholestyramine-aspartame oral powder in
packet 4 gram
(Questran) 1
colestipol hcl granules packet (Colestid) 1
colestipol oral granules (Colestid) 1
colestipol oral tablet (Colestid) 1
CRESTOR 1
fenofibrate micronized (Lofibra) 1
fenofibrate nanocrystallized (Tricor) 1
fenofibrate oral tablet (Lofibra) 1
fenofibric acid (Fibricor) 1
fenofibric acid (choline) (Trilipix) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
61
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
gemfibrozil oral (Lopid) 1
JUXTAPID 1 PA
KYNAMRO 1 PA; QL (4 per 28 days)
lovastatin (Mevacor) 1
niacin (Niacin) 1
niacin oral tablet extended release 24 hr (Niaspan) 1
omega-3 acid ethyl esters (Lovaza) 1
PRALUENT PEN 1 PA; QL (2 per 28 days)
PRALUENT SYRINGE 1 PA; QL (2 per 28 days)
pravastatin (Pravachol) 1
prevalite packet outer 4 gram (Cholestyramine/Asparta
me)
1
REPATHA SURECLICK 1 PA; QL (3 per 28 days)
REPATHA SYRINGE 1 PA; QL (3 per 28 days)
simvastatin oral tablet 10 mg, 20 mg, 40
mg, 5 mg
(Zocor) 1
simvastatin oral tablet 80 mg (Zocor) 1 QL (30 per 30 days)
VASCEPA 1
ZETIA 1
Renin-Angiotensin-Aldosterone
System Inhibitors
eplerenone (Inspra) 1
spironolactone (Aldactone) 1
spironolacton-hydrochlorothiaz (Aldactazide) 1
Vasodilators
isosorbide dinitrate oral (Isochron) 1
isosorbide dinitrate sublingual (Isosorbide Dinitrate) 1
isosorbide mononitrate oral tablet (Isosorbide Mononitrate) 1
isosorbide mononitrate oral tablet
extended release 24 hr
(Imdur) 1
minitran transdermal patch 24 hour 0.1
mg/hr, 0.2 mg/hr, 0.6 mg/hr
(Nitro-Dur) 1 QL (30 per 30 days)
minitran transdermal patch 24 hour 0.4
mg/hr
(Nitro-Dur) 1 QL (60 per 30 days)
minoxidil oral (Minoxidil) 1
NITRO-BID 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
62
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
nitroglycerin in 5 % dextrose intravenous
solution 100 mg/250 ml (400 mcg/ml), 25
mg/250 ml (100 mcg/ml), 50 mg/250 ml
(200 mcg/ml)
(Nitroglycerin/D5W) 1
nitroglycerin intravenous (Nitroglycerin) 1
nitroglycerin transdermal patch 24 hour
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
(Nitro-Dur) 1 QL (30 per 30 days)
nitroglycerin transdermal patch 24 hour
0.4 mg/hr
(Nitro-Dur) 1 QL (60 per 30 days)
NITROSTAT 1
PROGLYCEM 1
Central Nervous System Agents
Central Nervous System Agents
amphetamine salt combo (Adderall) 1 QL (60 per 30 days)
AMPYRA 1 PA; QL (60 per 30 days)
caffeine citrated intravenous (Cafcit) 1
caffeine citrated oral (Cafcit) 1
caffeine-sodium benzoate (Caffeine/Sodium
Benzoate)
1
clonidine hcl oral tablet extended release
12 hr
(Kapvay) 1
dexmethylphenidate oral tablet (Focalin) 1 QL (60 per 30 days)
dextroamphetamine oral capsule, extended
release
(Dexedrine) 1 QL (120 per 30 days)
dextroamphetamine oral tablet (Dexedrine) 1 QL (180 per 30 days)
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15
mg, 5 mg
(Adderall XR) 1 QL (30 per 30 days)
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 20 mg, 25
mg, 30 mg
(Adderall XR) 1 QL (60 per 30 days)
flumazenil (Romazicon) 1
guanfacine oral tablet extended release 24
hr
(Intuniv) 1
lithium carbonate oral capsule (Lithium Carbonate) 1
lithium carbonate oral tablet (Lithobid) 1
lithium carbonate oral tablet extended
release
(Lithobid) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
63
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
lithium citrate oral solution 8 meq/5 ml (Lithium Citrate) 1
methylphenidate cd 20 mg cap (Metadate Cd) 1 QL (30 per 30 days)
methylphenidate cd 40 mg cap (Metadate Cd) 1 QL (30 per 30 days)
methylphenidate oral capsule, er biphasic
30-70 10 mg, 50 mg, 60 mg
(Metadate Cd) 1 QL (30 per 30 days)
methylphenidate oral capsule, er biphasic
30-70 30 mg
(Metadate Cd) 1 QL (60 per 30 days)
methylphenidate oral capsule,er biphasic
50-50 20 mg, 40 mg
(Metadate Cd) 1 QL (30 per 30 days)
methylphenidate oral solution (Methylin) 1 QL (900 per 30 days)
methylphenidate oral tablet (Ritalin) 1 QL (90 per 30 days)
methylphenidate oral tablet extended
release
(Methylphenidate HCl) 1 QL (90 per 30 days)
methylphenidate oral tablet extended
release 24hr 18 mg, 27 mg, 54 mg
(Concerta) 1 QL (30 per 30 days)
methylphenidate oral tablet extended
release 24hr 36 mg
(Concerta) 1 QL (60 per 30 days)
NUEDEXTA 1 QL (60 per 30 days)
QUILLIVANT XR 1
riluzole (Rilutek) 1
SAVELLA 1 QL (60 per 30 days)
STRATTERA 1
tetrabenazine (Xenazine) 1 PA; QL (112 per 28
days)
XENAZINE 1 PA; QL (112 per 28
days)
Contraceptives
Contraceptives
ashlyna (Seasonique) 1
bekyree (28) (Mircette) 1
blisovi 24 fe (Loestrin Fe) 1
blisovi fe 1.5/30 (28) (Loestrin Fe) 1
blisovi fe 1/20 (28) (Loestrin Fe) 1
cyred (Desogen) 1
deblitane (Nor-Q-D) 1
desog-e.estradiol/e.estradiol (Mircette) 1
desogestrel-ethinyl estradiol (Desogen) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
64
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
desogestrel-ethinyl estradiol oral tablet
0.1/.125/.15-25 mg-mcg
(Desogen) 1
drospirenone-ethinyl estradiol (Yaz) 1
ELLA 1 QL (6 per 365 days)
ethinyl estradiol/drospirenone (Yaz) 1
ethynodiol d-ethinyl estradiol (Demulen 1-50-21) 1
gildess 1/20 (21) (Loestrin) 1
gildess 24 fe (Loestrin Fe) 1
gildess fe 1/20 (28) (Loestrin Fe) 1
juleber (Desogen) 1
junel fe 24 (Loestrin Fe) 1
kimidess (28) (Mircette) 1
l norgest/e.estradiol-e.estrad (Seasonique) 1 QL (91 per 84 days)
larin 24 fe (Loestrin Fe) 1
larin fe 1/20 (28) (Loestrin Fe) 1
levonor-eth estrad 0.15-0.03 outer (Amethyst) 1 QL (91 per 84 days)
levonorgestrel oral tablet 0.75 mg (Plan B One-Step) 1 QL (12 per 365 days)
levonorgestrel oral tablet 1.5 mg (Plan B One-Step) 1 QL (6 per 365 days)
levonorgestrel-ethin estradiol oral tablet
0.1-20 mg-mcg, 0.15-0.03 mg, 50-30
(6)/75-40 (5)/125-30(10)
(Amethyst) 1
levonorgestrel-ethin estradiol oral
tablets,dose pack,3 month 0.15-30 mg-mcg
(Levonorgestrel-Ethin
Estradiol)
1 QL (91 per 84 days)
levonorgestrel-ethinyl estrad oral tablet
0.1-20 mg-mcg
(Amethyst) 1
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month
(Amethyst) 1 QL (91 per 84 days)
l-norgest-eth estr/ethin estra (Seasonique) 1 QL (91 per 84 days)
norelgestromin/ethin.estradiol (Ortho Evra) 1 QL (3 per 28 days)
norethindrone (Nor-Q-D) 1
norethindrone (contraceptive) (Nor-Q-D) 1
norethindrone ac-eth estradiol oral tablet
1-20 mg-mcg, 1.5-30 mg-mcg
(Loestrin) 1
norethindrone-e.estradiol-iron oral tablet
1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg
(24)/75 mg (4), 1-20(5)/1-30(7) /1mg-
35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7)
(Loestrin Fe) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
65
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
norethindrone-ethinyl estrad oral tablet
0.4-35 mg-mcg, 0.5-35 mg-mcg, 0.5-35/1-
35 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35
mcg, 0.5/1/0.5-35 mg-mcg, 1-35 mg-mcg
(Modicon) 1
norethindrone-mestranol (Norinyl 1+50) 1
norg-ee 0.18-0.215-0.25/0.035 (Ortho-Cyclen) 1
norgestimate-ethinyl estradiol (Ortho-Cyclen) 1
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-25 mcg
(Ortho-Cyclen) 1
norgestrel-ethinyl estradiol (Norgestrel-Ethinyl
Estradiol)
1
NUVARING 1 ST; QL (1 per 28 days)
setlakin (Levonorgestrel-Ethin
Estradiol)
1 QL (91 per 84 days)
tarina fe 1/20 (28) (Loestrin Fe) 1
tri-lo-estarylla (Ortho-Cyclen) 1
tri-lo-marzia (Ortho-Cyclen) 1
tri-lo-sprintec (Ortho-Cyclen) 1
vienva (Amethyst) 1
Dental And Oral Agents
Dental And Oral Agents
cevimeline (Evoxac) 1
chlorhexidine gluconate mucous
membrane
(Peridex) 1
pilocarpine hcl oral (Salagen) 1
sodium fluoride oral tablet,chewable 0.25
mg fluorid (0.55 mg)
(Sodium Fluoride) 1
triamcinolone acetonide (Triamcinolone
Acetonide)
1
Dermatological Agents
Dermatological Agents, Other
8-MOP 1
acitretin (Soriatane) 1
acyclovir topical (Zovirax) 1 QL (30 per 30 days)
ALCOHOL PADS 1
ALCOHOL PREP PADS 1
ammonium lactate topical (Lac-Hydrin) 1
ANACAINE 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
66
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
calcipotriene (Calcipotriene) 1
calcipotriene scalp (Calcipotriene) 1
calcipotriene topical cream (Dovonex) 1
calcitriol topical (Vectical) 1
CONDYLOX TOPICAL GEL 1
COSENTYX 1 PA
COSENTYX (150 MG/ML) 300 MG
DOSE-2 PENS
1 PA
COSENTYX (150 MG/ML) 300 MG
DOSE-2 SYRINGES
1 PA
COSENTYX PEN 1 PA
FLUOROPLEX 1
fluorouracil topical cream (Carac) 1
fluorouracil topical solution (Fluorouracil) 1
imiquimod (Aldara) 1 PA NSO; QL (24 per 30
days)
isotretinoin oral capsule 10 mg, 20 mg, 30
mg, 40 mg
(Isotretinoin) 1
methoxsalen rapid (Oxsoralen-Ultra) 1
PANRETIN 1
PICATO TOPICAL GEL 0.015 % 1 QL (3 per 56 days)
PICATO TOPICAL GEL 0.05 % 1 QL (2 per 56 days)
podofilox (Condylox) 1
podophyllum resin (Podophyllum Resin) 1
potassium hydroxide (Potassium Hydroxide) 1
SANTYL 1
TOLAK 1
VALCHLOR 1
ZOVIRAX TOPICAL CREAM 1 QL (15 per 30 days)
Dermatological Antibacterials
clindamycin phosphate topical gel (Cleocin T) 1
clindamycin phosphate topical lotion (Cleocin T) 1
clindamycin phosphate topical solution (Cleocin T) 1
clindamycin phosphate topical swab (Cleocin T) 1
erythromycin base-ethanol (Erythromycin
Base/Ethanol)
1
erythromycin with ethanol topical gel (Emgel) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
67
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
erythromycin with ethanol topical solution (Erythromycin
Base/Ethanol)
1
erythromycin with ethanol topical swab (Erythromycin
Base/Ethanol)
1
gentamicin topical (Gentamicin Sulfate) 1
metronidazole topical cream 0.75 % (Metrocream) 1
metronidazole topical gel (Rosadan) 1
metronidazole topical lotion (Metrolotion) 1
mupirocin (Centany) 1
mupirocin calcium (Bactroban) 1
neomycin-polymyxin b gu (Neosporin G.U.
Irrigant)
1
selenium sulfide topical lotion (Selenium Sulfide) 1
selenium sulfide topical shampoo 2.25 % (Selenium Sulfide) 1
silver nitrate applicators (Silver Nitrate
Applicator)
1
silver nitrate topical (Silver Nitrate) 1
silver sulfadiazine (Silvadene) 1
sulfacetamide sodium (acne) (Klaron) 1
Dermatological Anti-
Inflammatory Agents
alclometasone (Alclometasone
Dipropionate)
1
betamethasone dipropionate (Betamethasone
Dipropionate)
1
betamethasone valerate topical cream (Betamethasone
Valerate)
1
betamethasone valerate topical foam (Luxiq) 1
betamethasone valerate topical lotion (Betamethasone
Valerate)
1
betamethasone valerate topical ointment (Betamethasone
Valerate)
1
betamethasone, augmented topical cream (Diprolene AF) 1
betamethasone, augmented topical gel (Betamethasone
Dipropionate)
1
betamethasone, augmented topical lotion (Diprolene) 1
betamethasone, augmented topical
ointment
(Diprolene) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
68
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
clobetasol 0.05% cream (Temovate) 1
clobetasol propionate scalp solution 0.05
%
(Clobetasol Propionate) 1
clobetasol scalp (Clobetasol Propionate) 1
clobetasol topical foam (Olux) 1
clobetasol topical gel (Clobetasol Propionate) 1
clobetasol topical lotion (Clobex) 1
clobetasol topical ointment (Temovate) 1
clobetasol topical shampoo (Clobex) 1
clobetasol-emollient topical cream (Temovate) 1
clocortolone pivalate (Cloderm) 1
desonide topical cream (Desowen) 1
desonide topical ointment (Desonide) 1
desoximetasone (Topicort) 1
ELIDEL 1
fluocinonide 0.05% cream (Vanos) 1
fluocinonide topical gel (Fluocinonide) 1
fluocinonide topical ointment (Fluocinonide) 1
fluocinonide topical solution (Fluocinonide) 1
fluocinonide-emollient base (Vanos) 1
fluticasone topical cream (Cutivate) 1
fluticasone topical ointment (Fluticasone Propionate) 1
halobetasol propionate (Ultravate) 1
hydrocortisone 1% ointment carton (otc) (Hydrocortisone) 1
hydrocortisone acet-aloe vera topical gel (Hydrocortisone
Acetate/Aloe V)
1
hydrocortisone acetate-urea (Hydrocortisone
Acetate/Urea)
1
hydrocortisone buty 0.1% cream (Hydrocortisone
Butyrate)
1
hydrocortisone butyrate topical ointment (Locoid) 1
hydrocortisone butyrate topical solution (Locoid) 1
hydrocortisone butyr-emollient (Hydrocortisone
Butyrate)
1
hydrocortisone rectal cream 1 % (Anusol-HC) 1
hydrocortisone rectal cream 2.5 % (Hydrocortisone) 1
hydrocortisone rectal enema (Cortenema) 1
hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
69
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
hydrocortisone topical lotion 2 %, 2.5 % (Scalacort) 1
hydrocortisone topical ointment 1 %, 2.5
%
(Hydrocortisone) 1
hydrocortisone valerate topical cream (Hydrocortisone
Valerate)
1
hydrocortisone valerate topical ointment (Westcort) 1
mometasone (Elocon) 1
ONFI ORAL TABLET 10 MG, 20 MG 1 PA NSO; QL (60 per 30
days)
prednicarbate (Dermatop) 1
tacrolimus topical (Protopic) 1
triamcinolone acetonide (Triamcinolone
Acetonide)
1
triamcinolone acetonide topical cream (Triamcinolone
Acetonide)
1
triamcinolone acetonide topical lotion (Triamcinolone
Acetonide)
1
triamcinolone acetonide topical ointment
0.025 %, 0.1 %, 0.5 %
(Triamcinolone
Acetonide)
1
Dermatological Retinoids
adapalene topical cream (Differin) 1
adapalene topical gel 0.1 % (Differin) 1
TAZORAC TOPICAL CREAM 1
tretinoin gel micro 0.04% tube (Retin-A Micro) 1 PA
tretinoin gel micro 0.1% tube (Retin-A Micro) 1 PA
tretinoin microspheres topical gel with
pump
(Retin-A Micro) 1 PA
tretinoin topical (Retin-A) 1 PA
Scabicides And Pediculicides
malathion (Ovide) 1
permethrin topical cream (Elimite) 1
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE 1 ML 29 GAUGE X 1/2"
1
BD ECLIPSE LUER-LOK SYRINGE 1
ML 27 X 1/2"
1
BD INSULIN SYR 0.3 ML 31GX5/16 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
70
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
BD INSULIN SYR 0.5 ML 31GX5/16" 1
BD INSULIN SYR 1 ML 31GX5/16" 1
BD ULTRA-FINE PEN NDL 8MMX31G
SHORT
1
INSULIN SYRINGE-NEEDLE U-100
SYRINGE 0.3 ML 29, 1 ML 29 X 1/2",
1/2 ML 28 GAUGE
1
PEN NEEDLE, DIABETIC NEEDLE 29
GAUGE X 1/2 "
1
VGO 40 DISPOSABLE DEVICE 1
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN 1
ALDURAZYME 1
CEREZYME INTRAVENOUS RECON
SOLN 400 UNIT
1
CREON 1
ELAPRASE 1
ELITEK INTRAVENOUS RECON
SOLN 1.5 MG
1
FABRAZYME INTRAVENOUS RECON
SOLN 35 MG
1
KANUMA 1 PA
KRYSTEXXA 1
KUVAN ORAL TABLET,SOLUBLE 1
lipase-protease-amylase (Lipase/Protease/Amylas
e)
1
MYOZYME 1
NAGLAZYME 1
ORFADIN 1
PULMOZYME 1 PA BvD
STRENSIQ 1 PA; LA
VIMIZIM 1 PA
VPRIV 1
ZAVESCA 1 QL (90 per 30 days)
ZENPEP 1
Eye, Ear, Nose, Throat Agents
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
71
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
Eye, Ear, Nose, Throat Agents,
Miscellaneous
AKTEN (PF) 1
altacaine (Tetravisc) 1
apraclonidine (Iopidine) 1
atropine ophthalmic drops (Isopto Atropine) 1
atropine ophthalmic ointment (Atropine Sulfate) 1
atropine sulfate ophthalmic drops 1 % (Isopto Atropine) 1
azelastine nasal aerosol,spray (Astepro) 1 QL (30 per 25 days)
azelastine ophthalmic (Azelastine HCl) 1
carteolol (Carteolol HCl) 1
cromolyn ophthalmic (Cromolyn Sodium) 1
CYCLOGYL OPHTHALMIC DROPS 0.5
%
1
cyclopentolate (Cyclogyl) 1
CYSTARAN 1
epinastine (Elestat) 1
homatropine hbr (Isopto Homatropine) 1
ipratropium bromide nasal spray,non-
aerosol 0.03 %
(Atrovent) 1 QL (30 per 28 days)
ipratropium bromide nasal spray,non-
aerosol 0.06 %
(Atrovent) 1 QL (15 per 10 days)
LACRISERT 1
naphazoline (Naphazoline HCl) 1
olopatadine ophthalmic (Patanol) 1
PATADAY 1 ST
phenylephrine hcl ophthalmic (Mydfrin) 1
proparacaine (Proparacaine HCl) 1
proparacaine hcl ophthalmic drops 0.5 % (Proparacaine HCl) 1
proparacaine-fluorescein sod (Proparacaine/Fluorescei
n Sod)
1
tetracaine hcl (pf) ophthalmic (Tetracaine HCl/PF) 1
Eye, Ear, Nose, Throat Anti-
Infectives Agents
acetic acid otic (Acetic Acid) 1
bacitracin ophthalmic (Bacitracin) 1
bacitracin-polymyxin b ophthalmic (Bacitracin/Polymyxin B
Sulfate)
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
72
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
CIPRODEX 1
ciprofloxacin hcl ophthalmic (Ciloxan) 1
ciprofloxacin hcl otic (Cetraxal) 1
COLY-MYCIN S 1
erythromycin ophthalmic (Ilotycin) 1
gatifloxacin (Zymaxid) 1
gentamicin ophthalmic (Garamycin) 1
gentamicin sulfate ophthalmic ointment
0.3 % (3 mg/gram)
(Garamycin) 1
levofloxacin ophthalmic (Levofloxacin) 1
MOXEZA 1
NATACYN 1
neomy sulf-bacitrac zn-poly-hc (Neomycin Su/Baci
Zn/Poly/HC)
1
neomycin-bacitracin-poly-hc (Neomycin Su/Baci
Zn/Poly/HC)
1
neomycin-bacitracin-polymyxin (Neomycin
Su/Bacitra/Polymyxin)
1
neomycin-polymyxin b-dexameth (Maxitrol) 1
neomycin-polymyxin-gramicidin (Neosporin) 1
neomycin-polymyxin-hc ophthalmic (Neomycin/Polymyxin B
Sulf/HC)
1
neomycin-polymyxin-hc otic
drops,suspension
(Neomycin/Polymyxin B
Sulf/HC)
1
neomycin-polymyxin-hc otic solution (Cortisporin) 1
neo-polycin (Neomycin
Su/Bacitra/Polymyxin)
1
ofloxacin ophthalmic (Ocuflox) 1
ofloxacin otic (Ocuflox) 1
polymyxin b sulf-trimethoprim (Polytrim) 1
sulfacetamide sodium ophthalmic (Sulfacetamide Sodium) 1
sulfacetamide-prednisolone (Sulfacetamide/Predniso
lone Sp)
1
TOBRADEX OPHTHALMIC
OINTMENT
1
TOBRADEX ST 1
tobramycin (Tobrex) 1
tobramycin-dexamethasone (Tobradex) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
73
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
trifluridine (Viroptic) 1
VIGAMOX 1
ZIRGAN 1
ZYLET 1
Eye, Ear, Nose, Throat Anti-
Inflammatory Agents
ALREX 1 ST
bromfenac (Bromfenac Sodium) 1
dexamethasone sodium phosphate
ophthalmic
(Dexasol) 1
diclofenac sodium ophthalmic (Diclofenac Sodium) 1
DUREZOL 1
flunisolide nasal spray,non-aerosol 25
mcg (0.025 %)
(Flunisolide) 1 QL (50 per 25 days)
fluorometholone (FML) 1
flurbiprofen sodium (Ocufen) 1
fluticasone nasal (Fluticasone Propionate) 1
ILEVRO 1
ketorolac ophthalmic (Acular) 1
LOTEMAX 1
NEVANAC 1
prednisolone acetate (Omnipred) 1
prednisolone sodium phosphate
ophthalmic
(Prednisolone Sod
Phosphate)
1
PROLENSA 1
RESTASIS 1 QL (60 per 30 days)
Gastrointestinal Agents
Antiulcer Agents And Acid
Suppressants
amoxicil-clarithromy-lansopraz (Prevpac) 1
CARAFATE ORAL SUSPENSION 1
cimetidine (Cimetidine) 1 (Rx Product Only)
cimetidine hcl oral (Cimetidine HCl) 1
esomeprazole sodium (Nexium I.V.) 1
famotidine (pf) (Famotidine) 1
famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso-
Osm/PF)
1
famotidine 40 mg/4 ml vial 25's,outer (Famotidine) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
74
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
famotidine oral tablet 20 mg, 40 mg (Pepcid) 1 (Rx Product Only)
lansoprazole oral capsule,delayed
release(dr/ec)
(Prevacid) 1 (Rx Product Only)
misoprostol (Cytotec) 1
omeprazole oral capsule,delayed
release(dr/ec)
(Prilosec) 1
pantoprazole oral (Protonix) 1
ranitidine hcl 50 mg/2 ml vial sdv (Zantac) 1 (Rx Product Only)
ranitidine hcl injection solution 25 mg/ml (Zantac) 1 (Rx Product Only)
ranitidine hcl oral capsule (Ranitidine HCl) 1 (Rx Product Only)
ranitidine hcl oral syrup (Ranitidine HCl) 1 (Rx Product Only)
ranitidine hcl oral tablet 150 mg, 300 mg (Zantac) 1 (Rx Product Only)
sucralfate oral suspension (Sucralfate) 1
sucralfate oral tablet (Carafate) 1
Gastrointestinal Agents, Other
AMITIZA 1 QL (60 per 30 days)
BUPHENYL ORAL TABLET 1
CARBAGLU 1
cromolyn oral (Gastrocrom) 1
dicyclomine oral capsule (Bentyl) 1
dicyclomine oral solution (Dicyclomine HCl) 1
dicyclomine oral tablet (Bentyl) 1
diphenoxylate-atropine oral liquid (Diphenoxylate
HCl/Atropine)
1
diphenoxylate-atropine oral tablet (Lomotil) 1
GATTEX 5 MG 30-VIAL KIT 1 PA
GATTEX ONE-VIAL 1 PA
glycopyrrolate injection (Robinul) 1
glycopyrrolate oral (Robinul) 1
kionex 15 gm/60 ml suspension 15
gram/60 ml
(Sodium Polystyrene
Sulfonate)
1
lactulose oral solution 10 gram/15 ml (Lactulose) 1
LINZESS 1 QL (30 per 30 days)
loperamide oral capsule (Loperamide HCl) 1
LOTRONEX 1
methscopolamine oral (Methscopolamine
Bromide)
1
metoclopramide hcl injection solution (Metoclopramide HCl) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
75
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
metoclopramide hcl oral solution (Metoclopramide HCl) 1
metoclopramide hcl oral tablet (Reglan) 1
MOVANTIK 1 QL (30 per 30 days)
NUTRESTORE 1
RAVICTI 1 PA
RELISTOR SUBCUTANEOUS
SOLUTION
1 PA; QL (28 per 28 days)
RELISTOR SUBCUTANEOUS
SYRINGE
1 PA; QL (28 per 28 days)
sodium polystyrene sulfonate oral powder (Sodium Polystyrene
Sulfonate)
1
sodium polystyrene sulfonate oral
suspension 15 gram/60 ml
(Sodium Polystyrene
Sulfonate)
1
sodium polystyrene sulfonate rectal enema
30 gram/120 ml
(Sodium Polystyrene
Sulfonate)
1
sps 15 gm/60 ml suspension 15 gram/60
ml
(Sodium Polystyrene
Sulfonate)
1
ursodiol oral capsule (Actigall) 1
ursodiol oral tablet (Urso) 1
VIBERZI 1 ST; QL (60 per 30 days)
Laxatives
MOVIPREP 1
peg 3350-electrolytes (Golytely) 1
PEG 3350-GRX 1
peg 3350-na sulf,bicarb,cl-kcl (Golytely) 1
peg-electrolyte soln (Nulytely with Flavor
Packs)
1
polyethylene glycol 3350 oral powder (Gavilyte-N) 1
polyethylene glycol 3350 powd 17 gm
packets (rx)
(Gavilyte-N) 1
sodium chloride-nahco3-kcl-peg oral
recon soln 420 gram
(Nulytely with Flavor
Packs)
1
Phosphate Binders
calcium acetate oral capsule (Phoslo) 1
calcium acetate oral tablet 667 mg (Calcium Acetate) 1
calcium carbonate-mag carb-fa (Calcium
Carbonate/Mag Carb/Fa)
1
PHOSLYRA 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
76
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
RENAGEL 1
RENVELA 1
Genitourinary Agents
Antispasmodics, Urinary
MYRBETRIQ 1
oxybutynin chloride oral tablet (Oxybutynin Chloride) 1
oxybutynin chloride oral tablet extended
release 24hr
(Ditropan XL) 1
tolterodine oral capsule,extended release
24hr
(Detrol LA) 1
tolterodine oral tablet (Detrol) 1
TOVIAZ 1
trospium (Trospium Chloride) 1
Genitourinary Agents,
Miscellaneous
alfuzosin (Uroxatral) 1
tamsulosin (Flomax) 1
terazosin (Terazosin HCl) 1
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine (Desferal) 1 PA BvD
DEPEN TITRATABS 1
EXJADE 1
FERRIPROX 1
sodium thiosulfate intravenous solution 1
gram/10 ml (100 mg/ml), 12.5 gram/50 ml
(250 mg/ml)
(Sodium Thiosulfate) 1
SYPRINE 1
Hormonal Agents,
Stimulant/Replacement/Modifying
Androgens
ANDRODERM 1 PA; QL (30 per 30 days)
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 20.25 MG/1.25
GRAM (1.62 %)
1 PA; QL (150 per 30
days)
ANDROGEL TRANSDERMAL GEL IN
PACKET 1.62 % (20.25 MG/1.25
GRAM), 1.62 % (40.5 MG/2.5 GRAM)
1 PA; QL (150 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
77
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
danazol oral (Danazol) 1
fluoxymesterone (Fluoxymesterone) 1
oxandrolone (Oxandrin) 1
testosterone cypionate (Depo-Testosterone) 1 PA
testosterone enanthate (Testosterone Enanthate) 1 PA; QL (5 per 28 days)
testosterone transdermal gel (Testim) 1 PA; QL (300 per 30
days)
testosterone transdermal gel in metered-
dose pump 1.25 gram/ actuation (1 %)
(Vogelxo) 1 PA; QL (300 per 30
days)
testosterone transdermal gel in packet 1 %
(25 mg/2.5gram)
(Androgel) 1 PA; QL (300 per 30
days)
testosterone transdermal gel in packet 1 %
(50 mg/5 gram)
(Testim) 1 PA; QL (300 per 30
days)
Estrogens And Antiestrogens
COMBIPATCH 1 PA-HRM; QL (8 per 28
days)
DUAVEE 1 PA-HRM
ESTRACE VAGINAL 1
estradiol oral (Estrace) 1 PA-HRM
estradiol transdermal patch semiweekly (Vivelle-Dot) 1 PA-HRM; QL (8 per 28
days)
estradiol transdermal patch weekly (Climara) 1 PA-HRM; QL (4 per 28
days)
estradiol valerate (Delestrogen) 1
estradiol/norethindrone acet (Activella) 1 PA-HRM
estradiol-norethindrone acet (Activella) 1 PA-HRM
estropipate (Estropipate) 1 PA-HRM
FEMRING 1 QL (1 per 84 days)
MENEST 1 PA-HRM
PREMARIN INJECTION 1
PREMARIN ORAL 1 PA-HRM
PREMARIN VAGINAL 1
PREMPHASE 1 PA-HRM
PREMPRO 1 PA-HRM
raloxifene (Evista) 1
VAGIFEM 1 QL (18 per 28 days)
Glucocorticoids/Mineralocorticoids
betamethasone acet,sod phos (Celestone) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
78
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
cortisone (Cortisone Acetate) 1 PA BvD
dexamethasone oral elixir (Dexamethasone) 1 PA BvD
dexamethasone oral tablet (Dexamethasone) 1 PA BvD
dexamethasone sodium phosphate
injection solution
(Dexamethasone Sod
Phosphate)
1
fludrocortisone (Fludrocortisone
Acetate)
1
hydrocortisone oral (Cortef) 1 PA BvD
hydrocortisone sod succinate (Hydrocortisone Sod
Succinate)
1
methylprednisolone (Medrol) 1 PA BvD
methylprednisolone acetate (Depo-Medrol) 1
methylprednisolone sodium succ injection
recon soln 125 mg, 40 mg
(A-Methapred) 1
methylprednisolone sodium succ
intravenous
(A-Methapred) 1
prednisolone sodium phosphate oral
solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml
(5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
(Pediapred) 1 PA BvD
prednisone oral (Prednisone) 1 PA BvD
SOLU-CORTEF (PF) INJECTION
RECON SOLN 100 MG/2 ML
1
triamcinolone acetonide injection (Triamcinolone
Acetonide)
1
Pituitary
desmopressin injection (Desmopressin Acetate) 1
desmopressin nasal solution (DDAVP) 1 QL (15 per 30 days)
desmopressin nasal spray,non-aerosol (Desmopressin Acetate) 1 QL (15 per 30 days)
desmopressin oral (DDAVP) 1
GENOTROPIN 1 PA
GENOTROPIN MINIQUICK 1 PA
INCRELEX 1
LUPRON DEPOT-PED 1
LUPRON DEPOT-PED (3 MONTH)
INTRAMUSCULAR SYRINGE KIT 30
MG
1 QL (1 per 84 days)
NORDITROPIN FLEXPRO 1 PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
79
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
octreotide acet 50 mcg/ml syr outer,single-
dose,10
(Octreotide Acetate) 1
octreotide acetate injection solution 1,000
mcg/ml, 100 mcg/ml, 200 mcg/ml, 500
mcg/ml
(Sandostatin) 1
octreotide acetate injection solution 50
mcg/ml
(Octreotide Acetate) 1
SAIZEN 1 PA
SAIZEN CLICK.EASY 1 PA
SANDOSTATIN LAR 10 MG KIT 1
SANDOSTATIN LAR 20 MG KIT 1
SANDOSTATIN LAR 30 MG KIT 1
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON
1
SEROSTIM SUBCUTANEOUS RECON
SOLN 4 MG, 5 MG, 6 MG
1 PA
SOMATULINE DEPOT 1 QL (1 per 28 days)
SOMAVERT 1
SUPPRELIN LA 1 QL (1 per 360 days)
Progestins
DEPO-PROVERA INTRAMUSCULAR
SOLUTION
1 QL (10 per 28 days)
medroxyprogesterone intramuscular (Depo-Provera) 1 QL (1 per 84 days)
medroxyprogesterone oral (Provera) 1
MEGACE ES 1
megestrol oral suspension 400 mg/10 ml
(40 mg/ml), 625 mg/5 ml
(Megace Es) 1
norethindrone acetate (Aygestin) 1
progesterone (Progesterone) 1
progesterone micronized (Prometrium) 1
Thyroid And Antithyroid Agents
levothyroxine intravenous (Levothyroxine Sodium) 1
levothyroxine oral (Levoxyl) 1
liothyronine oral (Cytomel) 1
methimazole oral tablet 10 mg, 5 mg (Tapazole) 1
propylthiouracil (Propylthiouracil) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
80
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
Immunological Agents
Immunological Agents
ARCALYST 1
ASTAGRAF XL 1 PA BvD
AUBAGIO 1 PA; QL (28 per 28 days)
azathioprine (Imuran) 1 PA BvD
azathioprine sodium (Azathioprine Sodium) 1 PA BvD
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 6
GRAM
1 PA BvD
CELLCEPT INTRAVENOUS 1 PA BvD
CIMZIA 1 PA
CIMZIA POWDER FOR RECONST 1 PA
cyclosporine intravenous (Sandimmune) 1 PA BvD
cyclosporine modified (Neoral) 1 PA BvD
cyclosporine oral capsule (Sandimmune) 1 PA BvD
cyclosporine, modified (Neoral) 1 PA BvD
ENBREL 1 PA
ENBREL SURECLICK 1 PA
ENVARSUS XR 1 PA BvD
FLEBOGAMMA DIF 1 PA BvD
GAMASTAN S/D 1 PA BvD
GAMMAGARD LIQUID 1 PA BvD
GAMMAPLEX 1 PA BvD
HUMIRA 1 PA
HUMIRA PEN 1 PA
HUMIRA PEN CROHN'S-UC-HS
START
1 PA
HYPERRAB S/D (PF) 1
HYQVIA 1 PA BvD
ILARIS (PF) 1 PA
IMOGAM RABIES-HT (PF) 1
KINERET 1 PA; QL (18.76 per 28
days)
leflunomide (Arava) 1
mycophenolate mofetil (Cellcept) 1 PA BvD
mycophenolate sodium (Myfortic) 1 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
81
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
NULOJIX 1 PA BvD
OCTAGAM 1 PA BvD
ORENCIA 1 PA
ORENCIA (WITH MALTOSE) 1 PA
PRIVIGEN 1 PA BvD
PROGRAF INTRAVENOUS 1 PA BvD
RAPAMUNE ORAL SOLUTION 1 PA BvD
RIDAURA 1
sirolimus (Rapamune) 1 PA BvD
tacrolimus oral (Hecoria) 1 PA BvD
TYSABRI 1 PA; LA; QL (15 per 28
days)
ZORTRESS 1 PA BvD; QL (120 per 30
days)
Vaccines
ACTHIB (PF) 1 (Vaccine for
Haemophilus B
Conjugate)
ADACEL(TDAP
ADOLESN/ADULT)(PF)
1 (Vaccine for Tetanus,
Diphtheria, and Pertussis
[Tdap])
BCG (TICE STRAIN) VIAL 1 PA BvD; (Vaccine for
Tuberculosis)
BCG VACCINE, LIVE (PF) 1 PA BvD; (Vaccine for
Tuberculosis)
BEXSERO (PF) 1
BOOSTRIX TDAP 1 (Vaccine for Tetanus,
Diphtheria, and Pertussis
[Tdap])
CERVARIX VACCINE (PF) 1 (Vaccine for Human
Papillomavirus 16, 18)
COMVAX (PF) 1 (Vaccine for
Haemophilus B
Conjugate/Hepatitis B)
DAPTACEL (DTAP PEDIATRIC) (PF) 1 (Vaccine for Pertussis,
Diphtheria, and Tetanus
[Dtap])
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
82
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
ENGERIX-B (PF) INTRAMUSCULAR
SYRINGE
1 PA BvD; (Vaccine for
Hepatitis B); QL (3 per
365 days)
ENGERIX-B 20 MCG/ML VIAL
10'S,ADULT,P/F,OUTER
1 PA BvD; (Vaccine for
Hepatitis B); QL (3 per
365 days)
ENGERIX-B PEDIATRIC (PF) 1 PA BvD; (Vaccine for
Hepatitis B); QL (3 per
365 days)
GARDASIL (PF) 1 (Vaccine for Human
Papillomavirus 6, 11, 16,
18); QL (1.5 per 365
days)
GARDASIL 9 (PF) 1 (Vaccine for Human
Papillomavirus 6, 11, 16,
18); QL (1.5 per 365
days)
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA UNIT/ML
1 (Vaccine for Hepatitis A)
HAVRIX (PF) INTRAMUSCULAR
SYRINGE
1 (Vaccine for Hepatitis A)
IMOVAX RABIES VACCINE (PF) 1 PA BvD; (Vaccine for
Rabies)
INFANRIX (DTAP) (PF)
INTRAMUSCULAR SUSPENSION
1 (Vaccine for Tetanus,
Diphtheria, and Pertussis
[Td/Tdap])
IPOL INJECTION SUSPENSION 1 (Vaccine for Polio)
IXIARO (PF) 1 (Vaccine for Japanese
Encephalitis)
KINRIX (PF) INTRAMUSCULAR
SUSPENSION
1
KINRIX (PF) INTRAMUSCULAR
SYRINGE
1 (Vaccine for
Diphtheria/Tetanus/Pertu
ssis/Polio)
MENACTRA (PF) INTRAMUSCULAR
SOLUTION
1 (Vaccine for
Meningococcal
Diphtheria)
MENHIBRIX (PF) 1 (Vaccine for
Haemophilus B/Tetanus
Toxoid Conjugate)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
83
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
MENOMUNE - A/C/Y/W-135 (PF) 1 (Vaccine for
Meningococcal
Polysaccharide)
MENVEO A-C-Y-W-135-DIP (PF) 1 (Vaccine for
Meningococcal
Oligosaccharide/Diphthe
ria)
MENVEO MENA COMPONENT (PF) 1 (Vaccine for
Meningoccal
Oligopsaccharide/Dipthe
ria)
MENVEO MENCYW-135 COMPNT
(PF)
1 (Vaccine for
Meningococcal
Oligosaccharide/Diphthe
ria)
M-M-R II (PF) 1 (Vaccine for
Measles/Mumps/Rubella
); QL (2 per 365 days)
PEDIARIX (PF) 1
PEDVAX HIB (PF) 1 (Vaccine for
Haemophilis B
Conjugate)
PENTACEL (PF) 1 (Vaccine for
Diphtheria/Haemophilis
B/Pertussis/Polio/Tetanu
s)
PENTACEL ACTHIB COMPONENT
(PF)
1 (Vaccine for
Diphtheria/Haemophilis
B/Pertussis/Polio/Tetanu
s)
PROQUAD (PF) 1 (Vaccine for
Measles/Mumps/Rubella
/Varicella); QL (2 per
365 days)
QUADRACEL (PF) 1
RABAVERT (PF) 1 PA BvD; (Vaccine for
Rabies)
RECOMBIVAX HB (PF)
INTRAMUSCULAR SUSPENSION 10
MCG/ML, 40 MCG/ML
1 PA BvD; (Vaccine for
Hepatitis B); QL (3 per
365 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
84
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
RECOMBIVAX HB (PF)
INTRAMUSCULAR SYRINGE
1 PA BvD; (Vaccine for
Hepatitis B); QL (3 per
365 days)
ROTARIX 1
ROTATEQ VACCINE 1 (Vaccine for Rotavirus)
TENIVAC (PF) INTRAMUSCULAR
SYRINGE
1 (Vaccine for Tetanus and
Diphtheria [Td])
TETANUS TOXOID,ADSORBED (PF) 1 PA BvD; (Vaccine for
Tetanus)
TETANUS,DIPHTHERIA TOX PED(PF) 1 (Vaccine for Tetanus and
Diphtheria [DT])
TETANUS-DIPHTHERIA TOXOIDS-TD 1 (Vaccine for Tetanus and
Diphtheria [Td])
TRUMENBA 1
TWINRIX (PF) 1 (Vaccine for Hepatitis
A/Hepatitis B)
TYPHIM VI INTRAMUSCULAR
SOLUTION
1 (Vaccine for Typhoid
VI)
TYPHIM VI INTRAMUSCULAR
SYRINGE
1
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 50 UNIT/ML
1 (Vaccine for Hepatitis A)
VAQTA (PF) INTRAMUSCULAR
SYRINGE
1 (Vaccine for Hepatitis A)
VAQTA 25 UNITS/0.5 ML VIAL SDV,
OUTER
1 (Vaccine for Hepatitis A)
VARIVAX (PF) 1 (Vaccine for Varicella);
QL (2 per 365 days)
YF-VAX (PF) 1 (Vaccine for Yellow
Fever)
ZOSTAVAX (PF) 1 (Vaccine for Shingles);
QL (1 per 365 days)
Inflammatory Bowel Disease
Agents
Inflammatory Bowel Disease
Agents
alosetron (Alosetron HCl) 1
APRISO 1
ASACOL HD 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
85
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
balsalazide (Colazal) 1
budesonide oral (Entocort EC) 1
DELZICOL 1
DIPENTUM 1 ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation (Acetic Acid) 1
LACTATED RINGERS IRRIGATION 1
ringers irrigation (Ringers Solution) 1
sodium chloride irrigation (Sodium Chloride Irrig
Solution)
1
sorbitol irrigation (Sorbitol Solution) 1
sorbitol-mannitol (Mannitol/Sorbitol
Solution)
1
water for irrigation, sterile (Water For
Irrigation,Sterile)
1
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate oral solution (Alendronate Sodium) 1 QL (300 per 28 days)
alendronate oral tablet 10 mg, 40 mg, 5
mg
(Fosamax) 1
alendronate oral tablet 35 mg, 70 mg (Fosamax) 1 QL (4 per 28 days)
calcitonin (salmon) (Miacalcin) 1 QL (3.7 per 28 days)
calcitriol intravenous solution 1 mcg/ml (Calcitriol) 1 (PA for ESRD Only)
calcitriol oral (Rocaltrol) 1 (PA for ESRD Only)
doxercalciferol intravenous (Doxercalciferol) 1 (PA for ESRD Only)
doxercalciferol oral (Hectorol) 1 (PA for ESRD Only)
FORTEO 1 PA; QL (2.4 per 28 days)
FORTICAL 1 QL (3.7 per 28 days)
ibandronate intravenous solution (Ibandronate Sodium) 1 (PA for ESRD Only);
QL (3 per 84 days)
ibandronate intravenous syringe (Boniva) 1 QL (3 per 84 days)
ibandronate oral (Boniva) 1 QL (1 per 28 days)
MIACALCIN INJECTION 1 (PA for ESRD Only)
NATPARA 1 PA; QL (2 per 28 days)
paricalcitol oral (Zemplar) 1 (PA for ESRD Only)
PROLIA 1 QL (1 per 180 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
86
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
risedronate oral tablet 150 mg (Actonel) 1 QL (1 per 28 days)
risedronate oral tablet 30 mg, 5 mg (Actonel) 1 QL (30 per 28 days)
ZEMPLAR INTRAVENOUS 1 (PA for ESRD Only)
zoledronic acid intravenous solution (Zometa) 1
zoledronic acid-mannitol-water
intravenous piggyback 4 mg/100 ml
(Zoledronic
Acid/Mannitol and
Water)
1
zoledronic acid-mannitol-water
intravenous solution
(Reclast) 1 QL (100 per 300 days)
ZOMETA INTRAVENOUS SOLUTION
4 MG/100 ML
1
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic
Agents
ACTEMRA INTRAVENOUS
SOLUTION 200 MG/10 ML (20 MG/ML)
1 PA
ACTEMRA SUBCUTANEOUS 1 PA
ACTIMMUNE 1
allopurinol (Zyloprim) 1
amifostine crystalline (Amifostine Crystalline) 1
anticoag citrate phos dextrose (Citrate Phosphate
Dextros Soln)
1
AVONEX (WITH ALBUMIN) 1 ST
AVONEX INTRAMUSCULAR PEN
INJECTOR KIT
1 ST
AVONEX INTRAMUSCULAR
SYRINGE KIT
1 ST
BENLYSTA INTRAVENOUS RECON
SOLN 120 MG
1 PA
BETASERON SUBCUTANEOUS KIT 1 ST
bethanechol chloride (Urecholine) 1
buspirone (Buspirone HCl) 1
CERDELGA 1 PA
colchicine oral tablet (Colcrys) 1
colchicine-probenecid (Colchicine/Probenecid) 1
COPAXONE SUBCUTANEOUS
SYRINGE
1
CYSTADANE 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
87
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
droperidol injection solution (Droperidol) 1
dutasteride (Avodart) 1
dutasteride-tamsulosin (Jalyn) 1 QL (30 per 30 days)
ELMIRON 1
ergoloid (Ergoloid Mesylates) 1
EXTAVIA SUBCUTANEOUS KIT 1 ST
finasteride oral tablet 5 mg (Proscar) 1
fomepizole (Fomepizole) 1
FUSILEV 1
GAUZE PAD TOPICAL BANDAGE 2 X
2 "
1
GILENYA 1 PA; QL (28 per 28 days)
GLUCAGEN HYPOKIT 1
GLUCAGON EMERGENCY KIT
(HUMAN)
1
guanidine (Guanidine HCl) 1
hydroxyzine hcl intramuscular (Hydroxyzine HCl) 1 PA-HRM
hydroxyzine hcl oral solution 10 mg/5 ml (Hydroxyzine HCl) 1 PA-HRM
hydroxyzine hcl oral tablet (Hydroxyzine HCl) 1 PA-HRM
hydroxyzine pamoate (Vistaril) 1 PA-HRM
JALYN 1 QL (30 per 30 days)
KEVEYIS 1 PA NSO; QL (120 per 30
days)
LEMTRADA 1 PA
leucovorin calcium 200 mg vial sdv, p/f,
latex-free
(Leucovorin Calcium) 1
leucovorin calcium injection recon soln
100 mg, 350 mg
(Leucovorin Calcium) 1
leucovorin calcium oral (Leucovorin Calcium) 1
levocarnitine (with sugar) (Levocarnitine (With
Sugar))
1 (PA for ESRD Only)
levocarnitine oral tablet (Carnitor) 1 (PA for ESRD Only)
mesna (Mesnex) 1
MESNEX ORAL 1
MESTINON ORAL SYRUP 1
MESTINON TIMESPAN 1
morrhuate sodium (Sodium Morrhuate) 1
OTEZLA 1 PA; QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
88
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
OTEZLA STARTER 1 PA; QL (60 per 30 days)
OTREXUP (PF) 1
PLEGRIDY SUBCUTANEOUS PEN
INJECTOR
1 ST
PLEGRIDY SUBCUTANEOUS
SYRINGE 125 MCG/0.5 ML
1 ST
PLEGRIDY SYRINGE STARTER PACK 1 ST
probenecid (Probenecid) 1
PROCYSBI 1
pyridostigmine bromide (Mestinon) 1
RASUVO (PF) 1
REBIF (WITH ALBUMIN) 1
REBIF REBIDOSE 1
REBIF TITRATION PACK 1
REMICADE 1 PA
SENSIPAR 1
SIGNIFOR 1 QL (60 per 30 days)
SIMPONI 1 PA
SIMPONI ARIA 1 PA
STELARA SUBCUTANEOUS
SYRINGE
1 PA
STERILE PADS 2" X 2" 1
SYNAREL 1
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
1 PA; QL (14 per 30 days)
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)- 240
MG (46), 240 MG
1 PA; QL (60 per 30 days)
THALOMID 1 PA NSO; QL (60 per 30
days)
TYBOST 1 QL (30 per 30 days)
ULORIC 1 ST; QL (30 per 30 days)
XELJANZ 1 PA; QL (60 per 30 days)
Ophthalmic Agents
Antiglaucoma Agents
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
89
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
acetazolamide oral capsule, extended
release
(Diamox Sequels) 1
acetazolamide oral tablet (Acetazolamide) 1
acetazolamide sodium (Acetazolamide Sodium) 1
ALPHAGAN P OPHTHALMIC DROPS
0.1 %
1
AZOPT 1
betaxolol ophthalmic (Betaxolol HCl) 1
bimatoprost (Bimatoprost) 1
brimonidine (Alphagan P) 1 (drops: 0.15%, 0.20%)
COMBIGAN 1
dorzolamide (Trusopt) 1
dorzolamide-timolol (Cosopt) 1
latanoprost (Xalatan) 1
levobunolol (Betagan) 1
LUMIGAN OPHTHALMIC DROPS 0.01
%
1 QL (2.5 per 25 days)
methazolamide oral (Neptazane) 1
metipranolol (Metipranolol) 1
PHOSPHOLINE IODIDE 1
pilocarpine hcl ophthalmic drops 1 %, 2
%, 4 %
(Isopto Carpine) 1
SIMBRINZA 1
timolol maleate ophthalmic drops (Timoptic) 1
timolol maleate ophthalmic gel forming
solution
(Timoptic-Xe) 1
TRAVATAN Z 1 QL (2.5 per 25 days)
travoprost (benzalkonium) (Travoprost
(Benzalkonium))
1 QL (2.5 per 25 days)
Replacement Preparations
Replacement Preparations
calcium chloride intravenous (Calcium Chloride) 1
calcium gluconate intravenous (Calcium Gluconate) 1 (PA for ESRD Only)
citric acid-sodium citrate (Citric Acid/Sodium
Citrate)
1
d10 %-0.45 % sodium chloride (Dextrose 10 % and 0.45
% NaCl)
1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
90
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % and
0.45 % NaCl)
1
d5 % and 0.9 % sodium chloride (Dextrose 5 % and 0.9 %
NaCl)
1
d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 %
NaCl)
1
dextrose 10 % and 0.2 % nacl (Dextrose 10 % and 0.2
% NaCl)
1
dextrose 5 %-lactated ringers (Dextrose 5%-Lactated
Ringers)
1
dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 %
NaCl)
1
dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and 0.3 %
NaCl)
1
dextrose with sodium chloride (Dextrose 5 %-0.2 %
NaCl)
1
electrolyte-48 in d5w (Electrolyte-48
Solution/D5W)
1
HYPERLYTE CR 1
IONOSOL-B IN D5W 1
IONOSOL-MB IN D5W 1
ISOLYTE M IN 5 % DEXTROSE 1
ISOLYTE-H IN 5 % DEXTROSE 1
ISOLYTE-P IN 5 % DEXTROSE 1
ISOLYTE-S 1
klor-con 10 (Potassium Chloride) 1
klor-con m10 tablet (Potassium Chloride) 1
klor-con m15 (Potassium Chloride) 1
klor-con m20 (Potassium Chloride) 1
klor-con sprinkle (Potassium Chloride) 1
magnesium chloride injection (Magnesium Chloride) 1
magnesium sulf in 0.45% nacl (Magnesium Sulf In
0.45% NaCl)
1
magnesium sulfate in d5w intravenous
piggyback 1 gram/100 ml, 4 gram/100 ml
(Magnesium
Sulfate/D5W)
1
magnesium sulfate in water (Magnesium Sulfate in
Water)
1
magnesium sulfate injection (Magnesium Sulfate) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
91
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
NORMOSOL-M IN 5 % DEXTROSE 1
NORMOSOL-R PH 7.4 1
NUTRILYTE 1
NUTRILYTE II 1
phosphorus #1 (K-Phos Neutral) 1
PLASMA-LYTE 148 1
PLASMA-LYTE A 1
PLASMA-LYTE-56 IN 5 % DEXTROSE 1
potassium acetate intravenous (Potassium Acetate) 1
potassium bicarb and chloride (Pot Chloride/Pot
Bicarb/Cit Ac)
1
potassium bicarb-citric acid (Klor-Con-Ef) 1
potassium bicarbonate-cit ac oral tablet,
effervescent 25 meq
(Klor-Con-Ef) 1
potassium chlorid-d5-0.45%nacl (Potassium Chloride/D5-
0.45nacl)
1
potassium chloride in 0.9%nacl
intravenous parenteral solution 20 meq/l,
40 meq/l
(Potassium Chloride In
0.9%NaCl)
1
potassium chloride in 5 % dex intravenous
parenteral solution 20 meq/l, 30 meq/l, 40
meq/l
(Potassium Chloride In
D5w)
1
potassium chloride in lr-d5 intravenous
parenteral solution 20 meq/l
(Potassium Chloride In
Lr-D5)
1
potassium chloride intravenous piggyback
10 meq/100 ml, 20 meq/100 ml, 30
meq/100 ml, 40 meq/100 ml
(Potassium Chloride) 1
potassium chloride intravenous solution (Potassium Chloride) 1
potassium chloride oral capsule, extended
release
(Potassium Chloride) 1
potassium chloride oral liquid (Potassium Chloride) 1
potassium chloride oral packet (Klor-Con) 1
potassium chloride oral tablet extended
release 8 meq
(K-Tab ER) 1
potassium chloride oral tablet,er
particles/crystals 10 meq
(K-Tab ER) 1
potassium chloride oral tablet,er
particles/crystals 20 meq
(Potassium Chloride) 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
92
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
potassium chloride-0.45 % nacl (Potassium Chloride-
0.45% NaCl)
1
potassium chloride-d5-0.2%nacl (Potassium Chloride/D5-
0.2%NaCl)
1
potassium chloride-d5-0.3%nacl
intravenous parenteral solution 20 meq/l
(Potassium Chloride/D5-
0.3%NaCl)
1
potassium chloride-d5-0.9%nacl (Potassium Chloride/D5-
0.9%NaCl)
1
potassium citrate (Urocit-K) 1
potassium citrate-citric acid oral packet (Potassium Citrate/Citric
Acid)
1
potassium cl 10 meq/50 ml sol (Potassium Chloride) 1
potassium cl 20 meq/50 ml sol (Potassium Chloride) 1
potassium cl er 10 meq tablet f/c (K-Tab ER) 1
potassium phosphate m-/d-basic (Potassium Phos,M-
Basic-D-Basic)
1
ringers intravenous (Ringers Solution) 1
sodium acetate intravenous (Sodium Acetate) 1
sodium bicarbonate intravenous solution 1
meq/ml (8.4 %)
(Sodium Bicarbonate) 1
sodium bicarbonate intravenous syringe (Sodium Bicarbonate) 1
sodium chloride 0.45 % intravenous
parenteral solution
(Sodium Chloride 0.45
%)
1
sodium chloride 0.9 % injection solution (0.9 % Sodium
Chloride)
1
sodium chloride 0.9 % intravenous
parenteral solution
(0.9 % Sodium
Chloride)
1
sodium chloride 3 % (Sodium Chloride 3 %) 1
sodium chloride 5 % (Sodium Chloride 5 %) 1
sodium chloride intravenous (Sodium Chloride) 1
sodium citrate-citric acid (Citric Acid/Sodium
Citrate)
1
sodium lactate (Sodium Lactate) 1
sodium phosphate (Sodium Phos,M-Basic-
D-Basic)
1
sod-pot-k cit-sod cit-cit acid (Sod/Pot/K Cit/Sod
Cit/Cit Acid)
1
TPN ELECTROLYTES 1
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
93
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
TPN ELECTROLYTES II IV SOLN
25'S,20ML/50ML FTV
1
Respiratory Tract Agents
Anti-Inflammatories, Inhaled
Corticosteroids
ADVAIR DISKUS 1 QL (60 per 30 days)
ADVAIR HFA 1 QL (12 per 28 days)
BREO ELLIPTA 1 QL (60 per 30 days)
DULERA 1 QL (13 per 28 days)
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 100
MCG/ACTUATION, 50
MCG/ACTUATION
1 QL (60 per 30 days)
FLOVENT DISKUS INHALATION
BLISTER WITH DEVICE 250
MCG/ACTUATION
1 QL (120 per 30 days)
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION
1 QL (12 per 28 days)
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 220
MCG/ACTUATION
1 QL (24 per 28 days)
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 44
MCG/ACTUATION
1 QL (21.2 per 28 days)
QVAR 1 QL (17.4 per 25 days)
Antileukotrienes
montelukast (Singulair) 1
zafirlukast (Accolate) 1
Bronchodilators
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml,
2.5 mg /3 ml (0.083 %), 5 mg/ml
(Albuterol Sulfate) 1 PA BvD
albuterol sulfate oral syrup (Albuterol Sulfate) 1
albuterol sulfate oral tablet (Albuterol Sulfate) 1
albuterol sulfate oral tablet extended
release 12 hr
(Vospire ER) 1
ATROVENT HFA 1 QL (25.8 per 28 days)
COMBIVENT RESPIMAT 1 QL (8 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
94
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
metaproterenol oral (Metaproterenol Sulfate) 1
PROAIR HFA 1
PROAIR RESPICLICK 1
SEREVENT DISKUS 1 QL (60 per 30 days)
SPIRIVA RESPIMAT 1
SPIRIVA WITH HANDIHALER 1
STRIVERDI RESPIMAT 1
terbutaline oral (Terbutaline Sulfate) 1
terbutaline subcutaneous (Terbutaline Sulfate) 1
theophylline anhydrous oral tablet
extended release 12 hr 100 mg, 200 mg,
300 mg
(Theophylline
Anhydrous)
1
theophylline in dextrose 5 % intravenous
parenteral solution 200 mg/100 ml, 200
mg/50 ml, 400 mg/250 ml, 400 mg/500 ml,
800 mg/250 ml
(Theophylline/D5W) 1
theophylline oral solution (Theophylline
Anhydrous)
1
theophylline oral tablet extended release (Theophylline
Anhydrous)
1
theophylline oral tablet extended release
12 hr
(Theophylline
Anhydrous)
1
TUDORZA PRESSAIR INHALATION
AEROSOL POWDR BREATH
ACTIVATED 400 MCG/ACTUATION
1 QL (2 per 28 days)
TUDORZA PRESSAIR INHALATION
AEROSOL POWDR BREATH
ACTIVATED 400 MCG/ACTUATION
(30 ACTUAT)
1 QL (1 per 28 days)
VENTOLIN HFA 1
Respiratory Tract Agents, Other
acetylcysteine (Acetadote) 1 PA BvD
acetylcysteine (Acetadote) 1 PA BvD
cromolyn inhalation (Cromolyn Sodium) 1 PA BvD
DALIRESP 1 QL (30 per 30 days)
ESBRIET 1 PA; QL (270 per 30
days)
KALYDECO 1 PA; QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
95
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
NUCALA 1 PA; LA; QL (1 per 28
days)
OFEV 1 PA
ORKAMBI 1 PA; QL (120 per 30
days)
PROLASTIN-C 1
XOLAIR 1 PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen (Baclofen) 1
carisoprodol (Soma) 1 PA-HRM; QL (120 per
30 days)
chlorzoxazone (Parafon Forte DSC) 1 PA-HRM
cyclobenzaprine oral tablet 10 mg, 5 mg (Fexmid) 1 PA-HRM
dantrolene (Dantrium) 1
dantrolene sodium (Dantrium) 1
metaxall (Skelaxin) 1 PA-HRM
metaxalone (Skelaxin) 1 PA-HRM
methocarbamol oral (Robaxin) 1 PA-HRM
tizanidine (Zanaflex) 1
Sleep Disorder Agents
Sleep Disorder Agents
BELSOMRA 1 QL (30 per 30 days)
HETLIOZ 1 PA
NUVIGIL 1 PA
ROZEREM 1
XYREM 1 LA
zaleplon (Sonata) 1 PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug); QL (60
per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
96
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
zolpidem oral tablet (Ambien) 1 PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug); QL (30
per 30 days)
zolpidem oral tablet,ext release multiphase (Ambien CR) 1 PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug); QL (30
per 30 days)
Vasodilating Agents
Vasodilating Agents
ADCIRCA 1 PA; QL (60 per 30 days)
ADEMPAS 1 PA; QL (90 per 30 days)
epoprostenol (glycine) (Flolan) 1 PA BvD
LETAIRIS 1 PA; QL (30 per 30 days)
OPSUMIT 1 PA; QL (30 per 30 days)
ORENITRAM 1 PA
REMODULIN 1 PA BvD
sildenafil intravenous (Revatio) 1 PA; QL (37.5 per 1 day)
sildenafil oral (Revatio) 1 PA; QL (90 per 30 days)
TRACLEER 1 PA; LA; QL (60 per 30
days)
TYVASO 1 PA BvD
TYVASO REFILL KIT 1 PA BvD
TYVASO STARTER KIT 1 PA BvD
UPTRAVI ORAL TABLET 1,000 MCG,
1,200 MCG, 1,400 MCG, 1,600 MCG,
400 MCG, 600 MCG, 800 MCG
1 PA; QL (60 per 30 days)
UPTRAVI ORAL TABLET 200 MCG 1 PA; QL (240 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
97
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Drug Name
Drug Tier Requirements/Limits
UPTRAVI ORAL TABLETS,DOSE
PACK
1 PA; QL (200 per 365
days)
Vitamins And Minerals
Vitamins And Minerals
multivit-fluor 0.5 mg tab chew chewable,
d/f, s/f 0.5 mg
(Pedi M.Vit No.17 with
Fluoride)
1
pnv prenatal plus multivit tab s/f, gluten-
free 27 mg iron- 1 mg
(Pnv with
Ca,No.72/Iron/Fa)
1 (All Rx Prenatal
Vitamins Covered)
prenatal vitamins oral tablet 27 mg iron- 1
mg
(Pnv with
Ca,No.72/Iron/Fa)
1 (All Rx Prenatal
Vitamins Covered)
sodium fluoride oral tablet (Pedi M.Vit No.17 with
Fluoride)
1
VITAFOL FE+ (WITH DOCUSATE) 1
I-1
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
8 8-MOP .................................... 65
A abacavir .................................. 46
abacavir-lamivudine-zidovudine
............................................ 46
ABELCET .............................. 38
ABILIFY DISCMELT ........... 43
ABILIFY MAINTENA .......... 43
ABRAXANE .......................... 25
acamprosate ............................ 17
acarbose .................................. 36
acebutolol ............................... 56
acetaminophen-codeine .......... 13
acetazolamide ................... 88, 89
acetazolamide sodium ............ 89
acetic acid ......................... 71, 85
acetylcysteine ......................... 94
acitretin ................................... 65
ACTEMRA ............................ 86
ACTHIB (PF) ......................... 81
ACTIMMUNE ....................... 86
acyclovir ........................... 48, 65
acyclovir sodium .................... 48
ADACEL(TDAP
ADOLESN/ADULT)(PF) .. 81
ADAGEN ............................... 70
adapalene ................................ 69
ADCETRIS ............................ 25
ADCIRCA .............................. 96
adefovir................................... 48
ADEMPAS ............................. 96
ADVAIR DISKUS ................. 93
ADVAIR HFA ....................... 93
AFINITOR ............................. 26
AFINITOR DISPERZ ............ 25
AGGRENOX ......................... 51
AKTEN (PF) .................... 70, 71
AKYNZEO ............................ 41
ALBENZA............................. 42
ALBUKED-25 ....................... 51
ALBUKED-5 ......................... 51
ALBUMIN, HUMAN 20 % .. 51
ALBUMIN, HUMAN 25 % .. 51
ALBUMIN, HUMAN 5 % .... 51
ALBUMINAR 25 % .............. 51
ALBUMINAR 5 % ................ 51
ALBURX (HUMAN) 5 % ..... 51
ALBUTEIN 25 % .................. 51
ALBUTEIN 5 % .................... 51
albuterol sulfate ..................... 93
alclometasone ........................ 67
ALCOHOL PADS ................. 65
ALCOHOL PREP PADS ...... 65
ALDURAZYME ................... 70
ALECENSA .......................... 26
alendronate ............................. 85
alfuzosin................................. 76
ALIMTA ................................ 26
ALINIA ................................. 42
allopurinol .............................. 86
ALLZITAL ............................ 13
alosetron................................. 84
ALPHAGAN P ...................... 89
alprazolam ............................. 18
ALREX .................................. 73
altacaine ................................. 71
amantadine hcl ....................... 42
AMBISOME .......................... 38
amifostine crystalline ............. 86
amiloride .......................... 59, 60
amiloride-hydrochlorothiazide
........................................... 60
AMINO ACIDS 15 % ........... 52
aminocaproic acid .................. 51
AMINOSYN 10 % ................ 52
AMINOSYN 3.5 % ................ 52
AMINOSYN 7 % ................... 52
AMINOSYN 7 % WITH
ELECTROLYTES ............. 52
AMINOSYN 8.5 % ................ 52
AMINOSYN 8.5 %-
ELECTROLYTES ............. 52
AMINOSYN II 10 % ............. 52
AMINOSYN II 15 % ............. 52
AMINOSYN II 7 % ............... 52
AMINOSYN II 8.5 % ............ 52
AMINOSYN II 8.5 %-
ELECTROLYTES ............. 52
AMINOSYN M 3.5 % ........... 52
AMINOSYN-HBC 7% .......... 52
AMINOSYN-PF 10 % ........... 52
AMINOSYN-PF 7 %
(SULFITE-FREE) .............. 52
AMINOSYN-RF 5.2 % ......... 52
amiodarone ............................. 55
amiodarone hcl ....................... 55
AMITIZA ............................... 74
amitriptyline ........................... 34
amlodipine.............................. 59
amlodipine-atorvastatin.......... 60
amlodipine-benazepril............ 59
amlodipine-valsartan .............. 59
amlodipine-valsartan-hcthiazid
............................................ 59
ammonium lactate .................. 65
amoxapine .............................. 34
amoxicil-clarithromy-lansopraz
............................................ 73
amoxicillin ....................... 22, 23
amoxicillin-pot clavulanate .... 23
amphetamine salt combo........ 62
amphotericin b ....................... 38
ampicillin ............................... 23
INDEX
I-2
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
ampicillin sodium ................... 23
ampicillin-sulbactam .............. 23
AMPYRA ............................... 62
ANACAINE ........................... 65
anagrelide ............................... 51
anastrozole .............................. 26
ANDRODERM ...................... 76
ANDROGEL .......................... 76
anticoag citrate phos dextrose 86
APOKYN ............................... 42
apraclonidine .......................... 71
APRISO .................................. 84
APTIOM................................. 32
APTIVUS ............................... 46
ARCALYST ........................... 80
aripiprazole ............................. 43
ARISTADA ...................... 43, 44
ASACOL HD ......................... 84
ashlyna .................................... 63
aspirin-dipyridamole .............. 51
ASSURE ID INSULIN
SAFETY ............................. 69
ASTAGRAF XL .................... 80
atenolol ................................... 56
atenolol-chlorthalidone........... 56
atorvastatin ............................. 60
atovaquone ............................. 42
atovaquone-proguanil ............. 42
ATRIPLA ............................... 46
atropine ............................. 32, 71
atropine sulfate ....................... 71
ATROVENT HFA ................. 93
AUBAGIO ............................. 80
AVASTIN .............................. 26
AVC VAGINAL .................... 40
AVONEX ............................... 86
AVONEX (WITH ALBUMIN)
............................................ 86
azacitidine............................... 26
azathioprine ............................ 80
azathioprine sodium ............... 80
azelastine ................................ 71
AZILECT............................... 42
azithromycin .......................... 22
AZOPT .................................. 89
AZOR .................................... 59
aztreonam ............................... 22
B bacitracin ......................... 19, 71
bacitracin-polymyxin b .......... 71
baclofen ................................. 95
balsalazide ............................. 85
BANZEL ............................... 32
BCG VACCINE, LIVE (PF) . 81
BD ECLIPSE LUER-LOK .... 69
BD INSULIN PEN NEEDLE
UF SHORT ........................ 70
BD INSULIN SYRINGE
ULTRA-FINE .............. 69, 70
bekyree (28) ........................... 63
BELBUCA............................. 13
BELEODAQ .......................... 26
BELSOMRA ......................... 95
benazepril ............................... 55
benazepril-hydrochlorothiazide
........................................... 55
BENDEKA ............................ 26
BENICAR .............................. 54
BENICAR HCT ..................... 54
BENLYSTA .......................... 86
benztropine ............................ 42
betamethasone acet,sod phos . 77
betamethasone dipropionate .. 67
betamethasone valerate .......... 67
betamethasone, augmented .... 67
BETASERON ........................ 86
betaxolol .......................... 56, 89
bethanechol chloride .............. 86
BETHKIS .............................. 18
bexarotene .............................. 26
BEXSERO (PF) ..................... 81
bicalutamide ........................... 26
BICILLIN C-R ...................... 23
BICILLIN L-A ...................... 23
bimatoprost ............................ 89
bisoprolol fumarate ................ 56
bisoprolol-hydrochlorothiazide
............................................ 56
bleomycin ............................... 26
BLINCYTO ........................... 26
blisovi 24 fe............................ 63
blisovi fe 1.5/30 (28) .............. 63
blisovi fe 1/20 (28) ................. 63
BOOSTRIX TDAP ................ 81
BOSULIF ............................... 26
BREO ELLIPTA .................... 93
BRILINTA ............................. 51
brimonidine ............................ 89
BRINTELLIX ........................ 35
bromfenac .............................. 73
bromocriptine ......................... 42
budesonide ............................. 85
bumetanide ............................. 60
BUMINATE 25 % ................. 52
BUMINATE 5 % ................... 52
BUPHENYL .......................... 74
buprenorphine hcl ............ 13, 17
buprenorphine-naloxone ........ 17
bupropion hcl ................... 18, 35
buspirone ................................ 86
butalb-acetaminophen-caffeine
............................................ 13
butalbital-acetaminop-caf-cod 13
butalbital-acetaminophen ....... 13
butalbital-acetaminophen-caff 13
butalbital-aspirin-caffeine ...... 13
BUTRANS ............................. 13
BYSTOLIC ............................ 56
C cabergoline ............................. 42
caffeine citrated ...................... 62
caffeine-sodium benzoate ...... 62
calcipotriene ........................... 66
calcitonin (salmon)................. 85
calcitriol ........................... 66, 85
calcium acetate ....................... 75
I-3
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
calcium carbonate-mag carb-fa
............................................ 75
calcium chloride ..................... 89
calcium gluconate ................... 89
CALDOLOR .......................... 16
CANCIDAS ........................... 39
candesartan ............................. 54
candesartan-hydrochlorothiazid
............................................ 54
CAPASTAT ........................... 41
CAPRELSA ........................... 26
captopril .................................. 55
captopril-hydrochlorothiazide 55
CARAFATE ........................... 73
CARBAGLU .......................... 74
carbamazepine ........................ 32
carbidopa ................................ 42
carbidopa-levodopa ................ 42
carbidopa-levodopa-entacapone
............................................ 42
CARIMUNE NF
NANOFILTERED ............. 80
carisoprodol ............................ 95
carteolol .................................. 71
cartia xt ................................... 56
carvedilol ................................ 56
CAYSTON ............................. 22
cefaclor ................................... 20
cefadroxil .......................... 20, 21
cefazolin ................................. 21
cefazolin in dextrose (iso-os) . 21
CEFAZOLIN IN DEXTROSE
(ISO-OS) ............................ 21
cefdinir ................................... 21
cefditoren pivoxil ................... 21
cefepime ................................. 21
CEFEPIME IN DEXTROSE 5
%......................................... 21
CEFEPIME IN
DEXTROSE,ISO-OSM...... 21
cefotaxime .............................. 21
cefoxitin .................................. 21
cefoxitin in dextrose, iso-osm 21
cefpodoxime .......................... 21
cefprozil ................................. 21
ceftazidime ............................. 21
ceftibuten ............................... 21
ceftriaxone ............................. 21
CEFTRIAXONE ................... 21
ceftriaxone in dextrose,iso-os 21
CEFTRIAXONE IN
DEXTROSE,ISO-OS ........ 21
cefuroxime axetil ................... 21
cefuroxime sodium ................ 21
celecoxib ................................ 16
CELLCEPT INTRAVENOUS
........................................... 80
CELONTIN ........................... 32
cephalexin ........................ 21, 22
CEPROTIN (BLUE BAR) .... 49
CERDELGA .......................... 86
CEREZYME .......................... 70
CERVARIX VACCINE (PF) 81
cevimeline .............................. 65
CHANTIX ............................. 18
CHANTIX CONTINUING
MONTH BOX ................... 18
CHANTIX STARTING
MONTH BOX ................... 18
chloramphenicol sod succinate
........................................... 19
chlordiazepoxide hcl .............. 18
chlorhexidine gluconate ......... 65
chloroquine phosphate ........... 42
chlorothiazide ........................ 60
chlorothiazide sodium............ 60
chlorpromazine ...................... 44
chlorthalidone ........................ 60
chlorzoxazone ........................ 95
cholestyramine (with sugar) .. 60
cholestyramine-aspartame 60, 61
choline,magnesium salicylate 16
ciclopirox ............................... 39
ciclopirox-ure-camph-menth-
euc ...................................... 39
cilostazol ................................ 51
cimetidine ............................... 73
cimetidine hcl ......................... 73
CIMZIA ................................. 80
CIMZIA POWDER FOR
RECONST ......................... 80
CINRYZE .............................. 50
CIPRODEX............................ 72
ciprofloxacin .......................... 24
ciprofloxacin hcl .............. 24, 72
ciprofloxacin in 5 % dextrose 24
ciprofloxacin lactate ............... 24
citalopram .............................. 35
citric acid-sodium citrate........ 89
clarithromycin ........................ 22
CLEVIPREX.......................... 59
clindamycin hcl ...................... 19
clindamycin in 5 % dextrose .. 19
clindamycin palmitate hcl ...... 19
clindamycin phosphate.... 19, 40,
66
CLINIMIX 5%/D15W
SULFITE FREE ................. 52
CLINIMIX 5%/D25W
SULFITE-FREE ................ 52
CLINIMIX 2.75%/D5W
SULFIT FREE ................... 52
CLINIMIX 4.25%/D10W SULF
FREE .................................. 52
CLINIMIX 4.25%/D5W
SULFIT FREE ................... 52
CLINIMIX 4.25%-D20W
SULF-FREE ....................... 52
CLINIMIX 4.25%-D25W
SULF-FREE ....................... 52
CLINIMIX 5%-
D20W(SULFITE-FREE) ... 52
CLINIMIX E 2.75%/D10W
SUL FREE ......................... 52
I-4
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
CLINIMIX E 2.75%/D5W
SULF FREE ....................... 52
CLINIMIX E 4.25%/D10W
SUL FREE.......................... 53
CLINIMIX E 4.25%/D25W
SUL FREE.......................... 53
CLINIMIX E 4.25%/D5W
SULF FREE ....................... 53
CLINIMIX E 5%/D15W
SULFIT FREE.................... 53
CLINIMIX E 5%/D20W
SULFIT FREE.................... 53
CLINIMIX E 5%/D25W
SULFIT FREE.................... 53
CLINISOL SF 15 % ............... 53
clobetasol ................................ 68
clobetasol propionate.............. 68
clobetasol-emollient ............... 68
clocortolone pivalate .............. 68
clomipramine .......................... 35
clonazepam ............................. 18
clonidine ................................. 54
clonidine hcl ..................... 54, 62
clonidine hcl-chlorthalidone ... 54
clopidogrel .............................. 51
clorazepate dipotassium ......... 18
clotrimazole ............................ 39
clotrimazole-betamethasone ... 39
clozapine................................. 44
COARTEM ............................ 42
codeine sulfate ........................ 13
codeine-butalbital-asa-caffein 13
colchicine ............................... 86
colchicine-probenecid ............ 86
colestipol ................................ 60
colistin (colistimethate na) ..... 19
COLY-MYCIN S ................... 72
COMBIGAN .......................... 89
COMBIPATCH ...................... 77
COMBIVENT RESPIMAT ... 93
COMETRIQ ........................... 26
COMPLERA .......................... 46
COMVAX (PF) ..................... 81
CONDYLOX ......................... 66
COPAXONE ......................... 86
CORLANOR ......................... 57
cortisone................................. 78
COSENTYX .......................... 66
COSENTYX (2 SYRINGES) 66
COSENTYX PEN ................. 66
COSENTYX PEN (2 PENS) . 66
COTELLIC ............................ 26
CREON .................................. 70
CRESTOR ............................. 60
CRIXIVAN ............................ 46
cromolyn .................... 71, 74, 94
CUBICIN ............................... 19
cyclobenzaprine ..................... 95
CYCLOGYL ......................... 71
cyclopentolate ........................ 71
cyclophosphamide ................. 26
CYCLOPHOSPHAMIDE ..... 26
CYCLOSET........................... 36
cyclosporine ........................... 80
cyclosporine modified ........... 80
cyclosporine, modified .......... 80
cyproheptadine ................. 39, 40
CYRAMZA ........................... 26
cyred ...................................... 63
CYSTADANE ....................... 86
CYSTARAN .......................... 71
cysteine (l-cysteine) ............... 53
D d10 %-0.45 % sodium chloride
........................................... 89
d2.5 %-0.45 % sodium chloride
........................................... 90
d5 % and 0.9 % sodium chloride
........................................... 90
d5 %-0.45 % sodium chloride 90
dactinomycin ......................... 26
DAKLINZA........................... 48
DALIRESP ............................ 94
danazol ................................... 77
dantrolene ............................... 95
dantrolene sodium .................. 95
dapsone .................................. 41
DAPTACEL (DTAP
PEDIATRIC) (PF) ............. 81
DARAPRIM .......................... 42
DARZALEX .......................... 27
deblitane ................................. 63
decitabine ............................... 27
deferoxamine.......................... 76
DELZICOL ............................ 85
DEMSER ............................... 57
DEPEN TITRATABS ............ 76
DEPO-PROVERA ................. 79
desipramine ............................ 35
desmopressin .......................... 78
desog-e.estradiol/e.estradiol ... 63
desogestrel-ethinyl estradiol . 63,
64
desonide ................................. 68
desoximetasone ...................... 68
dexamethasone ....................... 78
dexamethasone sodium
phosphate ..................... 73, 78
dexmethylphenidate ............... 62
dextroamphetamine ................ 62
dextroamphetamine-
amphetamine ...................... 62
dextrose 10 % and 0.2 % nacl 90
dextrose 10 % in water (d10w)
............................................ 53
dextrose 20 % in water (d20w)
............................................ 53
dextrose 25 % in water (d25w)
............................................ 53
dextrose 40 % in water (d40w)
............................................ 53
dextrose 5 % in ringers .......... 53
dextrose 5 % in water (d5w) .. 53
dextrose 5 %-lactated ringers . 90
dextrose 5%-0.2 % sod chloride
............................................ 90
I-5
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
dextrose 5%-0.3 % sod.chloride
............................................ 90
dextrose 50 % in water (d50w)
............................................ 53
dextrose 70 % in water (d70w)
............................................ 53
dextrose with sodium chloride90
diazepam................................. 18
diazepam intensol ................... 18
diclofenac potassium .............. 16
diclofenac sodium ............ 16, 73
diclofenac-misoprostol ........... 16
dicloxacillin ............................ 23
dicyclomine ............................ 74
didanosine............................... 46
DIFICID ................................. 22
diflunisal ................................. 16
digitek ..................................... 57
digoxin .................................... 58
DIGOXIN ............................... 58
dihydroergotamine ................. 40
DILANTIN ............................. 32
diltiazem hcl ........................... 57
dilt-xr ...................................... 57
dimenhydrinate ....................... 41
DIPENTUM ........................... 85
diphenhydramine hcl .............. 40
diphenoxylate-atropine ........... 74
disopyramide phosphate ......... 55
disulfiram ............................... 18
divalproex ............................... 32
dobutamine ............................. 58
dobutamine in d5w ................. 58
donepezil ................................ 34
dopamine ................................ 58
dopamine in 5 % dextrose ...... 58
dorzolamide ............................ 89
dorzolamide-timolol ............... 89
doxazosin ................................ 54
doxepin ................................... 35
doxercalciferol ........................ 85
doxorubicin hcl ....................... 27
doxorubicin hcl peg-liposomal
........................................... 27
doxorubicin, peg-liposomal ... 27
doxycycline hyclate ............... 25
doxycycline monohydrate ...... 25
dronabinol .............................. 41
droperidol............................... 87
drospirenone-ethinyl estradiol 64
DROXIA ................................ 27
DUAVEE ............................... 77
DULERA ............................... 93
duloxetine .............................. 35
DUREZOL............................. 73
dutasteride .............................. 87
dutasteride-tamsulosin ........... 87
DYRENIUM .......................... 60
E econazole ............................... 39
EDURANT ............................ 46
EFFIENT ............................... 51
ELAPRASE ........................... 70
electrolyte-48 in d5w ............. 90
ELIDEL ................................. 68
ELIGARD .............................. 27
ELIQUIS ................................ 49
ELITEK ................................. 70
ELLA ..................................... 64
ELMIRON ............................. 87
EMCYT ................................. 27
EMEND ................................. 41
EMPLICITI ........................... 27
EMSAM................................. 35
EMTRIVA ............................. 46
enalapril maleate .................... 55
enalaprilat .............................. 55
enalapril-hydrochlorothiazide 55
ENBREL ................................ 80
ENBREL SURECLICK ........ 80
ENGERIX-B (PF).................. 82
ENGERIX-B PEDIATRIC (PF)
........................................... 82
enoxaparin ............................. 49
entacapone.............................. 43
entecavir ................................. 48
ENTRESTO ........................... 54
ENVARSUS XR .................... 80
ephedrine sulfate .................... 58
epinastine ............................... 71
epinephrine ....................... 58, 59
epinephrine hcl (pf) ................ 58
EPIPEN 2-PAK ...................... 59
EPIPEN JR 2-PAK ................ 59
EPIVIR HBV ......................... 46
eplerenone .............................. 61
EPOGEN ................................ 50
epoprostenol (glycine) ........... 96
EPZICOM .............................. 46
ergoloid .................................. 87
ERGOMAR............................ 40
ERIVEDGE............................ 27
ERYTHROCIN ...................... 22
erythromycin .................... 22, 72
erythromycin base .................. 22
ERYTHROMYCIN BASE .... 22
erythromycin base-ethanol ..... 66
erythromycin ethylsuccinate .. 22
erythromycin stearate ............. 22
erythromycin with ethanol 66, 67
ESBRIET ............................... 94
escitalopram oxalate............... 35
esmolol ................................... 56
esomeprazole sodium ............. 73
ESTRACE .............................. 77
estradiol .................................. 77
estradiol valerate .................... 77
estradiol/norethindrone acet ... 77
estradiol-norethindrone acet... 77
estropipate .............................. 77
ethambutol.............................. 41
ethamolin................................ 59
ethinyl estradiol/drospirenone 64
ethosuximide .......................... 32
ethynodiol d-ethinyl estradiol 64
etodolac .................................. 16
I-6
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
ETOPOPHOS ......................... 27
etoposide................................. 27
EVOTAZ ................................ 46
EXELON ................................ 34
exemestane ............................. 27
EXJADE ................................. 76
EXTAVIA .............................. 87
F FABRAZYME ....................... 70
famciclovir ............................. 48
famotidine......................... 73, 74
famotidine (pf)........................ 73
famotidine (pf)-nacl (iso-os) . 73
FANAPT ................................ 44
FARESTON ........................... 27
FARYDAK............................. 27
FASLODEX ........................... 27
felbamate ................................ 32
felodipine ................................ 59
FEMRING .............................. 77
fenofibrate .............................. 60
fenofibrate micronized ........... 60
fenofibrate nanocrystallized ... 60
fenofibric acid ........................ 60
fenofibric acid (choline) ......... 60
fenoprofen .............................. 16
fentanyl ................................... 13
fentanyl citrate ........................ 13
FERRIPROX .......................... 76
FETZIMA............................... 35
finasteride ............................... 87
FIRAZYR ............................... 59
FLEBOGAMMA DIF ............ 80
flecainide ................................ 55
FLECTOR .............................. 16
FLEXBUMIN 25 % ............... 52
FLEXBUMIN 5 % ................. 52
FLOVENT DISKUS .............. 93
FLOVENT HFA ..................... 93
floxuridine .............................. 27
fluconazole ............................. 39
fluconazole in dextrose(iso-o) 39
fluconazole in nacl (iso-osm) 39
flucytosine ............................. 39
fludrocortisone ....................... 78
flumazenil .............................. 62
flunisolide .............................. 73
fluocinonide ........................... 68
fluocinonide-emollient base .. 68
fluorometholone..................... 73
FLUOROPLEX ..................... 66
fluorouracil ................ 25, 27, 66
fluoxetine ............................... 35
fluoxymesterone .................... 77
fluphenazine decanoate .......... 44
fluphenazine hcl ..................... 44
flurbiprofen ............................ 16
flurbiprofen sodium ............... 73
flutamide ................................ 27
fluticasone ........................ 68, 73
fluvoxamine ........................... 35
fomepizole ............................. 87
fondaparinux .......................... 49
FORTEO ................................ 85
FORTICAL ............................ 85
foscarnet ........................... 47, 48
fosinopril ................................ 55
fosinopril-hydrochlorothiazide
........................................... 55
fosphenytoin .......................... 32
FREAMINE HBC 6.9 % ....... 53
FREAMINE III 10 % ............ 53
furosemide ............................. 60
FUSILEV ............................... 87
FUZEON ............................... 46
FYCOMPA ............................ 32
G gabapentin .............................. 33
GABITRIL............................. 33
galantamine ............................ 34
GAMASTAN S/D ................. 80
GAMMAGARD LIQUID ..... 80
GAMMAPLEX ..................... 80
ganciclovir sodium ................ 49
GARDASIL (PF) ................... 82
GARDASIL 9 (PF) ................ 82
gatifloxacin ............................ 72
GATTEX 30-VIAL ................ 74
GATTEX ONE-VIAL ........... 74
GAUZE PAD ......................... 87
GAZYVA ............................... 27
gemfibrozil ............................. 61
GENOTROPIN ...................... 78
GENOTROPIN MINIQUICK 78
gentamicin .................. 19, 67, 72
gentamicin in nacl (iso-osm) .. 19
gentamicin sulfate .................. 72
gentamicin sulfate (ped) (pf) .. 19
gentamicin sulfate (pf) ........... 19
GENVOYA ............................ 46
GEODON ............................... 44
gildess 1/20 (21) ..................... 64
gildess 24 fe ........................... 64
gildess fe 1/20 (28)................. 64
GILENYA .............................. 87
GILOTRIF ............................. 27
GLEEVEC ....................... 27, 28
GLEOSTINE.......................... 28
glimepiride ............................. 38
glipizide.................................. 38
glipizide-metformin ............... 38
GLUCAGEN HYPOKIT ....... 87
GLUCAGON EMERGENCY
KIT (HUMAN) .................. 87
glyburide ................................ 38
glyburide micronized ............. 38
glyburide-metformin .............. 38
glycopyrrolate ........................ 74
glydo ...................................... 17
GLYXAMBI .......................... 36
granisetron (pf)....................... 41
granisetron hcl ........................ 41
GRANIX ................................ 50
griseofulvin microsize ............ 39
guanfacine ........................ 54, 62
guanidine ................................ 87
I-7
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
H halobetasol propionate............ 68
haloperidol .............................. 44
haloperidol decanoate ............. 44
haloperidol lactate .................. 44
HARVONI ............................. 48
HAVRIX (PF) ........................ 82
heparin (porcine) .................... 50
heparin (porcine) in 5 % dex . 49,
50
heparin (porcine) in nacl (pf) . 50
heparin sodium,porcine-pf ..... 50
heparin(porcine) in 0.45% nacl
............................................ 50
heparin, porcine (pf) ............... 50
HEPATAMINE 8%................ 53
HEPATASOL 8 % ................. 53
HERCEPTIN .......................... 28
HETLIOZ ............................... 95
HEXALEN ............................. 28
homatropine hbr ..................... 71
HUMIRA ................................ 80
HUMIRA PEN ....................... 80
HUMIRA PEN CROHN'S-UC-
HS START ......................... 80
HUMULIN R U-500
(CONCENTRATED) ......... 37
hydralazine ............................. 59
hydrochlorothiazide ................ 60
hydrocodone-acetaminophen 13,
14
hydrocodone-ibuprofen .......... 14
hydrocortisone ............ 68, 69, 78
hydrocortisone acet-aloe vera. 68
hydrocortisone acetate-urea.... 68
hydrocortisone butyrate .......... 68
hydrocortisone butyr-emollient
............................................ 68
hydrocortisone sod succinate . 78
hydrocortisone valerate .......... 69
hydromorphone ...................... 14
hydromorphone (pf) ............... 14
hydroxychloroquine ............... 42
hydroxyurea ........................... 28
hydroxyzine hcl ..................... 87
hydroxyzine pamoate ............. 87
HYPERLYTE CR.................. 90
HYPERRAB S/D (PF)........... 80
HYQVIA ............................... 80
I ibandronate ............................ 85
IBRANCE .............................. 28
ibuprofen ................................ 16
ICLUSIG ............................... 28
ifosfamide .............................. 28
ifosfamide-mesna ................... 28
ILARIS (PF) .......................... 80
ILEVRO................................. 73
IMBRUVICA ........................ 28
imipenem-cilastatin ............... 22
imipramine hcl ....................... 35
imipramine pamoate .............. 35
imiquimod .............................. 66
IMLYGIC .............................. 28
IMOGAM RABIES-HT (PF) 80
IMOVAX RABIES VACCINE
(PF) .................................... 82
INCRELEX ........................... 78
indapamide............................. 60
indomethacin ......................... 16
indomethacin sodium ............. 16
INFANRIX (DTAP) (PF) ...... 82
INLYTA ................................ 28
INSULIN SYRINGE-NEEDLE
U-100 ................................. 70
INTELENCE ......................... 46
INTRALIPID ......................... 53
INTRON A ............................ 48
INVANZ ................................ 22
INVEGA ................................ 44
INVEGA SUSTENNA .... 44, 45
INVEGA TRINZA ................ 45
INVIRASE............................. 47
INVOKAMET ....................... 36
INVOKANA .......................... 36
IONOSOL-B IN D5W ........... 90
IONOSOL-MB IN D5W........ 90
IPOL ....................................... 82
ipratropium bromide .............. 71
IPRIVASK ............................. 50
irbesartan ................................ 54
irbesartan-hydrochlorothiazide
............................................ 54
IRESSA .................................. 28
ISENTRESS ........................... 47
ISOLYTE M IN 5 %
DEXTROSE ....................... 90
ISOLYTE-H IN 5 %
DEXTROSE ....................... 90
ISOLYTE-P IN 5 %
DEXTROSE ....................... 90
ISOLYTE-S ........................... 90
isoniazid ................................. 41
isosorbide dinitrate ................. 61
isosorbide mononitrate ........... 61
isotretinoin ............................. 66
isradipine ................................ 59
itraconazole ............................ 39
ivermectin .............................. 42
IXEMPRA.............................. 28
IXIARO (PF) ......................... 82
J JAKAFI .................................. 28
JALYN ................................... 87
jantoven .................................. 50
JANUMET ............................. 36
JANUMET XR ...................... 36
JANUVIA .............................. 36
JARDIANCE ......................... 36
JENTADUETO ...................... 36
juleber .................................... 64
junel fe 24 .............................. 64
JUXTAPID ............................ 61
K KABIVEN.............................. 53
KALETRA ............................. 47
I-8
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
KALYDECO .......................... 94
KANUMA .............................. 70
KEDBUMIN .......................... 52
ketoconazole ........................... 39
ketoprofen............................... 16
ketorolac ........................... 16, 73
KEVEYIS ............................... 87
KEYTRUDA .......................... 28
kimidess (28) .......................... 64
KINERET ............................... 80
KINRIX (PF) .......................... 82
klor-con 10 ............................. 90
klor-con m10 .......................... 90
klor-con m15 .......................... 90
klor-con m20 .......................... 90
klor-con sprinkle .................... 90
KORLYM............................... 37
KRYSTEXXA ........................ 70
KUVAN ................................. 70
KYNAMRO ........................... 61
KYPROLIS ............................ 28
L l norgest/e.estradiol-e.estrad ... 64
labetalol .................................. 56
LACRISERT .......................... 71
LACTATED RINGERS ......... 85
lactulose .................................. 74
LAMICTAL ........................... 33
lamivudine .............................. 47
lamivudine-zidovudine ........... 47
lamotrigine ............................. 33
LANOXIN .............................. 59
lansoprazole ............................ 74
LANTUS ................................ 37
LANTUS SOLOSTAR .......... 37
larin 24 fe ............................... 64
larin fe 1/20 (28) ..................... 64
latanoprost .............................. 89
LATUDA ............................... 45
LAZANDA............................. 14
leflunomide............................. 80
LEMTRADA .......................... 87
LENVIMA ............................. 28
LETAIRIS ............................. 96
letrozole ................................. 29
leucovorin calcium ................ 87
LEUKERAN .......................... 29
LEUKINE .............................. 50
leuprolide ............................... 29
levetiracetam .......................... 33
levobunolol ............................ 89
levocarnitine .......................... 87
levocarnitine (with sugar) ...... 87
levocetirizine ......................... 40
levofloxacin ..................... 24, 72
levofloxacin in d5w ............... 24
levonorgestrel ........................ 64
levonorgestrel-ethin estradiol 64
levonorgestrel-ethinyl estrad . 64
levothyroxine ......................... 79
LEXIVA ................................ 47
lidocaine................................. 17
lidocaine (pf) .................... 17, 55
lidocaine hcl ........................... 17
lidocaine in 5 % dextrose (pf) 55
lidocaine-prilocaine ............... 17
linezolid ................................. 19
LINZESS ............................... 74
liothyronine ............................ 79
lipase-protease-amylase ......... 70
LIPOSYN II ........................... 53
LIPOSYN III ......................... 53
lisinopril ................................. 55
lisinopril-hydrochlorothiazide 55
lithium carbonate ................... 62
lithium citrate ......................... 63
l-norgest-eth estr/ethin estra .. 64
lomustine ............................... 29
LONSURF ............................. 29
loperamide ............................. 74
lorazepam ............................... 18
losartan................................... 54
losartan-hydrochlorothiazide . 54
LOTEMAX ............................ 73
LOTRONEX .......................... 74
lovastatin ................................ 61
loxapine succinate .................. 45
LUMIGAN ............................. 89
LUPRON DEPOT .................. 29
LUPRON DEPOT (3 MONTH)
............................................ 29
LUPRON DEPOT (4 MONTH)
............................................ 29
LUPRON DEPOT (6 MONTH)
............................................ 29
LUPRON DEPOT-PED ......... 78
LUPRON DEPOT-PED (3
MONTH)............................ 78
LYNPARZA .......................... 29
LYRICA ................................. 33
LYSODREN .......................... 29
M magnesium chloride ............... 90
magnesium sulf in 0.45% nacl90
magnesium sulfate ................. 90
magnesium sulfate in d5w ..... 90
magnesium sulfate in water ... 90
malathion................................ 69
maprotiline ............................. 35
MARPLAN ............................ 35
MATULANE ......................... 29
matzim la ................................ 57
meclizine ................................ 41
medroxyprogesterone ............. 79
mefenamic acid ...................... 16
mefloquine ............................. 42
MEFOXIN IN DEXTROSE
(ISO-OSM) ........................ 22
MEGACE ES ......................... 79
megestrol .......................... 29, 79
MEKINIST ............................ 29
meloxicam .............................. 16
memantine .............................. 34
MENACTRA (PF) ................. 82
MENEST................................ 77
MENHIBRIX (PF) ................. 82
I-9
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
MENOMUNE - A/C/Y/W-135
(PF) ..................................... 83
MENVEO A-C-Y-W-135-DIP
(PF) ..................................... 83
MENVEO MENA
COMPONENT (PF) ........... 83
MENVEO MENCYW-135
COMPNT (PF) ................... 83
mercaptopurine ....................... 29
meropenem ............................. 22
mesna ...................................... 87
MESNEX ............................... 87
MESTINON ........................... 87
MESTINON TIMESPAN ...... 87
metaproterenol ........................ 94
metaxall .................................. 95
metaxalone ............................. 95
metformin ............................... 37
methadone .............................. 14
methadone hcl ........................ 14
methazolamide ....................... 89
methenamine hippurate .......... 19
methenamine mandelate ......... 19
methimazole ........................... 79
methocarbamol ....................... 95
methotrexate sodium .............. 29
methotrexate sodium (pf) ....... 29
methoxsalen rapid .................. 66
methscopolamine .................... 74
methyclothiazide .................... 60
methylphenidate ..................... 63
methylprednisolone ................ 78
methylprednisolone acetate .... 78
methylprednisolone sodium succ
............................................ 78
metipranolol ........................... 89
metoclopramide hcl .......... 74, 75
metolazone ............................. 60
metoprolol succinate .............. 56
metoprolol ta-hydrochlorothiaz
............................................ 56
metoprolol tartrate .................. 56
metronidazole ............ 19, 40, 67
metronidazole in nacl (iso-os) 19
mexiletine .............................. 55
MIACALCIN......................... 85
miconazole nitrate .................. 39
midodrine ............................... 54
milrinone ................................ 59
milrinone in 5 % dextrose ...... 59
minitran .................................. 61
minocycline ........................... 25
minoxidil ................................ 61
MIRCERA ............................. 50
mirtazapine ............................ 35
misoprostol ............................ 74
mitoxantrone .......................... 29
M-M-R II (PF) ....................... 83
moexipril ................................ 55
moexipril-hydrochlorothiazide
........................................... 55
molindone .............................. 45
mometasone ........................... 69
montelukast ............................ 93
morphine .......................... 14, 15
MORPHINE .......................... 15
morphine (pf) in 0.9 % nacl ... 14
morphine concentrate ............ 14
morphine in dextrose 5 % ...... 14
morrhuate sodium .................. 87
MOVANTIK ......................... 75
MOVIPREP ........................... 75
MOXEZA .............................. 72
moxifloxacin .......................... 24
MOZOBIL ............................. 50
MULTAQ .............................. 55
mupirocin ............................... 67
mupirocin calcium ................. 67
mycophenolate mofetil .......... 80
mycophenolate sodium .......... 80
MYOZYME........................... 70
MYRBETRIQ ........................ 76
N nabumetone ............................ 16
nadolol.................................... 56
nafcillin .................................. 23
NAGLAZYME ...................... 70
naloxone ................................. 18
naltrexone ............................... 18
NAMENDA XR..................... 34
NAMZARIC .......................... 34
naphazoline ............................ 71
naproxen ........................... 16, 17
naproxen sodium .................... 17
naratriptan .............................. 40
NATACYN ............................ 72
nateglinide .............................. 37
NATPARA ............................. 85
NEBUPENT ........................... 42
nefazodone ............................. 35
neomy sulf-bacitrac zn-poly-hc
............................................ 72
neomycin ................................ 19
neomycin-bacitracin-poly-hc . 72
neomycin-bacitracin-polymyxin
............................................ 72
neomycin-polymyxin b gu ..... 67
neomycin-polymyxin b-
dexameth ............................ 72
neomycin-polymyxin-
gramicidin .......................... 72
neomycin-polymyxin-hc ........ 72
neo-polycin ............................ 72
NEPHRAMINE 5.4 % ........... 53
NEULASTA .......................... 50
NEUMEGA............................ 51
NEUPOGEN .......................... 51
NEUPRO................................ 43
NEVANAC ............................ 73
nevirapine ............................... 47
NEXAVAR ............................ 29
niacin ...................................... 61
nicardipine.............................. 59
NICOTROL ........................... 18
nifedipine ............................... 59
NILANDRON ........................ 29
I-10
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
NINLARO .............................. 29
NITRO-BID ........................... 61
nitrofurantoin macrocrystal .... 20
nitrofurantoin monohyd/m-cryst
............................................ 20
nitroglycerin ........................... 62
nitroglycerin in 5 % dextrose . 62
NITROSTAT .......................... 62
NORDITROPIN FLEXPRO .. 78
norelgestromin/ethin.estradiol 64
norepinephrine bitartrate ........ 59
norethindrone ......................... 64
norethindrone (contraceptive) 64
norethindrone acetate ............. 79
norethindrone ac-eth estradiol 64
norethindrone-e.estradiol-iron 64
norethindrone-ethinyl estrad .. 65
norethindrone-mestranol ........ 65
norgestimate-ethinyl estradiol 65
norgestrel-ethinyl estradiol ..... 65
NORMOSOL-M IN 5 %
DEXTROSE ....................... 91
NORMOSOL-R PH 7.4 ......... 91
NORTHERA .......................... 54
nortriptyline ............................ 35
NORVIR................................. 47
NOVOLIN 70/30.................... 37
NOVOLIN N .......................... 37
NOVOLIN R .......................... 37
NOVOLOG ............................ 37
NOVOLOG FLEXPEN.......... 37
NOVOLOG MIX 70-30 ......... 37
NOVOLOG MIX 70-30
FLEXPEN .......................... 37
NOVOLOG PENFILL ........... 37
NOXAFIL .............................. 39
NUCALA ............................... 95
NUCYNTA ............................ 15
NUCYNTA ER ...................... 15
NUEDEXTA .......................... 63
NULOJIX ............................... 81
NUTRESTORE ...................... 75
NUTRILIPID ......................... 53
NUTRILYTE ......................... 91
NUTRILYTE II ..................... 91
NUVARING .......................... 65
NUVIGIL............................... 95
nystatin................................... 39
NYSTATIN (BULK) ............. 39
nystatin-triamcinolone ........... 39
O OCTAGAM ........................... 81
octreotide acetate ................... 79
ODOMZO .............................. 29
OFEV ..................................... 95
ofloxacin .......................... 24, 72
olanzapine .............................. 45
olanzapine-fluoxetine ............ 35
olopatadine............................. 71
OLYSIO................................. 48
omega-3 acid ethyl esters ...... 61
omeprazole ............................. 74
ONCASPAR .......................... 29
ondansetron ............................ 41
ondansetron hcl ...................... 41
ondansetron hcl (pf) ............... 41
ONFI ................................ 18, 69
OPDIVO ................................ 30
OPSUMIT .............................. 96
ORAP..................................... 45
ORENCIA ............................. 81
ORENCIA (WITH MALTOSE)
........................................... 81
ORENITRAM ....................... 96
ORFADIN ............................. 70
ORKAMBI ............................ 95
OTEZLA ................................ 87
OTEZLA STARTER ............. 88
OTREXUP (PF) ..................... 88
oxacillin ........................... 23, 24
oxacillin in dextrose(iso-osm) 23
oxandrolone ........................... 77
oxcarbazepine ........................ 33
OXTELLAR XR.................... 33
oxybutynin chloride ............... 76
oxycodone .............................. 15
oxycodone hcl-acetaminophen
............................................ 15
oxycodone hcl-aspirin ............ 15
oxycodone-acetaminophen .... 15
oxycodone-aspirin .................. 15
OXYCONTIN ........................ 15
oxymorphone ......................... 15
P paliperidone............................ 45
PANRETIN ............................ 66
pantoprazole ........................... 74
papaverine .............................. 59
paricalcitol.............................. 85
paromomycin ......................... 42
paroxetine hcl ................... 35, 36
PASER ................................... 41
PATADAY ............................ 71
PAXIL .................................... 36
pedi m.vit no.17 with fluoride 97
PEDIARIX (PF) ..................... 83
PEDVAX HIB (PF) ............... 83
peg 3350-electrolytes ............. 75
PEG 3350-GRX ..................... 75
peg 3350-na sulf,bicarb,cl-kcl 75
PEGANONE .......................... 33
PEGASYS .............................. 48
PEGASYS PROCLICK ......... 48
peg-electrolyte soln ................ 75
PEGINTRON ......................... 48
PEN NEEDLE, DIABETIC ... 70
penicillin g pot in dextrose ..... 24
penicillin g potassium ............ 24
penicillin g procaine ............... 24
penicillin v potassium ............ 24
PENTACEL (PF) ................... 83
PENTACEL ACTHIB
COMPONENT (PF)........... 83
PENTAM ............................... 42
pentoxifylline ......................... 51
PERIKABIVEN ..................... 53
I-11
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
perindopril erbumine .............. 55
permethrin .............................. 69
perphenazine........................... 45
perphenazine-amitriptyline..... 36
phenelzine............................... 36
phenobarbital .......................... 33
phenobarbital sodium ............. 33
phenylephrine hcl ............. 54, 71
phenytoin ................................ 33
phenytoin sodium ................... 33
phenytoin sodium extended .... 33
PHOSLYRA ........................... 75
PHOSPHOLINE IODIDE ...... 89
phosphorus #1 ........................ 91
PICATO ................................. 66
pilocarpine hcl .................. 65, 89
pimozide ................................. 45
pindolol................................... 56
pioglitazone ............................ 37
pioglitazone-glimepiride ........ 37
pioglitazone-metformin .......... 37
piperacillin-tazobactam .......... 24
piroxicam ................................ 17
PLASBUMIN 25 % ............... 52
PLASBUMIN 5 % ................. 52
PLASMA-LYTE 148 ............. 91
PLASMA-LYTE A ................ 91
PLASMA-LYTE-56 IN 5 %
DEXTROSE ....................... 91
PLEGRIDY ............................ 88
podofilox ................................ 66
podophyllum resin .................. 66
polyethylene glycol 3350 ....... 75
polymyxin b sulfate ................ 20
polymyxin b sulf-trimethoprim
............................................ 72
POMALYST .......................... 30
PORTRAZZA ........................ 30
potassium acetate.................... 91
potassium bicarb and chloride 91
potassium bicarb-citric acid ... 91
potassium bicarbonate-cit ac .. 91
potassium chlorid-d5-0.45%nacl
........................................... 91
potassium chloride ........... 91, 92
potassium chloride in 0.9%nacl
........................................... 91
potassium chloride in 5 % dex91
potassium chloride in lr-d5 .... 91
potassium chloride-0.45 % nacl
........................................... 92
potassium chloride-d5-0.2%nacl
........................................... 92
potassium chloride-d5-0.3%nacl
........................................... 92
potassium chloride-d5-0.9%nacl
........................................... 92
potassium citrate .................... 92
potassium citrate-citric acid ... 92
potassium hydroxide .............. 66
potassium phosphate m-/d-basic
........................................... 92
POTIGA................................. 33
PRADAXA ............................ 50
PRALUENT PEN .................. 61
PRALUENT SYRINGE ........ 61
pramipexole ........................... 43
PRANDIMET ........................ 37
pravastatin .............................. 61
prazosin .................................. 54
prednicarbate ......................... 69
prednisolone acetate .............. 73
prednisolone sodium phosphate
..................................... 73, 78
prednisone .............................. 78
PREMARIN........................... 77
PREMASOL 10 %................. 53
PREMASOL 6 %................... 53
PREMPHASE ........................ 77
PREMPRO............................. 77
prenatal vitamins.................... 97
PREZCOBIX ......................... 47
PREZISTA............................. 47
PRIFTIN ................................ 41
PRIMAQUINE ...................... 42
primidone ............................... 33
PRISTIQ ................................ 36
PRIVIGEN ............................. 81
PROAIR HFA ........................ 94
PROAIR RESPICLICK ......... 94
probenecid .............................. 88
procainamide .......................... 55
PROCALAMINE 3% ............ 54
prochlorperazine .................... 41
prochlorperazine edisylate ..... 42
prochlorperazine maleate ....... 42
PROCRIT ............................... 51
PROCYSBI ............................ 88
progesterone ........................... 79
progesterone micronized ........ 79
PROGLYCEM ....................... 62
PROGRAF ............................. 81
PROLASTIN-C...................... 95
PROLENSA ........................... 73
PROLEUKIN ......................... 30
PROLIA ................................. 85
PROMACTA ......................... 51
promethazine .................... 40, 42
promethazine hcl .................... 42
propafenone...................... 55, 56
propantheline.......................... 32
proparacaine ........................... 71
proparacaine hcl ..................... 71
proparacaine-fluorescein sod . 71
propranolol ............................. 56
propranolol-hydrochlorothiazid
............................................ 56
propylthiouracil ...................... 79
PROQUAD (PF) .................... 83
PROSOL 20 % ....................... 54
protamine ............................... 51
protriptyline............................ 36
PULMOZYME ...................... 70
PURIXAN .............................. 30
pyrazinamide .......................... 41
pyridostigmine bromide ......... 88
I-12
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
Q QUADRACEL (PF) ............... 83
quetiapine ............................... 45
QUILLIVANT XR ................. 63
quinapril ................................. 55
quinapril-hydrochlorothiazide 55
quinidine gluconate ................ 56
quinidine sulfate ..................... 56
quinine sulfate ........................ 42
QVAR..................................... 93
R RABAVERT (PF) .................. 83
raloxifene ................................ 77
ramipril ................................... 55
RANEXA ............................... 59
ranitidine hcl ........................... 74
RAPAMUNE ......................... 81
RASUVO (PF) ....................... 88
RAVICTI ................................ 75
REBIF (WITH ALBUMIN) ... 88
REBIF REBIDOSE ................ 88
REBIF TITRATION PACK .. 88
RECOMBIVAX HB (PF) 83, 84
RELADOR PAK .................... 17
RELENZA DISKHALER ...... 48
RELISTOR ............................. 75
REMICADE ........................... 88
REMODULIN ........................ 96
RENAGEL ............................. 76
RENVELA ............................. 76
repaglinide .............................. 37
repaglinide-metformin ............ 37
REPATHA SURECLICK ...... 61
REPATHA SYRINGE ........... 61
RESCRIPTOR ........................ 47
RESTASIS ............................. 73
RETROVIR ............................ 47
REVLIMID ............................ 30
REXULTI ............................... 45
REYATAZ ............................. 47
ribavirin .................................. 49
RIDAURA .............................. 81
rifabutin ................................. 41
rifampin ................................. 41
RIFATER............................... 41
riluzole ................................... 63
rimantadine ............................ 48
ringers .............................. 85, 92
risedronate ............................. 86
RISPERDAL CONSTA ........ 45
risperidone ....................... 45, 46
RITUXAN ............................. 30
rivastigmine ........................... 34
rivastigmine tartrate ............... 34
rizatriptan ............................... 40
ropinirole ............................... 43
ROTARIX ............................. 84
ROTATEQ VACCINE .......... 84
ROZEREM ............................ 95
S SABRIL ................................. 34
SAIZEN ................................. 79
SAIZEN CLICK.EASY......... 79
salsalate .................................. 17
SANDOSTATIN LAR DEPOT
........................................... 79
SANTYL ............................... 66
SAPHRIS (BLACK CHERRY)
........................................... 46
SAVELLA ............................. 63
selegiline hcl .......................... 43
selenium sulfide ..................... 67
SELZENTRY ........................ 47
SENSIPAR ............................ 88
SEREVENT DISKUS ........... 94
SEROSTIM ........................... 79
sertraline ................................ 36
setlakin ................................... 65
SIGNIFOR ............................. 88
sildenafil ................................ 96
SILENOR .............................. 36
silver nitrate ........................... 67
silver nitrate applicators ......... 67
silver sulfadiazine .................. 67
SIMBRINZA.......................... 89
SIMPONI ............................... 88
SIMPONI ARIA .................... 88
simvastatin ............................. 61
sirolimus ................................. 81
SIRTURO .............................. 41
sodium acetate ........................ 92
sodium bicarbonate ................ 92
sodium chloride ................ 85, 92
sodium chloride 0.45 % ......... 92
sodium chloride 0.9 % ........... 92
sodium chloride 3 % .............. 92
sodium chloride 5 % .............. 92
sodium chloride-nahco3-kcl-peg
............................................ 75
sodium citrate-citric acid........ 92
sodium fluoride ................ 65, 97
sodium lactate ........................ 92
sodium phosphate................... 92
sodium polystyrene sulfonate 74,
75
sodium thiosulfate .................. 76
sod-pot-k cit-sod cit-cit acid .. 92
SOLTAMOX ......................... 30
SOLU-CORTEF (PF) ............ 78
SOMATULINE DEPOT ........ 79
SOMAVERT.......................... 79
sorbitol ................................... 85
sorbitol-mannitol .................... 85
sotalol ..................................... 56
sotalol hcl ............................... 56
SOVALDI .............................. 48
SPIRIVA RESPIMAT ........... 94
SPIRIVA WITH
HANDIHALER ................. 94
spironolactone ........................ 61
spironolacton-hydrochlorothiaz
............................................ 61
SPRYCEL .............................. 30
stavudine ................................ 47
STELARA.............................. 88
STERILE PADS .................... 88
I-13
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
STIOLTO RESPIMAT .......... 32
STIVARGA ............................ 30
STRATTERA ......................... 63
STRENSIQ ............................. 70
streptomycin ........................... 19
STRIBILD .............................. 47
STRIVERDI RESPIMAT ...... 94
sucralfate ................................ 74
sulfacetamide sodium ............. 72
sulfacetamide sodium (acne) .. 67
sulfacetamide-prednisolone .... 72
sulfadiazine............................. 24
sulfamethoxazole-trimethoprim
............................................ 24
sulfasalazine ........................... 25
sulfatrim ................................. 25
sulfazine ec ............................. 25
sulindac................................... 17
sumatriptan ............................. 40
sumatriptan succinate ............. 40
SUPPRELIN LA .................... 79
SUPRAX ................................ 22
SURMONTIL......................... 36
SUSTIVA ............................... 47
SUTENT................................. 30
SYLATRON........................... 48
SYLVANT ............................. 30
SYMLINPEN 120 .................. 37
SYMLINPEN 60 .................... 37
SYNAGIS............................... 48
SYNAREL ............................. 88
SYNERCID ............................ 20
SYNJARDY ........................... 37
SYNRIBO .............................. 30
SYPRINE ............................... 76
T TABLOID .............................. 30
tacrolimus ......................... 69, 81
TAFINLAR ............................ 30
TAGRISSO ............................ 30
TAMIFLU .............................. 48
tamoxifen ................................ 30
tamsulosin .............................. 76
TARCEVA ............................ 30
TARGRETIN......................... 30
tarina fe 1/20 (28) .................. 65
TASIGNA .............................. 30
TAZORAC ............................ 69
taztia xt .................................. 57
TECFIDERA ......................... 88
TECHNIVIE .......................... 48
TEFLARO ............................. 22
telmisartan ............................. 54
telmisartan-hydrochlorothiazid
........................................... 54
TEMODAR ........................... 30
TENIVAC (PF)...................... 84
terazosin ................................. 76
terbinafine hcl ........................ 39
terbutaline .............................. 94
terconazole ............................. 40
testosterone ............................ 77
testosterone cypionate ............ 77
testosterone enanthate ............ 77
TETANUS
TOXOID,ADSORBED (PF)
........................................... 84
TETANUS,DIPHTHERIA TOX
PED(PF)............................. 84
TETANUS-DIPHTHERIA
TOXOIDS-TD ................... 84
tetrabenazine .......................... 63
tetracaine hcl (pf) ................... 71
tetracycline ............................. 25
THALOMID .......................... 88
theophylline ........................... 94
theophylline anhydrous.......... 94
theophylline in dextrose 5 % . 94
thioridazine ............................ 46
thiotepa .................................. 31
thiothixene ............................. 46
tiagabine................................. 34
TICE BCG ............................. 81
TIKOSYN .............................. 56
timolol maleate................. 56, 89
TIVICAY ............................... 47
tizanidine ................................ 95
TOBI PODHALER ................ 19
TOBRADEX .......................... 72
TOBRADEX ST .................... 72
tobramycin ............................. 72
tobramycin in 0.225 % nacl ... 19
tobramycin in 0.9 % nacl ....... 19
tobramycin sulfate .................. 19
tobramycin-dexamethasone ... 72
TOLAK .................................. 66
tolazamide .............................. 38
tolbutamide ............................ 38
tolmetin .................................. 17
tolterodine .............................. 76
topiramate .............................. 34
toposar .................................... 31
torsemide ................................ 60
TOUJEO SOLOSTAR ........... 38
TOVIAZ ................................. 76
TPN ELECTROLYTES......... 92
TPN ELECTROLYTES II ..... 93
TRACLEER ........................... 96
TRADJENTA ........................ 37
tramadol ................................. 15
tramadol-acetaminophen ........ 15
trandolapril ............................. 55
tranexamic acid ...................... 51
TRANSDERM-SCOP............ 42
tranylcypromine ..................... 36
TRAVASOL 10 % ................. 54
TRAVATAN Z ...................... 89
travoprost (benzalkonium) ..... 89
trazodone ................................ 36
TREANDA ............................ 31
TRECATOR .......................... 41
TRELSTAR ........................... 31
tretinoin .................................. 69
tretinoin (chemotherapy) ........ 31
tretinoin microspheres ............ 69
TREXALL ............................. 31
I-14
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
triamcinolone acetonide .. 65, 69,
78
triamterene-hydrochlorothiazid
............................................ 60
TRIBENZOR ......................... 54
trifluoperazine ........................ 46
trifluridine............................... 73
trihexyphenidyl....................... 43
tri-lo-estarylla ......................... 65
tri-lo-marzia ............................ 65
tri-lo-sprintec .......................... 65
trimethoprim ........................... 20
trimipramine ........................... 36
TRIUMEQ .............................. 47
TROKENDI XR ..................... 34
TROPHAMINE 10 % ............ 54
TROPHAMINE 6% ............... 54
trospium .................................. 76
TRULICITY ........................... 37
TRUMENBA ......................... 84
TRUVADA ............................ 47
TUDORZA PRESSAIR ......... 94
TWINRIX (PF) ...................... 84
TYBOST ................................ 88
TYGACIL .............................. 25
TYKERB ................................ 31
TYPHIM VI ........................... 84
TYSABRI ............................... 81
TYVASO ................................ 96
TYVASO REFILL KIT ......... 96
TYVASO STARTER KIT ..... 96
TYZEKA ................................ 49
U ULORIC ................................. 88
UNITUXIN ............................ 31
UPTRAVI......................... 96, 97
ursodiol ................................... 75
V VAGIFEM .............................. 77
valacyclovir ............................ 49
VALCHLOR .......................... 66
valganciclovir ......................... 49
valproate sodium.................... 34
valproic acid .......................... 34
valproic acid (as sodium salt) 34
valsartan ................................. 54
valsartan-hydrochlorothiazide 54
VALSTAR ............................. 31
vancomycin ............................ 20
vancomycin in d5w ................ 20
VAQTA (PF) ......................... 84
VARIVAX (PF) ..................... 84
VASCEPA ............................. 61
VELCADE............................. 31
venlafaxine ............................. 36
VENTOLIN HFA .................. 94
verapamil ............................... 57
VERSACLOZ ........................ 46
VGO 40.................................. 70
VIBERZI ............................... 75
VICTOZA 3-PAK ................. 37
VIDEX 2 GRAM PEDIATRIC
........................................... 47
VIDEX 4 GRAM PEDIATRIC
........................................... 47
VIEKIRA PAK ...................... 48
vienva..................................... 65
VIGAMOX ............................ 73
VIIBRYD............................... 36
VIMIZIM ............................... 70
VIMPAT ................................ 34
vinorelbine ............................. 31
VIRACEPT ............................ 47
VIRAMUNE XR ................... 47
VIRAZOLE ........................... 49
VIREAD ................................ 47
VITAFOL FE+ (WITH
DOCUSATE)..................... 97
VITEKTA .............................. 47
VOLTAREN .......................... 17
voriconazole ........................... 39
VOTRIENT ........................... 31
VPRIV ................................... 70
VRAYLAR ............................ 46
W warfarin .................................. 50
water for irrigation, sterile ..... 85
X XALKORI.............................. 31
XARELTO ............................. 50
XELJANZ .............................. 88
XENAZINE ........................... 63
XIFAXAN.............................. 20
XOLAIR ................................ 95
XTANDI ................................ 31
xylon 10 ................................. 15
XYREM ................................. 95
Y YERVOY ............................... 31
YF-VAX (PF) ........................ 84
YONDELIS............................ 31
Z zafirlukast ............................... 93
zaleplon .................................. 95
ZARXIO ................................ 51
ZAVESCA ............................. 70
ZELBORAF ........................... 31
ZEMPLAR ............................. 86
ZENPEP ................................. 70
ZEPATIER ............................. 48
ZETIA .................................... 61
ZIAGEN ................................. 47
zidovudine .............................. 47
ziprasidone hcl ....................... 46
ZIRGAN ................................ 73
ZOLADEX ............................. 31
zoledronic acid ....................... 86
zoledronic acid-mannitol-water
............................................ 86
ZOLINZA .............................. 31
zolmitriptan ............................ 40
zolpidem ................................. 96
ZOMETA ............................... 86
zonisamide ............................. 34
ZORTRESS............................ 81
ZOSTAVAX (PF) .................. 84
I-15
Denver Health Medical Plan, Inc. 2016 Part D Formulary - DSB
Formulary ID: 16484.001, Version: 12
Effective: April 01, 2016
ZOVIRAX .............................. 66
ZUBSOLV ............................. 18
ZYDELIG............................... 32
ZYKADIA ............................. 32
ZYLET................................... 73
ZYPREXA RELPREVV ....... 46
ZYTIGA ................................. 32
ZYVOX.................................. 20
Este formulario se actualizó el 03/23/2016. Para obtener información más reciente o si
tiene preguntas, llame a nuestro departamento de Servicios al miembro de
Denver Health Medical Plan, Inc. al 1-877-956-2111. Los usuarios de TTY deben llamar al 711.
Nuestro horario de atención es de 8 a. m. a 8 p. m., los siete días de
la semana, o puede visitar www.denverhealthmedicalplan.org.