2022 member formulary - List of covered drugs - Geisinger
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GHP FAMILY 2022 member formulary List of covered drugs
A. What is the Statewide PDL and GHP Family Formulary?
Geisinger Health Plan, like other Medicaid Managed Care Organizations follows the Statewide
Preferred Drug List (PDL). The Statewide PDL is developed by the Department of Human
Services’ (DHS) Pharmacy and Therapeutics Committee. A formulary is a list of drugs selected
by GHP Family, which represents medications believed to be a necessary part of a quality
treatment program. Only medications that are not part of the PDL may be included in the GHP
Family formulary.
This formulary is up to date at the time of print. For the most up to date information, please go
to our website at https://www.geisinger.org/health-plan/plans/ghp-family and visit
https://www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Preferred-Drug-List.aspx for
information on the Statewide PDL.
Can the Formulary change?
The plan may add or remove drugs from the formulary. If we remove drugs from our formulary
or add restrictions on a drug such as a requirement for prior authorization, quantity limits and/or
step therapy restrictions on a drug, we must notify affected members of the change at least 30
days before the change becomes effective. See section, “Are there any requirements or limits on
my drugs?” for more information.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Drug Class
The formulary begins on page 13. The drugs in this formulary are grouped into the class of
drugs they belong to. If you know what class your drug belongs to, look for the class name in the
list that begins on page 10. Then look under the class name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that
is included at the end of this document. The Index provides an alphabetical list of all the drugs
included in this document.
The first column of the formulary lists the formulary drug. Brand drugs are printed in all upper-
case letters (e.g. DIURIL ORAL SUSPENSION). Generic drugs are printed in all lower-case
italic letters (e.g. furosemide). Drug names that appear in the third column for generic covered
drugs are the name of the brand medication. The brand name in the third column appears for
reference only to assist in identifying the generic medication and does NOT indicate that the
brand name drug is on the formulary.
The second column of the formulary lists the tier the drug is covered on. Tier 1 contains generic
medications. Tier 2 contains brand name medications. Drugs listed as OTC are over-the-counter
medications.
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family 2022 Supplemental Formulary Page 2 of 77
Effective 6/01/2022
The fourth and final column of the formulary lists any requirements or limits that may apply to
the drug. See the section titled “Are there any requirements or limits on my drugs” below.
Sometimes a drug comes in multiple forms (e.g., drops, liquid, tablet, syrup, etc.). If this column
lists a specific drug form, then only that form is included in the formulary.
What are generic drugs?
GHP Family covers both brand name drugs and generic drugs. If your doctor prescribes a brand
name drug and a generic is available, your pharmacist will give you the generic version of that
drug. A generic drug is approved by the Federal Food & Drug Administration (FDA) as having
the same active ingredient as the brand name drug and is just as safe and effective. Generally,
generic drugs cost less than brand name drugs. Prescriptions written as “brand medically
necessary” by your doctor will require prior authorization.
Are Over-the-Counter (OTC) drugs covered?
Certain OTC medications are listed on the Statewide PDL or formulary. OTC drugs will require
a prescription from your doctor.
Dispensing Limits
GHP Family will cover up to a 34-day supply of your medication unless the prescription is
written for less by your physician or the medication is subject to a quantity limit restriction. If
there are medications you take on a regular basis, such as blood pressure medications or
medications to treat cholesterol (maintenance medications), you have the option to obtain a 90-
day supply from a participating retail pharmacy or mail order pharmacy. Please call GHP Family
Pharmacy services at (855) 552-6028 or (570) 214–3554 for assistance in finding a participating
pharmacy. Certain medications such as controlled substances and specialty medications are
excluded from this 90-day supply program. If you have questions about which medications are
considered maintenance medications you can check online at
https://healthplan.geisinger.org/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinger or call
GHP Family Pharmacy services at (855) 552-6028 or (570) 214–3554. A medication may be
refilled when 85% has been used. Controlled medications, which may cause addiction, such as
those used for pain or anxiety, may be refilled when 90% has been used. If for some reason you
need a refill before 85% or 90% of the medication has been used please call GHP Family
Pharmacy Services at (855) 552-6028 or (570) 214-3554 for assistance.
GHP Family will grant one early refill if you are traveling outside of Pennsylvania and will run
out of medication before you return home. GHP Family will allow this once per medication per
member per year. Your pharmacy should contact GHP Family Pharmacy Services at (855) 552-
6028 or (570) 214-3554 to obtain a vacation supply. Any additional requests for a vacation
supply will require prior authorization.
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family 2022 Supplemental Formulary Page 3 of 77
Effective 6/01/2022Requests to replace medications that are lost, stolen, or destroyed must be reviewed by GHP
Family Pharmacy Services. Members should contact GHP Family Pharmacy Services at (855)
552-6028 or (570) 214-3554 for more information.
Blood Glucose Monitors and Strips
Members are entitled to receive one new blood glucose monitor every two years and 200 strips
every month. You can also receive a new monitor if you switch to a different one that is
preferred on the PDL.
Medical Benefit Drugs
Medical benefit drugs are drugs dispensed and administered in a physician’s office and are not
included in the formulary. For some Medical Benefit Drugs, your provider must first obtain prior
authorization. Your provider can find a list of medical benefit drugs that require prior
authorization here: https://www.geisinger.org/health-plan/providers/pharmacy-forms. Any
questions regarding the coverage of medical benefit drugs should be directed to GHP Family
Pharmacy Services at (855) 552-6028.
Vaccines
The vaccines included in the formulary are available to members at a retail pharmacy without a
prescription. The typhoid vaccine (Vivotif) is also available at retail pharmacies but requires a
prescription. Other vaccines are considered a medical benefit and should be administered by
your physician.
Are there any requirements or limits on my drugs?
Some drugs may have additional requirements or limits. These requirements and limits may
include:
• Prior Authorization: GHP Family requires your physician to get prior approval for
certain drugs. This means that your prescriber will need to get approval from GHP
Family before you fill prescriptions for these drugs. Without this approval, GHP Family
will not pay for the drug. If GHP denies the prior authorization request, you can appeal
the decision. Please see the GHP member handbook, section 15, Complaint, Appeal and
Fair Hearing Processes, for information about filing an appeal.
• Quantity Limits: For certain drugs, there are limits to the amount of the drug that you
can get. GHP Family follows DHS’ quantity limits except for blood glucose meters and
strips, condoms, spacers (OptiChamber), injectable anticoagulants (Lovenox), vaccines,
and medications used to treat low blood sugar (glucagon, GVOKE, etc.). Quantity limits
are available at www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Quantity-Limits-
and-Daily-Dose-Limits.aspx or
https://healthplan.geisinger.org/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinge
r If your prescriber wants you to have more than the limit, your prescriber must request
prior authorization.
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family 2022 Supplemental Formulary Page 4 of 77
Effective 6/01/2022• Step Therapy: In some cases, GHP Family requires you to first try certain drugs to treat
your medical condition before we will approve another drug for that condition. For
example, if Drug A and Drug B both treat your medical condition, GHP Family may not
approve Drug B unless you try Drug A first. If Drug A does not work for you, GHP
Family will then approve Drug B. Your prescriber may request prior authorization if
Drug A does not work for you or if you cannot take Drug A.
• Specialty Pharmacy: Specialty medications can only be filled by certain pharmacies in
the GHP Family network. Specialty drugs are medications used to treat complex
diseases. These medications usually require specialized handling and monitoring. If you
are taking a specialty medicine or if you have a question about finding a specialty
pharmacy, please call PerformRx at (844) 399-0477. Specialty medications that are
included in this formulary have the initials SP next to them. A complete list of specialty
medications and pharmacies that can fill them can be found here:
https://www.geisinger.org/health-plan/plans/ghp-family/pharmacy-coverage Any
Specialty Medication that is also a Medical Benefit Drug can either be dispensed by a
contracted specialty pharmacy or a prescriber can obtain, administer and bill GHP Family
for the cost of the medications.
The following abbreviations are found within column three of this formulary and indicate
the requirements and limits listed above:
ABBREVIATION DESCRIPTION EXPLANATION
Utilization Management Restrictions
Your physician is required to get prior
Prior Authorization authorization from GHP Family before you fill
PA
Restriction your prescription for this drug. Without prior
approval, GHP Family will not pay for this drug.
GHP Family limits the amount of this drug that can
Quantity Limit
QL be obtained per prescription, or within a specific
Restriction
time frame.
Before GHP Family will approve this drug, you
Step Therapy must first try another drug(s) to treat your medical
ST
Restriction condition. This drug may only be approved if the
other drug(s) does not work for you.
Some drugs are not available at your retail
pharmacy. These drugs are called specialty drugs
SP Specialty Pharmacy and can be obtained at specialty pharmacies. To
find out how and where to obtain a specialty drug,
please contact PerformRx at (844) 399-0477.
Prior Authorization If you are a new member or if you have not taken this
PA-NSO
Restriction for drug before, you (or your physician) are required to
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family 2022 Supplemental Formulary Page 5 of 77
Effective 6/01/2022ABBREVIATION DESCRIPTION EXPLANATION
New Starts Only get prior authorization from GHP Family before you
fill your prescription for this drug. Without prior
approval, GHP Family will not pay for this drug.
How much will I pay for my drugs?
Pharmacy copays will apply to members 18 years of age and older unless otherwise listed below.
Brand name prescription drugs have a $3 copayment. Generic prescription and over-the-counter
drugs have a $1 copayment. Services cannot be denied if the member is unable to afford the
copay.
There are no copays for:
• Pregnant women (including the postpartum period which ends 60 days after delivery)
• Children under 18 years of age
• Medical benefit drugs
• Members in a nursing home
• Members in an Intermediate Care Facility for Mental Retardation or Intermediate Care
Facility for Other Related Conditions
• Family planning drugs or supplies
• Drugs, including immunizations, when dispensed and/or administered by a physician
• Title IV-B Foster Care and IV-E Foster Care and Adoption Assistance
• Members eligible under the Breast and Cervical Cancer Prevention and Treatment Programs
• There is no copay for the following groups of medications:
o Antihypertensives (high blood pressure)
o Antidiabetes (high blood sugar)
o Anticonvulsants (seizure)
o Cardiovascular preparations (heart disease)
o Antipsychotics (except those that are controlled substance antianxiety drugs)
o Antineoplastics (cancer drugs)
o Antiglaucoma drugs
o Anti-Parkinson’s drugs
o HIV/AIDS drugs
o Preferred naloxone injection/nasal spray for drug overdose
Non-covered medications
The following medications are not eligible for coverage under the Medical Assistance Program:
• Drugs that are designated by the FDA as less than effective (DESI) drugs
• Any drug marketed by a drug company that does not participate in the Medicaid Rebate
Program
• Drugs used for weight loss
• Drugs used for cosmetic purposes or hair growth
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family 2022 Supplemental Formulary Page 6 of 77
Effective 6/01/2022• Drugs used for fertility
• Drugs used for erectile dysfunction
• Cough and cold medications for members over 21 years of age
• Drugs and devices classified as experimental
• Drugs ordered by a prescriber who has been barred or suspended from participating the MA
program
What if my drug requires prior authorization?
If you learn that GHP Family requires prior authorization of your drug, you have two options:
• You can ask GHP Family Pharmacy Services for a list of similar drugs that are on the
GHP Family formulary. You can call GHP Family Pharmacy Services at (855) 552-6028
or (570) 214-3554. When you receive the list, show it to your doctor and ask him or her
if one of these drugs will work for you.
• Your physician can ask GHP Family for approval of your drug through a prior
authorization. See below for information about how your physician can request a prior
authorization.
What if I need a drug that is not listed on the Statewide PDL or GHP Family
Formulary?
• Please check the PDL (https://www.dhs.pa.gov/providers/Pharmacy-
Services/Pages/Preferred-Drug-List.aspx) and formulary to see if there is a preferred
alternative or formulary alternative that you can ask your physician to switch you to
• Your physician can ask us to approve your drug even if it is not on our formulary or the
PDL
Generally, GHP Family will only approve your physician’s request if the alternative drugs
included on the plan’s formulary would not be as effective in treating your condition and/or
would cause you to have a negative medical effect. We must make our decision within 24 hours
of getting your prescriber’s request.
If the pharmacy cannot fill your prescription because of the medication being non-formulary or
requiring prior authorization, GHP Family will authorize a temporary supply of the medication.
If your prescription is for an ongoing medication, a 15-day temporary supply will be authorized.
If your prescription is for a new medication, a 5-day temporary supply of medication will be
authorized. Members are limited to one emergency supply per medication every 180 days.
A member whose prescription rejects for prior authorization or other utilization management
criteria should not be turned away at the pharmacy without receiving a temporary supply of
medication unless the dispensing pharmacist feels that dispensing the medication would
jeopardize the health and safety of the member.
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family 2022 Supplemental Formulary Page 7 of 77
Effective 6/01/2022¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family 2022 Supplemental Formulary Page 8 of 77
Effective 6/01/2022¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family 2022 Supplemental Formulary Page 9 of 77
Effective 6/01/2022Table of Contents
ADRENALS ................................................................................................................................................13
ALCOHOL DETERRENTS ........................................................................................................................13
ALKALINIZING AGENTS ..........................................................................................................................13
AMMONIA DETOXICANTS.......................................................................................................................13
ANALGESICS AND ANTIPYRETICS ......................................................................................................14
ANDROGENS.............................................................................................................................................15
ANOREXIGENIC AGENTS AND RESPIRATORY AND CNS STIMULANTS ......................................15
ANTACIDS AND ADSORBENTS .............................................................................................................15
ANTHELMINTICS ......................................................................................................................................16
ANTIANEMIA DRUGS ...............................................................................................................................16
ANTIBACTERIALS ....................................................................................................................................16
ANTICHOLINERGIC AGENTS .................................................................................................................17
ANTIDIARRHEA AGENTS........................................................................................................................17
ANTIDOTES ...............................................................................................................................................18
ANTIEMETICS............................................................................................................................................18
ANTIFLATULENTS....................................................................................................................................18
ANTIFUNGALS ..........................................................................................................................................18
ANTIGLAUCOMA AGENTS .....................................................................................................................18
ANTIHYPOGLYCEMIC AGENTS .............................................................................................................19
ANTI-INFECTIVES .....................................................................................................................................19
ANTI-INFLAMMATORY AGENTS............................................................................................................19
ANTIMANIC AGENTS ...............................................................................................................................20
ANTIMYCOBACTERIALS.........................................................................................................................20
ANTINEOPLASTIC AGENTS ...................................................................................................................21
ANTIPARKINSONIAN AGENTS ..............................................................................................................22
ANTIPROTOZOALS ..................................................................................................................................22
ANTIPRURITICS AND LOCAL ANESTHETICS .....................................................................................22
ANTISENSE OLIGONUCLEOTIDES .......................................................................................................22
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 10 of 77
Effective Date: 6/1/2022ANTITHROMBOTIC AGENTS ..................................................................................................................22
ANTITOXINS AND IMMUNE GLOBULINS .............................................................................................23
ANTITUSSIVES..........................................................................................................................................23
ANTIULCER AGENTS AND ACID SUPPRESSANTS ...........................................................................23
ANTIVIRALS...............................................................................................................................................23
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS ...................................................................................23
ASTRINGENTS ..........................................................................................................................................24
CARDIAC DRUGS .....................................................................................................................................24
CARIOSTATIC AGENTS...........................................................................................................................24
CATHARTICS AND LAXATIVES .............................................................................................................25
CENTRAL NERVOUS SYSTEM AGENTS, MISC...................................................................................27
CONTRACEPTIVES ..................................................................................................................................27
CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR MODULATORS ............27
DENTAL AGENTS .....................................................................................................................................27
DEVICES.....................................................................................................................................................27
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS ...............................................................................48
DIURETICS .................................................................................................................................................48
EENT DRUGS, MISCELLANEOUS..........................................................................................................49
EMOLLIENTS, DEMULCENTS, AND PROTECTANTS .........................................................................49
ENZYMES ...................................................................................................................................................49
EXPECTORANTS ......................................................................................................................................50
FIRST GENERATION ANTIHISTAMINES ...............................................................................................50
GOLD COMPOUNDS ................................................................................................................................51
HEMORRHEOLOGIC AGENTS ...............................................................................................................51
HYPOTENSIVE AGENTS..........................................................................................................................51
IMMUNOMODULATORY AGENTS..........................................................................................................51
IMMUNOSUPPRESSIVE AGENTS ..........................................................................................................51
ION-REMOVING AGENTS ........................................................................................................................51
IRRIGATING SOLUTIONS ........................................................................................................................51
KALLIKREIN-KININ SYSTEM INHIBITORS ...........................................................................................51
KERATOLYTIC AGENTS..........................................................................................................................51
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 11 of 77
Effective Date: 6/1/2022MOUTHWASHES AND GARGLES ..........................................................................................................52
MUCOLYTIC AGENTS ..............................................................................................................................52
MULTIVITAMIN PREPARATIONS ...........................................................................................................52
MYDRIATICS..............................................................................................................................................54
NON-AHFS SUBCLASS ...........................................................................................................................54
NONHORMONAL CONTRACEPTIVES...................................................................................................54
OTHER MISCELLANEOUS THERAPEUTIC AGENTS .........................................................................55
OXYTOCICS ...............................................................................................................................................56
PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS ......................................................................56
PARATHYROID AND ANTIPARATHYROID AGENTS ..........................................................................56
PITUITARY .................................................................................................................................................56
PROGESTINS ............................................................................................................................................56
RENIN-ANGIOTENSIN-ALDOSTERONE SYS INHIB ............................................................................56
REPLACEMENT PREPARATIONS .........................................................................................................56
RESPIRATORY SMOOTH MUSCLE RELAXANTS ...............................................................................58
SKIN AND MUCOUS MEMBRANE AGENTS, MISC .............................................................................58
SOMATOSTATIN AGONISTS AND ANTAGONISTS ............................................................................59
SYMPATHOMIMETIC (ADRENERGIC) AGENTS ..................................................................................59
THYROID AND ANTITHYROID AGENTS ...............................................................................................59
TOXOIDS ....................................................................................................................................................59
URINARY ANTI-INFECTIVES...................................................................................................................60
URINE AND FECES CONTENTS .............................................................................................................60
VACCINES..................................................................................................................................................60
VASOCONSTRICTORS ............................................................................................................................61
VASODILATING AGENTS ........................................................................................................................62
VITAMIN B COMPLEX ..............................................................................................................................62
VITAMIN C ..................................................................................................................................................63
VITAMIN D ..................................................................................................................................................63
VITAMIN E ..................................................................................................................................................63
VITAMIN K ACTIVITY................................................................................................................................63
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 12 of 77
Effective Date: 6/1/2022F o rm u la ry D ru g L is t
Drug
Drug Name Reference Name Requirements/Limits1
Tier
THERAPEUTIC CATEGORY
Therapeutic Class
ADRENALS
Adrenals
methylprednisolone acetate 40
mg/ml Injection Suspension, 80
mg/ml Injection Suspension 1 DEPO-MEDROL
methylprednisolone sodium succ
1000 mg Injection Solution
Reconstituted, 125 mg Injection
Solution Reconstituted, 40 mg
Injection Solution Reconstituted,
500 mg Injection Solution
Reconstituted 1 SOLU-MEDROL
READYSHARP
DEXAMETHASONE 1
SOLU-CORTEF 2
SOLU-MEDROL 1000 mg Injection
Solution Reconstituted, 125 mg
Injection Solution Reconstituted, 40
mg Injection Solution
Reconstituted, 500 mg Injection
Solution Reconstituted 2
ALCOHOL DETERRENTS
Alcohol Deterrents
disulfiram 250 mg Oral Tablet, 500
mg Oral Tablet 1 ANTABUSE
ALKALINIZING AGENTS
Alkalinizing Agents
cytra-2 OTC SHOHLS MODIFIED
potassium citrate er 1 UROCIT-K
sod citrate-citric acid 500-334
mg/5ml Oral Solution OTC SHOHLS MODIFIED
AMMONIA DETOXICANTS
Ammonia Detoxicants
constulose 1 CONSTULOSE
enulose 1 CONSTULOSE
generlac 1 CONSTULOSE
lactulose 10 gm/15ml Oral Solution,
20 gm/30ml Oral Solution 1 CONSTULOSE
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 13 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
lactulose encephalopathy 1 CONSTULOSE
ANALGESICS AND ANTIPYRETICS
Analgesics And Antipyretics, Misc
acetaminophen 650 mg Rectal
Suppository OTC QL(6 EA per 1 days)
acetaminophen 325 mg Oral Tablet OTC QL(10 EA per 1 days)
acetaminophen 120 mg Rectal
Suppository, 160 mg Oral Tablet
Chewable OTC QL(20 EA per 1 days)
acetaminophen 80 mg Oral Tablet
Chewable OTC QL(30 EA per 1 days)
acetaminophen 160 mg/5ml Oral
Liquid, 160 mg/5ml Oral Solution OTC QL(75 ML per 1 days)
acetaminophen 650 mg/20.3ml
Oral Solution, 650 mg/20.3ml Oral
Suspension OTC QL(100 ML per 1 days)
acetaminophen extra strength 500
mg Oral Tablet OTC QL(6 EA per 1 days)
childrens acetaminophen 80 mg tab
disint OTC QL(30 EA per 1 days)
childrens acetaminophen 160
mg/5ml Oral Suspension OTC QL(75 ML per 1 days)
childrens apap OTC QL(30 EA per 1 days)
childrens silapap OTC QL(75 ML per 1 days)
childrens tactinal OTC QL(30 EA per 1 days)
HEALTHY MAMA SHAKE THAT
ACHE OTC QL(6 EA per 1 days)
mapap 500 mg Oral Capsule OTC QL(6 EA per 1 days)
MAPAP CHILDRENS 80 mg Oral
Tablet Chewable OTC QL(30 EA per 1 days)
m-pap OTC QL(75 ML per 1 days)
non-aspirin extra strength OTC QL(6 EA per 1 days)
pain & fever childrens 160 mg Oral
Tablet Chewable OTC QL(20 EA per 1 days)
pain reliever extra strength 500 mg
Oral Tablet OTC QL(6 EA per 1 days)
Nonsteroidal Anti-inflammatory Agents
aspirin 81 mg Oral Tablet
Chewable OTC
aspirin 325 mg Oral Tablet, 81 mg
Oral Tablet Delayed Release OTC QL(12 EA per 1 days)
aspirin adult OTC QL(12 EA per 1 days)
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 14 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
salsalate 500 mg Oral Tablet, 750
mg Oral Tablet 1 DISALCID QL(4 EA per 1 days)
ANDROGENS
Androgens
danazol 100 mg Oral Capsule, 200
mg Oral Capsule, 50 mg Oral
Capsule 1 DANOCRINE
ANOREXIGENIC AGENTS AND RESPIRATORY AND CNS STIMULANTS
Respiratory And Cns Stimulants
caffeine citrate 20 mg/ml Oral
Solution, 60 mg/3ml Oral Solution 1 AL(Max 2 years)
ANTACIDS AND ADSORBENTS
Antacids And Adsorbents
ACID GONE 160-105 mg Oral
Tablet Chewable OTC
ACID GONE 95-358 mg/15ml Oral
Suspension OTC
alumina-magnesia-simethicone OTC
aluminum hydroxide gel 320
mg/5ml Oral Suspension OTC
antacid 500 mg Oral Tablet
Chewable OTC
antacid 200-200-20 mg/5ml Oral
Suspension OTC
antacid anti-gas OTC
antacid anti-gas reg strength OTC
antacid calcium OTC
antacid calcium extra strength OTC
antacid calcium rich OTC
antacid extra strength 750 mg Oral
Tablet Chewable OTC
antacid fast relief OTC
antacid liquid OTC
antacid m OTC
antacid maximum OTC
antacid plus anti-gas fast act OTC
antacid plus anti-gas relief 200-
200-20 mg/5ml Oral Suspension OTC
antacid regular strength 500 mg
Oral Tablet Chewable OTC
antacid regular strength 200-200-
20 mg/5ml Oral Suspension OTC
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 15 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
antacid ultra strength 1000 mg Oral
Tablet Chewable OTC
calcium antacid OTC
calcium antacid ultra max st OTC
calcium antacid ultra strength OTC
calcium carbonate antacid 500 mg
Oral Tablet Chewable, 750 mg Oral
Tablet Chewable OTC
calcium carbonate antacid 1250
mg/5ml Oral Suspension OTC
geri-lanta OTC
geri-mox OTC
goodsense antacid 500 mg Oral
Tablet Chewable OTC
hm antacid OTC
hm antacid/antigas OTC
hm calcium antacid 500 mg Oral
Tablet Chewable OTC
hm calcium antacid ultra st OTC
mag-al plus OTC
magnesium oxide 400 mg Oral
Tablet OTC
sodium bicarbonate 325 mg Oral
Tablet, 650 mg Oral Tablet OTC
ANTHELMINTICS
Anthelmintics
albendazole 200 mg Oral Tablet 1 ALBENZA QL(4 EA per 1 days)
PA, QL(2 EA per 1
EMVERM 2 days)
praziquantel 600 mg Oral Tablet 1 BILTRICIDE
ANTIANEMIA DRUGS
Iron Preparations
EZFE 200 OTC
FERREX 150 OTC
ferrous gluconate 324 (37.5 Fe) mg
Oral Tablet OTC
ICAR-C PLUS 1
IFEREX 150 OTC
pc pediatric iron drops OTC FER-IN-SOL
POLY-IRON 150 OTC
ANTIBACTERIALS
Antibacterials, Miscellaneous
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 16 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
clindamycin hcl 150 mg Oral
Capsule, 300 mg Oral Capsule, 75
mg Oral Capsule 1 CLEOCIN
clindamycin palmitate hcl 1 CLEOCIN
linezolid 600 mg Oral Tablet 1 ZYVOX
linezolid 100 mg/5ml Oral
Suspension Reconstituted 1 ZYVOX PA
PA, QL(1 EA per 1
SIVEXTRO 200 mg Oral Tablet 2 days)
XENLETA 600 mg Oral Tablet 2 PA
Sulfonamides
sulfamethoxazole-trimethoprim
400-80 mg Oral Tablet, 800-160
mg Oral Tablet 1 SEPTRA
sulfamethoxazole-trimethoprim
200-40 mg/5ml Oral Suspension 1 SEPTRA
SULFATRIM PEDIATRIC 1
ANTICHOLINERGIC AGENTS
Antimuscarinics/antispasmodics
dicyclomine hcl 10 mg Oral
Capsule, 20 mg Oral Tablet 1 BENTYL
dicyclomine hcl 10 mg/5ml Oral
Solution 1 BENTYL
glycopyrrolate 1 mg Oral Tablet, 2
mg Oral Tablet 1 ROBINUL
propantheline bromide 15 mg Oral
Tablet 1 PRO-BANTHINE
ANTIDIARRHEA AGENTS
Antidiarrhea Agents
ALIGN OTC
ALIGN JR FOR KIDS OTC
bismatrol 262 mg Oral Tablet
Chewable OTC
bismatrol 262 mg/15ml Oral
Suspension OTC SOOTHE
bismatrol maximum strength OTC
diphenoxylate-atropine 2.5-0.025
mg Oral Tablet 1 LOMOTIL
diphenoxylate-atropine 2.5-0.025
mg/5ml Oral Liquid 1 LOMOTIL
geri-pectate OTC SOOTHE
hm loperamide hcl OTC IMODIUM QL(8 EA per 1 days)
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 17 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
IMODIUM A-D 2 mg Oral Capsule OTC QL(8 EA per 1 days)
KAOPECTATE 262 mg/15ml Oral
Suspension OTC
KAOPECTATE EXTRA
STRENGTH OTC
loperamide hcl 2 mg Oral Capsule 1 IMODIUM QL(8 EA per 1 days)
peptic relief OTC
SOOTHE 262 mg Oral Tablet, 262
mg Oral Tablet Chewable OTC
SOOTHE 262 mg/15ml Oral
Suspension OTC
stomach relief 262 mg Oral Tablet
Chewable OTC
SP, PA, QL(3 EA per 1
XERMELO 2 days)
ANTIDOTES
Antidotes
acetylcysteine 200 mg/ml
Intravenous Solution 1 ACETADOTE
acetylcysteine 10 % Inhalation
Solution, 20 % Inhalation Solution 1 MUCOMYST
leucovorin calcium 10 mg Oral
Tablet, 15 mg Oral Tablet, 25 mg
Oral Tablet, 5 mg Oral Tablet 1
ANTIEMETICS
5-ht3 Receptor Antagonists
ondansetron hcl 24 mg Oral Tablet 1 ZOFRAN QL(1 EA per 1 days)
ANTIFLATULENTS
Antiflatulents
gas relief 180 mg Oral Capsule,
250 mg Oral Capsule OTC
gas relief extra strength 125 mg
Oral Capsule OTC
gas relief ultra strength OTC
simethicone 125 mg Oral Capsule,
180 mg Oral Capsule OTC
ANTIFUNGALS
Polyenes
nystatin Powder 1
ANTIGLAUCOMA AGENTS
Carbonic Anhydrase Inhibitors
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 18 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
acetazolamide 125 mg Oral Tablet,
250 mg Oral Tablet 1 DIAMOX
acetazolamide er 1 DIAMOX
methazolamide 25 mg Oral Tablet,
50 mg Oral Tablet 1 NEPTAZANE
ANTIHYPOGLYCEMIC AGENTS
Antihypoglycemic Agents, Miscellaneous
glucose 4 gm Oral Tablet
Chewable 2
Glycogenolytic Agents
GLUCAGEN DIAGNOSTIC 2 QL(2 EA per 30 days)
ANTI-INFECTIVES
Antibacterials
metronidazole 0.75 % External
Cream 1 METROCREAM
metronidazole 0.75 % External Gel,
1 % External Gel 1 METROGEL
metronidazole 0.75 % External
Lotion 1 METROLOTION
Antivirals
trifluridine 1 VIROPTIC
Eent Anti-infectives, Miscellaneous
chlorhexidine gluconate 0.12 %
Mouth/Throat Solution 1 PERIOGARD
Local Anti-infectives, Miscellaneous
selenium sulfide 2.25 % External
Shampoo, 2.3 % External
Shampoo 1
selenium sulfide 2.5 % External
Lotion 1 SELSUN
silver sulfadiazine 1 % External
Cream 1 SILVADENE
SSD 1
ANTI-INFLAMMATORY AGENTS
Anti-inflammatory Agents
hydrocortisone 100 mg/60ml Rectal
Enema 1 CORTENEMA
Corticosteroids
COLOCORT 1
hydrocortisone 100 mg/60ml Rectal
Enema 1 CORTENEMA
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 19 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
hydrocortisone (perianal) 2.5 %
External Cream 1 ANUSOL HC
QL(0.72 GM per 1
ORALONE 1 days)
PREPARATION H 1 % External
Cream OTC
PROCTO-MED HC 1
PROCTO-PAK 1
PROCTOSOL HC 1
PROCTOZONE-HC 1
triamcinolone acetonide 0.1 % KENALOG IN QL(0.72 GM per 1
Mouth/Throat Paste 1 ORABASE days)
Mast-cell Stabilizers
cromolyn sodium 100 mg/5ml Oral
Concentrate 1 GASTROCROM
cromolyn sodium 20 mg/2ml
Inhalation Nebulization Solution 1 INTAL
ANTIMANIC AGENTS
Antimanic Agents
lithium 1
lithium carbonate 150 mg Oral
Capsule, 600 mg Oral Capsule 1
lithium carbonate 300 mg Oral
Capsule 1 ESKALITH
lithium carbonate 300 mg Oral
Tablet 1 LITHOBID
lithium carbonate er 450 mg Oral
Tablet Extended Release 1 ESKALITH CR
lithium carbonate er 300 mg Oral
Tablet Extended Release 1 LITHOBID
ANTIMYCOBACTERIALS
Antimycobacterials, Miscellaneous
dapsone 100 mg Oral Tablet, 25
mg Oral Tablet 1
Antituberculosis Agents
ethambutol hcl 100 mg Oral Tablet,
400 mg Oral Tablet 1 MYAMBUTOL
isoniazid 100 mg Oral Tablet, 300
mg Oral Tablet 1
isoniazid 50 mg/5ml Oral Syrup 1
pretomanid 2 PA
pyrazinamide 500 mg Oral Tablet 1
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 20 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
rifabutin 1 MYCOBUTIN
rifampin 150 mg Oral Capsule, 300
mg Oral Capsule 1 RIFADIN
ANTINEOPLASTIC AGENTS
Antineoplastic Agents
ALKERAN 2 mg Oral Tablet 2
bexarotene 75 mg Oral Capsule 1 TARGRETIN SP, PA
carboplatin 150 mg/15ml
Intravenous Solution, 50 mg/5ml
Intravenous Solution, 600 mg/60ml
Intravenous Solution 2 PARAPLATIN
carboplatin 450 mg/45ml
Intravenous Solution 2 PARAPLATIN SP
cyclophosphamide 25 mg Oral
Capsule, 50 mg Oral Capsule 1 SP
EMCYT 2 SP
etoposide 50 mg Oral Capsule 1 SP
flutamide 1 EULEXIN QL(6 EA per 1 days)
HYCAMTIN 0.25 mg Oral Capsule,
1 mg Oral Capsule 2 SP
INQOVI 2 "SP", PA
INTRON A 10000000 unit Injection
Solution Reconstituted, 18000000
unit Injection Solution
Reconstituted, 50000000 unit
Injection Solution Reconstituted 2 SP
INTRON A 10000000 unit/ml
Injection Solution, 6000000 unit/ml
Injection Solution 2 SP
LEUKERAN 2 SP
LYSODREN 2 SP
MATULANE 2 SP
megestrol acetate 40 mg Oral
Tablet 1 MEGACE
megestrol acetate 40 mg/ml Oral
Suspension, 400 mg/10ml Oral
Suspension 1 MEGACE
melphalan 1 ALKERAN
mercaptopurine 50 mg Oral Tablet 1 PURINETHOL
MYLERAN 2 SP
SP, QL(2 EA per 1
NILANDRON 2 days)
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 21 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
SP, QL(2 EA per 1
nilutamide 1 NILANDRON days)
ANTIPARKINSONIAN AGENTS
Dopamine Receptor Agonists
cabergoline 1 DOSTINEX
ANTIPROTOZOALS
Antiprotozoals, Miscellaneous
atovaquone 750 mg/5ml Oral
Suspension 1 MEPRON QL(20 ML per 1 days)
MEPRON 2 QL(20 ML per 1 days)
ANTIPRURITICS AND LOCAL ANESTHETICS
Antipruritics And Local Anesthetics
hemorrhoidal relief 1
lidocaine (anorectal) 5 % External
Cream 1
lidocaine-hydrocortisone ace 3-2.5
% Rectal Kit 1 ANAMANTLE HC
lidocaine-hydrocortisone ace 3-1 % ANAMANTLE HC
Rectal Kit 1 FORTE
lidocaine-hydrocortisone ace 2-2 %
Rectal Kit 1 PERANEX HC
lidopac 1
lidopin 3 % External Cream 1 LIDAMANTLE
phenazopyridine hcl 100 mg Oral
Tablet, 200 mg Oral Tablet 1 PYRIDIUM
pramoxine hcl 1 % External Lotion OTC
pramoxine hcl (perianal) OTC
PRIZOTRAL-II 1
PROCTOFOAM HC 2
ANTISENSE OLIGONUCLEOTIDES
Antisense Oligonucleotides
TEGSEDI 2 SP, PA
ANTITHROMBOTIC AGENTS
Anticoagulants
heparin sodium (porcine) 1000
unit/ml Injection Solution, 10000
unit/ml Injection Solution, 20000
unit/ml Injection Solution, 5000
unit/0.5ml Injection Solution
Prefilled Syringe, 5000 unit/ml
Injection Solution 1
heparin sodium (porcine) pf 1
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 22 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
Antithrombotic Agents, Misc
CABLIVI 2 SP, PA
Platelet-aggregation Inhibitors
cilostazol 1 PLETAL QL(2 EA per 1 days)
Platelet-reducing Agents
anagrelide hcl 1 AGRYLIN
ANTITOXINS AND IMMUNE GLOBULINS
Antitoxins And Immune Globulins
WINRHO SDF 2 SP
ANTITUSSIVES
Antitussives
benzonatate 100 mg Oral Capsule,
200 mg Oral Capsule 1 TESSALON
HYCODAN 5-1.5 mg/5ml Oral QL(30 ML per 1 days),
Solution, 5-1.5 mg/5ml Oral Syrup 1 AL(Max 20 years)
hydrocod polst-cpm polst er 10-8
mg/5ml Oral Suspension Extended TUSSIONEX QL(10 ML per 1 days),
Release 1 PENNKINETIC EXT AL(Max 20 years)
hydrocodone bit-homatrop mbr 5- QL(6 EA per 1 days),
1.5 mg Oral Tablet 1 AL(Max 20 years)
hydrocodone bit-homatrop mbr 5- QL(30 ML per 1 days),
1.5 mg/5ml Oral Solution 1 AL(Max 20 years)
QL(6 EA per 1 days),
hydrocodone-homatropine 1 AL(Max 20 years)
QL(30 ML per 1 days),
hydromet 1 AL(Max 20 years)
QL(30 ML per 1 days),
promethazine-codeine 1 AL(Min 18 years)
ANTIULCER AGENTS AND ACID SUPPRESSANTS
Prostaglandins
misoprostol 100 mcg Oral Tablet,
200 mcg Oral Tablet 1 CYTOTEC
Protectants
sucralfate 1 gm Oral Tablet 1 CARAFATE
sucralfate 1 gm/10ml Oral
Suspension 1 CARAFATE
ANTIVIRALS
Antivirals, Miscellaneous
PAXLOVID 10 x 150 MG & 10 x
100mg Oral Tablet Therapy Pack 2
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS
Anxiolytics, Sedatives, & Hypnotics Misc
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 23 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
sleep tabs OTC
ASTRINGENTS
Astringents
DRYSOL 2
MEDPURA ZINC OXIDE OTC
XERAC AC 2
zinc oxide 20 % External Ointment,
25 % External Paste OTC
zinc oxide 25 % External Ointment OTC DELAZINC
CARDIAC DRUGS
Antiarrhythmic Agents
amiodarone hcl 100 mg Oral
Tablet, 200 mg Oral Tablet, 400 mg
Oral Tablet 1 CORDARONE
disopyramide phosphate 1 NORPACE
dofetilide 1 TIKOSYN QL(2 EA per 1 days)
flecainide acetate 1 TAMBOCOR
mexiletine hcl 150 mg Oral
Capsule, 200 mg Oral Capsule,
250 mg Oral Capsule 1 MEXITIL
PACERONE 1
propafenone hcl 1 RYTHMOL
quinidine sulfate 200 mg Oral
Tablet, 300 mg Oral Tablet 1
Cardiotonic Agents
DIGITEK 1
digox 1 LANOXIN
digoxin 125 mcg Oral Tablet, 250
mcg Oral Tablet 1 LANOXIN
digoxin 0.05 mg/ml Oral Solution 1 LANOXIN
CARIOSTATIC AGENTS
Cariostatic Agents
DENTA 5000 PLUS 1
DENTAGEL 1
FLORIVA 0.25-400 mg-unit/ml Oral
Liquid OTC
FLUORABON OTC
FLURA-DROPS OTC
LUDENT OTC
sf 1
PREVIDENT 5000
sf 5000 plus 1 PLUS
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 24 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
sodium fluoride 1.1 % Dental Gel 1
sodium fluoride 2.2 (1 F) mg Oral
Tablet Chewable OTC
sodium fluoride 0.55 (0.25 F) mg
Oral Tablet Chewable, 1.1 (0.5 F)
mg Oral Tablet Chewable OTC LURIDE
sodium fluoride 1.1 (0.5 F) mg/ml
Oral Solution OTC LURIDE
sodium fluoride 1.1 % Dental PREVIDENT 5000
Cream 1 PLUS
PREVIDENT 5000
sodium fluoride 5000 plus 1 PLUS
sodium fluoride 5000 ppm 1.1 %
Dental Gel, 1.1 % Dental Paste 1
sodium fluoride 5000 ppm 1.1 % PREVIDENT 5000
Dental Cream 1 PLUS
CATHARTICS AND LAXATIVES
Cathartics And Laxatives
bisacodyl 10 mg Rectal
Suppository OTC
bisacodyl ec OTC
bisacodyl laxative OTC
calcium polycarbophil 625 mg Oral
Tablet OTC
citrate of magnesia OTC
CLENPIQ 2
diocto 60 mg/15ml Oral Syrup OTC
docuzen OTC
DOK PLUS OTC
ducodyl OTC
easy-lax plus OTC
fiber laxative OTC
fiber-lax OTC
GAVILYTE-C 1
GAVILYTE-G 1
GAVILYTE-N WITH FLAVOR
PACK 1
gentle laxative OTC
glycerin (adult) 2 gm Rectal
Suppository OTC
glycerin (child) OTC
glycerin adult OTC
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 25 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
goodsense magnesium citrate OTC
goodsense stimulant laxative OTC
hm fiber 500 mg Oral Tablet OTC
hm magnesium citrate OTC
hm senna-s OTC
hm stool softener/laxative OTC
kls fiber-tabs OTC
laxacin OTC
laxative 10 mg Rectal Suppository OTC
magnesium citrate 1.745 gm/30ml
Oral Solution OTC
milk of magnesia 7.75 % Oral
Suspension OTC
milk of magnesia concentrate OTC
PEDIA-LAX 1 gm Rectal
Suppository OTC
peg 3350 17 gm Oral Packet OTC MIRALAX
peg 3350 17 gm/scoop Oral
Powder OTC MIRALAX
peg 3350-kcl-na bicarb-nacl 1 NULYTELY
peg-3350/electrolytes 1 GOLYTELY
polyethylene glycol 3350 17 gm
Oral Packet 1 MIRALAX
polyethylene glycol 3350 17
gm/scoop Oral Powder 1 MIRALAX
senexon-s OTC
SENEXON-S OTC
senna 8.8 mg/5ml Oral Liquid OTC
senna plus 8.6-50 mg Oral Tablet OTC
senna s OTC
senna-docusate sodium OTC
senna-plus OTC
senna-s OTC
senna-time s OTC
sennosides-docusate sodium 8.6-
50 mg Oral Tablet OTC
silace 60 mg/15ml Oral Syrup OTC
SOLUBLE FIBER THERAPY OTC
stimulant laxative 8.6-50 mg Oral
Tablet OTC
stool softener plus laxative OTC
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 26 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
stool softener/laxative 50-8.6 mg
Oral Tablet OTC
TRILYTE 1
vegetable lax+stool softener OTC
CENTRAL NERVOUS SYSTEM AGENTS, MISC
Central Nervous System Agents, Misc
acamprosate calcium 1 CAMPRAL
riluzole 50 mg Oral Tablet 1 RILUTEK QL(2 EA per 1 days)
SP, PA, QL(20 ML per
TIGLUTIK 2 1 days)
CONTRACEPTIVES
Contraceptives
ECONTRA EZ OTC
ECONTRA ONE-STEP OTC
levonorgestrel 1.5 mg Oral Tablet OTC PLAN B ONE-STEP
MY WAY OTC
OPCICON ONE-STEP OTC
OPTION 2 OTC
CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR MODULATORS
Cystic Fibrosis Transmembrane Conductance Regulator (cftr) Correctors
ORKAMBI 100-125 mg Oral SP, PA, QL(2 EA per 1
Packet, 150-188 mg Oral Packet 2 days)
ORKAMBI 100-125 mg Oral Tablet, SP, PA, QL(4 EA per 1
200-125 mg Oral Tablet 2 days)
SP, PA, QL(2 EA per 1
SYMDEKO 2 days)
TRIKAFTA 50-25-37.5 & 75 mg PA, QL(3 EA per 1
Oral Tablet Therapy Pack 2 days)
TRIKAFTA 100-50-75 & 150 mg SP, PA, QL(3 EA per 1
Oral Tablet Therapy Pack 2 days)
Cystic Fibrosis Transmembrane Conductance Regulator (cftr) Potentiators
SP, PA, QL(2 EA per 1
KALYDECO 2 days)
DENTAL AGENTS
Dental Agents
sodium fluoride 5000 sensitive 1.1-
5 % Dental Gel 1
DEVICES
Devices
1st tier unifine pentips 2
1st tier unifine pentips plus 2
1st tier unilet comfortouch 2
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 27 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
ABOUTTIME PEN NEEDLE 2
ACCU-CHEK FASTCLIX LANCET 2
ACCU-CHEK FASTCLIX
LANCETS 2
ACCU-CHEK MULTICLIX LANCET
DEV 2
ACCU-CHEK MULTICLIX
LANCETS 2
ACCU-CHEK SAFE-T PRO
LANCETS 2
ACCU-CHEK SOFTCLIX LANCET
DEV 2
ACCU-CHEK SOFTCLIX
LANCETS 2
acti-lance 28g 2
acti-lance lite lancets 28g 2
acti-lance special lancets 17g 2
acti-lance universal 23g 2
adjustable lancing device 2 QL(1 EA per 1 days)
adult mask large 2 QL(2 EA per 365 days)
advanced mobile lancet 2
ADVOCATE INSULIN PEN
NEEDLES 2
ADVOCATE INSULIN SYRINGE 2
ADVOCATE LANCETS 2
ADVOCATE LANCETS 30G 2
ADVOCATE LANCING DEVICE 2 QL(1 EA per 1 days)
ADVOCATE RAPID-SAFE
LANCING 2 QL(1 EA per 1 days)
ADVOCATE SAFETY LANCETS 2
ADVOCATE SAFETY LANCETS
26G 2
AGAMATRIX ULTRA-THIN
LANCETS 2
aimsco twist lancets 32g 2
AIMSCO TWIST LANCETS 33G 2
alternate site lancing device 2 QL(1 EA per 1 days)
aqua lance adjustable lancing 2 QL(1 EA per 1 days)
AQUALANCE LANCETS 30G 2
assure comfort lancets 28g 2
ASSURE HAEMOLANCE PLUS
HIGH 2
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 28 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
ASSURE HAEMOLANCE PLUS
LOW 2
ASSURE HAEMOLANCE PLUS
MICRO 2
ASSURE HAEMOLANCE PLUS
NORMAL 2
ASSURE HAEMOLANCE PLUS
PED 2
ASSURE ID INSULIN SAFETY
SYR 2
ASSURE ID SAFETY PEN
NEEDLES 2
ASSURE LANCE LANCETS 2
ASSURE LANCE LANCETS 21G 2
ASSURE LANCE PLUS SAFETY
25G 2
ASSURE LANCE PLUS SAFETY
30G 2
ASSURE LANCE SAFETY
LANCET 28G 2
ASSURE LANCETS 2
aum mini insulin pen needle 32G X
4 MM Miscellaneous, 32G X 5 MM
Miscellaneous, 32G X 6 MM
Miscellaneous, 32G X 8 MM
Miscellaneous 2
AUM READYGARD DUO PEN
NEEDLE 2
AUM SAFETY PEN NEEDLE 2
aurora lancet super thin 30g 2
aurora lancet thin 23g 2
aurora pen needles 2
aurora unifine pentips 2
AUTO-LANCET 2 QL(1 EA per 1 days)
AUTO-LANCET MINI 2 QL(1 EA per 1 days)
AUTOLET LANCING DEVICE 2 QL(1 EA per 1 days)
BD AUTOSHIELD 2
BD AUTOSHIELD DUO 2
BD INSULIN SYR ULTRAFINE II
31G X 5/16" 0.3 ml Miscellaneous,
31G X 5/16" 0.5 ml Miscellaneous,
31G X 5/16" 1 ml Miscellaneous 2
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 29 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
BD INSULIN SYRINGE 2
BD INSULIN SYRINGE HALF-
UNIT 2
BD INSULIN SYRINGE
MICROFINE 2
BD INSULIN SYRINGE U/F 2
BD INSULIN SYRINGE U/F
1/2UNIT 2
BD INSULIN SYRINGE U-500 2
BD INSULIN SYRINGE
ULTRAFINE 2
BD LANCET ULTRAFINE 30G 2
BD LANCET ULTRAFINE 33G 2
BD LUER-LOK SYRINGE 20G X 1"
1 ml Miscellaneous 2
BD MICROTAINER LANCETS 2
BD PEN NEEDLE MICRO U/F 2
BD PEN NEEDLE MINI U/F 2
BD PEN NEEDLE NANO 2ND
GEN 2
BD PEN NEEDLE NANO U/F 2
BD PEN NEEDLE ORIGINAL U/F 2
BD PEN NEEDLE SHORT U/F 2
BD SAFETYGLIDE INSULIN
SYRINGE 2
BD SAFETYGLIDE
SYRINGE/NEEDLE 2
BD SAFETY-LOK INSULIN
SYRINGE 2
BD SYRINGE 2
BD VEO INSULIN SYR U/F
1/2UNIT 2
BD VEO INSULIN SYRINGE U/F 2
CARDIOCOM LANCING DEVICE 2 QL(1 EA per 1 days)
CAREFINE PEN NEEDLES 2
careone advanced lancing dev 2 QL(1 EA per 1 days)
careone insulin syringe 2
CAREONE LANCET SUPER THIN
30G 2
careone lancet thin 23g 2
careone unifine pentips 2
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 30 of 77
Effective Date: 6/1/2022Drug
Drug Name Reference Name Requirements/Limits1
Tier
careone unifine pentips plus 29G X
12MM Miscellaneous, 31G X 5 MM
Miscellaneous, 31G X 6 MM
Miscellaneous, 31G X 8 MM
Miscellaneous, 32G X 4 MM
Miscellaneous 2
CARESENS LANCETS 2
CARETOUCH HYPODERMIC
NEEDLE 26G X 1" Miscellaneous 2
CARETOUCH INSULIN SYRINGE 2
CARETOUCH
LANCING/EJECTOR 2 QL(1 EA per 1 days)
CARETOUCH PEN NEEDLES 2
CARETOUCH SAFETY LANCETS 2
CARETOUCH SAFETY LANCETS
26G 2
CARETOUCH TWIST LANCETS
28G 2
CARETOUCH TWIST LANCETS
30G 2
CARETOUCH TWIST LANCETS
33G 2
CLEANLET LANCETS 28G 2
CLEVER CHEK LANCETS 2
CLEVER CHOICE COMFORT EZ 2
CLEVER CHOICE LANCETS 21G 2
CLEVER CHOICE LANCETS 23G 2
CLEVER CHOICE LANCETS 28G 2
clickfine pen needles 31G X 6 MM
Miscellaneous, 31G X 8 MM
Miscellaneous, 32G X 4 MM
Miscellaneous 2
CLICKFINE PEN NEEDLES 2
COAGUCHEK LANCETS 2
COMFORT ASSIST INSULIN
SYRINGE 29G X 1/2" 0.3 ml
Miscellaneous, 29G X 1/2" 0.5 ml
Miscellaneous, 29G X 1/2" 1 ml
Miscellaneous, 30G X 5/16" 0.3 ml
Miscellaneous, 30G X 5/16" 0.5 ml
Miscellaneous, 30G X 5/16" 1 ml
Miscellaneous, 31G X 5/16" 0.3 ml 2
¹You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document
Geisinger Family Supplemental Formulary Page 31 of 77
Effective Date: 6/1/2022You can also read
