1. Healthcare

RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
3
ABILIFY DISCMELT
2
ABILIFY TABLETS / SOLUTION
3
ABSORICA CAPSULES (PA)
3
ABSTRAL SUBLINQUAL TABLET (PA)
3
*
Acamprosate Calcium Tablets
1
*
Acarbose Tablets
1
*
ACCOLATE TABLETS
3
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Isotretinoin (SOTRET, AMNESTEEN, CLARVIS)
ACANYA GEL
3
ACCU-CHEK ACTIVE TEST STRIPS (QL) (PA)
3
ACCU-CHEK ADVANTAGE TEST STRIPS (QL) (PA)
3
ACCU-CHEK AVIVA PLUS TEST STRIPS (QL) (PA)
3
ACCU-CHEK AVIVA TEST STRIPS (QL) (PA)
3
ACCU-CHEK COMFORT CURVE TEST STRIPS (QL) (PA)
3
ACCU-CHEK COMPACT PLUS TEST STRIPS / DRUM (QL) (PA)
3
ACCU-CHEK SMARTVIEW TEST STRIPS (QL) (PA)
1
1
1
1
1
1
1
1
3
1
3
1
1
1
1
3
3
3
1
1
3
1
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ACCUPRIL TABLETS
ACCURETIC TABLETS
ACCUTANE CAPSULES (QL)
Acebutolol Capsules
ACEON TABLETS
Acetaminophen / Codeine Tablets
Acetaminophen 2.5 / Hydrocodone 1.67 Elixir
Acetaminophen 325 / Hydrocodone 5 Tablets
ACETASOL HC OTIC SOLUTION (QL)
Acetazolamide Tablets
Acetic Acid 2% / Hydrocortisone 1% Otic Solution
Acetic Acid 2% Otic Solution
Acetic Acid Otic Aluminum Acetate Solution
Acetylcysteine
ACHROMYCIN V CAPSULES
ACIPHEX SPRINKLE (PA)
ACIPHEX TABLETS (PA) (QL)
Acitretin Capsules
ACLOVATE CREAM / OINTMENT
ACTICIN CREAM (QL)
ACTICLATE TABLETS (PA)
ACTIGALL CAPSULES
1
*
ACTIQ LOZENGES (PA)
1
3
3
1
3
1
1
1
3
1
3
1
1
1
3
2
1
1
*
*
ACTIVELLA TABLETS
ACTONEL TABLETS 150 MG (EST) (QL)
ACTONEL TABLETS 5MG, 35MG (EST) (QL)
ACTOPLUS MET TABLETS
ACTOPLUS MET XR TABLETS
ACTOS TABLETS
ACULAR LS OPHTHALMIC SOLUTION
ACULAR OPHTHALMIC SOLUTION
ACUVAIL OPHTHALMIC SOLUTION
Acyclovir Oral Tablets / Capsules / Suspension
ACZONE GEL
ADALAT CC TABLETS
ADALAT TABLETS
Adapalene Cream (QL)
ADAZIN CREAM
ADCIRCA TABLETS (PA) (N)
ADDERALL TABLETS
ADDERALL XR CAPSULES (QL)
ADEMPAS TABLETS (PA) (N)
ADOXA TABLETS (EST)
ADVAIR DISKUS (QL)
ADVAIR HFA (QL)
*
*
*
*
*
*
*
*
*
*
*
*
*
*
3
3
2
2
*
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
CORTISPORIN OTIC, CIPRODEX
CORTISPORIN OTIC, CIPRODEX
Morphine Sulfate (MSIR, MS CONTIN), Hydromorphone (DILAUDID), KADIAN,
OPANA ER, AVINZA, Meperidine (DEMEROL), Codeine, Oxycodone
Immediate Release, Oxycodone / Acetaminophen (PERCOCET 5/325),
Oxycodone / Aspirin (PERCODAN 5/325)
Alendronate (FOSAMAX)
Alendronate (FOSAMAX) PLUS CALCIUM SUPPLEMENT
Use ActosPlus MET immediate release
FOR PAH DIAGNOSIS ONLY
Doxycycline Hyclate (Immediate release)
1
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
2
3
3
2
2
3
3
3
1
1
1
3
3
3
1
1
1
1
1
1
1
1
1
1
1
3
3
2
1
3
2
*
*
*
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
FLOVENT HFA, QVAR, ASMANEX
FLOVENT HFA, QVAR, ASMANEX
Dipyridamole (PERSANTINE) + Aspirin
AKYNZEO CAPSULE (PA) (N)
*
*
*
*
*
*
*
*
*
*
*
*
*
3
1
2
1
1
3
3
1
1
DRUG NAME
ADVICOR TABLETS (QL)
AEROBID INHALER
AEROBID-M INHALER
AEROCHAMBER
AEROSPAN AEROSOL (QL)
AFINITOR DISPERZ (PA) (N)
AFINITOR TABLETS (PA) (N)
AGGRENOX CAPSULES
AGRYLIN CAPSULES
AK-PENTOLATE OPHTHALMIC SOLUTION
AK-TOB OPHTHALMIC SOLUTION
ALAMAST OPHTHALMIC SOLUTION
ALBENZA TABLETS
Albuterol ER Tablets
Albuterol Nebulizer Solution
Albuterol Tablets
Alclometasone Dipropionate Cream / Ointment
ALDACTAZIDE TABLETS
ALDACTONE TABLETS
ALDARA CREAM
ALDOMET TABLETS
ALDORIL TABLETS
Alendronate Tablets (QL)
ALESSE TABLETS
Alfuzosin SR 24 Hr. Tablets (QL)
ALINIA SUSPENSION / TABLETS
ALKERAN TABLETS
Allopurinol Tablets
ALOCRIL OPHTHALMIC SOLUTION
ALOMIDE OPHTHALMIC SOLUTION
ALOMIDE OPHTHALMIC SOLUTION
CONDYLOX GEL
Doxazosin (CARDURA), Terazosin (HYTRIN), Finasteride (PROSCAR) (PA)
ALOMIDE OPHTHALMIC SOLUTION
Estradiol Transdermal System (CLIMARA), VIVELLE PATCH, VIVELLE DOT
PATCH
ALORA PATCHES (QL)
*
*
*
*
*
3
ALPHAGAN OPHTHALMIC SOLUTION
ALPHAGAN P 0.1% OPHTHALMIC SOLUTION
ALPHAGAN P 0.15% OPHTHALMIC SOLUTION
Alprazolam Tablets
ALREX OPHTHALMIC SUSPENSION
ALTABAX OINTMENT
ALTACE CAPSULES
Altavera Tablets
Mupirocin (Bactroban)
GENERIC FOR NORDETTE
Atorvastatin (LIPITOR), Lovastatin (MEVACOR), Pravastatin (PRAVACHOL),
Simvastatin (ZOCOR), VYTORIN
ALTOPREV TABLETS
1
3
1
1
1
*
*
*
*
Aluminum Chloride Hexahydrate
ALVESCO AEROSOL
Alyacen Tablets
Amantadine Capsules
AMARYL TABLETS
3
*
AMBIEN CR TABLETS 6.25 MG, 12.5 MG (QL)
1
1
1
1
1
1
1
1
1
2
3
1
1
1
1
1
1
2
1
2
1
*
*
*
*
*
*
*
*
*
AMBIEN TABLETS (QL)
Amcinonide Cream
AMERGE TABLETS (QL)
Amethia (QL) (3 MONTH SUPPLY)
Amethia LO (QL) (3 MONTH SUPPLY)
Amiloride
Amiloride / Hydrochlorothiazide Tablets
Aminophylline Tablets
Amiodarone Tablets
AMITIZA CAPSULES
Amitriptyline / Perphenazine Tablets
Amitriptyline Tablets
Amlodipine / Benazepril Capsules
Amlodipine / Valsartan Tablets (EST)
Amlodipine-valsartan-hydrochlorothiazide (EST)
Amlodipine Tablets (QL)
AMNESTEEM CAPSULES (QL)
Amoxapine Tablets
Amoxicillin 250 mg Chewable Tablets
Amoxicillin 400 mg Chewable Tablets
Amoxicillin Capsules / Suspension / Chewable Tablets
*
*
*
*
*
*
*
*
*
*
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
FLOVENT HFA, QVAR, ASMANEX
GENERIC FOR ORTHO NOVUM
Zolpidem (AMBIEN), Temazepam (RESTORIL), Lorazepam (ATIVAN),
Flurazepam (DALMANE)
GENERIC FOR SEASONIQUE
Lactulose (CEPHULAC), Polyethylene Glycol 3350 (MIRALAX)
Amitrptyline (ELAVIL) AND Perphenazine (TRILAFON)
2
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
1
1
1
1
1
1
2
3
2
1
1
1
1
1
1
1
1
1
1
3
2
1
2
3
2
1
3
1
1
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
3
DRUG NAME
PACKETS NOT COVERED
ANZEMET (PA) (QL)
Ondansetron (ZOFRAN), Ondansetron Orally Disintegrating Tablet (ZOFRAN
ODT)
1
3
3
3
1
1
3
3
2
1
1
*
*
*
APAP / Dichloralphenazone / Isometheptene Capsules
APIDRA INSULIN (QL)
APIDRA SOLOSTAR INSULIN (QL)
APLENZIN TAB SR 24HR (QL) (EST)
APRESOLINE TABLETS
Apri Tablets
APRISO SR CAPSULES
APTIOM TABLETS (QL)
APTIVUS CAPSULES
ARALEN TABLETS
Aranelle Tablets
1
*
ARAVA TABLETS
3
3
1
1
1
1
1
2
1
1
3
*
*
*
*
ARCAPTA NEOHALER
ARNUITY ELLIPTA AEROSOL
ARICEPT 23 MG TABLETS (QL)
ARICEPT 5 MG, 10 MG TABLETS
ARICEPT ODT 5 MG, 10 MG
ARIMIDEX TABLETS
ARISTOCORT CREAM / OINTMENT
ARMOUR THYROID
AROMASIN TABLETS
ARTANE TABLETS
*
ARTHROTEC TABLETS
*
*
*
*
*
2
2
ASACOL HD TABLETS
ASACOL TABLETS (QL)
3
ASCENSIA TEST STRIPS (QL) (PA)
2
1
1
3
1
1
*
*
ASMANEX AEROSOL (QL)
Aspirin, Delayed Release Tablets, EC
Aspirin, Sustained Release Tablets
ASTAGRAF XL CAPSULES (EST)
ASTELIN NASAL SPRAY (QL)
ASTEPRO 0.15% NASAL SPRAY (QL)
3
*
ATACAND HCT TABLETS
3
*
ATACAND TABLETS
*
*
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Amoxicillin Clavulanate Potassium SR Tablets
Amoxicillin Clavulanate Potassium Tablets / Suspension
AMOXIL CAPSULES/SUSPENSION
Amphetamine-Dextroamphetamine SR 24 hr Capsule (QL)
Amphetamine-Dextroamphetamine Tablets
Ampicillin Capsules / Suspension
AMPYRA TABLETS (QL) (PA) (LD) (N)
AMRIX CAPSULES (EST) (QL)
AMTURNIDE TABLETS (EST)
Amylase / Lipase / Protease
Amylase / Lipase / Protease / Pancreatin
ANAFRANIL CAPSULES
Anagrelide Capsules
ANALPRAM HC CREAM 1%
ANALPRAM HC CREAM 2.5%-1%
ANAPROX DS TABLETS
ANAPROX TABLETS
ANASPAZ TABLETS
Anastrozole Tablets
ANDRODERM PATCHES
ANDROGEL (QL)
ANDROID CAPSULES
ANDROXY 10 MG TABLETS
ANGELIQ TABLETS
ANORO ELLIPTA INHALER
ANTABUSE TABLETS
ANTARA CAPSULES 30 MG, 90 MG
ANTARA CAPSULES 43 MG, 130 MG
ANUSOL-HC SUPP
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
USE CYCLOBENZAPRINE TABLETS
ANDROGEL
PREMPRO, CLIMARA PRO PATCH
Bupropion HBr Tab SR 24HR
GENERIC FOR ORTHO-CEPT
GENERIC FOR TRI-NORINYL
Azathioprine, Hydroxychloroquine (PLAQUENIL), Methotrexate
(RHEUMATREX), Sulfasalazine (AZULFIDINE)
Diclofenac (VOLTAREN) AND Misoprostol (CYTOTEC), Etodolac IR (LODINE),
Ibuprofen (MOTRIN), Indomethacin (INDOCIN SR), Meloxicam (MOBIC),
Naproxen (NAPROSYN)
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
Losartan / HCTZ (HYZAAR), Valsartan / HCTZ (DIOVAN HCT), Irbesartan /
HCTZ (AVALIDE), BENICAR HCT
Losartan (COZAAR), Irbesartan (AVAPRO), Valsartan (DIOVAN), Benazepril
(LOTENSIN), Lisinopril (ZESTRIL), BENICAR
3
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
1
3
1
1
1
1
1
3
3
3
2
1
2
1
3/SP
1
1
1
3
1
1
2
2
2
1
1
1
1
1
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
3
3
1
1
3
3
1
3
1
*
*
AXERT TABLETS (QL)
AXID CAPSULES
AXID SOLUTION
AXIRON SOLUTION (QL) (EST)
AZASITE OPHTHALMIC SOLUTION
Azathioprine Tablets
Azelastine Nasal Spray (QL)
*
Azelastine Ophthalmic Solution (QL)
*
*
Use Alendronate (Fosamax)
GENERIC FOR ALESSE
Finasteride (PROSCAR) (PA), Doxazosin (CARDURA), Terazosin (HYTRIN),
Tamsulosin (FLOMAX)
Sumatriptan (IMITREX), Naratriptan (AMERGE), Rizatriptan (MAXALT)
Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A
MICRO), DIFFERIN, Clindamycin/Benzoyl Peroxide (DUAC), TAZORAC,
Sulfacetamide/sulfur (SULFACET-R)
AZELEX CREAM
2
AZILECT TABLETS
*
2
Azithromycin Tablets (QL)
AZOPT OPHTHALMIC SOLUTION
2
AZOR TABLETS (EST)
1
*
AZULFIDINE TABLETS (ENTERIC COATED NOT COVERED)
1
*
Azurette Tablets
1
*
Baclofen Tablets
1
*
BACTRIM DS TABLETS
1
*
BACTRIM TABLETS
1
*
BACTROBAN CREAM / OINTMENT
1
*
Balsalazide Capsules (QL)
3
*
Balzia Tablets
2
1
2
3
1
1
3
SP
1
1
1
1
2
2
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
AVODART CAPSULES (EST)
3
1
DRUG NAME
ATARAX TABLETS
ATELVIA TABLETS (EST) (QL)
Atenolol / Chlorthalidone Tablets
Atenolol Tablets
ATIVAN TABLETS
Atorvastatin Tablets (QL)
Atovaquone Suspension
Atovaquone/ Proguanil Tablets
Atovaquone-Proguanil Tablets
ATRALIN GEL (QL)
ATRIPLA TABLETS
Atropine Sulfate Ophthalmic Solution & Ointment
ATROVENT HFA INHALER (QL)
ATROVENT NASAL SPRAY
AUBAGIO TABLETS (PA) (LD) (N)
Augmented Betamethasone Dipropionate Cream
AUGMENTIN CAPSULES / SUSPENSION
AUGMENTIN XR TABLETS
AURALGAN OTIC SOLUTION
AUROTO OTIC SOLUTION
AVALIDE TABLETS
AVANDAMET TABLETS
AVANDARYL TABLETS
AVANDIA TABLETS
AVAPRO TABLETS
AVELOX TABLETS (QL)
AVENTYL CAPSULES
Aviane Tablets
AVINZA CAPSULES (QL)
*
*
*
*
*
*
*
GENERIC FOR MIRCETTE
GENERIC FOR OVCON
BANZEL TABLETS
BARACLUDE TABLETS
B-D BRAND DISPOSABLE INSULIN NEEDLES & SYRINGES
BECONASE AQ (QL)
BEEPEN-VK TABLETS / SUSPENSION
Belladonna / Phenobarbital Tablets/ Elixir
BELSOMRA TABLETS (PA)
BELVIQ TABLETS (PA)
Benazepril / Amlodipine Tablets
Benazepril / HCTZ Tablets
Benazepril Capsules
BENEMID TABLETS
BENICAR HCT TABLETS
BENICAR TABLETS
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Fluticasone (FLONASE), NASONEX, VERAMYST
NOT COVERED BY ALL PLANS - CHECK BENEFITS FOR COVERAGE
4
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
1
*
BENTYL CAPSULES
3
*
BENZACLIN GEL
1
1
1
1
3
3
1
1
1
1
1
1
1
3
2
2
2
1
1
1
1
3
2
1
3
1
1
1
2
1
3
3
3
2
1
3
2
1
3
3
1
1
1
3
1
3
3
1
1
3
3
1
1
1
1
*
*
*
*
*
*
*
*
*
BENZAMYCIN
Benzocaine / Antipyrine Otic Solution
Benzonatate Capsules
Benztropine Mesylate Tablets
BEPREVE OPHTHALMIC SOLUTION (QL)
BESIVANCE OPHTHALMIC SOLUTION
BETAGAN OPHTHALMIC SOLUTION
Betamethasone Dipropionate Cream / Ointment
BETAPACE AF TABLETS
BETAPACE TABLETS
Betaxolol Ophthmalic Solution
Betaxolol Tablets
Bethanechol Tablets
BETHKIS NEBULIZER SOLUTION
BETIMOL OPHTHALMIC SOLUTION
BETOPTIC-S OPHTHALMIC SOLUTION
BEYAZ TABLETS
BIAXIN SUSPENSION
BIAXIN TABLETS
BIAXIN XL TABLETS (QL)
Bicalutamide Tablets
BIDIL TABLETS
BILTRICIDE TABLETS
Bimatoprost 0.3% Ophthalmic Solution (QL)
BINOSTO EFFERVESCENT TABLETS (PA)
Bisoprolol / Hydrochlorothiazide Tablets
Bisoprolol Tablets
BLEPH 10 OPHTHALMIC OINT./ SOLUTION
BLEPHAMIDE OPHTHALMIC OINTMENT
BLOCADREN TABLETS
B-NEXA
BONIVA TABLETS (QL)
BOSULIF TABLETS (PA) (LD) (N)
BREO ELLIPTA INHALER (QL)
BRETHINE TABLETS
Briellyn Tablets
BRILINTA TABLETS
Brimonidine Ophthalmic Solution
BRINTELLIX TABLETS (EST)
BRISDELLE TABLETS
Bromcriptine Capsules / Tablets
BROMDAY OPHTHALMIC SOLUTION
Bromfenac Ophthalmic Solution
BROVANA SOLUTION FOR INHALATION
Budesonide Inhalation Suspension 0.25mg / 2ml, 0.5 mg / 2 ml
Budesonide Nasal Solution (QL)
Budesonide Nasal Suspension
Budesonide SR Capsules 3 mg Enteric Coated
BUMEX TABLETS
BUNAVAIL FILM
Buprenorphine-Naloxone SL Tablet (PA) (QL)
Bupropion Sustained Release Tablets
Bupropion Tablets
BUSPAR TABLETS
Buspirone Tablets
1
*
Butalbital 50 / Acetaminophen 325 / Caffeine 40 Tablets
1
*
Butalbital 50 / Aspirin 325 / Caffeine 40 Tablets / Capsules
1
*
Butalbital 50 / Aspirin 650 Tablets
3
*
Butorphanol Nasal Spray (QL)
3
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A
MICRO), DIFFERIN, Clindamycin/Benzoyl Peroxide (DUAC), TAZORAC,
Sulfacetamide/sulfur (SULFACET-R)
Hydralazine (APRESOLINE) PLUS Isosorbide (ISORDIL)
TRY Alendronate (FOSAMAX)
Prenatal Vitamins
TRY Alendronate (FOSAMAX)
GLEEVEC, SPRYCEL, TASIGNA
GENERIC FOR OVCON
SEREVENT, Ipratropium Inhaler, ATROVENT HFA INHALER
Acetaminophen and Codeine (TYLENOL/CODEINE), Hydrocodone and
Acetaminophen (VICODIN, LORTAB ), Tramadol (ULTRAM), Oxycodone 5 /
Acetaminophen 325 (PERCOCET), Oxycodone 4.5 / Aspirin 325
(PERCODAN), Hydromorphone Tablets (DILAUDID)
Morphine Sulfate (MSIR, MS CONTIN), Hydromorphone (DILAUDID), KADIAN,
OPANA ER, AVINZA, Meperidine (DEMEROL),Codeine, Oxycodone Immediate
Release, Oxycodone / Acetaminophen (PERCOCET 5/325), Oxycodone /
Aspirin (PERCODAN 5/325)
BUTRANS PATCH (QL)
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
5
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
SP
BYDUREON INJECTION (PA) (N) (Covered under Pharmacy only if Plan has a "Specialty Tier")
SP
3
*
1
*
BYETTA INJECTION (PA) (N) (Covered under Pharmacy only if Plan has a "Specialty Tier")
Atenolol (TENORMIN), Metoprolol / SR (LOPRESSOR, TOPROL XL),
Carvedilol (COREG) immediate release
Desmopressin Tablets / Spray, Megestrol Tablets, SYNAREL NASAL
Cabergoline Tablets (QL)
SOLUTION
Amlodipine (NORVASC) PLUS Atorvastatin LIPITOR), Simvastatin (ZOCOR),
CADUET TABLETS (PA)
VYTORIN, lovastatin (MEVACOR), pravastatin (PRAVACHOL)
CAFCIT ORAL SOLUTION
1
*
CAFERGOT TABLETS / SUPPOSITORIES
1
*
Caffeine Oral Solution
1
*
CALAN SR TABLETS
1
1
1
1
1
3
1
3
1
1
2
1
1
1
1
1
3
1
1
1
1
2
1
1
1
1
1
3
1
1
*
*
*
*
*
*
*
*
*
*
*
*
*
CALAN TABLETS
Calcipotriene Cream
Calcitonin (Salmon) Nasal Soln
Calcitriol Capsules
Calcitriol Ointment (QL)
CAMBIA GRANULES (QL)
Camila
CAMPRAL TABLETS
Camrese (QL) (3 MONTH SUPPLY)
Camrese LO (QL) (3 MONTH SUPPLY)
CANASA SUPPOSITORIES
Candesartan / HCTZ Tablets
Candesartan Tablets
Capecitabine Tablets (N)
CAPOTEN TABLETS
CAPOZIDE TABLETS
CAPRELSA TABLETS (N)
Captopril / HCTZ Tablets
Captopril Capsules
CARAC CREAM
CARAFATE TABLETS
CARBAGLU TABLETS (LD) (N)
Carbamazepine SR Capsules / Tablets 12 hour
Carbamazepine Tablets
CARBATROL CAPSULES
Carbidopa / Levodopa CR Tablets
Carbidopa / Levodopa Tablets
Carbidopa Tablets
Carbinoxamine 4 / Pseudoephedrine 60 / DM 15 Syrup
CARBOPTIC OPHTHALMIC SOLUTION
3
*
CARDENE CAPSULES
1
1
1
1
1
1
1
1
*
*
*
*
*
*
*
*
CARDIZEM CD CAPSULES (QL)
CARDIZEM LA TABLETS
CARDIZEM SR CAPSULES
CARDIZEM TABLETS
CARDURA TABLETS
Carisoprodol / Aspirin Tablets
Carisoprodol Tablets
CASODEX TABLETS
3
*
CATAFLAM TABLETS
1
3
2
3
1
1
3
1
1
1
1
1
1
*
*
CATAPRES -TABLETS ONLY
CATAPRES-TTS PATCHES
CAVAN-EC SOD DHA
CAYSTON INHALATION SOLUTION (QL) (LD) (N)
Caziant Tablets
CECLOR CAPSULES / SUSPENSION
CEDAX CAPSULES / SUSPENSION
CEENU CAPSULES
Cefaclor Capsules / Suspension
Cefadroxil Capsules
Cefdinir Capsules / Suspension
Cefpodoxime Proextil Tablets
CEFTIN CAPSULES / SUSPENSION
3
3
BYSTOLIC TABLETS
*
*
*
*
*
*
*
*
*
*
*
*
*
*
3
GENERIC FOR ORTHO-MICRONOR
Naltrexone (REVIA), Disulfiram (ANTABUSE)
GENERIC FOR SEASONIQUE
GENERIC FOR LOSEASONIQUE
Divalproex SR (DEPAKOTE ER), Topiramate (TOPAMAX)
Nifedipine SR (ADALAT CC), Felodipine (PLENDIL), SULAR, Verapamil SA
Tabs (CALAN SR), Amlodipine (NORVASC)
Nifedipine SR (ADALAT CC), Felodipine (PLENDIL), SULAR, Verapamil SA
Tabs (CALAN SR), Amlodipine (NORVASC)
CARDENE SR CAPSULES
*
*
*
*
*
*
*
*
*
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Diltiazem Coated Beads 24 HR (CARDIZEM CD CAPSULES) (QL)
Ibuprofen (MOTRIN), Meloxicam (MOBIC), Indomethacin/SR (INDOCIN/SR),
Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin (DAYPRO), Sulindac
(CLINORIL), Diclofenac (VOLTAREN), Piroxicam (FELDENE)
Clonidine Tablets (CATAPRES)
Prenatal Vitamins
GENERIC FOR CYCLESSA
6
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
1
1
1
3
1
1
2
*
*
*
*
*
3
1
1
3/SP
2
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Cefuroxime Capsules
CEFZIL CAPSULES / SUSPENSION
CELEBREX (AL) (QL)
CELEXA ORAL SOLUTION
CELEXA TABLETS (QL)
CELLCEPT
CELONTIN CAPSULES
MINIMUM AGE LIMIT OF 60
PREMARIN, Estradiol (ESTRACE), Estradiol patch (CLIMARA, VIVELLEDOT), Estropipate (OGEN, ORTHO-EST)
CENESTIN TABLETS
*
*
3
Cephalexin Capsules / Suspension (750mg is non-Formulary)
CEPHULAC SOLUTION
CERDELGA CAPSULES (PA)
CERVICAL CAP
Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN), prochlorperazine
(COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN)
CESAMET CAPSULES (PA) (QL)
1
1
3
1
3
1
1
1
1
1
1
1
1
1
1
*
*
*
*
3
*
1
1
1
1
*
*
*
*
Cesia Tablets
GENERIC FOR CYCLESSA
CETRAXAL OTIC SOLUTION
Cevimeline Capsules
CHATEAL TABLETS
GENERIC FOR NORDETTE
CHENODAL TABLETS
Chloral Hydrate Capsules
Chlordiazepoxide Capsules
Chlorhexidine Gluconate (Covered Only If Dental Rider purchased)
Chloroquine Tablets
Chlorpheniramine 2/ Phenylephrine 10/ Methscopolamine 1.25-Syrup
Chlorpheniramine 4 / Pseudoephedrine 60 Capsules
Chlorpheniramine 4.5 / Phenylephrine 5 Suspension
Chlorpheniramine 8/ Phenylephrine 20/ Methscopolamine 2.5 Caps
Chlorpromazine Tablets
Chlorthalidone Tablets
Methocarbamol (ROBAXIN), Carisoprodol (SOMA), Cyclobenzaprine
Chlorzaxozone Tablets
(FLEXERIL)
Cholestyramine - Bulk Powder Only
Choline Fenofibrate Capsules
Choline Magnesium Salicylate Solution
Choline Magnesium Salicylate Tablets
CIALIS TABLETS (QL) (PA)
NOT COVERED BY ALL PLANS - CHECK BENEFITS AND SPECIFIC COPAY
3
1
FOR BENIGN PROSTATIC HYPERTROPHY (BPH) ONLY
*
CIALIS TABLETS 2.5MG, 5 MG (QL) (PA)
Ciclopirox Cream
3
*
Ciclopirox Gel / Suspension
1
1
1
*
*
*
Cilostazol Tablets
CILOXAN OPHTHALMIC SOLUTION
Cimetidine 400 mg, 800 mg Tablets
*
*
*
*
*
*
*
*
*
*
SP
3
Ketoconazole (NIZORAL), Econazole (SPECTAZOLE), LAMISIL OTC, Nystatin
Cream / Ointment
Hydrocortisone / Neomycin / Polymyxin Otic Solution / Suspension
(CORTISPORIN OTIC), TOBRADEX, ZYLET SUSPENSION, CIPRODEX
OTIC SOLUTION
CIPRO HC OTIC SOLUTION
1
1
1
2
1
1
1
2
2
3
2
3
2
1
3
3
1
1
*
*
*
*
*
*
*
*
CIPRO TABLETS
CIPRO XR 1000 mg TABLETS (QL)
CIPRO XR 500 mg TABLETS (QL)
CIPRODEX OTIC SUSPENSION (QL)
Ciprofloxacin Ophthalmic Solution
Ciprofloxacin Tablets
Citalopram Tablets
CITRANATAL 90 DHA
CITRANATAL ASSURE
CITRANATAL B-CALM
CITRANATAL DHA
CITRANATAL HARMONY
CITRANATAL RX
CLARIFOAM EF
CLARINEX REDI-TABS (PA) (QL)
CLARINEX TABLETS (PA) (QL)
Clarithromycin Tablets
Clemastine Tablets
3
*
CLENIA CREAM
1
*
CLEOCIN VAGINAL CREAM
*
*
*
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Loratadine (CLARITIN), Cetirizine (ZYRTEC) - BOTH AVAILABLE OTC
Loratadine (CLARITIN), Cetirizine (ZYRTEC) - BOTH AVAILABLE OTC
Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), (RETIN A
MICRO), DIFFERIN, Clindamycin/Benzoyl Peroxide (DUAC), TAZORAC,
Sulfacetamide/sulfur (SULFACET-R), Metronidazole Topical Cream
7
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
1
1
2
1
1
3
1
1
1
*
*
*
*
*
*
*
*
Clidinium / Chlordiazepoxide Capsules
CLIMARA PATCHES (QL)
CLIMARA PRO PATCHES (QL)
Clindamycin / Benzoyl Peroxide 1% / 5% Gel
Clindamycin Capsules
Clindamycin Phosphate 1% Foam
Clindamycin Solution 1% (Swabs & Pads Excluded)
CLINORIL TABLETS
Clobetasol Propionate Cream / Ointment/ Gel / Solution / Emollient
3
*
CLOBEX LOTION, SHAMPOO
Clobetasol Propionate Solution (TEMOVATE), Augmented Betamethasone
Dipropionate Cream, Diflorasone Diacetate Cream / Oinment
1
*
CLOMID TABLETS (QL)
NOT COVERED BY ALL PLANS - CHECK BENEFITS AND SPECIFIC COPAY
1
*
Clomiphene Tablets (QL)
NOT COVERED BY ALL PLANS - CHECK BENEFITS AND SPECIFIC COPAY
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
2
1
1
1
1
*
*
*
*
*
*
*
*
*
Clomipramine Capsules
Clonazepam Tablets
Clonidine (Tablets only)
Clopidogrel Tablets
Clorazepate Capsules
Clotrimazole / Betamethasone Cream / Lotion (QL)
Clotrimazole Troches
Clozapine Tablets
CLOZARIL TABLETS
COARTEM TABLETS (QL)
Codeine / Aspirin Tablets
Codeine 10 / Bromodiphenhydramine 12.5 Syrup
Codeine 10 / Brompheniramine 2 / Phenylephrine 12.5 Syrup
CODEINE TABLETS
COGENTIN TABLETS
COLAZAL CAPSULES (QL)
COL-BENEMID TABLETS
COLCHICINE TABLETS
Colchicine Tablets
COLCRYS TABLETS
COLESTID GRANULES
COLESTID TABLETS
Colestipol Tablets / Granules
COLYTE
*
*
*
*
*
*
*
*
*
*
*
*
*
3
COMBIGAN OPHTHALMIC SOLN.
3
COMBIPATCH PATCHES
3
1
3
3
1
2
2
3
2
1
2
*
*
*
*
*
3
3
1
1
COMBIVENT RESPIMAT (QL)
COMBIVIR TABLETS
COMBUNOX TABLETS
COMETRIQ CAPSULES (PA) (LD) (N)
COMPAZINE TABLETS / SUPPOSITORIES
COMPLERA TABLETS
COMPLETENATE
COMTAN TABLETS
CONCEPT DHA
CONCERTA SA TABLET (QL)
CONDYLOX – GEL
Oxycodone (OXYIR) AND Ibuprofen (MOTRIN)
Prenatal Vitamins
Prenatal Vitamins
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
CONTOUR TEST STRIPS (QL) (PA)
*
*
3
3
1
1
1
1
2
1
1
1
Timolol (TIMOPTIC) plus Brimodine (ALPHAGAN P) or LUMIGAN or
TRAVATAN
PREMPRO, PREMPHASE, PREMARIN and Medroxyprogesterone
(PROVERA), CLIMARA PRO PATCH
CONZIP CAPSULES
COPEGUS TABLETS (PA)
CORDARONE TABLETS
Betamethasone Dip. (DIPROSONE), Betamethasone Val. (VALISONE),
Fluocinolone (SYNALAR), ELOCON, Triamcinolone (KENALOG,
ARISTOCORT)
Carvedilol (COREG) - Immediate Release Tablets
CORDRAN CREAM / OINTMENT / TAPE
*
*
*
*
*
*
*
COREG CR CAPSULES
COREG TABLETS (QL)
CORGARD TABLETS
CORTEF TABLETS
CORTENEMA
CORTIFOAM
Cortisone Tablets
CORTISPORIN OPHTHALMIC SOLUTION & OINTMENT
CORTISPORIN OTIC SOLUTION / SUSPENSION
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
8
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
1
3
1
3
1
2
3
3
2
2
1
1
1
3
1
2
*
1
*
CUTIVATE CREAM / OINTMENT
1
*
Cyclafem Tablets
1
*
CYCLESSA TABLETS
3
*
Cyclobenzaprine hcl Capsule SR 24hr (EST) (QL)
1
*
Cyclobenzaprine Tablets
1
*
CYCLOGYL OPHTHALMIC SOLUTION
1
*
Cyclopentolate Ophthalmic Solution
1
*
Cyclophosphamide Tablets
1
*
CYCLORT CREAM
3
*
Cycloserine Capsules
1
*
Cyclosporine Capsules
1
1
1
*
*
*
Cyclosporine Modified
CYMBALTA CAPSULES (QL)
Cyproheptadine 4 mg Tablets Only
1
*
Cyproheptadine Syrup
1
*
CYTOMEL TABLETS
1
*
CYTOTEC TABLETS
1
*
CYTOVENE CAPSULES
1
*
CYTOXAN TABLETS
1
*
CYTRA-2 SOLUTION
1
*
CYTRA-K SOLUTION
1
*
DALMANE CAPSULES
1
*
Danazol Capsules
1
*
DANOCRINE CAPSULES
1
*
DANTRIUM CAPSULES
*
*
*
*
*
*
*
2
Atorvastatin (LIPITOR), Simvastatin (ZOCOR), VYTORIN
GENERIC FOR LO/OVRAL
GENERIC FOR ORTHO NOVUM
CYSTARAN OPHTHALMIC SOLUTION (QL) (LD)
3
DALIRESP TABLETS (QL)
2
DAPSONE TABLETS
3
DARAPRIM TABLETS
*
*
*
3
1
1
1
1
1
1
1
2
1
1
1
1
Verapamil SA Tabs (CALAN SR)
CUVPOSA SOLUTION
3
1
1
1
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
COSOPT OPHTHALMIC SOLUTION
COSOPT PF OPHTHALMIC SOLUTION
COUMADIN TABLETS
COVERA -HS TABLETS
COZAAR TABLETS
CREON CAPSULES
CRESTOR TABLETS 10 MG, 20MG, 40 MG (QL)
CRESTOR TABLETS 5 MG (QL) (EST)
CRINONE 8% VAGINAL CREAM (PA)
CRIXIVAN CAPSULES
CROLOM OPHTHALMIC SOLUTION
Cromolyn Sodium Inhaled/Nasal/Nebulizer
Cromolyn Sodium Ophthalmic Solution
Cromolyn Sodium Oral Concentrate
Cryselle Tablets
CUPRIMINE CAPSULES
MYCOBUTIN CAPSULES, Ethambutol Tablets, Isoniazid Tablets, TRECATOR
TABLETS, PYRAZINAMIDE TABLETS
GENERIC FOR ORTHO NOVUM
Dasetta Tablets
DAYPRO TABLETS
Daysee (QL) (3 MONTH SUPPLY)
GENERIC FOR SEASONIQUE
Amphetamine-Dextroamphetamine (ADDERALL or ADDERALL XR),
Methylphenidate (RITALIN, RITALIN SR, METADATE ER), Methylphenidate SA
OSM (CONCERTA), VYVANSE
DAYTRANA PATCH
*
*
*
*
*
*
*
*
*
*
*
DDAVP
DECADRON OPHTHALMIC SOLUTION & OINTMENT
DECADRON TABLETS
DECLOMYCIN TABLETS
DECONAMINE SR CAPSULES
DELTA CORTEF TABLETS
DELTASONE TABLETS
DELZICOL CAPSULES
DEMADEX TABLETS
Demeclocycline Tablets
DEMEROL TABLETS
DEMULEN
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Furosemide (LASIX), Bumetanide (BUMEX)
9
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
3
1
1
1
2
1
1
1
1
1
1
1
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
ABREVA (AVAILABLE OTC-NOT COVERED), Acyclovir (ZOVIRAX (oral),
Valacyclovir (VALTREX)
DENAVIR CREAM (QL)
*
*
*
*
*
*
*
*
*
*
3
3
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
2
3
DRUG NAME
DEPAKENE CAPSULES
DEPAKOTE ER TABLETS
DEPAKOTE TABLETS
DEPEN
DERMATOP CREAM
Desipramine Tablets
Desmopressin Tablets / Spray
Desogen Tablets
Desonide Cream / Ointment / Lotion
DESOWEN CREAM / OINTMENT / LOTION
Desoximetasone 0.05% CREAM
GENERIC FOR ORTHO-CEPT
Amphetamine-Dextroamphetamine (ADDERALL or ADDERALL XR),
Methylphenidate (RITALIN, RITALIN SR, METADATE ER), Methylphenidate SA
OSM (CONCERTA), VYVANSE
DESOXYN TABLETS (PA)
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Desvenlafaxine Tab SR 24HR (EST) (QL)
DESYREL TABLETS
DETROL LA CAPSULES (QL)
DETROL TABLETS (QL)
Dexamethasone / Neomycin / Polymyxin Ophth. Soln & Oint
Dexamethasone Ophthalmic Solution & Ointment
Dexamethasone Tablets
Dexchlorpheniramine Tablets
DEXEDRINE SPANSULES
DEXEDRINE TABLETS
DEXILANT CAPSULES (EST) (QL)
Dexmethylphenidate Tablets (QL)
Dextroamphetamine CR Capsules
Dextroamphetamine Tablets
DIABETA TABLETS
DIAMOX SEQUELS
DIAMOX TABLETS
Diazepam Tablets
DIBENZYLINE
DICLEGIS TABLETS (QL)
3
*
Diclofenac Extended Release Tablets
3
1
1
1
3
1
1
3
3
1
1
1
1
*
*
*
*
*
*
*
*
*
*
*
Diclofenac Sodium Solution
Diclofenac Sodium Tablets
Dicloxacillin Capsules / Suspension
Dicyclomine Capsules
DIDRONEL TABLETS
DIFFERIN 0.1% CREAM or GEL
DIFFERIN 0.3% GEL
DIFFERIN LOTION (QL)
DIFICID TABLETS
Diflorasone Diacetate Cream / Ointment
Diflorasone Diacetate, Emollient Cream
DIFLUCAN 150 MG TAB ONLY (QL)
DIFLUCAN TABLET (PA)
3
*
Diflunisal Tablets
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
*
*
*
*
*
*
*
*
*
*
Digoxin Tablets
DILACOR XR CAPSULES
DILANTIN CAPSULES
DILANTIN CHEWABLE TABLETS
DILAUDID TABLETS
Diltiazem Extended Release Capsules
Diltiazem Immediate Release Tablets
Diltiazem SR Capsules
DIOVAN HCT TABLETS
DIOVAN TABLETS
DIPENTUM CAPSULES
Diphenoxylate / Atropine Tablets
Dipivefrin Ophthalmic Solution
DIPROLENE AF CREAM
DIPROSONE CREAM / OINTMENT
Dipyridamole Tablets
DISALCID TABLETS
*
*
*
*
*
*
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
MUST TRY AND FAIL Pantoprazole (PROTONIX)
Ibuprofen (MOTRIN), Meloxicam (MOBIC), Indomethacin/SR (INDOCIN/SR),
Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin (DAYPRO), Sulindac
(CLINORIL), Diclofenac (VOLTAREN), Piroxicam (FELDENE)
Alendronate (FOSAMAX)
Choline Magnesium Salicylate Tablets (TRILISATE), Salsalate (DISALCID,
SALFLEX)
ASACOL TABLETS
10
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
1
1
1
*
*
*
Disopyramide Capsules
Disulfiram Tablets
DITROPAN TABLETS
1
*
DITROPAN XL TABLETS
1
1
1
1
1
2
1
1
*
*
*
*
*
Divalproex sodium Tab SR 24 hr
DOLOPHINE TABLETS (QL)
DOMEBORO OTIC SOLUTION
Donepezil Orally Disintegrating Tablets
Donepezil Tablets
DONNATAL EXTENTABS
DONNATAL TABLETS / ELIXIR
DOPAR
*
*
3
3
1
1
3
1
1
1
1
3
3
1
3
1
2
*
*
*
*
*
*
*
*
*
*
*
*
*
*
DUET DHA COMPLETE
3
Prenatal Vitamins
DUET DHA EC
1
3
2
*
DUETACT TABLETS
DUEXIS TABLETS (PA)
DULERA AEROSOL (QL)
1
*
Duloxetine EC Capules (QL)
3
*
DUONEB NEBULIZER SOLUTION
1
*
DURAGESIC PATCHES (QL)
*
DURICEF
*
DYAZIDE CAPSULES
3
Prenatal Vitamins
DUREZOL OPHTHALMIC EMULSION
3
DUTOPROL SR TABLETS
3
Azelastine (ASTELIN), Fluticasone Nasal Spray (FLONASE), NASONEX,
VERAMYST
Minocycline Capsules (MINOCIN CAPSULES)
Amlodipine (NORVASC), Nifedipine SR (ADALAT CC, PROCARDIA XL),
Felodipine (PLENDIL)
DYMISTA NASAL SPRAY (QL)
*
3
DYNACIN- (USE MINOCYCLINE CAPSULES)
DYNACIRC CR TABLETS
3
1
Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN), prochlorperazine
(COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN)
DROXIA CAPSULES
DRYSOL
DUAC GEL (QL)
DUAVEE TABLETS
DUET DHA
DUET DHA BALANCED
3
Bromocriptine (PARLODEL)
Dronabinol Capsules (PA)
2
1
Zolpidem (AMBIEN), Lorazepam (ATIVAN), Temazepam (RESTORIL),
Flurazepam (DALMANE)
Doxycycline Hyclate (Immediate release)
DORYX TABLETS (EST)
Dorzolamide Ophthalmic Solution
Dorzolamide-Timolol Ophthalmic Solution
DOSTINEX TABLETS (QL)
DOVONEX CREAM / OINTMENT (QL)
DOVONEX SOLUTION
Doxazosin Mesylate Tablets
Doxepin Capsules
Doxercalciferol Capsules
Doxycycline Hyclate 20mg, 40mg Capsules / Tablets
Doxycycline Hyclate 50mg, 100mg Capsules / Tablets
Doxycycline Hyclate Delayed Release Tablets
DRISDOL CAPSULES
DRITHO-CRÈME HP
3
1
Oxybutinin Immediate Release Tabs., Tolterodine (DETROL), Tolterodine LA
(DETROL LA), TOVIAZ
DORAL TABLETS
3
3
1
1
3
3
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
DYRENNIUM CAPSULES
*
Econazole Cream
3
ECOZA FOAM
3
EDARBI TABLETS
3
EDARBYCLOR TABLETS
3
EDECRIN TABLETS
Losartan (COZAAR), Irbesartan (AVAPRO), Valsartan (DIOVAN), Benazepril
(LOTENSIN), Lisinopril (ZESTRIL), BENICAR
Furosemide (LASIX), Bumetanide (BUMEX), Metolazone (ZAROXOLYN)
3
EDLUAR SUBLINGUAL TABLETS (EST) (QL)
Zolpidem (AMBIEN)
2
EDURANT TABLETS
1
*
EES SUSPENSION
1
*
EFFEXOR TABLETS
1
*
EFFEXOR XR CAPSULES (QL) (EST)
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
11
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
2
DRUG NAME
1
*
EFUDEX CREAM
1
*
ELAVIL TABLETS
1
*
ELDEPRYL CAPSULES
3
3
*
ELESTAT OPHTHALMIC SOLUTION
ELESTRIN GEL
3
1
1
3
1
3
3
1
2
*
*
*
*
*
*
*
*
*
*
EMGEL
EMLA CREAM
Emoquette Tablets
EMPIRIN TABLETS #2, #3, #4
GENERIC FOR ORTHO-CEPT
Amitriptyline (ELAVIL),Bupropion/SR (WELLBUTRIN/SR),Citalopram
(CELEXA), Desipramine (NORPRAMIN), Doxepin (SINEQUAN), Fluoxetine
(PROZAC), Imipramine (TOFRANIL), Mirtazapine/soltab (REMERON/
SOLTAB), Nortriptyline (AVENTYL, PAMELOR), Paroxetine (PAXIL), Sertraline
(ZOLOFT), Trazodone (DESYREL), Venlafaxine IR (EFFEXOR)
EMTRIVA CAPSULES 200MG
E-MYCIN TABLETS
Oxybutinin Immediate Release Tabs., Tolterodine (DETROL), Tolterodine LA
(DETROL LA), TOVIAZ
Enalapril Tablets
ENDOMETRIN SUPPOSITORIES (PA)
PREMARIN, Estradiol (ESTRACE), Estradiol patch (CLIMARA, VIVELLE /
VIVELLE DOT), Estropipate (OGEN, ORTHO-EST)
GENERIC FOR TRIPHASIL,TRI-LEVLEN
GENERIC FOR ORTHO-CEPT
ENJUVIA TABLETS
*
*
*
*
*
3
2/SP
2/SP
3
1
3
2
1
2
1
1
1
1
2
2
1
3
1
1
1
2
2
1
Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN), prochlorperazine
(COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN)
ENABLEX TABLETS
3
1
1
3
1
1
3
GENERIC FOR LO/OVRAL
EMSAM PATCHES
3
1
3
ELIMITE CREAM (QL)
Elinest Tablets
ELIQUIS TABLETS
ELIXOPHYLLINE LIQ.
ELLA TABLETS (QL)
ELMIRON CAPSULES
ELOCON CREAM / OINTMENT
EMCYT CAPSULES
EMEND CAPSULES (QL)
3
2
1
Cromolyn (CROLOM), ALOMIDE, PATANOL, PATADAY
ESTRACE VAGINAL CREAM
PROTOPIC (PA), Betamethasone dipropionate, Augmented betamethasone
dipropionate (DIPROLENE), Betamethasone valerate 0.1% (BETA-VAL),
Clobetasol proprionate (TEMOVATE), Desoximetasone (TOPICORT),
Diflorasone cream & ointment (APEXICON, APEXICON E, PSORCON E),
Fluocinolone 0.025% (SYNALAR), Fluocinonide (LIDEX, LIDEX E), Halobetasol
propionate (ULTRAVATE), Mometasone (ELOCON), Triamcinolone 0.1%
(ARISTOCORT, KENALOG)
ELIDEL CREAM
3
1
3
1
1
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
EFFIENT TABLETS
Enpresse Tablets
Enskyce Tablets
Entacapone Tablets
Entecavir Tablets
ENTOCORT EC CAPSULES
EPANED SOLUTION
Erythromycin / Benzoyl Peroxide (BENZAMYCIN), Clindamycin / Benzoyl
Peroxide (DUAC GEL)
EPIPEN INJECTION (QL) (Covered under Pharmacy only if Plan has a "Specialty Tier")
EPIPEN JR. INJECTION (QL) (Covered under Pharmacy only if Plan has a "Specialty Tier")
EPIVIR HBV TABLETS
EPIVIR TABLETS
Eplerenone Tablets
Spironolactone (ALDACTONE)
EPZICOM TABLETS
Ergocalciferol Capsules 50,000 U
ERGOMAR TABLETS
Ergonovine Maleate Tablets
Ergotamine / Caffeine Tablets / Suppositories
Ergotamine Tartrate Tablets
Ergotamine/ Belladonna/ Phenobarbital Tablets / Elixir
ERGOTRATE TABLETS
ERIVEDGE CAPSULES (N)
Errin Tablets
GENERIC FOR ORTHO MOCRONOR
ERTACZO CREAM
Nystatin, Econazole (SPECTAZOLE), LAMISIL AT (OTC-NOT COVERED)
ERYCETTE SOLN (SWABS & PADS EXCLUDED)
ERYDERM SOLN (SWABS & PADS EXCLUDED)
ERYGEL
ERYPED TABLETS
ERY-TAB
ERYTHROCIN TABLETS
EPIDUO GEL (QL)
*
*
*
*
*
*
*
*
*
*
*
*
*
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
12
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
1
1
1
1
1
1
1
1
1
3/SP
1
1
1
3
*
*
*
*
*
*
*
*
*
*
*
*
*
Erythromycin / Benzoyl Peroxide Cream
Erythromycin / Sulfisoxazole Suspension
Erythromycin 1.5 % Solution (Swabs & Pads EXCLUDED)
Erythromycin 2 % Gel
Erythromycin 2.0 % Soln (Swabs & Pads EXCLUDED)
Erythromycin Base Tablets
Erythromycin Ethylsuccinate Suspension
Erythromycin Ophthalmic Ointment
Erythromycin Stearate TABLETS
ESBRIET CAPSULES (PA) (N)
Escitalopram Tablets
ESGIC TABLETS
ESKALITH CAPSULES
Estarylla Tablets
1
*
Estazolam Tablets
1
2
2
1
3
1
1
*
ESTRACE TABLETS
ESTRACE VAGINAL CREAM
ESTRADERM PATCHES (QL)
Estradiol Tablets
ESTRASORB TOPICAL EMULSION
ESTRATEST HS TABLETS
ESTRATEST TABLETS
*
*
*
3
ESTRING (3 Month's Supply)
3
ESTROGEL (QL)
1
3
3
1
1
1
3
1
1
*
*
*
*
*
*
*
*
*
Estropipate Tablets
ESTROSTEP Fe
Eszopiclone Capsules (QL)
Ethambutol Tablets
Ethionamide Tablets
Ethosuximide Capsules
Etidronate Tablets
Etodolac ER Tablets
Etodolac Tablets/Capsules
1
*
Etoposide Capsules
1
*
EULEXIN CAPSULES
2
GENERIC FOR ORTHO CYCLEN
Zolpidem (AMBIEN), Zaleplon (SONATA), Lorazepam (ATIVAN), Temazepam
(RESTORIL), Flurazepam (DALMANE)
ESTRADERM, Estradiol Patches (CLIMARA), VIVELLE, VIVELLE-DOT
Estradiol Patches (CLIMARA), VIVELLE-DOT, ESTRACE VAGINAL CR,
PREMARIN VAGINAL CR
PREMARIN, Estropipate (OGEN, ORTHO-EST), Esterified Estrogens
(MENEST, ESTRATAB), Estradiol Tablets (ESTRACE), Estradiol patches
(CLIMARA), VIVELLE, VIVELLE-DOT, ESTRADERM, ESTRACE VAGINAL
CR, PREMARIN VAGINAL CR
EURAX CREAM / LOTION
3
1
3
*
*
EVAMIST SPRAY
EVISTA TABLETS (QL)
EVOCLIN AEROSOL
3
*
EVOXAC CAPSULES
3
*
EXALGO TABLETS (QL)
3
1
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Refer to Preventive Drug List
Nystatin (MYCOSTATIN), LAMISIL AT CREAM (OTC AVAILABLE - NOT
COVERED), Econazole (SPECTAZOLE), Ketoconazole Tablets (NIZORAL)
EXELDERM CREAM / SOLUTION
*
2
EXELON CAPSULES
EXELON PATCHES
1
*
EXFORGE HCT TABLETS (EST)
1
*
EXFORGE TABLETS (EST)
1
*
EXTENDRYL SR CAPSULES
1
2
EXJADE TABLETS (N)
*
EXTENDRYL SYRUP
3
3
1
*
FABIOR FOAM (QL)
FACTIVE TABLETS (QL)
Falmina Tablets
1
*
Famciclovir Tablets
1
*
Famotidine Tablets
1
*
FAMVIR TABLETS
3
FANAPT TABLETS (PA)
2
FANSIDAR TABLETS
2
FARESTON TABLETS
3
FARXIGA TABLETS
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
GENERIC FOR ALESSE
13
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
3
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
FASTTAKE TEST STRIPS (PA) (QL)
1
*
Felbamate Tablets
1
*
FELBATOL TABLETS
1
*
FELDENE CAPSULES
1
1
*
*
FEMARA TABLETS
FEMHRT TABLETS
3
Estradiol Patches (CLIMARA), ESTRADERM, VIVELLE, VIVELLE-DOT,
ESTRACE VAGINAL CR, PREMARIN VAGINAL CR
TRICOR TABLETS 48 mg, 145 mg, TRILIPIX
FEMRING (3 months Supply)
1
1
1
*
*
*
Fenofibrate Micronized Capsules 67mg, 134 mg, 200 mg
Fenofibrate Tablets 48 mg, 54 mg, 145 mg, 160 mg
Fenoprofen Capsules
3
*
Fentanyl Lozenges (PA)
1
*
Fentanyl Patches (QL)
Morphine Sulfate (MSIR, MS CONTIN), Hydromorphone (DILAUDID), KADIAN,
OPANA ER, AVINZA, Meperidine (DEMEROL),Codeine, Oxycodone Immediate
Release, Oxycodone / Acetaminophen (PERCOCET 5/325), Oxycodone /
Aspirin (PERCODAN 5/325)
Morphine Sulfate (MSIR, MS CONTIN), Hydromorphone (DILAUDID), KADIAN,
OPANA ER, AVINZA, Meperidine (DEMEROL),Codeine, Oxycodone Immediate
Release, Oxycodone / Acetaminophen (PERCOCET 5/325), Oxycodone /
Aspirin (PERCODAN 5/325)
3
FENTORA BUCCAL TABLETS (PA)
3
3
3
3
2
1
1
1
3
1
1
1
2
1
1
3
1
1
1
1
1
2
2
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
2
1
3
1
1
1
2
1
FERRIC CITRATE TABLETS
FERRIPROX TABLETS
FETZIMA CAPSULES (EST)
FIBRICOR TABLETS
FINACEA GEL
Finasteride Tablets (EST)
FIORICET CAPSULES
FIORICET TABLETS
FIORINAL CODEINE CAPSULES
FIORPAP TABLETS
FLAGYL CAPSULES 375 MG
FLAGYL TABLETS 250 mg or 500 mg Only
FLAREX OPHTHALMIC SOLUTION
Flavoxate Tablets
Flecainide Tablets
FLECTOR PADS
Diclofenac Oral Tablets (VOLTAREN)
FLEXERIL TABLETS
FLOMAX CAPSULES
FLONASE NASAL SPRAY (QL)
FLORINEF TABLETS
FLORONE CREAM
FLOVENT DISKUS (QL)
FLOVENT HFA (QL)
FLOXIN OTIC SOLUTION
Fluconazole 150 mg Tab – Females Only (QL)
Fluconazole Tablets (QL)
Fludrocortisone Tablets
FLUMADINE TABLETS
Flunisolide Nasal Solution 0.025%
Fluocinolone Acetonide 0.01% Cream / Ointment / Solution
Fluocinolone Acetonide 0.025% Cream / Ointment
Fluocinolone Acetonide 0.2% HP Cream
Fluocinonide Cream/ Ointment
Fluoride / Polyvitamins (Without Iron; Drops & Tabs) (age limit 6 years and younger)
Fluoride / Vitamins A,D,C (Without Iron; Drops & Tabs) (age limit 6 years and younger)
Fluorometholone Ophthalmic Suspension
Fluorometholone Ophthalmic Suspension & Ointment
FLUOR-OP OPHTHALMIC SOLUTION
FLUOROPLEX CREAM / SOLUTION
Fluoxetine Tablets / Capsules
FLUOXETINE TABLETS 60 MG (EST)
USE FLUOXETINE CAPSULES 20 MG + 40MG
Fluoxymesterone Tablets
Fluphenazine Tablets
Flurazepam Capsules
Flurbiprofen 50 mg Tablets
Flutamide Capsules
Betamethasone Dip. (DIPROSONE), Betamethasone Val. (VALISONE),
Fluticasone Cream / Ointment
Fluocinolone (SYNALAR), ELOCON, Triamcinolone (KENALOG,
ARISTOCORT)
Fluticasone Nasal Spray 0.05% (QL)
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
1
*
1
*
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
14
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
1
*
Fluvoxamine SR Capsules
3
*
Fluvoxamine Tablets
2
1
*
FML FORTE OPHTHALMIC SOLUTION
FML OPHTHALMIC SOLUTION & OINTMENT
1
*
FOCALIN TABLETS (QL)
3
*
FOCALIN XR CAPSULES
*
FOLBECAL
FOLCAL DHA
FOLCAPS OMEGA 3
Folic Acid 1 mg Tablets
2
3
3
1
3
*
*
FORTAMET TABLETS
FORTESTA GEL (QL) (EST)
FORTICAL NASAL SPRAY
1
*
FOSAMAX TABLETS (QL)
*
Fosinopril Capsules
3
FOSRENOL TABLETS
2
FREESTYLE INSULINX TEST STRIPS (QL)
2
FREESTYLE TEST LITE STRIPS (QL)
2
FREESTYLE TEST STRIPS (QL)
3
Alendronate (FOSAMAX)
Calcium Acetate (PHOSLO)
FROVA TABLETS (QL)
*
2
Sumatriptan (IMITREX), Naratriptan (AMERGE), Rizatriptan (MAXALT)
FULVICIN P/G TABLETS
FULVICIN U/F TABLETS
3
FULYZAQ DELAYED RELEASE TABLETS (PA) (QL)
1
*
FURADANTIN SUSPENSION
1
*
Furosemide Tablets
1
*
Gabapentin Tablets / Capsules / Solution
1
*
GABARONE TABLETS
3
*
GABITRIL TABLETS
3
*
Galantamine ER Tablets
3
*
Galantamine Tablets
1
*
Ganciclovir Capsules
1
*
GASTROCROM ORAL CONCENTRATE
1
*
Gatifloxacin Ophthalmic Solution
1
*
GAVILYTE-C SOLUTION
*
Gemfibrozil Tablets
3
FYCOMPA TABLETS (N)
3
3
1
1
1
1
1
2
1
3
3
1
1
3/SP
2
2
1
1
Metformin Tablets SR (GLUCOPHAGE XR)
USE ANDROGEL - TIER 2
FOSAMAX-D TABLETS (PA) (QL)
3
1
Amphetamine-Dextroamphetamine (ADDERALL or ADDERALL XR),
Methylphenidate (RITALIN, RITALIN SR, METADATE ER), Methylphenidate SA
OSM (CONCERTA), VYVANSE
Amphetamine-Dextroamphetamine (ADDERALL or ADDERALL XR),
Methylphenidate (RITALIN, RITALIN SR, METADATE ER), Methylphenidate SA
OSM (CONCERTA), VYVANSE
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
FORFIVO XL TABLETS (EST)
3
3
1
1
Fluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL),
Venlafaxine (EFFEXOR), Venlafaxine SR Capsules (EFFEXOR XR), Bupropion
(WELLBUTRIN, WELLBUTRIN SR), Escitalopram (LEXAPRO)
FORADIL AEROLIZER (QL)
3
1
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Methsuximide (CELONTIN) , Valproic Acid/ER (DEPAKOTE ER), Felbamate
(FELBATOL), Carbamazepine SR (TEGRETOL SR), Topiramate (TOPAMAX),
Oxcarbazepine (TRILEPTAL)
GELNIQUE GEL (QL)
*
*
*
*
*
*
*
*
*
*
GENERESS FE CHEWABLE TABLET
GENGRAF CAPSULES / SOLUTION
GENOPTIC OPHTHALMIC OINT./ SOLUTION
Gentamicin Ophthalmic Solution & Ointment
Gentamicin Sulfate Cream / Ointment
GEODON CAPSULES
GESTICARE DHA
Gianvi Tablets
GIAZO TABLETS (EST)
Gildagio Tablets
Gildess Fe Tablets
Gildess Tablets
GILENYA CAPSULES (PA) (LD) (N)
GILOTRIF TABLETS (PA) (N)
GLEEVEC TABLETS (N)
Glimepiride Tablets
Glipizide Long Acting
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Prenatal Vitamins
GENERIC FOR YAZ
GENERIC FOR OVCON
GENERIC FOR LOESTRIN FE
GENERIC FOR LOESTRIN
AVAILABLE THROUGH SPECIALTY PHARMACY ONLY
15
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
1
*
2/SP
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Glipizide Tablets
GLUCAGEN (QL) (Covered under Pharmacy only if Plan has a "Specialty Tier")
2/SP
GLUCAGON (QL) (Covered under Pharmacy only if Plan has a "Specialty Tier")
1
*
GLUCOPHAGE TABLETS
1
*
GLUCOPHAGE XR TABLETS
1
*
GLUCOTROL TABLETS
1
*
GLUCOTROL XL TABLETS
1
*
GLUCOVANCE TABLETS
1
1
3
1
*
*
*
Glyburide Micronized Tablets
Glyburide Tablets
GLYCATE TABLETS
Glycopyrrolate Tablets
1
*
GLYNASE TABLETS
GLYSET TABLETS
Acarbose (PRECOSE)
*
GOLYTELY SOLUTION
NULYTELY SOLUTION
1
*
Griseofulvin Microsize Suspension
1
*
Griseofulvin Ultramicrosized Tablets
1
*
GRIS-PEG TABLETS
1
*
Guaifenesin 10 / Codeine Phosphate 100 Liq NR Expectorant
1
*
Guaifenesin 100 / Codeine 10 / Pseudoephedrine 30
1
*
Guaifenesin 100 / Codeine 10 Expectorant
1
*
Guaifenesin 600 / Pseudoephedrine 120 Tablets
1
*
Guanabenz Tablets
1
*
Guanfacine Tablets
3
*
Guanfacine hcl SR 24hr Tablet
*
HALCION TABLETS
3
GLUMETZA TABLETS
3
3
3
GRALISE TABLETS (PA)
2
1
GUANIDINE TABLETS
3
1
Augmented Betamethasone Dip. (DIPROLENE AF), Betamethasone Val.
(VALISONE), Fluocinonide (LIDEX/E), Diflorasone cream (MAXIFLOR,
PSORCON E)
HALOG CREAM / OINTMENT
*
Haloperidol Tablets
1
*
HCTZ TABLETS / CAPSULES
1
1
3
3
2
2
2
3
1
3
2
2
2
2
2
2
1
2
2
2
1
1
1
1
1
3
1
1
1
1
*
*
*
Heather Tablets
HECORIA CAPSULES
HECTOROL CAPSULES
HEMANGEOL ORAL SOLUTION
HEMENATAL OB + DHA
HEPSERA TABLETS
HEXALEN CAPSULES
HIPREX TABLETS
Homatropine Ophthalmic Solution
HORIZANT TABLETS (QL)
HUMALOG INSULIN (QL)
HUMALOG INSULIN PENS (QL)
HUMALOG MIX 50/50 INSULIN (QL)
HUMALOG MIX 50/50 INSULIN PENS / KWIKPENS (QL)
HUMALOG MIX 75/25 INSULIN / KWIKPENS (QL)
HUMALOG MIX 75/25 INSULIN PENS / KWIKPENS (QL)
HUMATIN CAPSULES
HUMULIN INSULIN (QL)
HUMULIN INSULIN PENS (QL)
HYCAMTIN CAPSULES (PA) (N)
HYCODAN SYRUP
HYCOTUSS EXPECTORANT
Hydralazine Tablets
HYDREA TABLETS
Hydrochlorothiazide (HCTZ) Capsules 12.5mg
Hydrochlorothiazide (HCTZ) Tablets 12.5mg
Hydrochlorothiazide (HCTZ) Tablets 25mg, 50mg
Hydrocodone - Ibuprofen Tablets
Hydrocodone 2.5 / Phenylephrine 5 / Chlorpheniramine 2 Syrup
Hydrocodone 2.5 / Guaifenesin 100 / Pseudoephedrine 30 Soln
3/SP
HARVONI TABLETS (SP) (N)
*
*
*
*
*
*
*
*
*
*
*
*
*
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
16
GENERIC FOR ORTHO MICRONOR
Calcitriol (ROCALTROL)
Prenatal Vitamins
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
1
1
1
1
*
*
*
*
Hydrocodone 5 / Guaifenesin 100 Expectorant
Hydrocodone 5 / Homatropine 1.5 Syrup
Hydrocortisone (Rectal Cream)
Hydrocortisone 2.5% Cream / Ointment
1
*
Hydrocortisone / Chloroxylenol / Pramoxine hydrochloride Otic Sol.
1
*
Hydrocortisone / Neomycin / Polymyxin Ophth. Susp & Oint
1
*
Hydrocortisone / Neomycin / Polymyxin Otic Solution/ Susp.
1
*
Hydrocortisone 2.5% Lotion
1
*
Hydrocortisone Butyrate Cream
3
*
Hydrocortisone Butyrate Ointment
1
1
*
*
Hydrocortisone Retention Enema
Hydrocortisone Suppositories
1
*
Hydrocortisone Tablets
3
*
Hydrocortisone Valerate Cream / Ointment
1
*
HYDROCORTONE TABLETS
1
*
HYDRODIURIL TABLETS
1
*
Hydromorphone Tablets
1
*
Hydroxychloroquine Tablets
1
*
Hydroxyurea Tablets
1
*
Hydroxyzine HCl Tablets
1
*
Hydroxyzine Pamoate Capsules
1
*
Hyoscyamine Sulfate CR Tablets
1
*
Hyoscyamine Sulfate Tablets
1
*
HYPERCARE 20% SOLUTION
1
*
HYTONE CREAM / OINTMENT
1
*
HYTRIN TABLETS / CAPSULES
1
*
HYZAAR TABLETS
3
*
Ibandronate Tablets (QL)
1
*
IBU TABLETS
1
*
Ibuprofen Tablets
*
ILOTYCIN OPHTHALMIC OINTMENT
1
*
IMDUR TABLETS
3
1
1
1
1
1
3/SP
3
1
1
1
1
1
1
1
1
1
3
3
2
3
1
2
3
3
*
*
*
*
*
*
*
Imipramine Pamoate Capsules
Imipramine Tablets
Imiquimod Cream 5%
IMITREX NASAL SPRAY (QL)
IMITREX TABLETS (QL)
IMURAN TABLETS
INCIVEK TABLETS (PA) (LD) (N)
INCRUSE ELLIPTA POWDER
Indapamide Tablets
INDERAL LA CAPSULES
INDERAL TABLETS
INDERIDE TABLETS
INDOCIN CAPSULES
INDOCIN SR CAPSULES
Indomethacin Capsules
Indomethacin, Sustained Release Capsules
INFLAMASE FORTE OPHTHALMIC SOLUTION & OINTMENT
INLYTA TABLETS (PA) (N)
INNOPRAN XL CAPSULES
INSPIREASE
INSPRA TABLETS
INTAL INHALER
INTELENCE TABLETS
INTERMEZZO SL TABLETS (PA) (SL)
Introvale Tablets (3 Months)
3
*
INTUNIV TABLETS (QL)
3
1
Fluocinolone, Triamcinolone, Mometasone (ELOCON)
ICLUSIG TABLETS (PA) (N) (LD)
3
3
2
Fluocinolone (SYNALAR), Triamcinolone (KENALOG), Mometasone
(ELOCON)
IMBRUVICA CAPSULES (PA) (LD) (N)
*
*
*
*
*
*
*
*
*
*
*
AVAILABLE THROUGH SPECIALTY PHARMACY ONLY
Propranolol ER (INDERAL LA CAPSULES)
Spironolactone (ALDACTONE)
GENERIC FOR SEASONALE
Amphetamine-Dextroamphetamine (ADDERALL,ADDERALLXR), CLONIDINE
TABLETS (CATAPRES), Methylphenidate SA (CONCERTA), Methylphenidate
(RITALIN), Gaunfacine (TENEX)
INVEGA TABLETS
INVIRASE CAPSULES
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
17
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
2
2
1
1
3
1
1
3
1
1
*
*
*
*
*
*
*
2
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
INVOKAMET TABLETS
INVOKANA TABLETS
Iodinated Glycerol / Dextromethorphan Syrup
IOPHEN-DM SYRUP
IOPIDINE OPHTHALMIC SOLUTION
Ipratropium Inhaler
Ipratropium Nebulizer Solution
Ipratropium-Albuterol Nebulizer Solution
Irbesartan Tablets
Irbesartan Tablets / Hydrochlorthiazde Tablets
IRESSA TABLETS
2
ISENTRESS TABLETS
1
*
Isoniazid Tablets
1
*
ISOPTIN SR TABLETS
1
*
ISOPTIN TABLETS
1
*
ISOPTO ATROPINE OPHTHALMIC SOLUTION
1
*
ISOPTO CARPINE OPHTHALMIC SOLUTION
1
*
ISOPTO-HOMATROPINE OPHTHALMIC SOLUTION
1
*
ISORDIL TABLETS
1
*
Isosorbide Dinitrate Tablets
1
1
3
*
*
Isosorbide Mononitrate Tablets
Isotretinoin Caps (QL)
ISTALOL OPHTHALMIC SOLUTION
1
*
Itraconazole Capsules (PA)
2
ISOPTO CETAPRED OPHTHALMIC SOLUTION
Timolol (TIMOPTIC)
2
JAKAFI TABLETS (N)
NOT AVAILABLE THRU MAIL ORDER
3
JALYN CAPSULES (EST)
Finasteride (PROSCAR and Tamsulosin (FLOMAX)
1
*
JANTOVEN TABLETS
2
JANUMET TABLETS
2
JANUMET XR TABLETS
2
JANUVIA TABLETS
3
JARDIANCE TABLETS
2
JENTADUETO TABLETS
1
*
Jinteli Tablets
3
*
Jolessa Tablets (3 MO SUPPLY)
GENERIC FOR SEASONALE
1
*
Jolivette Tablets
GENERIC FOR ORTHO MICRONOR
1
*
Junel Fe Tablets
GENERIC FOR LOESTRIN Fe
1
*
Junel Tablets
GENERIC FOR LOESTRIN
1
3
2
2
1
3
3
1
1
3
1
3
1
1
1
1
1
1
*
*
*
*
*
*
*
KADIAN CR CAPSULES 10MG, 20MG, 30MG, 50MG, 80MG, 100MG (QL)
KADIAN CR CAPSULES 40MG, 70MG,130MG, 150MG, 200MG (QL)
KALETRA CAPSULES
KALYDECO TABLETS (PA) (N)
KAON-CL TABLETS
KAPVAY SR TABLETS (QL)
KARBINAL ER SUSPENSION
Kariva Tablets
GENERIC FOR MIRCETTE
KAYEXALATE POWDER
KAZANO TABLETS
K-DUR TABLETS
KEFLEX 750MG CAPSULES
Cephalexin 500mg (KEFLEX 500mg)
KEFLEX CAPSULES 250MG & 500MG
KEFLEX SUSPENSION
Kelnor Tablets
GENERIC FOR DEMULEN
KENALOG CREAM / OINTMENT
KENALOG IN ORABASE
KEPPRA TABLETS
3
*
KEPPRA XR TABLETS
*
KERLONE TABLETS
3
JUBLIA SOLUTION (PA)
3
JUXTAPID CAPSULES (PA) (LD) (N)
*
*
*
*
*
3
1
3
GENERIC FOR FEMHRT
KERALAC CREAM / LOTION 50%
Atenolol (TENORMIN), Metoprolol/SR (LOPRESSOR, TOPROL XL)
KERYDIN SOLUTION (PA) (QL)
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
18
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
3
DRUG NAME
KETEK CAPSULES
1
*
Ketoconazole 2% Cream (QL)
3
1
1
*
*
*
Ketoconazole 2% Shampoo
Ketoconazole Tablets
Ketoprofen Capsules
1
*
Ketorolac Ophthalmic Solution
1
*
Ketorolac Oral Tablets (QL)
2
KETOSTIX (QL)
3
*
KLARON LOTION
1
*
KLONOPIN TABLETS
1
*
KLONOPIN WAFERS
1
*
KLOR-CON PACKETS
1
*
KLOR-CON TABLETS
*
K-LYTE (DS) PACKETS
2
1
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Amoxicillin/clavulanate (AUGMENTIN), Azithromycin (ZITHROMAX),
Doxycycline (VIBRAMYCIN), Clarithromycin/SR (BIAXIN XL)
Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A
MICRO), DIFFERIN, Clindamycin/Benzoyl Peroxide (DUAC), TAZORAC,
Sulfacetamide/sulfur (SULFACET-R)
KLOR-CON TABLETS 15mEq
3
KOMBIGLYZE XR
2
K-PHOS TABLETS
1
*
K-TABS
1
*
Kurvelo Tablets
GENERIC FOR NORDETTE
2
KUVAN POWDER (LD) (N)
AVAILABLE THROUGH SPECIALTY PHARMACY ONLY
2
KUVAN TABLETS (LD) (N)
AVAILABLE THROUGH SPECIALTY PHARMACY ONLY
Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN), prochlorperazine
(COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN)
3
*
KYTRIL TABLETS (QL)
1
*
Labetalol Tablets
*
Lactulose Solution
1
*
LAMICTAL TABLETS
3
*
LAMICTAL XR TABLETS (PA)
1
*
LAMISIL TABLETS (QL)
3
1
LACRISERT INSERTS
3
3
1
3
1
1
3
2
2
1
1
1
2
1
LAMICTAL ODT (PA)
*
*
*
*
*
*
*
*
*
3
LAMISIL GRANULES, SPRAY (PA)
Lamotrigine Tablets
Lamotrigine XR Tablets (PA)
LANOXIN TABLETS
Lansoprazole Capsules
Lantoprazole Delayed Release Capsules (PA) (QL)
LANTUS SOLOSTAR (QL)
LANTUS VIALS (QL)
LARIAM TABLETS (QL)
LARODOPA TABLETS
LASIX TABLETS
LASTACAFT OPHTHALMIC SOLUTION (QL)
Latanoprost Ophthalmic Solution (QL)
Omeprazole (PRILOSEC), Pantoprazole (PROTONIX), ACIPHEX
Risperidone (RISPERDAL), Ziprasidone (GEODON), Quetiapine
(SEROQUEL), Olanzapine (ZYPREXA)
LATUDA TABLETS
3
1
*
LAZANDA NASAL SPRAY (PA)
Leena Tablets
1
*
Leflunomide Tablets
3
*
LESCOL CAPSULES (QL)
*
Lesinna Tablets
LETAIRIS TABLETS (LD) (N)
Letrozole Tablets
Leucovorin Tablets
LEUKERAN TABLETS
Levalbuterol Nebulizer Solution
LEVAQUIN TABLETS (QL)
LEVEMIR INSULIN (QL) VIALS, PEN
Levetiracetam Tablets
3
1
2
1
1
2
3
1
2
1
Lamotrigine Tablets (LAMICTAL)
GENERIC FOR TRI-NORINYL
Azathioprine, Hydroxychloroquine (PLAQUENIL), Methotrexate
(RHEUMATREX), Sulfasalazine (AZULFIDINE)
Atorvastatin (LIPITOR), Lovastatin (MEVACOR), Pravastatin (PRAVACHOL),
Simvastatin (ZOCOR), VYTORIN
Atorvastatin (LIPITOR), Lovastatin (MEVACOR), Pravastatin (PRAVACHOL),
Simvastatin (ZOCOR), VYTORIN
GENERIC FOR ALESSE
AVAILABLE THROUGH SPECIALTY PHARMACY ONLY
LESCOL XL TABLETS (QL) (PA)
*
*
*
*
*
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Ciprofloxacin (CIPRO), AVELOX
19
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
1
1
1
3
1
3
1
1
1
1
1
1
1
1
1
1
2
2
1
1
1
1
1
1
2
1
1
2
1
1
1
1
1
1
3
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
DRUG NAME
3
LIVALO TABLETS (EST) (QL)
3
2
1
1
*
*
LO LOESTRIN FE TABLETS
LO MINASTRIN FE
LO/OVRAL TABLETS
LOCOID CREAM
3
*
LOCOID OINTMENT
1
1
3
1
3
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
3
1
1
1
3
1
1
*
*
*
*
LODINE TABLETS / CAPSULES
LODINE XL TABLETS
LODOSYN TABLETS
LOESTRIN TABLETS
LOESTRIN 24 TABLETS
LOESTRIN FE TABLETS
LOFIBRA CAPSULES
Lomedia 24 FE
LOMOTIL TABLETS
Lomustine Capsules
LONITEN TABLETS
LOPID TABLETS
LOPRESSOR HCT TABLETS
LOPRESSOR TABLETS
LOPROX CREAM
LOPROXGEL / SHAMPOO
Lorazepam Tablets
LORCET 5/325 TABLETS
LORTAB ELIXIR 10 /300 mg/ 5ml
Loryna Tablets
LORZONE TABLETS
Losartan Potassium / Hydrochlorothiazide Tablets
Losartan Potassium Tablets
LOSEASONIQUE TABLETS (3 MONTH SUPPLY)
LOTEMAX OPHTHALMIC GEL / SUSPENSION (QL)
LOTENSIN HCT TABLETS
LOTENSIN TABLETS
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
LEVLEN TABLETS
LEVLITE TABLETS
Levobunolol Ophthalmic Solution
Levocitirize Tablets (QL)
Levodopa Tablets
Levofloxacin Ophthalmic Solution
Levofloxacin Oral Solution
Levofloxacin Tablets (QL)
Levonest Tablets
Levora Tablets
LEVOTHROID TABLETS
Levothyroxine Tablets
Levoxyl Tablets
LEVSIN TABLETS
LEVSINEX TABLETS
LEXAPRO TABLETS
LEXIVA TABLETS
LIALDA TABLETS
LIBRAX CAPSULES
LIBRIUM CAPSULES
LIDEX CREAM / OINTMENT
LIDEX E CREAM
Lidocaine, Viscous Solution
LIDODERM PATCHES (QL)
LINZESS CAPSULES
LIORESAL TABLETS
LIPITOR TABLETS (QL)
LIPTRUZET TABLETS (QL)
LIQUID PRED SOLUTION
Lisinopril / HCTZ Tablets
Lisinopril Tablets
Lithium Carbonate CR Tablets
Lithium Carbonate Tablets / Capsules
LITHOBID TABLETS
LITHOSTAT TABLETS
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
GENERIC FOR TRIPHASIL,TRI-LEVLEN
GENERIC FOR NORDETTE
Atorvastatin (LIPITOR), Pravastatin (PRAVACHOL), Simvastatin (ZOCOR),
VYTORIN
Betamethasone dipropionate lotion, Betamethasone valerate 0.1% cream
(BETA-VAL), Fluocinolone 0.025% (SYNALAR), Mometasone (ELOCON),
Triamcinolone 0.1% (ARISTOCORT, KENALOG)
GENERIC FOR LOESTRIN 24 FE
GENERIC FOR YAZ
20
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
1
1
3
*
*
LOTREL CAPSULES
LOTRISONE CREAM / LOTION (QL)
LOTRONEX TABLETS
1
*
Lovastatin Tablets (QL)
1
*
LOVAZA CAPSULES
Niacin SR, Gemfibrozil (LOPID), Fenofibrate (TRICOR), TRILIPIX
1
*
Low-Ogestrel Tablets
GENERIC FOR LO/OVRAL
1
*
Loxapine Capsules
1
*
LOXITANE CAPSULES
1
*
LOZOL TABLETS
2
LUMIGAN OPHTHALMIC SOLUTION (QL)
Flurazepam (DALMANE), Temazepam (RESTORIL), Triazolam (HALCION),
Zolpidem (AMBIEN), Zaleplon (SONATA)
3
*
LUNESTA TABLETS (QL)
1
*
LURIDE TABLETS
1
*
Lutera Tablets
GENERIC FOR ALESSE
1
*
LUVOX CR CAPSULES
Fluvoxamine (LUVOX) Tablets
3
LUZU CREAM
3
LYBREL TABLETS
3
LYNPARZA CAPSULES
3
LYRICA TABLETS / SOLUTION (PA) (QL)
2
LYSODREN TABLETS
3
Gabapentin (NEURONTIN)
LYSTEDA TABLETS (QL)
1
*
MACROBID CAPSULES
1
*
MACRODANTIN CAPSULES
3
*
MALARONE TABLETS
1
*
Maprotiline Tablets
3
*
MARINOL CAPSULES (PA)
Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN), prochlorperazine
(COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN)
1
*
Marlissa Tablets
GENERIC FOR NORDETTE
2
1
FANSIDAR TABLETS
MATULANE CAPSULES (LD)
*
MAVIK TABLETS
1
*
MAXALT TABLETS (QL)
1
*
MAXALT-MLT TABLETS (QL)
1
1
1
1
1
1
1
1
1
3
1
1
2
1
2
3
1
2
*
*
*
*
*
*
*
*
*
MAXIDEX OPHTHALMIC SOLUTION
MAXIFLOR CREAM / OINTMENT
MAXITROL OPHTHALMIC SOLUTION & OINTMENT
MAXIVATE CREAM / OINTMENT
MAXZIDE TABLETS
Mebendazole Tablets (QL)
MEDROL TABLETS
Medroxyprogesterone Tablets
Mefloquine Tablets (QL)
MEGACE ES SUSPENSION
MEGACE TABLETS
Megestrol Tablets
MEKINIST TABLETS (PA) (N)
Meloxicam Tablets (QL)
MENEST TABLETS
MENOSTAR PATCH (QL)
Meperidine Tablets
MEPHYTON TABLETS
2
MAXAIR AUTOHALER (QL)
*
*
*
*
3
Sumatriptan (IMITREX), Naratriptan (AMERGE), Rizatriptan (MAXALT)
Lorazepam (ATIVAN), Diazepam (VALIUM), Alprazolam (XANAX), Oxazepam
(SERAX)
Meprobamate Tablets
1
1
1
3/SP
1
2
*
*
*
3
*
METADATE CD CAPSULES
1
1
*
*
METADATE ER TABLETS (QL)
METAGLIP TABLETS
*
MEPRON SUSPENSION
Mercaptopurine Tablets
Mesalamine Enema
MESNEX TABLETS (N)
MESTINON TABLETS
MESTINON TIMESPAN TABLETS / SYRUP
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Amphetamine-Dextroamphetamine (ADDERALL or ADDERALL XR),
Methylphenidate (RITALIN, RITALIN SR, METADATE ER), Methylphenidate SA
OSM (CONCERTA), VYVANSE
21
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
3
1
1
1
1
1
1
3
2
1
2
1
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Metaxolone 800 mg Tablets
Metformin Tablets
Metformin / Glipizide Tablets
Metformin / Glyburide Tablets
Metformin SR Tablets
Methadone Tablets (QL)
Methazolamide Tablets
Methenamine Hippurate Enteric Coated
METHERGINE TABLETS (QL)
Methimazole Tablets
METHITEST TABLETS
Methocarbamol Tablets
Methotrexate Tablets
Methscopolamine Tablets 2.5 mg
Methscopolamine Tablets 5 mg
Methyldopa / Hydrochlorothiazide Tablets
Methyldopa Tablets
METHYLIN ORAL SOLN
Methylphenidate SR Tablets
Methylphenidate Tablets
Methylphenidate Tablets
Methylprednisolone Tablets
Methyltestosterone Capsules
MetiPranolol Ophth. Soln.
Metoclopramide Tablets
Metolazone Tablets
Metoprolol / HCTZ Tablets
Metoprolol SR Tablets
Metoprolol Tablets
METROCREAM TOPICAL CREAM
METROGEL GEL TOPICAL
METROGEL VAGINAL GEL
METROLOTION 0.75%
Metronidazole Capsules 375 mg
Metronidazole Lotion 0.75%
Metronidazole Tablets 250 mg and 500 mg Only
Metronidazole Topical Cream
Mexiletine Capsules
MEXITIL CAPSULES
MIACALCIN NASAL SPRAY
1
*
MICARDIS HCT TABLETS
1
*
MICARDIS TABLETS
1
1
1
1
1
1
3
*
*
*
*
*
*
Microgestin Fe Tablets
Microgestin Tablets
MICRO-K CAPSULES
MICRONASE TABLETS
MICROZIDE CAPSULES
MIDRIN CAPSULES
MIGRANAL NASAL SPRAY (QL)
3
*
MILTOWN TABLETS
*
3
1
3
1
3
*
*
3
*
1
1
3
1
1
1
1
3
1
2
1
*
*
*
*
*
*
*
*
*
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Losartan / HCTZ (HYZAAR), Valsartan / HCTZ (DIOVAN HCT), Irbesartan /
HCTZ (AVALIDE), BENICAR HCT
Losartan (COZAAR), Irbesartan (AVAPRO), Valsartan (DIOVAN), Benazepril
(LOTENSIN), Lisinopril (ZESTRIL), BENICAR
GENERIC FOR LOESTRIN FE
GENERIC FOR LOESTRIN
Sumatriptan (IMITREX NASAL SPRAY)
Lorazepam (ATIVAN), Diazepam (VALIUM), Alprazolam (XANAX), Oxazepam
(SERAX)
MINASTRIN 24 CHEWABLE FE TABLETS
MINIPRESS CAPSULES
MINIVELLE PATCHES (QL)
Minocycline Capsules 50 MG, 100 MG (IMMEDIATE RELEASE ONL)
Minocycline SR Tablets (EST)
Minocycline Capsules (MINOCIN CAPSULES 50 MG, 100 MG; IMMEDIATE
Minocycline Tablets (PA) 50 MG, 100 MG (IMMEDIATE RELEASE O
RELEASE ONLY-PELLETS NOT COVERED)
Minoxidil Tablets
MIRALAX POWDER (QL)
MIRAPEX ER TABLETS
MIRAPEX TABLETS
MIRCETTE TABLETS
Mirtazapine Soluble Tabs
Mirtazapine Tablets
MIRVASO OPHTHALMIC GEL (PA)
Misoprostol Tablets
MITIGARE CAPSULES
MOBIC TABLETS (QL)
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
22
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
1
1
1
1
3
3
3
1
1
1
1
1
2
1
1
3
2
1
1
1
2
1
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
DRUG NAME
*
MODICON TABLETS
MODURETIC TABLETS
Moexipril-HCTZ Tablets
Mometasone Furoate Cream / Ointment / Lotion
MONODOX CAPSULES
Mono-Linyah Tablets
Mononessa Tablets
MONOPRIL / HCT TABLETS
MONOPRIL TABLETS
Montelukast Tablets
Morphine Solution
Morphine SR Tablets (QL)
Morphine Sulfate SR Capsules (QL)
Morphine Suppositories
MOTRIN TABLETS
MOXATAG TABLETS (PA) (QL)
MOXEZA OPHTHALMIC SOLUTION
MS CONTIN TABLETS (QL)
MSIR TABLETS
MUCOMYST
MULTAQ TABLETS
Mupirocin Ointment
1
*
MY WAY TABLETS
1
*
MYAMBUTOL TABLETS
1
*
MYCELEX TROCHES
1
*
MYCOBUTIN CAPSULES
1
*
MYCOLOG II CREAM / OINTMENT
1
*
Mycophenolate Mofetil Tablets / Capsules
3
*
Mycophenolate Sodium Tablets
1
*
MYCOSTATIN CREAM / OINTMENT
1
*
MYCOSTATIN TABLETS
1
*
MYCOTRIACET CREAM / OINTMENT
1
*
MYDFRIN OPHTHALMIC SOLUTION
3
*
MYFORTIC TABLETS
*
*
*
SP
Uuse Doxycycline (VIBRAMYCIN) at tier 1
GENERIC FOR ORTHO CYCLEN
GENERIC FOR ORTHO CYCLEN
Amoxicillin Capsules
MUSE INSERTS (QL) (PA)
2
MYLERAN TABLETS
3
MYRBETRIQ TABLETS SR (QL)
1
*
MYSOLINE TABLETS
1
*
Myzilra Tablets
1
*
Nabumetone Tablets (QL)
1
*
Nadolol Tablets
3
1
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Mycophenolate (CELLCEPT)
Oxybutinin Immediate Release Tabs., Tolterodine (DETROL), Tolterodine LA
(DETROL LA), TOVIAZ
GENERIC FOR TRIPHASIL, TRI-LEVLEN
Ketoconazole (NIZORAL), Econazole (SPECTAZOLE), LAMISIL OTC - NOT
COVERED
NAFTIN CREAM / GEL
*
Naltrexone Tablets
3
NAMENDA TABLETS (PA)
3
NAMENDA XR CAPSULES (PA)
3
*
NAPRALEAN SR TABLETS
1
*
NAPROSYN TABLETS
1
*
Naproxen Sodium Tablets
1
*
Naproxen Sodium, DS Tablets
1
*
Naproxen Tablets (Enteric Coated Not Covered)
1
*
Naratriptan Tablets (QL)
1
3
1
3
2
2
2
1
3
1
2
1
*
*
*
NARDIL TABLETS
NASACORT AQ AEROSOL (QL)
NASALIDE NASAL SOLUTION
NASAREL NASAL SOLUTION
NASONEX NASAL SPRAY (QL)
NATACYN OPHTHALMIC SUSPENSION
NATAZIA TABLETS
Nateglinide Tablets
NATELLE ONE
NAVANE CAPSULES
NEBUPENT SOLUTION
Necon Tablets
*
*
*
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Donezepil (ARICEPT), Rivastigmine (EXELON)
NASONEX, Fluticasone Nasal (FLONASE), VERAMYST
NASONEX, Fluticasone Nasal (FLONASE), VERAMYST
Prenatal Vitamins
GENERIC FOR ORTHO NOVUM
23
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
3
3
2
1
1
1
1
1
1
1
3
3
2
3
1
*
*
*
*
*
*
*
*
*
3
DRUG NAME
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Diclofenac Ophthalmic Solution (VOLTAREN), ACULAR (LS) OPHTHALMIC
SOLUTION
NEVANAC OPHTHALMIC SUSPENSION
1
3
3
3
2
3
3
3
1
*
*
*
Nevirapine Tablets
Nevirapine XR Tablets
NEXA PLUS
NEXA SELECT
NEXAVAR TABLETS (LD) (N)
NEXIUM CAPSULES (PA) (QL)
NEXIUMPACKETS (PA)
NIACOR TABLETS
NIASPAN TABLETS
3
*
Nicardipine Capsules
1
1
1
2
1
1
1
3
1
1
1
1
1
1
1
2
3
1
1
1
1
1
1
1
1
1
1
1
1
1
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Nifedipine Immediate Release Tablets
Nifedipine, Sustained Release Tablets
NIKKI TABLETS
NILANDRON TABLETS
NILSTAT TABLETS
Nimodipine Capsules
NIMOTOP CAPSULES
Nislodipine Tablets
NITRO-BID CAPSULES
Nitrofurantoin Macrocrystals
Nitrofurantoin Suspension
Nitroglycerin Ointment
Nitroglycerin Oral Capsules
Nitroglycerin Patches (QL)
Nitroglycerin Sublingual Tablets
NITROLINGUAL SPRAY
NITROMIST SPRAY
NITROSTAT SL TABLETS
Nizatadine Capsules
Nizatadine Solution
NIZORAL CREAM (QL)
NIZORAL TABLETS
NOLVADEX TABLETS
NORA-BE TABLETS
NORCO TABLETS
Norethindrone Tablets
NORFLEX TABLETS
NORGESIC FORTE TABLETS
NORGESIC TABLETS
NORINYL TABLETS
1
*
NORMODYNE TABLETS
*
*
NORPACE CAPSULES
NORPACE CR CAPSULES
NORPRAMIN TABLETS
1
*
Nortrel Tablets
1
*
Nortriptyline Tablets
1
*
NORVASC TABLETS (QL)
*
*
*
*
*
*
*
*
*
*
3
1
2
1
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
NEEVO DHA
Nefazodone Tablets
NEO-FRADIN ORAL SOLUTION
Neomycin / Bacitracin / Polymyxin Ophthalmic Solution & Oint.
Neomycin / Polymyxin / Prednisone Ophth. Soln.
Neomycin Tablets
NEORAL CAPSULES
NEOSPORIN OPHTHALMIC OINTMENT
NEOSPORIN OPHTHALMIC SOLUTION
NEPTAZANE TABLETS
NESINA TABLETS
NESTABS
NESTABS DHA
NEUPRO PATCHES
NEURONTIN CAPSULES / TABLETS / SOLUTION
Prenatal Vitamins
Prenatal Vitamins
Omeprazole (PRILOSEC), Pantoprazole (PROTONIX), ACIPHEX
Omeprazole (PRILOSEC), Pantoprazole (PROTONIX), ACIPHEX
Nifedipine SR (ADALAT CC), Felodipine (PLENDIL), SULAR, Amlodipine
(NORVASC)
GENERIC FOR YAZ
Refer to Preventive Drug List
GENERIC FOR ORTHO MICRONOR
NOROXIN TABLETS
3
Ciprofloxacin (CIPRO), AVELOX
NORTHERA CAPSULES (PA)
2
NORVIR CAPSULES
3
NOVAHISTINE DH EXPECTORANT
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
GENERIC FOR ORTHO NOVUM
24
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
3
NOVOLIN (QL) (VIALS OR CARTRIDGES ONLY)
HUMULIN IS AT LOWER COST TIER
3
NOVOLOG (QL) (VIALS OR CARTRIDGES ONLY)
HUMALOG IS AT LOWER COST TIER
3
NOVOLOG MIX (VIALS OR CARTRIDGES ONLY)
HUMALOG MIX IS AT LOWER COST TIER
3
NOXAFIL DELAYED RELEASE TABLETS
3
NOXAFIL SUSPENSION
2
NUCYNTA ER TABLETS (QL)
2
NUCYNTA TABLETS (QL)
2
1
NUEDEXTA CAPSULES
*
NULYTELY SOLUTION
3
NUTRIDOX CAPSULES (PA)
USE DOXYCYCLINE HYCLATE
2
NUTRI-TAB OB + DHA
Prenatal Vitamins
2
NUVARING
3
NUVIGIL TABLETS (PA)
1
*
NYAMYC POWDER
1
*
Nystatin Cream / Ointment
1
*
Nystatin Oral Suspension
1
*
Nystatin Powder
1
*
Nystatin Tablets
3
3
1
*
*
OBREDON SOLUTION
Ocella Tablets
OCUFEN OPHTHALMIC SOLUTION
1
1
3
3/SP
2
1
1
3
1
3
3/SP
1
1
3
3
1
1
1
1
1
*
*
*
*
*
*
*
*
*
*
*
*
*
*
OCUFLOX OPHTHALMIC SOLUTION
Ofloxacin Ophthalmic Solution
Ofloxacin Tablets
OFEV CAPSULES (PA) (N)
OFORTA TABLETS (N)
OGEN TABLETS
Ogestrel Tablets
Olanzapine Orally Disintegrating Tablets
Olanzapine Tablets
OLEPTRO TABLETS 24 HR
OLYSIO CAPSULES (PA) (N)
Omega-3-Acid Ethyl Esters Capsules
Omeprazole Capsules
OMNARIS NASAL SPRAY
OMNEL TABLETS (PA)
OMNICEF CAPSULES / SUSPENSION
OMNIPEN CAPSULES / SUSPENSION
OMS CONCENTRATE
Ondansetron Orally Disintegrating Tablets (QL)
Ondansetron Tablets (QL)
3
ONETOUCH TEST STRIPS (PA) (QL)
2
2
3
3
3
ONETOUCH ULTRA TEST STRIPS (QL)
ONETOUCH VERIO IQ TEST STRIPS (QL)
ONFI TABLETS
ONGLYZA TABLETS
ONMEL TABLETS (PA)
3
ONSOLIS FILM (PA)
2
OPANA ER TABLETS (QL)
3
*
OPSUMIT TABLETS (PA)
3
OPTIVAR OPHTHALMIC SOLUTION
3
3
1
3
1
1
3
ORACEA CAPSULES (EST)
ORAFATE PASTE
Oral Colon Lavage Solution
ORAP TABLETS
ORAPRED ODT
ORASONE TABLETS
ORAVIG BUCCAL TABLETS
*
*
Ciprofloxacin (CIPRO), AVELOX
GENERIC FOR OVRAL
NASONEX, Fluticasone Nasal (FLONASE), VERAMYST
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
Morphine Sulfate (MSIR, MS CONTIN), Hydromorphone (DILAUDID), KADIAN,
OPANA ER, AVINZA, Meperidine (DEMEROL),Codeine, Oxycodone Immediate
Release, Oxycodone / Acetaminophen (PERCOCET 5/325), Oxycodone /
Aspirin (PERCODAN 5/325)
Morphine Sulfate (MSIR, MS CONTIN), Hydromorphone (DILAUDID), KADIAN,
OPANA ER, AVINZA, Meperidine (DEMEROL),Codeine, Oxycodone Immediate
Release, Oxycodone / Acetaminophen (PERCOCET 5/325), Oxycodone /
Aspirin (PERCODAN 5/325)
OPANA TABLETS
3
*
GENERIC FOR YASMIN
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
ALOMIDE, PATANOL, PATADAY, ZADITOR (AVAILABLE OTC - NOT
COVERED)
Doxycycline Hyclate (VIBRAMYCIN)
25
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
3
3
1
1
1
2
1
1
2
1
1
1
1
1
1
1
DRUG NAME
*
*
*
*
*
*
*
ORBIVAN CF TABLETS
ORENITRAM ER TABLETS (PA) (N) (LD)
Orphenadrine / Aspirin / Caffeine Tablets
Orphenadrine Citrate Tablets
Orsythia Tablets
ORTHO DIAPHRAGM
ORTHO EVRA PATCH
ORTHO MICRONOR TABLETS
ORTHO TRI-CYCLEN LO TABLETS
ORTHO TRI-CYCLEN TABLETS
ORTHO-CEPT TABLETS
ORTHO-CYCLEN TABLETS
ORTHO-EST TABLETS
ORTHO-NOVUM 10/11 TABLETS
ORTHO-NOVUM 7/7/7 TABLETS
ORTHO-NOVUM TABLETS
*
ORUDIS CAPSULES
*
OSENI TABLETS
OSPHENA TABLETS
OTEZLA TABLETS (PA) (N)
OTICIN HC OTIC SOLUTION
1
*
OVACE WASH
1
*
OVCON-35 (Balzia, Zenchent)
3
*
OVCON-50
3
*
OVIDE LOTION
1
*
OVRAL TABLETS
1
*
OXANDRIN TABLETS
1
*
Oxandrolone Tablets
1
*
Oxaprozin Tablets
1
*
Oxazepam Capsules
1
*
Oxcarbazepine Tablets / Suspension
1
3
3
3/SP
1
*
*
*
*
*
3
GENERIC FOR ALESSE
OVACE PLUS LOTION
3
OXISTAT CREAM
2
OXSORALEN ULTRA CAPSULES ONLY
3
EURAX, Permethrin (ELIMITE, ACTICIN)
Nystatin, Econazole (SPECTAZOLE), LAMISIL AT (AVAILABLE OTC - NOT
COVERED), LOTRIMIN (AVAILABLE OTC-NOT COVERED)
OXTELLAR XR SR 24 Hr. TABLETS (PA)
1
*
Oxybutynin Immediate Release Tablets
1
*
Oxybutynin SR 24 Hr. Tablets
1
*
Oxycodone 4.5 / Aspirin 325 Tablets
1
*
Oxycodone 5 / Acetaminophen 325 Tablets
1
*
Oxycodone Capsules / Tablets (Immediate Release)
3
Oxycodone HCl Tab (Abuse Deterrent)
3
Morphine Sulfate (MSIR, MS CONTIN), Hydromorphone (DILAUDID), KADIAN,
OPANA ER, AVINZA, Meperidine (DEMEROL),Codeine, Oxycodone Immediate
Release, Oxycodone / Acetaminophen (PERCOCET 5/325), Oxycodone /
Aspirin (PERCODAN 5/325)
Oxybutinin Immediate Release Tabs., Tolterodine (DETROL), Tolterodine LA
(DETROL LA), TOVIAZ
OXYCONTIN TABLETS (QL)
3
OXYTROL PATCHES
1
*
PALGIC SOLUTION
1
*
PAMELOR CAPSULES
1
*
PAMINE FORTE TABLETS
1
*
PAMINE TABLETS
*
*
*
*
*
*
*
PANCREAZE CAPSULES
PANCRELIPASE CAPSULES
PANRETIN GEL (PA)
Pantoprazole Tablets
PARCOPA ORALLY DISINTEGRATING TABLETS
PARLODEL TABLETS / CAPSULES
PARNATE TABLETS
Paromomycin Capsules
Paroxetine CR Tablets
Paroxetine HCl Tablets
PATADAY OPHTHALMIC SOLUTION (QL)
PATANASE NASAL SOLUTION
PATANOL OPHTHALMIC SOLUTION
3
2
3
1
3
1
1
1
1
1
2
3
3
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
*
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Azelastine (ASTELIN NASAL SPRAY), ASTEPRO NASAL SPRAY
ALOMIDE OPHTHALMIC SOLUTION
26
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
1
1
2
1
1
*
*
*
*
PAXIL CR TABLETS
PAXIL TABLETS
PEAK FLOW METER
PEDIAZOLE SUSPENSION
Penicillin VK Tablets / Suspension
3
*
PENLAC NAIL LACQUER
3
3
1
1
1
1
1
3
1
1
1
3
1
1
3
1
1
*
PENNSAID SOLUTION (QL)
PENTASA TABLETS
PENTOLAIR OPHTHALMIC SOLUTION
Pentoxifylline Tablets
PEPCID TABLETS
PERCOCET 5 / 325 TABLETS
PERCODAN FULL STRENGTH TABLETS
PERFOROMIST NEBULIZER SOLUTION 20MCG (QL)
PERIACTIN 2mg / 5ml SYRUP
PERIACTIN 4 MG TABLETS
PERIDEX (Covered Only With Dental Rider)
Perindopril Tablets
Perindopril Tablets
Permethrin Cream (QL)
Permethrin Lotion
Perphenazine Tablets
PERSANTINE TABLETS
*
*
*
*
*
*
*
*
*
*
*
*
*
3
1
1
1
1
1
1
1
1
3
1
1
1
1
3
1
2
2
3
1
1
2
1
1
1
1
1
1
3
1
1
1
1
3
3
3
2
3
1
1
1
1
1
1
1
2
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Ketoconazole (NIZORAL), Econazole (SPECTAZOLE), LAMISIL OTC-NOT
COVERED
Balsalazide (COLAZAL), ASACOL, LIALDA
Fluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL),
Bupropion (WELLBUTRIN, WELLBUTRIN SR)
PEXEVA TABLETS
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Phenazopyridine Tablets
Phenelzine Tablets
PHENERGAN / DM SYRUP
PHENERGAN SYRUP
PHENERGAN TABLETS
PHENERGAN VC CODEINE
PHENERGAN/ CODEINE
Phenobarbital Tablets
Phentermine Capsules / Tablets (PA)
Phenylephrine 2.5% Ophthalmic Solution
PHENYTEK CAPSULES
Phenytoin Capsules
Phenytoin Chewable Tablets
Philith Tablets
PHOSLO CAPSULES
PHOSLYRA SOLUTION
PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION
PICATO GEL
PILOCAR OPHTHALMIC SOLUTION
Pilocarpine HCL Ophthalmic Solution
PILOPINE HS OPHTHALMIC GEL
PIMA SOLUTION
Pindolol Tablets
Pioglitazone / Glimpride Tablets
Pirmella Tablets
Piroxicam Capsules
PLAN B (AGE LIMIT)
PLAN B ONE STEP (AGE LIMIT)
PLAQUENIL TABLETS
PLAVIX TABLETS (QL)
PLENDIL TABLETS
PLETAL TABLETS (QL)
PLEXION CLEANSER
PLEXION SCT CREAM
PLIAGLIS CREAM
PNV OB+DHA
PNV-DHA
POLARAMINE TABLETS
POLYCITRA-K CRYSTALS
Polyethylene Glycol 3350
POLY-HISTINE ELIXIR
Polymixin B Sulfate / Trimethoprim Ophthalmic Solution
POLYTRIM OPHTHALMIC SOLUTION
POLY-VI-FLOR TABLETS / DROPS (age limit 6 years and younger)
POMALYST CAPSULES (N)
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
27
NOT COVERED BY ALL PLANS - CHECK BENEFITS FOR COVERAGE
GENERIC FOR OVCON
GENERIC FOR ORTHO NOVUM
Prenatal Vitamins
Prenatal Vitamins
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
3
*
PONSTEL CAPSULES
1
1
1
3
1
1
1
1
1
2
2
2
2
2
1
1
1
3
1
1
1
1
1
2
2
1
1
1
1
1
2
1
1
3
2
*
*
*
Portia Tablets
Potassium Chloride 8 mEq, 10 mEq, 20 mEq
Potassium Chloride Effervescent Tablets
Potassium Chloride ER Capules 20 mEq
Potassium Chloride Liquid
Potassium Chloride Packets.
Potassium Citrate & Citric Acid Crustals
Potassium Citrate CR Tablets
Potassium Iodide Solution
POTIGA TABLETS
PR NATAL 400
PR NATAL 430
PR NATAL 430 EC
PRADAXA CAPSULES
Pramipexole Tablets
PRAMOSONE CREAM 1-2.5%
Pramoxine-Hydrocortisone Cream 1-2.5%
PRANDIMET TABLETS
PRANDIN TABLETS
PRASCION EMULSION
PRAVACHOL TABLETS (QL)
Pravastatin Tablets (QL)
Prazosin Capsules
PRECISION Q.I.D. TEST STRIPS (QL)
PRECISION XTRA TEST STRIPS (QL)
PRECOSE TABLETS
PRED FORTE OPHTHALMIC SUSPENSION
PRED MILD OPHTHALMIC SUSPENSION
Prednicarbate Cream
Prednisolone Acetate Ophthalmic Suspension 1%
Prednisolone Phosphate Ophthalmic Solution
Prednisolone Tablets
Prednisone Tablets
PREFERA OB
PREFERA OB + DHA
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
3
1
2
2
2
2
3
3
2
2
2
2
3
2
2
2
2
2
3
3
2
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
CLIMARA PRO, PREMPRO, PREMPHASE, Medroxyprogesterone
(PROVERA) PLUS Estradiol tablets (ESTRACE), Estradiol patches
(CLIMARA), VIVELLE, VIVELLE-DOT, or Estropipate (OGEN, ORTHO-EST)
PREFEST TABLETS
*
3
3
3
3
1
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Ibuprofen (MOTRIN), Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin
(DAYPRO), Sulindac (CLINORIL), Diclofenac (VOLTAREN), Piroxicam
(FELDENE)
GENERIC FOR NORDETTE
PRELONE SYRUP
PREMARIN TABLETS
PREMARIN VAGINAL CREAM
PREMPHASE TABLETS
PREMPRO TABLETS
PRENA1 PLUS/QUATREFOLIC
PRENAISSANCE
PRENAPLUS
PRENATA
PRENATABS FA
PRENATABS RX
PRENATAL 19
PRENATAL AD
PRENATAL PLUS
PRENATAL PLUS IRON
PRENATAL VITAMINS PLUS
PRENATE ESSENTIAL
PRENATE MINI
PRENEXA
PRENTIF CAVITY-RIM CERVICAL CAP
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
Omeprazole (PRILOSEC), Pantoprazole (PROTONIX), ACIPHEX
Omeprazole (PRILOSEC) OR Pantoprazole (PROTONIX) PLUS Naproxen
Omeprazole (PRILOSEC), Pantoprazole (PROTONIX), ACIPHEX
GENERIC FOR ORTHO-CYCLEN
Omeprazole (PRILOSEC) OR Pantoprazole (PROTONIX) PLUS amoxicillin
PLUS clarithromycin
PRESTIGE TEST STRIPS (PA) (QL)
*
*
*
PREVACID CAPSULES (QL)
PREVACID NAPRAPAC (PA) (QL)
PREVACID SOLUTABS (PA) (QL)
Previfem Tablets
2
PREVPAC (PA) (QL)
2
PREZISTA TABLETS (QL)
3
PRILOSEC SUSPENSION (PA)
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
28
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
2
1
DRUG NAME
*
3
Primidone Tablets
PROAIR HFA
1
*
Probenecid / Colchicine Tablets
1
1
1
*
*
*
Probenecid Tablets
Procainamide Capsules
Prochlorperazine Tablets / Supositories
1
*
PROCTOCORT SUPPOSITORIES
1
*
PROCTO-CREAM
2
PROCTOFOAM HC
3
PROCYSBI CAPSULES (PA) (N)
1
*
PRODRIN TABLETS
3
*
Progesterone Micronized Capsules
*
PROGRAF CAPSULES
*
PROLIXIN TABLETS
1
*
Promethazine / Codeine Syrup
1
*
Promethazine / Phenylephrine Syrup
1
1
1
3
*
*
*
*
Promethazine Suppository
Promethazine Syrup
Promethazine Tablets
PROMETRIUM CAPSULES (QL)
1
*
Propafenone Tablets
1
*
PROPINE OPHTHALMIC SOLUTION
1
*
Propranolol / Hydrochlorothiazide Tablets
1
1
1
*
*
*
Propranolol Tablets
Propylthiouracil (PTU) TABLETS
PROSCAR TABLETS (AGE LIMIT)
1
*
PROSOM TABLETS
3
PROGLYCEM SUSPENSION
3
1
PROLENSA OPHTHALMIC SOLUTION
3
PROMACTA TABLETS (PA) (QL) (N)
1
2
1
1
2
1
1
Citalopram (CELEXA, Setraline (ZOLOFT), Fluoxetine (PROZAC), Paroxetine
(PAXIL), Venlafaxine XR (EFFEXOR XR)
USE PROVENTIL HFA
PRISTIQ TABLETS (EST) (QL)
3
1
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
PRIMAQUINE TABLETS
Promethazine / Phenylephrine/ Codeine Syrup
Medroxyprogesterone (PROVERA), Norethindrone (AYGESTIN)
Temazepam (RESTORIL), Flurazepam (DALMANE), Oxazepam (SERAX),
Triazolam (HALCION), Zolpidem (AMBIEN)
*
*
PROSTIGMIN TABLETS
PROTONIX TABLETS
PROTOPIC OINTMENT (PA) (QL)
PROVENTIL HFA AEROSOL (QL)
PROVENTIL NEBULIZER SOLUTION
PROVERA TABLETS
3
*
PROVIGIL TABLETS (PA) (QL)
1
*
PROZAC CAPSULES
1
*
PROZAC TABLETS
3
*
PROZAC WEEKLY CAPSULES
1
1
2
1
*
*
PSORCON CREAM / OINTMENT
PSORCON E CREAM
PULMICORT FLEXHALER (QL)
PULMICORT INHALATION SUSPENSION 0.25MG, 0.5MG (QL)
*
*
*
2
PULMOZYME (QL) (N)
*
PURINETHOL TABLETS
1
*
PYRAZINAMIDE TABLETS
1
*
PYRIDIUM TABLETS
1
*
Pyridostigmine Tablets
3
3
SP
Fluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL),
Bupropion (WELLBUTRIN, WELLBUTRIN SR)
Fluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL),
Bupropion (WELLBUTRIN, WELLBUTRIN SR)
PULMICORT INHALATION SUSPENSION 1 MG
2
1
Amphetamine-Dextroamphetamine (ADDERALL or ADDERALL XR),
Methylphenidate (RITALIN, RITALIN SR, METADATE ER), Methylphenidate SA
OSM (CONCERTA), VYVANSE
PURIXAN SUSPENSION
QNASL AEROSOL
Fluticasone (FLONASE), NASONEX, VERAMYST
QSYMIA CAPSULES (PA)
NOT COVERED BY ALL PLANS - CHECK BENEFITS FOR COVERAGE
3
QUALAQUIN CAPSULES (PA) (QL)
3
QUARTETTE TABLETS (3 Months supply)
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
29
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
3
DRUG NAME
*
Quasense Tablets (3 months)
1
*
QUESTRAN BULK - POWDER ONLY
1
*
QUESTRAN LIGHT - POWDER ONLY
1
*
Quetiapine fumarate Tablets
1
1
1
*
*
*
QUINAGLUTE TABLETS
Quinapril Tablets
QUINIDEX TABLETS
1
*
Quinidine Gluconate Tablets
1
*
Quinidine Sulfate Sustained Release Tablets
1
*
Quinidine Sulfate Tablets
3
*
QUIXIN OPHTHALMIC SOLUTION
3
QUDEXY XR CAPSULES
3
QUILLIVANT XR SUSPENSION
2
*
Rabeprazole Tablets (PA) (QL)
1
*
Raloxifene Tablets (QL)
1
*
Ramipril Capsules
1
*
Ranitidine 300 mg Tablets Only
1
*
Ranitidine 75mg / 5ml Syrup
*
RAPAMUNE CAPSULES
3
RAPAFLO TABLETS
3
Terazosin (HYTRIN), Tamsulosin (FLOMAX), Doxazosin (CARDURA)
RAVICTI LIQUID (PA) (N) (LD)
*
*
*
*
*
*
*
*
3
RAYOS TABLETS (N)
RAZADYNE ER CAPSULES (QL)
RAZADYNE TABLETS
REBETOL CAPSULES (PA) (N)
Reclipsen Tablets
REGIMEX TABLETS (PA)
REGLAN TABLETS
REGRANEX GEL (PA) (QL)
RELAFEN TABLETS (QL)
RELENZA (QL)
RELPAX TABLETS (QL)
REMERON SOLTABS
REMERON TABLETS
Donezepil (ARICEPT), Rivastigmine (EXELON)
Donezepil (ARICEPT), Rivastigmine (EXELON)
GENERIC FOR ORTHO-CEPT
NOT COVERED BY ALL PLANS - CHECK BENEFITS FOR COVERAGE
Sumatriptan (IMITREX), Naratriptan (AMERGE), Rizatriptan (MAXALT)
Calcium Carbonate (OTC AVAILABLE: NOT COVERED), Calcium Acetate
(PHOSLO)
Calcium Carbonate (OTC AVAILABLE: NOT COVERED), Calcium Acetate
(PHOSLO)
RENAGEL TABLETS
3
RENVELA TABLETS
1
1
1
*
*
*
Repaglinide Tablets
REPREXAIN TABLETS
REQUIP TABLETS
1
*
REQUIP XL TABLETS
2
RESCRIPTOR TABLETS
3
2
3
RESCULA OPHTHALMIC SOLUTION (QL)
RESERPINE TABLETS
RESTASIS OPHTHALMIC EMULSION (QL)
3
*
RESTORIL 22.5 MG CAPSULES
1
*
RESTORIL 7.5 MG, 15 MG, 30 MG CAPSULES
1
*
RETIN A CREAM / GEL
2
REFRESH, VISINE TEARS (OTC NOT COVERED)
RETIN A MICRO 0.04% GEL (QL)
3
RETIN A MICRO 0.08% GEL (PA)
1
*
RETROVIR CAPSULES / TABLETS
3
*
REVATIO TABLETS (PA) (N)
1
*
REVIA TABLETS
3
REVLIMID CAPSULES (PA) (LD) (N)
3
REXAPHENAC CREAM (QL)
2
1
3
3
1
Refer to Preventive Drug List
RANEXA TABLETS (QL)
3
3
3
3
1
1
3
1
3
1
3
3
1
1
Ciprofloxacin (CILOXAN), OCUFLOX
QVAR INHALER (QL)
3
3
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
GENERIC FOR SEASONALE
TRACLEER, LETAIRIS
AVAILABLE THROUGH SPECIALTY PHARMACY ONLY
REYATAZ CAPSULES
*
*
*
RHEUMATREX TABLETS
RHINOCORT AQUA (QL)
RIAX FOAM
Ribavirin Tablets / Capsules (PA) (N)
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Fluticasone (FLONASE), NASONEX, VERAMYST
30
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
2
1
1
2
1
3
3
3
3
1
3
1
DRUG NAME
*
*
*
RIDAURA CAPSULES
Rifabutin Capsules
RIFADIN CAPSULES
RIFAMATE CAPSULES
Rifampin Capsules
RILUTEK TABLETS
Riluzole Tablets
Rimantadine Tablets
RIOMET SOLUTION
RISPERDAL TABLETS
RISPERDAL-M TABLETS
Risperidone Tablets
3
*
RITALIN LA CAPSULES
1
1
1
1
1
1
1
1
*
*
*
*
*
*
*
*
RITALIN SR TABLETS
RITALIN TABLETS
ROBAXIN TABLETS
ROBINUL FORTE TABLETS
ROBINUL TABLETS
ROCALTROL CAPSULES
RONDEC DM SYRUP
Ropinirole Tablets
3
*
ROSAC CREAM
1
*
ROSULA CLARIFYING WASH
3
*
ROSULA GEL
1
1
1
*
*
*
ROWASA ENEMA
ROXICET 5 / 325 TABLETS
ROXICODONE
*
*
*
*
*
3
ROZEREM TABLETS (EST) (QL)
3
3
1
1
*
*
RYBIX ODT
RYTARY CR CAPSULE
RYTHMOL SR CAPSULES
RYTHMOL TABLETS
3
*
RYZOLT SR TABLETS
2
*
SALAGEN TABLETS
1
*
SALEX CREAM
1
*
Salicylic Acid Cream
1
*
Salsalate Tablets
1
*
SANCTURA TAB 20MG
1
*
SANCTURA XR CAPSULES
2
Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A
MICRO), DIFFERIN, Clindamycin/Benzoyl Peroxide (DUAC), TAZORAC,
Sulfacetamide/sulfur (SULFACET-R)
Flurazepam (DALMANE), Temazepam (RESTORIL), Triazolam (HALCION),
Zolpidem (AMBIEN)
SAMSCA TABLETS (QL) (N)
3
Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN), prochlorperazine
(COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN)
SANCUSO PATCHES (PA) (QL)
*
SANDIMMUNE CAPSULES
*
SARAFEM CAPSULES
2
3
1
3
1
1
3
1
1
1
3
1
1
2
Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A
MICRO), DIFFERIN, Clindamycin/Benzoyl Peroxide (DUAC), TAZORAC,
Sulfacetamide/sulfur (SULFACET-R)
SAFYRAL TABLETS
1
3
Amphetamine-Dextroamphetamine (ADDERALL or ADDERALL XR),
Methylphenidate (RITALIN, RITALIN SR, METADATE ER), Methylphenidate SA
OSM (CONCERTA), VYVANSE
SABRIL TABLETS / PACKETS (LD) (N)
2
1
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
SAPHRIS SL TABLETS
*
*
*
*
*
*
*
*
*
Fluoxetine Capsules (PROZAC)
SAVELLA TABLETS (PA) (QL)
Scopolamine HBr Ophthalmic Solution
SEASONALE (3 MONTH SUPPLY) (Quasense, Jolessa)
SEASONIQUE (3 MONTH SUPPLY) (Amethia, Camrese, Daysee)
SECTRAL CAPSULES
SELECT-OB+DHA
Prenatal Vitamins
Selegiline Tablets
Selenium Sulfide 2.5% Lotion
Selenium sulfide-pyrithione zinc in Urea Shampoo
SELRX SHAMPOO
SELSEB SHAMPOO
SELSUN LOTION
SELZENTRY TABLETS
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
31
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
3
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Calcium Carbonate (OTC AVAILABLE: NOT COVERED), Calcium Acetate
(PHOSLO)
SENSIPAR TABLETS (N)
1
1
1
2
3
*
*
*
SEPTRA DS TABLETS
SEPTRA TABLETS
SERAX CAPSULES
SEREVENT DISKUS (QL)
SEROMYCIN CAPSULES
SP
*
SEROPHENE TABLETS (QL)
1
3
1
2
1
3
1
1
2
1
1
1
1
1
3
3
3
2
3
1
1
1
3
3
1
3
3
3
1
1
1
3
3
1
1
3/SP
1
*
*
SEROQUEL TABLETS
SEROQUEL XR TABLETS
Sertraline Tablets
SETON ET-EC
Sildenafil 20 mg Tablets (PA) (N)
SILENOR TABLETS (EST)
SILVADENE CREAM
Silver Sulfadiazine cream
SIMCOR EXTENDED RELEASE TABLETS
Simvastatin 10 mg, 20 mg, 40 mg, 80 mg Tablets
SINEMET CR TABLETS
SINEMET TABLETS
SINEQUAN CAPSULES
SINGULAIR TABLETS
Sirolimus Capsules
SIRTURO TABLETS (N)
SITAVIG BUCCAL TABLETS (PA)
SIVEXTRO TABLETS (QL)
SKELAXIN TABLETS
Sodium Fluoride Tablets and Drops (age limit 6 years and younger)
Sodium Polysterene Sulfonate Powder
Sodium Polysterene Sulfonate Solution
SOLAICE PADS
SOLARAZE GEL
Solia Tablets
SOLODYN SR TABS (EST)
SOLTAMOX SOLUTION
SOMA 250 MG TABLETS
SOMA 350 MG TABLETS
SOMA COMPOUND 250/325 MG TABLETS
SONATA CAPSULES (QL)
SORIATANE CAPSULES
SORILUX AEROSOL (QL)
Sotalol Tablets
SOTRET CAPSULES (QL)
SOVALDI TABLETS (PA) (N)
SPECTAZOLE CREAM
3
*
SPECTRACEF TABLETS
2
1
1
1
1
3
2
1
1
1
1
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
NOT COVERED BY ALL PLANS - CHECK BENEFITS AND SPECIFIC COPAY
Prenatal Vitamins
USE EFUDEX (Fluoruracil)
GENERIC FOR ORTHO-CEPT
Minocycline Capsules (MINOCIN CAPSULES)
Cefdinir (OMNICEF), Cefprozil (CEFZIL), Cefuroxime (CEFTIN), Cefadroxil
(DURICEF), Cephalexin (KEFLEX)
*
*
*
*
SPIRIVA INHALER (QL)
Spironolactone / HCTZ Tablets
Spironolactone Tablets
SPORANOX CAPSULES (PA)
Sprintec Tablets
SPRIX NASAL SPRAY (QL)
SPRYCEL TABLETS (N)
SPS SOLUTION
Sronyx Tablets
SSD CREAM
SSKI SOLUTION
3
*
STADOL NASAL SPRAY (QL)
Acetaminophen and codeine (TYLENOL/CODEINE), Hydrocodone and
Acetaminophen (VICODIN, LORTAB), Tramadol (ULTRAM)
1
1
1
*
*
*
STALEVO TABLETS
STARLIX TABLETS
Stavudine Capsules
Repaglinide (PRANDIN)
STAVZOR CAPSULES
Valproic Acid (DEPAKENE), Divalproex sodium/ER (DEPAKOTE/ER)
3
SP
SP
*
*
*
*
GENERIC FOR ORTHO-CYCLEN
GENERIC FOR ALESSE
STAXYN TABLETS (PA) (QL)
STENDRA TABLETS (PA) (QL)
3
STIMATE SOLUTION (N)
3
STIVARGA TABLETS (PA) (N)
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
32
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
3
STRATTERA CAPSULES (QL)
3
STRIANT BUCCAL TABLETS
2
STRIBILD TABLETS
3
STRIVERDI RESPIMAT (QL)
3
1
3
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
3
3
SUBOXONE SL FILM (PA)
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
3
3
2
2
1
2
3
3/SP
1
*
*
*
*
SURMONTIL CAPSULES
SUSTIVA CAPSULES / TABLETS
SUTENT CAPSULES (N)
GLEEVEC - AVAILABLE THROUGH SPECIALTY PHARMACY ONLY
Syeda Tablets
GENERIC FOR YASMIN
SYMBICORT AEROSOL
SYMBYAX CAPSULES
Olanzapine (ZYPREXA) PLUS Fluoxetine (PROZAC)
SYMLIN INJECTION (PA) (Covered under Pharmacy only if Plan has a "Specialty Tier") (N)
SYNALAR CREAM / OINTMENT / SOLUTION
SYNTHROID TABLETS
SYPRINE CAPSULES
2
TABLOID TABLETS
*
3
TACLONEX OINTMENT (EST) (QL)
Calcipotriene (DOVONEX) OR VECTICAL plus Betamethasone Dipropionate
TACLONEX SUSPENSION (EST) (QL)
*
Tacrolimus Capsules
1
*
TAGAMET 400 MG, 800 MG TABLETS
3
*
TALWIN NX TABLETS
1
*
TAMBOCOR TABLETS
1
*
Tamoxifen Citrate Tablets
1
*
Tamsulosin Capsules
2
TAFINLAR CAPSULES (N) (PA)
3
SP
1
2
2
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
Amitriptyline (ELAVIL), Doxepin (SINEQUAN), Nortriptyline (PAMELOR),
Imipramine (TOFRANIL), Paroxetine (PAXIL), Citalopram (CELEXA),
Fluoxetine (PROZAC), Sertraline (ZOLOFT)
SYNERA PATCHES
*
3
1
SUBSYS SPRAY (PA)
SUBUTEX (PA)
SUCRAID SOLUTION (PA) (N)
Sucralfate Tablets
SULAR SR TABLETS
SULFACET R LOTION (QL)
Sulfacetamide / Prednisolone Acetate Susp. & Oint.
Sulfacetamide / Prednisolone Ophthalmic Ointment
Sulfacetamide / Sulfur Lotion 10 % (QL)
Sulfacetamide Ophthalmic Solution
Sulfacetamide sodium liquid 10% Wash
Sulfacetamide Sodium w/ Sulfur Cream 10-5%
Sulfacetamide Sodium w/ Sulfur Emulsion 10-5%
Sulfacetamide Sodium w/ Sulfur Suspension 8%-4%
Sulfacetamide Sodium w/ Sulfur Suspension 9%-4%
Sulfacetamide Sodium-Sulfur in Urea Emulsion 10-4%
Sulfamethoxazole / Trimethoprim (SMZ / TMP) Tablets
Sulfamethoxazole / Trimethoprim DS (SMZ / TMP DS) Tablets
SULFAMYLON CREAM
Sulfasalazine Tablets (Enteric Coated Tablets Not Covered)
Sulindac Tablets
Sumatriptan Tablets (QL)
SUMAXIN TS SUSPENSION
SUMAXIN WASH
SUPRAX 400 MG CAPSULES (PA)
SUPRAX SUSPENSION / CHEW TABLETS
SYNAREL NASAL SOLUTION
3
3
SUBOXONE SL TABLETS (PA)
SURESTEP TEST STRIPS (PA) (QL)
2
1
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Amphetamine-Dextroamphetamine (ADDERALL or ADDERALL XR),
Methylphenidate (RITALIN, RITALIN SR, METADATE ER), Methylphenidate SA
OSM (CONCERTA), VYVANSE
ANDROGEL, METHITEST TABLETS
Hydrocodone and Acetaminophen (VICODIN, LORTAB)
TAMIFLU (QL)
*
Refer to Preventive Drug List
TANZEUM INJECTION (PA)
TAPAZOLE TABLETS
TARCEVA TABLETS (PA) (N)
TARGRETIN CAPSULES (N)
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
33
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
3
3
3
2
3
1
2
3/SP
1
1
2
2
2
1
1
3
1
1
1
1
1
1
1
1
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
TARKA TABLETS
*
*
*
*
*
*
*
*
*
*
*
TARON-BC
TARON-PREX
TASIGNA CAPSULES (PA) (N)
TASMAR TABLETS
TAVIST TABLETS
TAZORAC CREAM / GEL (QL)
TECFIDERA CAPSULES (PA) (LD) (N)
TEGRETOL TABLETS
TEGRETOL XR TABLETS
TEKAMLO TABLETS (EST)
TEKTURNA HCT TABLETS (EST)
TEKTURNA TABLETS (EST)
Telmisartan HCTZ Tablets
Telmisartan Tablets
Temazepam 22.5 mg Capsules
Temazepam 7.5mg, 15 mg, 30 mg Capsules
TEMODAR CAPSULES (QL) (N)
TEMOVATE CREAM / OINTMENT/ GEL/ SOLUTION/ EMOLLIENT
Temozolomide Capsules (QL) (N)
TENEX TABLETS
TENORETIC TABLETS
TENORMIN TABLETS
TERAZOL VAGINAL 7 CREAM
3
*
TERAZOL VAGINAL CREAM / TABLETS
1
1
1
1
1
3
1
*
*
*
*
*
*
*
Terazosin Capsules / Tablets
Terbinafine Tablets (PA)
Terbutaline Sulfate Tablets
Terconazole 7 Vaginal Cream
TESSALON PERLES
TESTIM GEL (EST)
Tetracycline Capsules
*
*
*
3
3
3
2
1
1
3
1
1
1
1
1
2
MONISTAT (AVAILABLE OTC - NOT COVERED), GYNE LOTRIMIN
(AVAILABLE OTC - NOT COVERED), VAGISTAT (AVAILABLE OTC - NOT
COVERED), Fluconazole (DIFLUCAN 150mg) (one tablet)
USE ANDROGEL - TIER 2
Losartan / HCTZ (HYZAAR), Valsartan / HCTZ (DIOVAN HCT), Irbesartan /
HCTZ (AVALIDE), BENICAR HCT
Losartan (COZAAR), Irbesartan (AVAPRO), Valsartan (DIOVAN), Benazepril
(LOTENSIN), Lisinopril (ZESTRIL), BENICAR
TEVETEN HCT CAPSULES (PA)
*
*
*
*
*
*
*
*
*
3
TEVETEN TABLETS (PA)
THALOMID CAPSULES (N)
THEO-24 CAPSULES.
THEODUR TABLETS
Theophylline Liquid
Theophylline, 80mg/15cc (Alcohol Free)
Theophylline, Immediate Release Tablets
Theophylline, Sustained Release Capsules
Thioridazine Tablets
Thiothixene Capsules
THORAZINE TABLETS
THYROID, ARMOUR
Theophylline SR (THEO-DUR)
Levothyroxine (SYNTHROID, LEVOXYL, LEVOTHROID), CYTOMEL,
ARMOUR THYROID
THYROLAR TABLETS
3
1
1
1
1
2
3
1
1
1
3
1
1
3
3
3
*
*
*
*
*
3
*
*
*
*
*
*
*
*
Tiagabine Tablets
TIAZAC CAPSULES
TICLID TABLETS
Ticlopidine Tablets
TIGAN CAPSULES
TIKOSYN CAPSULES (N)
TILIA Fe TABLETS
Timolol Maleate Ophthalmic Soln.
Timolol Tablets
Timolol XE Gel
TIMOPTIC OCUDOSE PRESERVATIVE FREE
TIMOPTIC OPHTHALMIC SOLUTION
TIMOPTIC XE OPHTHALMIC GEL
TINDAMAX TABLETS (PA)
TIROSINT CAPSULES
TIVICAY TABLETS
Metronidazole (FLAGYL), Paramomycin (HUMATIN)
Use Levothyroxine Tablets
Methocarbamol (ROBAXIN), Carisoprodol 350 mg (SOMA 350 mg),
Cyclobenzaprine (FLEXERIL)
Tizanidine Tablets
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Verapamil SR (CALAN SR) PLUS Benazepril (LOTENSIN), Captopril
(CAPOTEN), Lisinopril (ZESTRIL), Enalapril (VASOTEC), Fosinopril
(MONOPRIL), Quinapril (ACCUPRIL),or Moexipril (UNIVASC)
Prenatal Vitamins
Prenatal Vitamins
34
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
3
1
3
3
1
3
1
1
1
DRUG NAME
*
*
*
TL-SELECT
TOBI NEBULIZER SOLUTION (N)
TOBI PODHALER CAPSULES
TOBRADEX OPHTHALMIC OINTMENT
TOBRADEX OPHTHALMIC SUSPENSION (QL)
TOBRADEX ST OPHTHALMIC SUSPENSION (QL)
Tobramycin / Dexamethasone Ophthalmic Suspension (QL)
Tobramycin Ophthalmic Solution & Ointment
TOBREX OPHTHALMIC OINTMENT/ SOLUTION
3
*
TOFRANIL PM TABLETS
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
2
2
2
3
1
3
*
*
*
*
*
*
*
*
*
*
*
*
*
*
TOFRANIL TABLETS
Tolazamide Tablets
TOLBUTAMIDE 500 MG TABLETS
TOLECTIN DS CAPSULES
TOLECTIN TABLETS
TOLINASE TABLETS
Tolmetin DS Capsules
Tolterodine Immediate Release Tablets (QL)
Tolterodine LA Capsules
TOPAMAX TABLETS
TOPICORT LP CREAM
TOPICORT SPRAY (EST)
Topiramate Tablets
TOPROL XL TABLETS
TORADOL (QL) TABLETS
Torsemide Tablets
TOTACILLIN CAPSULES / SUSPENSION
TOVIAZ 24 HR TABLET (QL)
TRACLEER TABLETS (LD) (N)
TRADJENTA TABLETS
Tramadol / Acetaminophen Tablets
Tramadol Tablets (QL)
Tramadol Tablets SR 24 Hr
1
*
TRANDATE TABLETS
1
*
Trandolapril Tablets
1
1
2
*
*
TRANXENE CAPSULES
Tranylcypromine Tablets
TRAVATAN Z OPHTHALMIC SOLUTION (QL)
1
*
Trazodone Tablets
1
*
TRENTAL TABLETS
1
*
Tretinoin Cream / Gel
*
*
*
*
*
*
*
2
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Prenatal Vitamins
Amitriptyline (ELAVIL), Desipramine (NORPRAMIN), Imipramine (TOFRANIL),
Nortriptyline (PAMELOR)
Furosemide (LASIX), Bumetanide (BUMEX)
Tramadol (ULTRAM) PLUS Acetaminophen (TYLENOL)
TRECATOR TABLETS
3
TRETIN-X CREAM (QL)
3
TREXIMET TABLETS (QL) (PA)
3
TREZIX CAPSULES
1
*
Triamcinolone / Nystatin Cream / Ointment
1
*
Triamcinolone 0.1% in Orabase
1
*
Triamcinolone Acetonide Cream / Ointment / Lotion
1
*
Triamterene / HCTZ Capsules
1
*
Triamterene / HCTZ Tablets
1
*
Triazolam Tablets
1
*
TRICOR TABLETS 48 MG and 145 MG
1
*
Tri-Estarylla Tablets
1
*
Trifluoperazine Tablets
1
*
Trifluridine Ophthalmic Solution
1
1
1
*
*
*
Trihexyphenidyl Tablets
TRILEPTAL TABLETS / SUSPENSION
TRI-LEVLEN TABLETS
1
*
Tri-Linah Tablets
1
*
TRILIPIX CAPSULES
1
*
TRILISATE TABLETS
1
*
Trimethobenzamide Capsules
2
Naproxen Sodium (NAPROXEN) PLUS Sumatriptan (IMITREX)
TRIBENZOR TABLETS (EST)
3
GENERIC FOR ORTHO TRI-CYCLEN
TRIGLIDE TABLETS 50 MG, 160 MG
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
USE TRICOR 48 MG OR 145 MG
GENERIC FOR ORTHO TRI-CYCLEN
35
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
1
1
1
1
1
3
3
2
1
1
2
1
3
1
1
*
*
*
*
*
*
*
*
*
*
*
*
3
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Trimethoprim Tablets
TRIMOX CAPSULES / SUSPENSION
TRIMPEX TABLETS
Trinessa Tablets
TRI-NORINYL TABLETS
Tri-Previfem Tablets
Tri-Sprintec Tablets
TRIVEEN-DUO DHA
TRI-VI-FLOR TABLETS / DROPS
Trivora Tablets
TRIUMEQ TABLETS
TRIZIVIR TABLETS
TROKENDI XR CAPSULES (PA)
Trospium SR Capsules
Trospium Tablets 20 mg
GENERIC FOR ORTHO TRI-CYCLEN
GENERIC FOR ORTHO TRI-CYCLEN
GENERIC FOR ORTHO TRI-CYCLEN
Prenatal Vitamins
GENERIC FOR TRIPHASIL,TRI-LEVLEN
USE ONETOUCH ULTRA, ONETOUCH VERIO IQ, FREESTYLE LITE,
FREESTYLE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS
AZOPT OPHTHALMIC SOLUTION
TRUETRACK TEST STRIPS (PA) (QL)
1
2
2
*
TRUSOPT OPHTHALMIC SOLN.
TRUVADA TABLETS
TUDORZA PRESSAIR INHALER (QL)
1
*
TUSSEND SYRUP
1
*
TUSSIONEX SUSPENSION
2/SP
TWINJECT INJECTION (QL) (Covered under Pharmacy only if Plan has a "Specialty Tier")
Losartan (COZAAR), Irbesartan (AVAPRO), Valsartan (DIOVAN) PLUS
TWYNSTA TABLETS (EST)
Amlodipine (NORVASC)
TYBOST TABLETS
3
2
2
TYKERB TABLETS (N)
1
*
TYLENOL CODEINE TABLETS #2, #3, #4
1
*
TYLOX 5 / 500 CAPSULES
3
TYZEKA TABLETS (EST)
3
UCERIS 24 HR TABLETS (PA)
3
ULESFIA LOTION 5%
2
ULORIC TABLETS
3
ULTIMATECARE ONE
Prenatal Vitamins
3
*
ULTRACET TABLETS
Tramadol (ULTRAM) PLUS Acetaminophen (TYLENOL)
3
*
ULTRAM ER TABLETS
Tramadol (ULTRAM) - IMMEDIATE RELEASE
1
*
ULTRAM TABLETS
*
ULTRAVATE CREAM / OINTMENT
1
*
UNIPHYL TABLETS
1
*
UNIRETIC TABLETS
1
*
UNIVASC TABLETS
1
*
Urecholine Tablets
1
*
URISPAS TABLETS
1
*
UROCIT-K 5, 10 TABLETS
3
*
UROXATRAL TABLETS (QL)
1
*
URSO FORTE TABLETS
1
*
URSO TABLETS
1
*
Ursodiol Tablets and Capsules
2
1
ULTRASE MT CAPSULES
3
ULTRESA CAPSULES
2
UROCIT-K 15 TABLETS
3
1
3
2
1
1
1
1
1
3
3
1
1
Doxazosin (CARDURA), Terazosin (HYTRIN), Finasteride (PROSCAR) (PA)
Estradiol patches (CLIMARA), ESTRADERM, VIVELLE-DOT, ESTRACE
VAGINAL CR, PREMARIN VAGINAL CR
VAGIFEM VAGINAL TABLETS
*
*
*
*
*
*
*
*
*
*
Valacyclovir Tablets
VALCHLOR GEL (PA) (N) (LD)
VALCYTE TABLETS (QL) (N)
VALIUM TABLETS
Valproic Acid Capsules
Valsartan HCT Tablets
Valsartan Tablets
VALTREX TABLETS (QL)
VANCOCIN CAPSULES (PA) (QL)
Vancomycin Capsules (PA) (QL)
VANDAZOLE VAGINAL GEL
VANTIN TABLETS / SUSPENSION
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
36
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
3
1
1
1
1
1
3
1
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
*
VASCEPA CAPSULES
VASERETIC TABLETS
VASOTEC TABLETS
VECTICAL OINTMENT (QL)
VEETIDS TABLETS / SUSPENSION
Velivet Tablets
VELPHORO CHEWABLE TABS
Venlafaxine Capsules (Sustained Release 24 Hr)
1
*
Venlafaxine Tablets (Immediate Release)
3
*
Venlafaxine Tablets (Sustained Release 24 Hr)
USE Venlafaxine SR Capsules (EFFEXOR XR) CAPSULES
3
1
3
USE PROVENTIL HFA
*
VENTOLIN HFA (QL)
VEPESID CAPSULES
VERAMYST NASAL SUSPENSION (QL)
1
*
Verapamil CR Tablets
1
*
Verapamil SA Tablets
1
*
Verapamil Tablets
1
*
VERELAN CAPSULES
3
*
VERELAN PM CAPSULES
1
*
VERMOX TABLETS (QL)
1
*
VESANOID CAPSULES
*
*
*
*
*
3
VEREGEN OINTMENT (QL)
3
1
*
Vestura Tablets
*
VFEND TABLETS (QL)
VIAGRA TABLETS (PA) (QL)
1
*
VIBRAMYCIN CAPSULES
1
*
VIBRA-TABS
1
*
VICODIN TABLETS 5/300
1
*
VICOPROFEN TABLETS
SP
VICTRELIS CAPSULES (PA) (N)
VIDAYLIN/F TABLETS / DROPS (age limit 6 years and younger)
*
VIDEX EC CAPSULES
VIDEX SOLUTION
3/SP
VIEKIRA PAK (PA) (N)
2
VIGAMOX OPHTHALMIC SOLUTION (QL)
3
VIIBRYD TABLETS (EST)
3
VIMOVO TABLETS (PA)
2
2
2
2
2
1
VIMPAT TABLETS
VINACAL
VINATE CALCIUM
VINATE ONE
VIOKASE POWDER
Viorele Tablets
*
2
*
VIRAMUNE TABLETS
1
*
VIRAMUNE XR TABLETS
*
VIROPTIC OPHTHALMIC SOLUTION
*
VISCOUS XYLOCAINE
*
VISTARIL CAPSULES
2
GENERIC FOR MIRCETTE
VIRT-PN DHA
3
3
3
Prenatal Vitamins
Prenatal Vitamins
Prenatal Vitamins
VIREAD TABLETS
3
1
Fluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL),
Venlafaxine (EFFEXOR), Venlafaxine SR Capsules (EFFEXOR XR), Bupropion
(WELLBUTRIN, WELLBUTRIN SR), Escitalopram (LEXAPRO)
Naproxen (NAPROSYN) AND Omeprazole (PRILOSEC) OR Pantoprazole
(PROTONIX)
VIRACEPT TABLETS
1
1
AVAILABLE THROUGH SPECIALTY PHARMACY ONLY
*
2
1
NOT COVERED BY ALL PLANS - CHECK BENEFITS AND SPECIFIC COPAY
VICTOZA INJECTION (PA) (Covered under Pharmacy only if Plan has a "Specialty Tier"
3/SP
1
Oxybutynin Immediate Release Tablets, Tolterodine (DETROL), Tolterodine LA
(DETROL LA), TOVIAZ
GENERIC FOR YAZ
Dexamethasone (DEXASOL), Fluorometholone (FML, FML FORTE)
Prednisolone (PRED FORTE)
VEXOL OPHTHALMIC SUSPENSION
SP
1
Verapamil SA Tabs (CALAN SR), Felodipine (PLENDIL), Nifedipine SA
(ADALAT CC)
Verapamil SA Tabs (CALAN SR, ISOPTIN SR), Felodipine (PLENDIL),
Nifedipine SA (ADALAT CC)
VESICARE TABLETS
3
1
GENERIC FOR CYCLESSA
Prenatal Vitamins
VISICOL TABLETS
VITAMEDMD ONE RX/QUATREFO
VITAMEDMD PLUS RX/QUATRE
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Prenatal Vitamins
Prenatal Vitamins
37
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
3
*
2
3
U
2
DRUG NAME
VIVACTIL TABLETS
VIVELLE-DOT PATCHES
VOGELXO GEL (PA)
VOL-PLUS
VOL-TAB RX
3
USE ANDROGEL - TIER 2
Prenatal Vitamins
Prenatal Vitamins
Diclofenac (VOLTAREN TABLETS), Etodolac Immediate Release (LODINE),
Naproxen (NAPROSYN), meloxicam (MOBIC), naproxen (NAPROSYN)
VOLTAREN GEL
1
1
*
*
VOLTAREN IMMEDIATE RELEASE TABLETS
VOLTAREN OPHTHALMIC SOLUTION
3
*
VOLTAREN XR TABLETS
3
1
1
2
2
2
2
2
*
*
*
VOSOL HC OTIC SOLUTION
VOSOL OTIC SOLUTION
VOSPIRE ER TABLETS
VOTRIENT TABLETS (N)
VYTORIN 10-10 MG TABLETS (QL) (EST)
VYTORIN 10-80 MG TABLETS (QL) (PA)
VYTORIN TABLETS 10-20, 10-40 mg (QL)
VYVANSE CAPSULES (QL)
1
*
Warfarin Sodium Tablets
3
Ibuprofen (MOTRIN), Etodolac Immediate Release (LODINE), Naproxen
(NAPROSYN), Oxaprozin (DAYPRO), Sulindac (CLINORIL), Diclofenac
(VOLTAREN), Piroxicam (FELDENE)
Terbutaline (BRETHINE TABLETS)
NOT AVAILABLE THROUGH MAIL ORDER
Cholestyramine Powder (QUESTRAN, QUESTRAN LIGHT - BULK POWDER
ONLY), colestipol hcl (COLESTID)
WELCHOL TABLETS
1
*
WELLBUTRIN SR TABLETS
1
*
WELLBUTRIN TABLETS
1
*
WELLBUTRIN XL TABLETS (QL)
1
*
WELLCOVORIN TABLETS
1
*
Wera Tablets
3
*
WESTCORT CREAM / OINTMENT
1
*
WIGRAINE CAPSULES
1
*
WYMOX CAPSULES
3
*
Wymzya FE
1
*
WYTENSIN TABLETS
1
*
XALATAN OPHTHALMIC SOLUTION (QL)
1
*
XANAX TABLETS
3
*
XANAX XR TABLETS
3
2
3
3/SP
1
3
3
3
3
3
3
1
2
3
3
1
1
3
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Amitriptyline (ELAVIL), Desipramine (NORPRAMIN), Imipramine (TOFRANIL),
Nortriptyline (PAMELOR)
GENERIC FOR MODICON
Fluocinolone (SYNALAR), Mometasone (ELOCON), Triamcinolone
(ARISTOCORT, KENALOG)
GENERIC FOR FEMCON FE
XALKORI CAPSULES (PA) (N)
*
*
*
*
*
*
XARELTO TABLETS
XARTEMIS XR TABLETS (N)
XELJANZ TABLETS (PA) (QL) (N)
XELODA TABLETS (N)
XENICAL CAPSULES (PA)
XERESE CREAM
XIBROM OPHTHALMIC SUSPENSION
XIFAXAN 200 MG TABLETS (QL)
XIFAXAN 550 MG TABLETS (QL) (PA)
XIGDUO XR TABLETS
XODOL TABLETS
XOPENEX HFA AEROSOL (QL)
XOPENEX NEBULIZER SOLUTION
XTANDI CAPSULES (PA) (N)
XULANE PATCH
XYLON TABLETS
XYREM SOLUTION (PA) (LD) (N)
3
*
XYZAL TABLETS (PA)
1
*
YASMIN TABLETS
1
*
YAZ TABLETS
1
*
Zafirlukast Tablets
1
*
Zaleplon Capsules (QL)
3
*
ZANAFLEX TABLETS
1
*
ZANTAC 300 MG TABLETS ONLY
2
Alprazolam (XANAX), Lorazepam (ATIVAN), Oxazepam (SERAX), Diazepam
(VALIUM)
NOT COVERED BY ALL PLANS - CHECK BENEFITS FOR COVERAGE
ACULAR, DICLOFENAC (VOLTAREN)
Ciprofloxacin (CIPRO)
Albuterol Nebulizer Solution (PROVENTIL)
Methylphenidate/SR/ER (RITALIN, RITALIN SR, METADATE ER)
Loratadine (CLARITIN-OTC), Fexofenadine (ALLEGRA-OTC), Cetirizine
(ZYRTEC-OTC) - ALL AVAILABLE OTC
YODOXIN TABLETS
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Methocarbamol (ROBAXIN), Carisoprodol 350 mg (SOMA 350 mg),
Cyclobenzaprine (FLEXERIL)
38
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
DRUG NAME
1
*
Zarah Tablets
1
*
ZARONTIN CAPSULES
1
*
ZAROXOLYN TABLETS
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
GENERIC FOR YASMIN
3
ZATEAN-CH
3
ZATEAN-PN
Prenatal Vitamins
3
ZATEAN-PN DHA
Prenatal Vitamins
3
ZATEAN-PN PLUS
Prenatal Vitamins
3
ZAVESCA CAPSULES (PA) (N) (LD)
1
*
ZEBETA TABLETS
3
ZEGERID CAPSULES / POWDER
3
2
1
1
3
3
2
3
3
1
1
1
2
3
1
1
3
3
1
3
3
1
2
1
1
1
3
3
3
3
1
1
*
*
*
*
ZELAPAR DISINTEGRATING TABLETS
ZELBORAF TABLETS (PA) (N)
ZEMPLAR CAPSULES
ZENATANE CAPSULES (QL)
Zenchent
Zenchent FE
ZENPEP CAPSULES
ZENZEDI TABLETS
Zeosa Chewable Tablets
ZERIT CAPSULES
ZESTORETIC TABLETS
ZESTRIL TABLETS
ZETIA TABLETS
ZETONNA NASAL AEROSOL (QL)
ZIAC TABLETS
ZIAGEN TABLETS
ZIANA GEL (QL)
ZIOPTAN OPHTHALMIC SOLUTION (QL)
Ziprasidone Capsules
ZIPSOR CAPSULES (EST) (QL)
ZIRGAN OPHTHALMIC GEL
ZITHROMAX TABLETS (QL)
ZMAX ORAL SUSPENSION
ZOCOR TABLETS (QL)
ZOFRAN ODT TABLETS (QL)
ZOFRAN TABLETS (QL)
ZOHYDRO ER CAPSULES (PA)
ZOLINZA CAPSULES (PA) (N)
Zolmitriptan Orally Disintegrating Tablets (QL)
Zolmitriptan Tablets (QL)
ZOLOFT TABLETS
Zolpidem Capsules (QL)
3
*
Zolpidem CR Tablets 6.25 MG, 12.5 MG (EST) (QL)
3
3
3
3
1
1
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
2
2
3
1
3
1
1
2
3
3
3
3
3
3
3
2
1
3
*
*
*
*
Prenatal Vitamins
ZEGERID CAPSULES OTC, Omeprazole (PRILOSEC), Pantoprazole
(PROTONIX)
GENERIC FOR OVCON
GENERIC FOR OVCON FE
GENERIC FOR FEMCON FE
Lantanoprost (XALATAN), TRAVATAN Z, LUMIGAN
Zolpidem (AMBIEN), Temazepam (RESTORIL), Lorazepam (ATIVAN),
Flurazepam (DALMANE)
ZOMIG NASAL SPRAY (QL)
ZOMIG TABLETS (QL)
ZOMIG ZMT TABLETS (QL)
ZONALON CREAM
ZONEGRAN CAPSULES
Zonisamide Capsules
ZONTIVITY TABLETS
ZORTRESS TABLETS
ZORVOLEX CAPSULES (PA)
Zovia Tablets
ZOVIRAX CREAM (QL)
ZOVIRAX OINTMENT (QL)
ZOVIRAX ORAL CAPSULES / SUSPENSION
ZOVIRAX ORAL TABLETS
ZUBSOLV SL TABLETS (PA)
ZUPLENZ ORAL FILM (QL)
ZYCLARA CREAM (QL)
ZYDELIG TABLETS
ZYFLO CR TABLETS
ZYFLO TABLETS
ZYKADIA CAPSULES (PA)
ZYLET OPHTHALMIC SUSPENSION (QL)
ZYLOPRIM TABLETS
ZYMAR OPHTHALMIC SOLUTION
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Sumatriptan (IMITREX), Naratriptan (AMERGE), Rizatriptan (MAXALT)
Sumatriptan (IMITREX), Naratriptan (AMERGE), Rizatriptan (MAXALT)
OTC BENADRYL CREAM - NOT COVERED, Hydroxyzine (VISTARIL)
Montelukast (SINGULAIR), Zafirlukast (ACCOLATE)
Montelukast (SINGULAIR), Zafirlukast (ACCOLATE)
Ciprofloxacin (CILOXAN), Ofloxacin (OCUFLOX)
39
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail
RECOMMENDEDDRUGLISTALPHABETICALLISTING
BRANDDRUGNAMESLISTEDFORREFERENCEONLY‐GENERICSWILLBEUSEDWHENAVAILABLE
TIER GENERIC
1
1
3
2
2
*
*
*
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
ZYMAXID OPHTHALMIC SOLUTION
ZYPREXA TABLETS
ZYPREXA ZYDIS
ZYTIGA TABLETS (PA) (N)
ZYVOX TABLETS
CAPS=Brand
*=Generic will be used
SP=Specialty Drug-chk Plan for Coverage
LD=Limited Distribution
Ciprofloxacin (CILOXAN), Ofloxacin (OCUFLOX)
Olanzapine (ZYPREXA) TABLETS
40
2/1/15
PA=Prior Approval Required
QL=Qty Limit
EST=Step Edit
N=Not Available Thru Mail