affordable + rxboost formulary drug list
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Affordable PlanRxValue Formulary pg. 2-11
RxBoost Formulary pg. 12-17
Formulary Drug ListAffordable + RxBoost
1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797
© PRAM INSURANCE SERVICES, INC.
1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797
© PRAM INSURANCE SERVICES, INC.PG 1 OF 10
2020 RxVALUE FORMULARYThe following list by drug category contains generic drugs that are available to members
of the RxValue prescription Plan. The generic drugs (listed in lowercase) are available at a copay up to the monthly maximum benefit of the plan. All drugs not contained on this list
are not eligible for the copay benefit, however, are eligible at PRAM’s discounted rate. Please refer to your benefit materials for Limitations and Exclusions. Quantity limits per copay may
apply to certain medicaitons. This list is continually evaluated and changes can occur at any time. Please contact PRAM to confirm the most current drug list. We encourage you to share this list with
your physician at the time of your treatment.
*NO BRAND NAME DRUGS ARE COVERED ON THIS FORMULARY, ALL BRAND NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE COVERED GENERIC.
Category Covered Generic Name Brand Name*Anti-Infective Antibiotics Cephalosporins cefaclor Ceclor
cefadroxil Duricefcefdinir Omnicefcefprozil Cefzilcephalexin Keflex
Erythromycins & Other Macrolides
azithromycin Zithromax / Z-PAKclarithromycin Biaxin, Biaxin XLerythromycin ethylsuccinate EES, EryPederythromycin stearate Erythrocin
Penicilins amoxicillin Amoxilamoxicillin / pot. Clav Augmentindicloxacillin Dicloxacillinpenicillin VK Pen-Vee K
Quinolones ciprofloxacin Ciprolevofloxacin Levaquinofloxacin Floxin
Tetracyclines doxycycline Vibramycinminocycline Minocintetracycline Achromycin V
Antifungals clotrimazole / betamethasone Lotrisoneeconazole Spectazolefluconazole Diflucangriseofulvin Gris-PEG / Grifulvinketoconazole Nizoralmetronidazole Flagylnystatin oral Mycostatinterbinafine Lamisiltolnaftate
Antifungals - (Vaginal) clotrimazole Mycelex-7fluconazole Diflucanmiconazole Monistat
Anti-Infective Specialized Indications
ethambutol HCI Myambutolhydroxychloroquine Plaquenilmebendazole Vermoxneomycin
Antineoplastic/ Immunosupressants
azathioprine Imurancyclophosphamide Cytoxanflutamide Eulexinhydroxyurea Hydrealeucovorin Wellcorovin
1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797
© PRAM INSURANCE SERVICES, INC.PG 2 OF 10
Category Covered Generic Name Brand Name*Anti-Infective (cont.)
Antineoplastic/ Immunosuppressants (cont.)
megestrol Megacemethotrexatetamoxifen Nolvadex
Anti-Tubercular ethambutol MyambutolAntivirals acyclovir Zovirax
amantadine Symmetrelnevirapine Viramumerimantadine Flumadinezidovudine Retrovir
OtherAnti-Infectives
clindamycin HCI Cleocinisoniazid Nydrazidmethenamine Urexmethanamine/ sod bis/ phenyl salicyl/ methylene blue / hyos
Urimax
nitrofurantoin Macrodantin/ Macrobidrifampin Rifadintrimethoprim Trimpex
Topical Antibacterial silver sulfadiazine SilvadeneTopical Antifungals ciclopirox Loprox
ketoconazole cream/ shampoo Nizoral nystatin ointment
nystatin / triaminolone MycologAutonomicand CentralNervousSystem
Analgesics, Antimigrainal
pentazocine / naloxone Talacen / Talwin NXsumatriptan Imitrextramadol Ultram
Analgesics, Narcotics APAP / codeine Tylenol w/ CodeineAPAP / hydrocodone Vicodin / NorcoASA / codeine Empirin w/ Codeinebuprenorphine HCL/ Naloxone HCL Suboxonebuprenorphine HCI Subutexbutalbital/ acetaminophen Phrenlin, Sedapapbutalbital/ acetaminophen/ caffeine Floricethydrocodone/ ibuprofen Vicoprofenmeperidine Demerolmepiridine/ promethazine Meperganmorphine sulfate MSIR, MSContinoxycodone OxyIRoxycodone/ APAP Percocetoxycodone/ ASA Percodan
Analgesics, Non-SteroidalAnti-Inflammatory
colchicine HCL Mitgarediclofenac sodium Voltaren XRdiflunisal Dolobidibuprofen Motrinketorolac Toradolmeloxicam Mobicnaproxen Naprosynoxaprozin Daypropiroxicam Feldene
2020 RxVALUE FORMULARY*NO BRAND NAME DRUGS ARE COVERED ON THIS FORMULARY, ALL BRAND
NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE COVERED GENERIC.
1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797
© PRAM INSURANCE SERVICES, INC.PG 3 OF 10
Category Covered Generic Name Brand Name*Autonomicand CentralNervousSystem (cont.)
Anticonvulsants carbamezepine Tegretolclorazepate Tranxenedivalproex NA Depakote Sprinkle/ Depakote ERethosuximide Zarontingabapentin Neurontinlithium carbonatephenobarbitalphenytoin/ pheyntoin extended Dilantinprimidone Mysoline
topiramate Topamaxvolproic acid/ valproate sodium Depakene/ Depakote
Antiparkinsons amantadine Symmetrelbenzatropine mesylate Cogentinbromocriptine Parlodelcarbidopa/ levodopa Sinemet/ Sinemet CRropinirole HCI Requipselegiline Eldepryltrihexyphenidyl Artane
Antipsychotics chlorpromazine Thorazineclozapine Clozarilfluphenazine Prolixinhaloperidol Haldolloxapine Loxitaneperphenazinequetiapine fumarate Seroquelrisperidone Risperdalthioridazine Mellarilthiothixene Navanetrifluoperazine Stelazine
Antivertigo/ Antiemetics hydroxyzine Ataraxmeclizine HCI Antivertondansetron Zofranolanzapine Zyprexaprochlorperazine Compazinepromethazine HCI Phenergan
promethazine HCI suppository, rectal Phenergantrimethobenzamide Tigan
Anxiolytics, Sedatives and Hypnotics alprazolam Xanaxaquachloral supprettes Noctecbuspirone Busparchlordiazepoxide HCI Libriumclonazepam Klonopindiazepam Valiumestazolam Prosomfluzapam Dalmanelorazepam Ativan
2020 RxVALUE FORMULARY*NO BRAND NAME DRUGS ARE COVERED ON THIS FORMULARY, ALL BRAND
NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE COVERED GENERIC.
1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797
© PRAM INSURANCE SERVICES, INC.PG 4 OF 10
Category Covered Generic Name Brand Name*Autonomicand CentralNervousSystem(cont.)
Anxiolytics, Sedatives and Hypnotics(cont.)
oxazepam Seraxtemapzepam Restoriltriazolam Halcionzolpidem tartrate Ambien
CNS Stimulants amphetamine / dextroamphetamine
Adderall
destroamphetamine Dexedrine / Destrostatmethylphenidate Ritalin / Methylinmemantine Namenda
Drugs to Prevent and Treat Gout allopurinol Zyloprimprobenecid
Muscle Relaxants/ Antispasmodics baclofen Lioresalcarisoprodol Somacarisoprodol and aspirin Soma Compoundcarisoprodol, aspirin, codeine Soma Compound with Codeinechlorazoxazone Parafon Forte DSCcyclobenzaprine Flexerilmetaxalone Skelaxin
methocarbamol Robaxintizanidine Zanaflex
Psychotherapeutics Antidepressants amitriphtyline Elavilamitriptyline / chlordiazepoxide Limbitrolamitriptyline / perphenazine Triavilamoxapine Asendinbupropion Wellbutrin & Wellbutrin SR,
Wellbutrin XLcitalopram Celexaclomipramine Anafrildesirpramine Norpramindoxepin Sinequanduloxetine Cymbalta
fluoxetine Prozacfluvoxamine Luvoximipramine Tofranilmaprotiline Ludiomilmirtazapine Remeronnortriptyline Pamelorparoxetine Paxilsertraline Zolofttrazodone Desyrelvenlafaxine HCI Effexor XR
Cardiovascular ACE Inhibitors captopril Capotenenalapril Vasoteclisinopril Zestrilquinapril Accupril
2020 RxVALUE FORMULARY*NO BRAND NAME DRUGS ARE COVERED ON THIS FORMULARY, ALL BRAND
NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE COVERED GENERIC.
1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797
© PRAM INSURANCE SERVICES, INC.PG 5 OF 10
Category Covered Generic Name Brand Name*Cardiovascular(cont.)
Alpha Blockers doxazosin Carduraprazosin Minipressterazosin Hytrin
AngiotensinReceptor Blockers
irbesartan Avaprolosartan Cozaarolmesartan medoxomil Benicarvalsartan Diovan
Antiarrhythmics amiodarone Cordaronedisopyramide Norpacemexiletine Mexitilnitroglycerinprocainamide Procainamidepropafenone Rythmolquinidine
Beta-Adrenergic Antagonists
acebutolol Sectralatenolol Tenorminbetaxolol Kerlonebisoprolol Zebetacarvedilol Coreglabetolol Normodynemetoprolol Lopressormetoprolol succinate Toprol XLnadolol Corgardpindolol Viskenpropranolol Inderalsotalol Betapacetimolol Blocadren
Calcium Channel Blockers amlopidine Norvascdiltiazem Cardizem/ SR / Dilacor XRmatzim LA Cardizem LAnicardipine Cardenenifedipine Procardia XLverapamil Calan SR / Isoptin SR
Cardiac Glycosides digoxin LanoxinCholesterol - Lowering atorvastatin Lipitor
cholestyramineezetimibe Zetiagemfibrozil Lopidlovastatin Mevacorniacinpravastatin Pravacholrosuvastatin Crestorsimvastatin Zocor
Diuretics amiloride / HCTZ Modureticbumetanide Bumexchlorthalidone Hygroton
2020 RxVALUE FORMULARY*NO BRAND NAME DRUGS ARE COVERED ON THIS FORMULARY, ALL BRAND
NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE COVERED GENERIC.
1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797
© PRAM INSURANCE SERVICES, INC.PG 6 OF 10
Category Covered Generic Name Brand Name*Cardiovascular (cont.)
Diuretics (cont.) furosemide Lasixhydrochlorothiazideindapamide Lozolmethazolamidemetolazone Zaroxolynspironolactone Aldactonetorsemide Demadex
Diuretic Combinations atenolol / chlorthalidone Tenoreticbisoprolol / hydrochlorthiazide Ziaccaptopril / hydrochlorthiazide Capozidechlorothiazide Diurilenalapril / hydrochlorthiazide Vasoreticlisinopril / hydrochlorthiazide Zestoreticmethyldopa / hydrochlorthiazide Aldorilpropranolol / hydrochlorthiazide Inderidespironolactone / hydrochlorthiazide Aldactazidetriamterene / hydrochlorthiazide Dyazide
Other Antihypertensives clonidine Catapresguanfacine Tenexhydralazine Apresolinemethyldopa Aldometminoxidil Lonitenquinine sulfate Qualaquin
Other Cardiovascular Drugs pentoxifylline TrentalVasodilating isosorbide dinitrate Isordil
isosorbide mononitrate Imdurisoxsuprine Vasodilannitroglycerin Nitrolingual
Dermatologicals Anti-Acne clindamycin Celocin-T / Clindets Pledgetssulfacetamide Novacet / Sulfacet-R
Antipsoriasis selenium sulfide Exsel / SelsunOther Dermatological aluminum chloride DrysolTopical Corticosteroids alclometasone Aclovate
amcinonide Cyclocortaugmented betamethasone diproprionate
Diprosone, Maxivate
betamethasone valerate Valisoneclobetasol propionate Temovate/ Edesonide DesOwendesoximetasone Topicortfluocinaide Lidex-Efluocinolone acetonide Synalar / Derma SmootheFSmometasone furoate Eloconprednicarbate Dermatop
Ear, Nose & ThroatMedications
Drugs Affecting the Ear acetic acid VoSolacetic acid / aluminum acetate Domeboro Oticantipyrine / benzocaine Auralgan/ AB Otic Solution
2020 RxVALUE FORMULARY*NO BRAND NAME DRUGS ARE COVERED ON THIS FORMULARY, ALL BRAND
NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE COVERED GENERIC.
1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797
© PRAM INSURANCE SERVICES, INC.PG 7 OF 10
Category Covered Generic Name Brand Name*Ear, Nose & Throat Medications(cont.)
Drugs Affecting the Ear (cont.) hydrocortisone / acetic acid Acetasol HCneomycin / polymyxin / hc Cortisporin
ofloxacin Floxin Otic
Drugs Affecting the Throat and Mouth
chlorhexidine Peridexlidocaine HCI viscous solution Xylocaine Viscous Gelsodium fluoride Gel-Kamtriamcinolone acetonide Kenalog in Orabase
EndocrineMedications
Adrenal Corticosteroid dexamethasone Hexadrolfludricortisone Florinefhydrocortisone Cortefmethylprednisolone Medrol / Medrol Pakprednisolone Orapred / Pediapredprednisone Deltasone
Antidiabetic Agents chlorpropamide Diabineseglimepiride Amarylglipizide Glucotrolglyburide Diabeta/ Glynaseglyburide / metformin Glucovancemetformin Glucophagemiglitol Glysetnateglinide Starlixpioglitazone Actosrepaglinide Prandin
Drugs to Treat Osteoporosis
alendronate Fosamaxrisedronate sodium Actonel
Thyroid and Anti-Thyroid levothyroxine Synthroid / Levoxylmethimazolepropylthiouracilthyroid
Gastrointestinal Antispasmodics belladonna alkaloids Anti-Spas
belladonna alkaloids/ phenobarbital Donnataldiphenoxylate / atropine Lomotilclidinium / chlordiazepoxide Libraxdicyclomine Bentylhyoscyamine Levsinmetoclopramide Reglan
Other Gastrointestinal electrolyte solution/ PEG’s Golytelyhydrocortisone suppositories Anusol HCmagnesium oxide Mag-Oxmisoprostol CytotecPEG 3350 / electrolytes solution Colytepramoxine / hydrocortisone / chloroxylenol
Cortane B
sulfasalizine AzulfidineProton Pump Inhibitors omeprazole Prilosec
lasoprazole Prevacidpantoprazole Protonix
2020 RxVALUE FORMULARY*NO BRAND NAME DRUGS ARE COVERED ON THIS FORMULARY, ALL BRAND
NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE COVERED GENERIC.
1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797
© PRAM INSURANCE SERVICES, INC.PG 8 OF 10
Category Covered Generic Name Brand Name*Nutrition,BloodModifiers and Electrolytes
Drugs and VitaminsAffecting Coagulation
clopidogrel Plavixdipyridamole Persantineticlopidine Ticlidwarfarin Coumadin
Fluoride Products sodium fluoride Karidium/ LuridePotassium Supplements potassium chloride K-DUR/ Micro-KVitamins / Minerals ergocalciferol Calciferol
folic acid Folatepyridoxinezinc sulfate
Ophthalmic Glaucoma acetazolamide Diamoxapraclonidine Lopidinebetaxolol Betoptic / Sbrimonidine tartrate Alphagancarteolol Ocupressdipivefrin AKProdorzolamide Trusoptlatanoprost Xalatanlevobunolol Betaganmetipranolol Optipranololpilocarpine Pilocartimolol Timoptic/ XE
Ophthalmic Topical Antibacterial
bacitracin Ak-Tracinciprofloxacin Ciloxan ofloxacin Ocufloxoxytetracycline/ polymyxin B Terramycin and Polymyxin B
Ophthalmicsulfacetamide Bleph-10tobramycin Tobrex
Ophthalmic Antihistamines azelastine HCL OptivarOphthalmic Anti-Infectives/ Corticosteroids
gentamicin Garamycinneomycin / bacitracin / polymyxin Neosporinneomycin / bacitracin / polysporin / hydrocortisone
Cortisporin
neomycin / dexamethasone / polymyxin Dexacidin/ MaxitrolOphthalmic Anti-Infectives/ Corticosteroids(cont.)
polymyxin B / trimethoprim Polytrimsulfacetamide / prednisolone Blephamidesulfacetamide / prednisone Vasocidin
Ophthalmic Corticosteroids dexamethasone Decadronfluroromethalone FML Liquifilmprednisolone Econopred Plus / Pred Forteprednisolone Forte
Ophthalmic Topical Antivirals trifluridine ViropticOther Ophthalmic cyclopentolate Cyclogyl
2020 RxVALUE FORMULARY*NO BRAND NAME DRUGS ARE COVERED ON THIS FORMULARY, ALL BRAND
NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE COVERED GENERIC.
1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797
© PRAM INSURANCE SERVICES, INC.PG 9 OF 10
Category Covered Generic Name Brand Name*Obstetrical and Gynecological
Androgens danazol DanocrineContraceptives drosprienone/ehtinyl estradiol Yaz, Yazmin
ethinyl estradiol and desogestrel Ortho-Cept/ Desogenethinyl estradiol and ethynodiol diacetate Zoviaethinyl estradiol and levonorgesterel Triphasil/ Levlennorethindrone NorQD/ Ortho Micronornorethindrone / estradiol / fe fumarate Loestrin-fenorethindrone / ethinyl estradiol Mircettenorethindrone / ethinyl estradiol Modiconnorethindrone / mestranol Ortho-Novumnorgestrimate / ethinyl estradiol Ortho Cyclennorgestrimate / ethinyl estradiol Ortho Tri-Cyclennorelgestromin/ ethinyl estradiol patch Xulane/ Ortho Evra
Estrogen Patches estradiol Vivelle/DotOral Estrogens estradiol Estrace
estropipate Ortho-Est/ OgenPrenatal Vitamins All vitamins are preferred on formularyProgestins medroxyprogesterone Provera
norethindrone Aygestinprogesterone Prometrium
Respiratory, Allergy, Coughand Cold
Antihistamines/ Anti-Allergenics
cyproheptadine Cyproheptaddexchlorpheniramine tablet SA Polaramine Repetabfexofenadine Allegrahydroxyzine pamoate Vistarilmontelukast sodium Singulair
Anti-Tussive Combinations guaifenesin / codeine Robitussin A-Cguaifenesin / PSE / hydrocodone Deconamine CXguaifenesin / hydrocodone Codiclearhydrocodone / homatropine Hydromethydrocodone / potassium guiaco CoTussphenylephrine / hydrocodone / GG Levall 5.0phenylephrine / pyrilamine / DM PolyHist DMphenylephrine / pyrilamine / hydrocodone
Codimal DH
promethazine / codeinephenylephrine / chlorphen / hydrocodone
HC Tussive & Histinex HC
promethazine / DM
pseudoephedrine / brompheniramine / hydrocodone
Brovex HC
pseudoephedrine w/ codeine / GG Codafedpseudoephedrine-CPM / hydrocodone Genecof-HCpseudoephedrine / hydrocodone Pancofpseudoephedrine / hydro / GG Hydrotussin
2020 RxVALUE FORMULARY*NO BRAND NAME DRUGS ARE COVERED ON THIS FORMULARY, ALL BRAND
NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE COVERED GENERIC.
1 Pointe Dr Suite 120, Brea, CA 92821 phone: 1.800.262.7726 online: pram.comcalifornia license #. 0812797
© PRAM INSURANCE SERVICES, INC.PG 10 OF 10
Category Covered Generic Name Brand Name*Beta AgonistInhalers
metaproterenol Alupent
Inhaled CorticosteroidsIntranasal Steroids
flunisolide Nasalidefluticasone Flonasemometasone furoate Nasonex
Beta Agonist Oral albuterol Proventilalbuterol, multiphasic release Proventilmetaproterenol sulfate
Decongestants/ Antihistamines benzonatate Tessalon Perlecyproheptadine Periactinpseudoephedrine / chlorpheniramine tab / syrup / cap SA
Deconamine SR/ Deconamine
pseudoephedrine / methscopolamine Allerx-DExpectorant CombinationsLeukotriene ModifiersMiscellaneous Pulmonary Agents
guaifenesin / PSE / hydrocodone Guaifed/ Deconsal/ Entex PSEmontelkast sodium Singulairacetylcysteine Mucomyst
cromolyn sodium ampul Intalipratropium Atrovent Inhaler/ Nasal Spray
Pulmonary Agents Xanthines aminophyllinedyphyllinetheophylline Theo-Dur/ Slo-Phyllin/ Theolair-SR
UrologicalMedications
Anticholinergics/ Antispasmodics
flavoxate Urispas
Benign Prostatic Hypertrophy tamsulosin HCL FlomaxMiscellaneous Urologicals oxybutynin Ditropan
phenazopyridine Pyridiumtamsulosin HCL Flomaxterazosin Hytrin
Other Genitourinary Products potassium citrate Urocit-Kpotassium phosphate K-Phos
2020 RxVALUE FORMULARY*NO BRAND NAME DRUGS ARE COVERED ON THIS FORMULARY, ALL BRAND
NAMES ARE PROVIDED STRICTLY FOR CROSS REFERENCE TO THE APPLICABLE COVERED GENERIC.
DRUG NAME DRUG NAME DRUG NAMEAbilify Aristada Breo ElliptaAbilify M Armour Thyroid Breo ElliptaAbrilada (Biosimilar Remicade) Arnuity Ellipta Breo Ellipta 200Absorica Arranon Breo Ellipta 100Accutane (isotretinoin) Arzerra Breo Ellipta 200achtar Asacol BrilintaActemra SC Asacol 800mg Brineuraactimmune Asmanex Twisthaler BrukinsaAcuvail Asmanex/Asmanex HFA BydureonAdakevo Asragraf XL BydureonAdcentris Atripla Bydureon 2/0.85 mlAdcirca Atrovent HFA BystolicAdhansia XR Aubagio Bystolic 10AdvairHFA /Advair Diskus auryxia Bystolic 5Advate Austedo CabometyxAdynovate Avandia CalquenceAerochamber Plus Avastin CanasaAfinitor Avonex CapecitabineAimovig Avsola (remicaid biosim) CapecitabineAiromir Avycaz CaplytaAjovy Azopt CarbagluAkynzeo Bagsimi CaystonAldurazyme Balversa Cerdelga Aliqopa Baraclude CerezymeAlphagan P barhemsys CetrotideAlprolix Basaglar KwikPen (5 x 3ml) ChantixAlunbrig Basalgar CholbamAmitiza Bebulin VH CialisAmlodipine Benefix Cialis 10mgAmpyra Benicar/Olmetec Cialis 20mgAmzeeq Benlysta Cialis 5mgAnjeso Beovu CimduoAnnovera Betaseron-Betaplus CimziaAnoro Ellipta Bethkis CimziaApidra Biorphen CiprodexApligraf Bktarvy CoagadexAptivus Blincyto CoartemAralast Bosulif ColchicineAranesp Botox CombiganArikayce Braftovi Combivent Respimat
2020 Rx Boost Formulary
PRAM Insurance Services, Inc. 2020 Rx Boost Formulary
DRUG NAME DRUG NAME DRUG NAMECometriq Dysport FarydakComplera Edarbi FasenraConcerta Edarbi/Edarbychlor FeibaCopaxone 40mg (shared solution) Edurant FerrinproxCopiktra Effexor XR FetrojaCopiktra Effient FetzimaCorifact Egrifta Fiasp VialCortef Elaprase Flovent HFACosentyx Elelyso Focalin XRCotellic Eliquis FollistimCozaar Elmiron FolotynCozaar 25mg Eloctate Forteo Cozaar 50mg Elreada GablofenCreon Elzonrus GamunexCrestor Emflaza Ganirellix Crinone Emgality GattexCryvista Emtriva GelniqueCuprimine Enbrel GenosylCuprimine Enbrel Genotropin Cuprimine Endometrin GenvoyaCyclophosamide 50mg Enhertu Gilenya Cymbalta Enstilar GilotrifCystadane Enstilar GivlaariDaklinza Entresto Glatopa (20 or 40mg/ml)Dalvance Entyvio GleevecDarzolex Envarasus XR Glucagon InjectionDaurasmo Epclusa Glucagon InjectionDaurismo Epidiolex GluconormDDAVP Rhinyle EpiPen Auto-Injector GlumetzaDelzicol Epivir GlyxambiDemser Epogen Gonal- FDescovy Epzicom GvokeDexilant Erivedge Haldol D InjDificid Erleada Haldol InjDovato Esbriet HarvoniDuaklir Pressair Esperoct HepseraDuexis Estrace Cr HerceptinDulera Evenity HerzumaDulera/Zenhale 100 Evista HetliozDulera/Zenhale200 evotaz HizentraDuobrii Exjade Humalog Duopa Extavia Humalog KwikpenDupixent Eylea Humalog KwikPen (5 x 3ml)Duragesic Fabrazyme Humalog U-200 ONLYDurizol Farseton HumatropeDurysta Farxiga Humira
PRAM Insurance Services, Inc. 2020 Rx Boost Formulary
DRUG NAME DRUG NAME DRUG NAMEHumulin 30/70 Kitabis PK Mesalamine 800mgHumulin R U-500 ONLY Kogenate FS Mesalamine SuppositoriesHymactin Korlym ModeribaIbrance Koselugo MonoviscIclusig Krystexxa MonuralIdelvion Kuvan MotegreityIdhifa Kynamro MugardIlaris Lamictal MulpletaIlevro Lamictal MultaqIlumya Lamictal 200 MydayisImatinib (Gleevec) Lamictal 100 MyforticImbruvica Lamictal 200 MyobolocInbrija Lantus MyrbetriqIncruse Ellipta Lantus Solostar MyxredinInfed Latuda NaglazymeInlyta Lemtrada Namenda/Namenda XRInrebic Lenvima NamzaricIntelence Letaris NayzilamInvega Sustina Levemir FlexTouch (5 x 3mL) NeoralInvega T lexiva NerlynxInvega Trinza Libtayo NeulastaInvokana Linzess NeupogenInvokana 100mg Lipitor NexavarInvokana 300 Lipitor 10mg NexletolIressa Lipitor 80mg Ninlaroisentress Lixiana NorditropinIvokamet/XR Lokelma NortheraIxinity Lonsurf NorvascJadenu Lorbrena NorvirJanumet/Janumet XR Lotemax NouressJanuvia Lotemax NourianzJardiance Lucemyra NovoeightJatenzo Lumigan NovologJelmyto Lumizyme NovologJentadueto Lumoxiti Novolog FlextouchJuluca Lupaneta Pack Novolog Penfills (5 x 3mL)Juxtapid Lupron NoxafilJynarque Lupron Depot NplateJynneso Lupron Depot Ped NubeqaKaletra Lynparza Nucala Kalydeco Lyrica NuplazidKaterzia Mavelclad NurtecKeveyis Mekinist Nurtec ODTKevzara Mektovi Nutropin Keytruda Mesalamine OcalivaKisqali, XL Mesalamine 1.2 OCREVUS
PRAM Insurance Services, Inc. 2020 Rx Boost Formulary
DRUG NAME DRUG NAME DRUG NAMEOdefsey Prograf Rosuvastatin 40Odomzo Prolia RozlytrekOfev Promacta RubracaOlmetec Prozac RuxienceOlumiant Pulmicort RuzurgiOmegaven Pulmicort flexhaler RybelsusOmnitrope Pulmozyme RydaptOnpattro Purixan SaizenOpsumit Pylera SamscaOrencia Qutenza SancusoOrfadin Qvar Easi-Breathe Inhaler SandimmuneOrkambi Ranexa SandostatinOrlissa Rapaflo Sandostatin LAROrthovisc Syringe Rasilez/Tekturna Santyl OintOtezla Rasuvo SaphrisOthovisc Ravciti SarclisaOvidrel Reblozyl SaxendaOxbryta Reclast Saxenda (5 Pens)Oxtrexup Rectiv ScarlisaOzempic Regranex SceneesePadcev Relistor ScenessePalynzig Relvar/Breo Ellipta selzentryPataday Remicade SensiparPazeo 0.7% Reopro SevenfactPemazyre Repatha SigniforPemfexy rescriptor SildenafilPentasa Restasis Eye Drop Sildenafil 100mgPiqray Retisert SiliqPlegridy retrovir SimbrinzaPlenity Revatio SimponiPomolyst Revcovi Simponi AriaPoteligeo Revlimid SingulairPradaxa Rexulti Singulair 10Praluent Rexulti 2mg SkyriziPrandin Rexulti 3mg SlyndPred Forte Reyataz Somatuline Depot Premarin tabs Reyvow SomavertPremarin Vaginal Cr (ONLY - not Tabs) Rhopressa Soolantra Cream 1%Prevymis Ribasphere Ribapak SovaldiPrezcoxib Ribavirin Spiriva Prezista Rinvoq SporanoxPrialt Rinvoq SpravatoPristiq Risperdal Consta SprycelProair Rituxan StelaraProcrit Rocklatan StendraProcysbi Rosuvastatin Stiolto Respimat
PRAM Insurance Services, Inc. 2020 Rx Boost Formulary
DRUG NAME DRUG NAME DRUG NAMEStrattera Tobi ViagraStribild Tobi Podhaler Viagra 100mgStriverdi Respimat Torgarzo ViberziSunosi Tosmyra Victozasustiva Toujeo VigamoxSutent Toviaz ViibyrdSymbicort Inhaler Tracleer VimpatSymdeko Trajenta ViokaseSymfi Lo Travatan Z viraceptSymlin Trelegy Ellipta Viramune XRSymtuza Tremfya VireadSynagis Tresiba Flextouch Pens VistogardSynjardy/XR Tretten VitektaSynthroid Trikafta VitrakviSynvisc One Trilepta VivitrolSyprine Trimeq VizimproTaclonex Trintellix Voltaren EmulgelTadalafil TRIUMEQ VoseviTadalafil 10 trizivir VotrientTagrisso Trodelvy VprivTakhzyro Trokendi VraylarTalfinar Trulicity VumerityTalicia Truvada VyeptiTaltz Tudorza Genuair VyeptiTalzenna Turalio WakixTarceva Tybost WelcholTargretin Tykerb Wixela Inhub (Geq Advair)Targrisso Tymlos XalkoriTasigna Tysabri XareltoTavalisse Tyvaso XeljanzTazverik Ubrelvy Xeljanz XRTecentriq Ubrelvy XelodaTecfidera Uceris XenazineTeflaro Uloric XenletaTegretol Uloric XeominTegsedi Ultomeris XeravaTekturna Uptravi XermeloTestosterone Gel, Valchlor XgevaThalomid Varubi XiaflexThiola EC Vemlidy XidraThyroid Hormone Venclexta XifaxinThyroid Hormone Ventavis XolairThyroid Hormone 60mg Ventolin HFA XolairTibsovo Verzenio XospataTikosyn Vesicare XuridenTivicay Vesicare Xyntha
PRAM Insurance Services, Inc. 2020 Rx Boost Formulary
DRUG NAMEXyremYervoyYondeusYonsaYuperliZarxioZejulaZelborafZemairaZemdriZenpepZepatierZeposiziagenZiextenzoZirabev (Biosim - Avastin)ZolinzazortressZulressoZydeligZykadiaZyprexaZyprexa RelZyprexa ZydisZytiga
PRAM Insurance Services, Inc. 2020 Rx Boost Formulary
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