BLUE - Formulary
RED - Non Formulary

Table of Contents Index Policy Information

Formulary Index

Numbers A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

SA 6% (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

SABRIL (OTHER ANTICONVULSANTS)

sacrosidase (OTHER GI DRUGS)

SAFETY SYRINGE WITH SHIELD (DIABETIC SUPPLIES)

SAFETYGLIDE ALLERGY SYRINGE (MEDICAL (MISCELLANEOUS) SUPPLIES)

SAFETYGLIDE INSULIN SYRINGE (DIABETIC SUPPLIES)

SAIZEN (PAR) (GROWTH HORMONES AND RELATED DRUGS)

SAL-TROPINE (ANTISPASMODICS/DRUGS AFFECT GI MOTILITY)

SALACYN (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

SALAGEN (DRUGS AFFECTING THE THROAT AND MOUTH)

SALEX (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

SALICEPT (DRUGS AFFECTING THE THROAT AND MOUTH)

SALICYLIC ACID (KERATOLYTIC DRUGS)

SALICYLIC ACID (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

saline flush (ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.)

SALITOP (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

SALKERA (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

salmeterol (BETA-2 ADRENERGIC DRUGS)

salmeterol/fluticasone (OTHER DRUGS FOR ASTHMA)

salsalate (SALICYLATES AND RELATED DRUGS)

SALVAX (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

SALVAX DUO (KERATOLYTIC DRUGS)

SAMSCA (OTHER ENDOCRINE DRUGS)

SANCTURA (ANTICHOLINERGIC ANTISPASMODICS)

SANCTURA XR (ANTICHOLINERGIC ANTISPASMODICS)

SANCUSO (ANTIVERTIGO AND ANTIEMETIC DRUGS)

SANDIMMUNE (PAR) (ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS)

SANDOSTATIN (ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS)

SANDOSTATIN LAR (ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS)

SANTYL (TOPICAL DERMATOLOGICAL DRUGS)

SAPHRIS (ANTIPSYCHOTIC DRUGS)

saquinavir mesylate (ANTIRETROVIRALS & PROTEASE INH)

SARAFEM (SELECTIVE SEROTONIN REUPTAKE INHIBITORS)

SAVELLA (OTHER ANTIDEPRESSANTS)

SCALACORT (TOPICAL CORTICOSTEROID DRUGS)

SCOPACE (ANTISPASMODICS/DRUGS AFFECT GI MOTILITY)

SCOPOHIST (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SCOPOHIST-PE (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

scopolamine (ANTISPASMODICS/DRUGS AFFECT GI MOTILITY)

scopolamine (OTHER OPHTHALMIC DRUGS)

SCOPOLAMINE HYDROBROMIDE (ANTISPASMODICS/DRUGS AFFECT GI MOTILITY)

se-care (PRENATAL VITAMINS)

se-care conceive (PRENATAL VITAMINS)

SE-CARE GESTURE (PRENATAL VITAMINS)

SE-NATAL 19 (PRENATAL VITAMINS)

se-natal 90 (PRENATAL VITAMINS)

se-natal one (PRENATAL VITAMINS)

SE-PLETE DHA (PRENATAL VITAMINS)

SEASONALE (CONTRACEPTIVES)

SEASONIQUE (CONTRACEPTIVES)

SEB-PREV (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

SECONAL SODIUM (SEDATIVE/HYPNOTIC DRUGS)

SECTRAL (BETA-ADRENERGIC ANTAGONIST DRUGS)

SECURITY BEAD NEEDLE, LOCAL (MEDICAL (MISCELLANEOUS) SUPPLIES)

sedapap (DRUGS TO PREVENT AND TREAT HEADACHES)

SELECT-OB (PRENATAL VITAMINS)

SELECT-OB + DHA (PRENATAL VITAMINS)

selegiline (OTHER ANTIPARKINSON DRUGS)

selegiline hcl (OTHER ANTIPARKINSON DRUGS)

selenium (ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.)

selenium sulfide (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

SELENIUM SULFIDE (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

SELENOS (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

SELFEMRA (SELECTIVE SEROTONIN REUPTAKE INHIBITORS)

SELSEB (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

SELZENTRY (ANTIRETROVIRALS & PROTEASE INH)

SEMPREX-D (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SENOPHYLLINE (OTHER DRUGS FOR ASTHMA)

SENSIPAR (OTHER ENDOCRINE DRUGS)

SENSORCAINE (LOCAL ANESTHETICS)

SENSORCAINE WITH EPINEPHRINE (LOCAL ANESTHETICS)

SEPTRA (SULFONAMIDES)

SEPTRA DS (SULFONAMIDES)

SERADEX (ANTITUSSIVE AND EXPECTORANT DRUGS)

SERADEX-LA (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SEREVENT DISKUS (BETA-2 ADRENERGIC DRUGS)

SEROMYCIN (ANTITUBERCULOSIS DRUGS)

serophene (OVULATORY STIMULANTS)

SEROQUEL (PAR covered if prescribed by psychiatrist) (ANTIPSYCHOTIC DRUGS)

SEROQUEL XR (ANTIPSYCHOTIC DRUGS)

SEROQUEL XR (PAR covered if prescribed by psychiatrist) (ANTIPSYCHOTIC DRUGS)

sertraline (SELECTIVE SEROTONIN REUPTAKE INHIBITORS)

sertraline hcl (SELECTIVE SEROTONIN REUPTAKE INHIBITORS)

SETONET (PRENATAL VITAMINS)

SETONET-EC (PRENATAL VITAMINS)

sevelamer (BLOOD DETOXICANTS)

sevelamer carbonate (BLOOD DETOXICANTS)

SEVEN SYSTEM SENSOR (DIAGNOSTIC PRODUCTS)

SF (FLUORIDE PRODUCTS)

SF 5000 PLUS (FLUORIDE PRODUCTS)

SFROWASA (OTHER GI DRUGS)

SHOHL'S MODIFIED (POTASSIUM SUPPLEMENTS)

SIDEROL (INJECTABLE VITAMINS)

SIDEROL (VITAMINS & MINERALS & RELATED PRODUCTS)

SIDESTREAM (MEDICAL (MISCELLANEOUS) SUPPLIES)

sildec (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SILDEC PE-DM (ANTITUSSIVE AND EXPECTORANT DRUGS)

SILDEC-DM (ANTITUSSIVE AND EXPECTORANT DRUGS)

SILDEC-PE (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SILHOUETTE (MEDICAL (MISCELLANEOUS) SUPPLIES)

SILVADENE (TOPICAL ANTIBACTERIAL DRUGS)

silver nitrate (TOPICAL DERMATOLOGICAL DRUGS)

SILVER NITRATE APPLICATOR (TOPICAL DERMATOLOGICAL DRUGS)

silver sulfadiazine (TOPICAL ANTIBACTERIAL DRUGS)

SIMCOR (HMG-COA COMBINATIONS)

SIMETHICONE (PHARMACEUTICAL NECESSITIES)

SIMPONI (ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS)

SIMUC-DM (ANTITUSSIVE AND EXPECTORANT DRUGS)

simvastatin (HMG-COA REDUCTASE INHIBITORS)

SINA-12X (ANTITUSSIVE AND EXPECTORANT DRUGS)

sincalide (DIAGNOSTIC PRODUCTS)

SINEMET 10-100 (OTHER ANTIPARKINSON DRUGS)

SINEMET 25-100 (OTHER ANTIPARKINSON DRUGS)

SINEMET 25-250 (OTHER ANTIPARKINSON DRUGS)

SINEMET CR (OTHER ANTIPARKINSON DRUGS)

SINGULAIR (requires trial of non-sedating antihistamine & nasal corticosteroid or asthma medication) (Use for under age 12 does not require PA) (LEUKOTRIENE MODIFIERS)

SINUSTAR (MEDICAL (MISCELLANEOUS) SUPPLIES)

SINUTUSS DM (ANTITUSSIVE AND EXPECTORANT DRUGS)

SINUVENT PE (ANTITUSSIVE AND EXPECTORANT DRUGS)

sirolimus (ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS)

sitagliptin phos/metformin hcl (DIPEPTIDYL PEPTIDASE-IV INHIB & COMBOS)

sitagliptin phosphate (DIPEPTIDYL PEPTIDASE-IV INHIB & COMBOS)

SITREX PD (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SITZMARKS (DIAGNOSTIC PRODUCTS)

SKELAXIN (CNS MUSCLE RELAXANTS)

SKELID (OTHER ENDOCRINE DRUGS)

sod ferric gluc complex/sucr (VITAMINS & MINERALS & RELATED PRODUCTS)

SOD SULFACETAMIDE-SULFUR WASH (ANTIACNE DRUGS)

sodium acetate (ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.)

sodium bicarbonate (ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.)

sodium biphosphate (ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.)

sodium chloride (ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.)

sodium chloride (OTHER DRUGS FOR ASTHMA)

SODIUM CHLORIDE (OTHER DRUGS FOR ASTHMA)

sodium citrate & citric acid (POTASSIUM SUPPLEMENTS)

sodium citrate/citric acid (POTASSIUM SUPPLEMENTS)

SODIUM EDECRIN (LOOP DIURETICS)

sodium fluoride (FLUORIDE PRODUCTS)

SODIUM FLUORIDE (FLUORIDE PRODUCTS)

SODIUM HYALURONATE (TOPICAL DERMATOLOGICAL DRUGS)

sodium hyaluronate (OTHER OPHTHALMIC DRUGS)

sodium morrhuate (MISCELLANEOUS DRUGS)

sodium oxybate (OTHER CNS/AUTONOMIC DRUGS)

sodium phosphate (ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.)

sodium polystyrene sulfonate (POTASSIUM REMOVING RESINS)

SODIUM SULFA-SULFUR-MERATAN (ANTIACNE DRUGS)

SODIUM SULFACETAMIDE (ANTIACNE DRUGS)

sodium sulfacetamide-sulfur (ANTIACNE DRUGS)

SODIUM SULFACETAMIDE-SULFUR (ANTIACNE DRUGS)

sodium thiosulfate (DIAGNOSTIC PRODUCTS)

SOF-SENSOR (DIAGNOSTIC PRODUCTS)

SOF-SET (MEDICAL (MISCELLANEOUS) SUPPLIES)

SOF-SET MICRO (MEDICAL (MISCELLANEOUS) SUPPLIES)

SOF-TACT (DIABETIC SUPPLIES)

SOFT TOUCH (DIABETIC SUPPLIES)

SOFTCLIX (DIABETIC SUPPLIES)

SOLAGE (TOPICAL DERMATOLOGICAL DRUGS)

SOLARAZE (TOPICAL DERMATOLOGICAL DRUGS)

solia (CONTRACEPTIVES)

SOLODYN (TETRACYCLINES)

SOLOTUSS (ANTITUSSIVE AND EXPECTORANT DRUGS)

SOLU-CORTEF (GLUCOCORTICOID DRUGS)

SOLU-MEDROL (GLUCOCORTICOID DRUGS)

SOMA (CNS MUSCLE RELAXANTS)

SOMA 350mg Only (250mg not covered) (CNS MUSCLE RELAXANTS)

somatropin (GROWTH HORMONES AND RELATED DRUGS)

SOMATULINE DEPOT (ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS)

SOMNOTE (SEDATIVE/HYPNOTIC DRUGS)

SONAHIST (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SONAHIST DM (ANTITUSSIVE AND EXPECTORANT DRUGS)

SONATA (For members under the age of 60 requires trial of generic benzodiazepine) (SEDATIVE/HYPNOTIC DRUGS)

SORIATANE CK (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

sorine (OTHER ANTIARRHYTHMICS)

sotalol (OTHER ANTIARRHYTHMICS)

sotalol af (OTHER ANTIARRHYTHMICS)

sotret (ACCUTANES)

SPECTRACEF (CEPHALOSPORINS)

SPECTRAGEL (MEDICAL (MISCELLANEOUS) SUPPLIES)

SPIRIVA (OTHER DRUGS FOR ASTHMA)

spironolactone (POTASSIUM SPARING DIURETICS)

spironolactone-hctz (POTASSIUM SPARING DIURETICS)

spironolactone/hctz (POTASSIUM SPARING DIURETICS)

SPORANOX (PAR) (ORAL ANTIFUNGAL DRUGS)

SPRAY AND STRETCH (TOPICAL ANESTHETICS)

sprintec (CONTRACEPTIVES)

SPRYCEL (ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS)

sps (POTASSIUM REMOVING RESINS)

SRONYX (CONTRACEPTIVES)

ssd (TOPICAL ANTIBACTERIAL DRUGS)

ssd af (TOPICAL ANTIBACTERIAL DRUGS)

SSKI (ANTITUSSIVE AND EXPECTORANT DRUGS)

STAFLEX (ANALGESICS)

stagesic (CLASS III NARCOTICS)

STAHIST (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

STALEVO 100 (OTHER ANTIPARKINSON DRUGS)

STALEVO 125 (OTHER ANTIPARKINSON DRUGS)

STALEVO 150 (OTHER ANTIPARKINSON DRUGS)

STALEVO 200 (OTHER ANTIPARKINSON DRUGS)

STALEVO 50 (OTHER ANTIPARKINSON DRUGS)

STALEVO 75 (OTHER ANTIPARKINSON DRUGS)

STANNOUS FLUORIDE (FLUORIDE PRODUCTS)

STARLIX (ORAL HYPOGLYCEMICS & COMBOS)

stavudine (ANTIRETROVIRALS & PROTEASE INH)

STAVZOR (VALPROIC ACID AND DERIVATIVES)

STERAPRED (GLUCOCORTICOID DRUGS)

STIMATE (PAR) (OTHER ENDOCRINE DRUGS)

STRATTERA (PAR) (OTHER DRUGS FOR ADHD)

streptomycin (ANTITUBERCULOSIS DRUGS)

STREPTOMYCIN SULFATE (ANTITUBERCULOSIS DRUGS)

streptozocin (ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS)

STRIANT (ANDROGEN DRUGS)

STROMECTOL (ANTHELMINTICS)

strong iodine (THYROID SUPPLEMENTS)

STROVITE (VITAMINS & MINERALS & RELATED PRODUCTS)

STROVITE ADVANCE (VITAMINS & MINERALS & RELATED PRODUCTS)

STROVITE ADVANCE + D (VITAMINS & MINERALS & RELATED PRODUCTS)

STROVITE FORTE (VITAMINS & MINERALS & RELATED PRODUCTS)

STROVITE ONE (VITAMINS & MINERALS & RELATED PRODUCTS)

STROVITE PLUS (VITAMINS & MINERALS & RELATED PRODUCTS)

SU-TUSS DM (ANTITUSSIVE AND EXPECTORANT DRUGS)

sublimaze (CLASS II NARCOTICS)

SUBOXONE (CLASS III NARCOTICS)

SUBUTEX (CLASS III NARCOTICS)

succinylcholine (DIRECT MUSCLE RELAXANTS)

SUCLOR (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SUCRAID (OTHER GI DRUGS)

sucralfate (OTHER ANTIULCER DRUGS)

SUDAHIST (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SUDAL (ANTITUSSIVE AND EXPECTORANT DRUGS)

SUDAL 12 (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SUDAL-12 (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SUDATEX G (ANTITUSSIVE AND EXPECTORANT DRUGS)

SUDATRATE (DECONGESTANTS)

SULAR (CALCIUM ANTAGONISTS)

sulconazole nitrate (OTHER TOPICAL ANTIFUNGALS)

sulfacetamide sod/sulfur/ure (ANTIACNE DRUGS)

sulfacetamide sodium (ANTIPSORIASIS AND ANTIECZEMA DRUGS)

sulfacetamide sodium (OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS)

sulfacetamide-prednisolone (OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS)

sulfacetamide/prednis sp (OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS)

sulfacetamide/prednisolone ac (OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS)

sulfacetamide/sulfur (ANTIACNE DRUGS)

SULFADIAZINE (SULFONAMIDES)

sulfamethoxazole-trimethoprim (SULFONAMIDES)

sulfamethoxazole/trimethoprim (SULFONAMIDES)

sulfamide (OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS)

SULFAMYLON (TOPICAL ANTIBACTERIAL DRUGS)

sulfanilamide (OB/GYN TOPICAL ANTIINFECTIVES)

sulfasalazine (OTHER GI DRUGS)

sulfasalazine dr (OTHER GI DRUGS)

sulfatol (ANTIACNE DRUGS)

SULFATOL (ANTIACNE DRUGS)

SULFATOL C (ANTIACNE DRUGS)

SULFATOL SS (ANTIACNE DRUGS)

sulfatrim (SULFONAMIDES)

sulfazine (OTHER GI DRUGS)

sulfazine ec (OTHER GI DRUGS)

sulfisoxazole acetyl (SULFONAMIDES)

sulfuric acid/sulf phenol (DRUGS AFFECTING THE THROAT AND MOUTH)

sulindac (NON-STEROIDAL ANTIINFLAMMATORY AGENTS)

SULINDAC (requires trial of OTC NSAID) (NON-STEROIDAL ANTIINFLAMMATORY AGENTS)

SULZEE (ANTIACNE DRUGS)

sumatriptan (DRUGS TO PREVENT AND TREAT HEADACHES)

SUMATRIPTAN (DRUGS TO PREVENT AND TREAT HEADACHES)

sumatriptan succinate (DRUGS TO PREVENT AND TREAT HEADACHES)

SUMAXIN (ANTIACNE DRUGS)

SUNRISE COMPRESSOR-NEBULIZER (MEDICAL (MISCELLANEOUS) SUPPLIES)

SUPERVITE (VITAMINS & MINERALS & RELATED PRODUCTS)

SUPHERA (ANTIACNE DRUGS)

SUPPORT-500 (VITAMINS & MINERALS & RELATED PRODUCTS)

SUPRAX (CEPHALOSPORINS)

SURE-T (MEDICAL (MISCELLANEOUS) SUPPLIES)

SURESTEP (DIABETIC SUPPLIES)

SURGICEL (HEMOSTATICS)

SURGIFOAM (HEMOSTATICS)

SURMONTIL (TERTIARY AMINES)

SUSTIVA (ANTIRETROVIRALS & PROTEASE INH)

SUTAN-DM (ANTITUSSIVE AND EXPECTORANT DRUGS)

SUTENT (ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS)

SUTTAR-2 (ANTITUSSIVE AND EXPECTORANT DRUGS)

SUTTAR-SF (ANTITUSSIVE AND EXPECTORANT DRUGS)

symax (ANTISPASMODICS/DRUGS AFFECT GI MOTILITY)

SYMAX DUOTAB (ANTISPASMODICS/DRUGS AFFECT GI MOTILITY)

symax-sl (ANTISPASMODICS/DRUGS AFFECT GI MOTILITY)

SYMAX-SR (ANTISPASMODICS/DRUGS AFFECT GI MOTILITY)

SYMBICORT (OTHER DRUGS FOR ASTHMA)

SYMBYAX (PSYCHOTHERAPEUTIC COMBINATIONS)

SYMLIN (AMYLIN ANALOGUES)

SYMLINPEN 120 (AMYLIN ANALOGUES)

SYMLINPEN 60 (AMYLIN ANALOGUES)

SYMPAK (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SYMPAK DM (ANTITUSSIVE AND EXPECTORANT DRUGS)

SYMPAK PDX (ANTIHISTAMINE/DECONGESTANT COMBINATIONS)

SYNAGIS (IMMUNOLOGICALS AND VACCINES)

SYNALGOS-DC (CLASS III NARCOTICS)

SYNAREL (PAR) (SPECIALIZED OB/GYN DRUGS)

SYNERA (TOPICAL ANESTHETICS)

SYNTHROID (THYROID SUPPLEMENTS)

SYNVISC (OTHER DRUGS FOR ARTHRITIS)

SYNVISC-ONE (OTHER DRUGS FOR ARTHRITIS)

SYPRINE (OTHER DRUGS FOR ARTHRITIS)

syrex (ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.)

Formulary Date: 10/21/2009 Update Date: 10/26/2009 V1.3.0