Pharmacy Formulary - Tier 2 ($15.00 copay)

ADVAIR 100/50 DISKUS
ADVAIR 250/50 DISKUS
ADVAIR 500/50 DISKUS
ATROVENT HFA METERED DOSE INHALER 12.9GM
AZMACORT METERED DOSE INHALER
CLINDAMYCIN 1% TOPICAL SOLN 60ML
DOXYCYCLINE MONOHYDRATE 20MG CAPSULE
DOXYCYCLINE MONOHYDRATE 50MG CAPSULE
DOXYCYCLINE MONOHYDRATE 100MG CAPSULE
DOXYCYCLINE MONOHYDRATE 100MG TABLET
DULERA 100MCG/5MCG INHALER
DULERA 200MCG/5MCG INHALER
DULOXETINE 20mg DR (CYMBALTA GENERIC EQ)
DULOXETINE 30mg DR (CYMBALTA GENERIC EQ)
DULOXETINE 60mg DR (CYMBALTA GENERIC EQ)
ERYTHROMYCIN 2% TOPICAL SOLN 60ML
FLOVENT HFA 110MCG METERED DOSE INHALER 12GM
FLOVENT HFA 220MCG METERED DOSE INHALER 12GM
FLOVENT HFA 44MCG METERED DOSE INHALER 12GM
INSULINS (NOVOLIN/NOVOLOG)
   Novolin 70/30 Insulin 100 units/ml 10ml vial
   Novolin N Insulin 100 units/ml 10ml vial
   Novolin Regular Insulin 100 units/ml 10ml vial
   Novolog Insulin 100 units/ml 10ml vial
INSULIN PENS(NOVOLOG)
   Novolog Flexpens 3ml 5/box
   Novolog 70/30 Flexpens 3ml 5/box
NAPROXEN SODIUM 550MG TABLET
PODOFILOX 0.5% TOPICAL SOLUTION
PREDNISOLONE 1% OPHTHALMIC SUSPENSION 5ML
RELPAX 20MG TABLET**
RELPAX 40MG TABLET**
RIZATRIPTAN 5MG TABLET (MAXALT GENERIC EQ)**
RIZATRIPTAN 10MG TABLET (MAXALT GENERIC EQ)**
RIZATRIPTAN 5MG ODT (MAXALT MLT GENERIC EQ)**
RIZATRIPTAN 10MG ODT (MAXALT MLT GENERIC EQ)**
SUMATRIPTAN STAT KIT**
SUMATRIPTAN STAT REFILL**
ZOLMITRIPTAN 2.5MG TABLET (ZOMIG GENERIC EQ)**
ZOLMITRIPTAN 5MG TABLET (ZOMIG GENERIC EQ)**
ZOLMITRIPTAN 2.5MG ODT (ZOMIG ZMT GENERIC EQ)**
ZOLMITRIPTAN 5MG ODT (ZOMIG ZMT GENERIC EQ)**

**QUANTITY LIMITS