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Preferred Drug List (Formulary)


BLOOD

BLOOD MODIFIERS

Generic Drug (Tier 1) anagrelide
Preferred Brand-name Drug (Tier 2) NEUPOGEN (P)
Generic Drug (Tier 1) pentoxifylline (M)
Preferred Brand-name Drug (Tier 2) PROCRIT (P)

BLOOD THINNERS (ANTICOAGULANTS)

Generic Drug (Tier 1) enoxaparin
Generic Drug (Tier 1) fondaparinux
Preferred Brand-name Drug (Tier 2) FRAGMIN
Generic Drug (Tier 1) warfarin (M)
Preferred Brand-name Drug (Tier 2) XARELTO (M)

STROKE PREVENTION

Generic Drug (Tier 1) clopidogrel (M)
Generic Drug (Tier 1) ticlopidine (M)

CANCER DRUGS-OTHER (ANTINEOPLASTICS)

CANCER DRUGS-OTHER (ANTINEOPLASTICS)

Preferred Brand-name Drug (Tier 2) JAKAFI (P)

CANCER DRUGS-OTHER (ANTINEOPLASTICS)

CANCER DRUGS-OTHER (ANTINEOPLASTICS)

Preferred Brand-name Drug (Tier 2) SYLATRON (P)

CANCER DRUGS -ORAL (ANTINEOPLASTICS)

CANCER DRUGS -ORAL (ANTINEOPLASTICS)

Generic Drug (Tier 1) anastrozole (M)
Preferred Brand-name Drug (Tier 2) AFINITOR (P)
Generic Drug (Tier 1) bicalutamide
Preferred Brand-name Drug (Tier 2) BOSULIF (P)
Generic Drug (Tier 1) capecitabine (P)
Preferred Brand-name Drug (Tier 2) CAPRELSA (P)
Preferred Brand-name Drug (Tier 2) COMETRIQ (P)
Generic Drug (Tier 1) exemestane (M)
Preferred Brand-name Drug (Tier 2) ERIVEDGE (P)
Preferred Brand-name Drug (Tier 2) GILOTRIF (P)
Preferred Brand-name Drug (Tier 2) GLEEVEC (P)
Preferred Brand-name Drug (Tier 2) HYCAMTIN (P)
Preferred Brand-name Drug (Tier 2) IMBRUVICA (P)
Preferred Brand-name Drug (Tier 2) INLYTA (P)
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


CANCER DRUGS -ORAL (ANTINEOPLASTICS)

CANCER DRUGS -ORAL (ANTINEOPLASTICS)

Generic Drug (Tier 1) letrozole (M)
Preferred Brand-name Drug (Tier 2) MEKINIST (P)
Preferred Brand-name Drug (Tier 2) NEXAVAR (P)
Preferred Brand-name Drug (Tier 2) POMALYST (P)
Preferred Brand-name Drug (Tier 2) REVLIMID (P)
Preferred Brand-name Drug (Tier 2) SPRYCEL (P)
Preferred Brand-name Drug (Tier 2) STIVARGA (P)
Preferred Brand-name Drug (Tier 2) SUTENT (P)
Generic Drug (Tier 1) temozolomide (P)
Preferred Brand-name Drug (Tier 2) TAFINLAR (P)
Preferred Brand-name Drug (Tier 2) TARCEVA (P)
Preferred Brand-name Drug (Tier 2) TASIGNA (P)
Preferred Brand-name Drug (Tier 2) THALOMID (P)
Preferred Brand-name Drug (Tier 2) TYKERB (P)
Preferred Brand-name Drug (Tier 2) VOTRIENT (P)
Preferred Brand-name Drug (Tier 2) XALKORI (P)
Preferred Brand-name Drug (Tier 2) XTANDI (P)
Preferred Brand-name Drug (Tier 2) ZELBORAF (P)
Preferred Brand-name Drug (Tier 2) ZOLINZA (P)
Preferred Brand-name Drug (Tier 2) ZYTIGA (P)

CENTRAL NERVOUS SYSTEM

ALZHEIMER'S DRUGS

Generic Drug (Tier 1) donepezil (M)
Preferred Brand-name Drug (Tier 2) NAMENDA, NAMENDA XR (M)

ANTI-PARKINSON DRUGS

Generic Drug (Tier 1) amantadine (M)

CENTRAL NERVOUS SYSTEM

ANTI-PARKINSON DRUGS

Preferred Brand-name Drug (Tier 2) APOKYN
Generic Drug (Tier 1) bromocriptine (M)
Generic Drug (Tier 1) levodopa/carbidopa (M)
Generic Drug (Tier 1) pramipexole (M)
Generic Drug (Tier 1) ropinirole (M)
Generic Drug (Tier 1) selegiline (M)

ATTENTION DEFICIT DISORDER (ADD), NARCOLEPSY

Generic Drug (Tier 1) amphetamine/dextroamphetamine (M)
Generic Drug (Tier 1) dexmethylphenidate (M)
Generic Drug (Tier 1) dextroamphetamine (M)
Generic Drug (Tier 1) methamphetamine (M)
Generic Drug (Tier 1) methylphenidate sr (M)
Generic Drug (Tier 1) methylphenidate (M)

SEIZURE MEDICATIONS (ANTICONVULSANTS)

Generic Drug (Tier 1) carbamazepine extended release (M)
Generic Drug (Tier 1) carbamazepine (M)
Generic Drug (Tier 1) clonazepam (M)
Generic Drug (Tier 1) diazepam (M)
Generic Drug (Tier 1) divalproex (M)
Generic Drug (Tier 1) divalproex sodium (M)
Generic Drug (Tier 1) ethosuximide (M)
Generic Drug (Tier 1) gabapentin (M)
Generic Drug (Tier 1) lamotrigine (M)
Generic Drug (Tier 1) levetiracetam (M)
Generic Drug (Tier 1) phenytoin (M)
Generic Drug (Tier 1) primidone (M)
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


CENTRAL NERVOUS SYSTEM

SEIZURE MEDICATIONS (ANTICONVULSANTS)

Generic Drug (Tier 1) topiramate (M)
Generic Drug (Tier 1) valproic acid (M)
Generic Drug (Tier 1) zonisamide (M)

SLEEP AIDS

Generic Drug (Tier 1) temazepam
Generic Drug (Tier 1) zaleplon
Generic Drug (Tier 1) zolpidem

CHEST PAIN & HEART DISEASE

CHEST PAIN & HEART DISEASE

Generic Drug (Tier 1) isosorbide dinitrate (M)
Generic Drug (Tier 1) isosorbide mononitrate (M)
Generic Drug (Tier 1) nitroglycerin sl (M)
Generic Drug (Tier 1) transdermal nitroglycerin (M)

DIABETES & HIGH BLOOD SUGAR

ANTIDIABETIC DRUGS

Generic Drug (Tier 1) acarbose (M)
Preferred Brand-name Drug (Tier 2) BYETTA (M)
Generic Drug (Tier 1) glimepiride (M)
Generic Drug (Tier 1) glipizide extended release (M)

DIABETES & HIGH BLOOD SUGAR

ANTIDIABETIC DRUGS

Generic Drug (Tier 1) glipizide (M)
Generic Drug (Tier 1) glyburide and metformin (M)
Generic Drug (Tier 1) glyburide (M)
Preferred Brand-name Drug (Tier 2) JANUMET XR (M)
Preferred Brand-name Drug (Tier 2) JANUMET (M)
Preferred Brand-name Drug (Tier 2) JANUVIA (M)
Preferred Brand-name Drug (Tier 2) KOMBIGLYZE (M)
Preferred Brand-name Drug (Tier 2) LEVEMIR (M)
Generic Drug (Tier 1) metformin xr (M)
Generic Drug (Tier 1) metformin (M)
Generic Drug (Tier 1) nateglinide (M)
Preferred Brand-name Drug (Tier 2) NOVO INSULIN (M)
Preferred Brand-name Drug (Tier 2) NOVOLIN (M)
Preferred Brand-name Drug (Tier 2) NOVOLOG (M)
Preferred Brand-name Drug (Tier 2) ONGLYZA (M)
Generic Drug (Tier 1) piogliazone/metformin (M)
Generic Drug (Tier 1) pioglitazone/glimepiride (M)
Generic Drug (Tier 1) pioglitazone (M)
Generic Drug (Tier 1) repaglinide (M)
Preferred Brand-name Drug (Tier 2) VICTOZA (M)

BLOOD SUGAR TEST STRIPS

Preferred Brand-name Drug (Tier 2) ONE TOUCH meter test strips (M)
Preferred Brand-name Drug (Tier 2) SureStep (P,M)

DISEASES

ARTHRITIS (RHEUMATOID)

Preferred Brand-name Drug (Tier 2) ENBREL (P)
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


DISEASES

ARTHRITIS (RHEUMATOID)

Preferred Brand-name Drug (Tier 2) HUMIRA (P)
Generic Drug (Tier 1) leflunomide (M)
Generic Drug (Tier 1) methotrexate (M)

BONE DISEASE

Generic Drug (Tier 1) alendronate (M)
Generic Drug (Tier 1) calcitonin salmon nasal spray (M)
Generic Drug (Tier 1) etidronate (M)
Preferred Brand-name Drug (Tier 2) EVISTA (M)
Generic Drug (Tier 1) ibandronate (M)

GOUT

Generic Drug (Tier 1) allopurinol (M)
Preferred Brand-name Drug (Tier 2) COLCRYS (M)

HEPATITIS

Preferred Brand-name Drug (Tier 2) INTRON A (M)
Preferred Brand-name Drug (Tier 2) PEGASYS (P)
Generic Drug (Tier 1) ribavirin

MULTIPLE SCLEROSIS DRUGS

Preferred Brand-name Drug (Tier 2) COPAXONE (P,M)
Preferred Brand-name Drug (Tier 2) REBIF (P,M)

THYROID DISEASE

Generic Drug (Tier 1) levothyroxine (M)

DISEASES

THYROID DISEASE

Generic Drug (Tier 1) liothyronine (M)
Generic Drug (Tier 1) methimazole (M)
Generic Drug (Tier 1) propylthiouracil (M)

ENT (EAR/NOSE/THROAT)

ALLERGIES & COLDS (NASAL)

Generic Drug (Tier 1) azelastine
Generic Drug (Tier 1) fluticasone propionate
Generic Drug (Tier 1) triamcinolone

ALLERGIES (ORAL)

Generic Drug (Tier 1) desloratadine
Generic Drug (Tier 1) levocetirizine

MISCELLANEOUS

Generic Drug (Tier 1) lidocaine viscous

EYE

ANTI-INFLAMMATORY DROPS

Generic Drug (Tier 1) prednisolone acetate
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


EYE

COMBINATION EYE INFECTION DROPS

Generic Drug (Tier 1) dexamethasone/neomycin/polymyxin
Generic Drug (Tier 1) dexamethasone/tobramycin

EYE INFECTION DROPS

Generic Drug (Tier 1) ciprofloxacin
Generic Drug (Tier 1) ofloxacin
Generic Drug (Tier 1) polymyxin b/bacitracin
Generic Drug (Tier 1) polymyxin b/trimethoprim
Generic Drug (Tier 1) polymyxin/neomycin/gramicidin sol.
Generic Drug (Tier 1) sodium sulfacetamide
Generic Drug (Tier 1) tobramycin drops
Generic Drug (Tier 1) trifluridine
Preferred Brand-name Drug (Tier 2) VIGAMOX

GLAUCOMA DRUGS

Generic Drug (Tier 1) acetazolamide (M)
Preferred Brand-name Drug (Tier 2) ALPHAGAN P 0.1% (M)
Preferred Brand-name Drug (Tier 2) AZOPT (M)
Generic Drug (Tier 1) brimonidine 0.15% (M)
Preferred Brand-name Drug (Tier 2) COMBIGAN (M)
Generic Drug (Tier 1) dorzolamide/timolol (M)
Generic Drug (Tier 1) dorzolamide (M)
Generic Drug (Tier 1) latanoprost (M)
Generic Drug (Tier 1) levobunolol (M)
Preferred Brand-name Drug (Tier 2) LUMIGAN
Generic Drug (Tier 1) methazolamide (M)
Generic Drug (Tier 1) pilocarpine (M)
Generic Drug (Tier 1) timolol (M)

EYE

MISCELLANEOUS DRUGS

Generic Drug (Tier 1) atropine
Generic Drug (Tier 1) flurbiprofen
Generic Drug (Tier 1) ketoralac tromethamine, 0.4 %
Generic Drug (Tier 1) ketorolac tromethamine 0.5%
Preferred Brand-name Drug (Tier 2) RESTASIS (M)

HEART RHYTHM DISORDERS

HEART RHYTHM DISORDERS

Generic Drug (Tier 1) acebutolol (M)
Generic Drug (Tier 1) amiodarone (M)
Generic Drug (Tier 1) digoxin (M)
Generic Drug (Tier 1) disopyramide controlled release (M)
Generic Drug (Tier 1) disopyramide (M)
Generic Drug (Tier 1) propafenone (M)
Generic Drug (Tier 1) sotalol (M)

HIGH BLOOD PRESSURE & HEART DISEASE

ACE INHIBITORS

Generic Drug (Tier 1) benazepril (M)
Generic Drug (Tier 1) enalapril (M)
Generic Drug (Tier 1) lisinopril (M)
Generic Drug (Tier 1) moexipril (M)
Generic Drug (Tier 1) quinapril (M)
Generic Drug (Tier 1) trandolapril (M)
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


HIGH BLOOD PRESSURE & HEART DISEASE

ALPHA BETA BLOCKERS

Generic Drug (Tier 1) carvedilol (M)
Generic Drug (Tier 1) doxazosin (M)
Generic Drug (Tier 1) labetalol (M)
Generic Drug (Tier 1) prazosin (M)

ANGIOTENSIN II BLOCKERS

Preferred Brand-name Drug (Tier 2) BENICAR HCT (M)
Preferred Brand-name Drug (Tier 2) BENICAR (M)
Generic Drug (Tier 1) candesartan (M)
Preferred Brand-name Drug (Tier 2) DIOVAN (M)
Preferred Brand-name Drug (Tier 2) EDARBI (M)
Generic Drug (Tier 1) irbesartan (M)
Generic Drug (Tier 1) losartan (M)

BETA BLOCKERS

Generic Drug (Tier 1) acebutolol (M)
Generic Drug (Tier 1) atenolol (M)
Preferred Brand-name Drug (Tier 2) BYSTOLIC (M)
Generic Drug (Tier 1) metoprolol xl (M)
Generic Drug (Tier 1) metoprolol (M)
Generic Drug (Tier 1) nadolol (M)
Generic Drug (Tier 1) propranolol extended rel. (M)
Generic Drug (Tier 1) propranolol (M)

CALCIUM CHANNEL BLOCKERS

Generic Drug (Tier 1) amlodipine (M)

HIGH BLOOD PRESSURE & HEART DISEASE

CALCIUM CHANNEL BLOCKERS

Generic Drug (Tier 1) diltiazem extended release (M)
Generic Drug (Tier 1) diltiazem (M)
Generic Drug (Tier 1) nifedipine extended release (M)
Generic Drug (Tier 1) nifedipine sustained release (M)
Generic Drug (Tier 1) nisoldipine (M)
Generic Drug (Tier 1) verapamil extended release (M)
Generic Drug (Tier 1) verapamil (M)

COMBINATION DRUGS

Generic Drug (Tier 1) amlodipine/benazepril (M)
Generic Drug (Tier 1) atenolol/chlorthalidone (M)
Generic Drug (Tier 1) benazepril/hctz (M)
Generic Drug (Tier 1) bisoprolol/hctz (M)
Preferred Brand-name Drug (Tier 2) EDARBYCLOR (M)
Generic Drug (Tier 1) irbesartan/hctz (M)
Generic Drug (Tier 1) lisinopril/hctz (M)
Generic Drug (Tier 1) losartan/hctz (M)
Generic Drug (Tier 1) moexipril/hct (M)
Generic Drug (Tier 1) valsartan/hctz (M)

SYMPATHOLYTICS

Generic Drug (Tier 1) clonidine (M)
Generic Drug (Tier 1) guanfacine (M)

WATER PILLS OR DIURETICS

Generic Drug (Tier 1) furosemide (M)
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


HIGH BLOOD PRESSURE & HEART DISEASE

WATER PILLS OR DIURETICS

Generic Drug (Tier 1) hydrochlorothiazide (M)
Generic Drug (Tier 1) metolazone (M)
Generic Drug (Tier 1) spironolactone (M)
Generic Drug (Tier 1) torsemide (M)
Generic Drug (Tier 1) triamterene/hctz (M)

HIGH CHOLESTEROL DRUGS (ANTILIPEMICS)

HIGH CHOLESTEROL DRUGS (ANTILIPEMICS)

Generic Drug (Tier 1) atorvastatin (M)
Generic Drug (Tier 1) cholestyramine (M)
Generic Drug (Tier 1) colestipol (M)
Preferred Brand-name Drug (Tier 2) CRESTOR (M)
Generic Drug (Tier 1) fenofibrate micronized (M)
Generic Drug (Tier 1) fluvastatin (M)
Generic Drug (Tier 1) gemfibrozil (M)
Generic Drug (Tier 1) lovastatin (M)
Generic Drug (Tier 1) pravastatin (M)
Generic Drug (Tier 1) simvastatin (M)

HIV & AIDS

MISCELLANEOUS

Preferred Brand-name Drug (Tier 2) ATRIPLA (M)
Preferred Brand-name Drug (Tier 2) ISENTRESS (M)
Preferred Brand-name Drug (Tier 2) SELZENTRY (M)

HIV & AIDS

COMBINATION DRUGS

Generic Drug (Tier 1) abacavir/lamivudine/zidovudine (M)
Preferred Brand-name Drug (Tier 2) COMPLERA (M)
Preferred Brand-name Drug (Tier 2) EPZICOM (M)
Preferred Brand-name Drug (Tier 2) KALETRA (M)
Generic Drug (Tier 1) lamivudine/zidovudine (M)
Preferred Brand-name Drug (Tier 2) STRIBILD (M)
Preferred Brand-name Drug (Tier 2) TRUVADA (M)

NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

Preferred Brand-name Drug (Tier 2) EDURANT (M)
Preferred Brand-name Drug (Tier 2) INTELENCE (M)
Generic Drug (Tier 1) nevirapine (M)
Preferred Brand-name Drug (Tier 2) RESCRIPTOR (M)
Preferred Brand-name Drug (Tier 2) SUSTIVA (M)

NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

Generic Drug (Tier 1) abacavir (M)
Generic Drug (Tier 1) didanosine (M)
Preferred Brand-name Drug (Tier 2) EMTRIVA (M)
Preferred Brand-name Drug (Tier 2) FUZEON (M)
Preferred Brand-name Drug (Tier 2) HIVID (M)
Generic Drug (Tier 1) lamivudine (M)
Generic Drug (Tier 1) stavudine (M)
Preferred Brand-name Drug (Tier 2) VIDEX Powder (M)
Preferred Brand-name Drug (Tier 2) VIREAD (M)
Generic Drug (Tier 1) zidovudine capsules (M)
Generic Drug (Tier 1) zidovudine tablets and syrup (M)

PROTEASE INHIBITORS

Preferred Brand-name Drug (Tier 2) APTIVUS (M)
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


HIV & AIDS

PROTEASE INHIBITORS

Preferred Brand-name Drug (Tier 2) CRIXIVAN (M)
Preferred Brand-name Drug (Tier 2) FORTOVASE, INVIRASE (M)
Preferred Brand-name Drug (Tier 2) LEXIVA (M)
Preferred Brand-name Drug (Tier 2) NORVIR (M)
Preferred Brand-name Drug (Tier 2) PREZISTA (M)
Preferred Brand-name Drug (Tier 2) REYATAZ (M)
Preferred Brand-name Drug (Tier 2) VIRACEPT (M)

HORMONES

GROWTH

Preferred Brand-name Drug (Tier 2) NORDITROPIN (P)
Preferred Brand-name Drug (Tier 2) SEROSTIM (P)

HORMONE REPLACEMENT DRUGS

Generic Drug (Tier 1) ethinyl estradiol/norethindrone (M)

MALE

Preferred Brand-name Drug (Tier 2) ANDRODERM (M)
Preferred Brand-name Drug (Tier 2) AXIRON (M)
Generic Drug (Tier 1) oxandrolone

MISCELLANEOUS

Generic Drug (Tier 1) desmopressin acetate nasal spray (M)

HORMONES

MISCELLANEOUS

Generic Drug (Tier 1) desmopressin acetate tablets (M)

STEROID REPLACEMENT MEDICATION

Generic Drug (Tier 1) hydrocortisone

IMMUNE SYSTEM

ANTI-REJECTION (IMMUNOSUPPRESSANTS)

Generic Drug (Tier 1) azathioprine (M)
Generic Drug (Tier 1) cyclosporine (M)
Generic Drug (Tier 1) mercaptopurine (M)
Generic Drug (Tier 1) mycophenolate (M)
Preferred Brand-name Drug (Tier 2) RAPAMUNE (M)
Generic Drug (Tier 1) tacrolimus (M)

INFECTIONS

BACTERIAL (CEPHALOSPORINS)

Generic Drug (Tier 1) cefuroxime
Generic Drug (Tier 1) cephalexin capsules

BACTERIAL (COMBINATION ANTIBIOTICS)

Generic Drug (Tier 1) trimethoprim/sulfamethoxazole
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


INFECTIONS

BACTERIAL (FLUROQUINOLONES)

Generic Drug (Tier 1) ciprofloxacin er
Generic Drug (Tier 1) ciprofloxacin
Generic Drug (Tier 1) levofloxacin
Generic Drug (Tier 1) moxifloxacin

BACTERIAL (MACROLIDES)

Generic Drug (Tier 1) azithromycin suspension (Q)
Generic Drug (Tier 1) azithromycin tablets (Q)
Generic Drug (Tier 1) clarithromycin extended release
Generic Drug (Tier 1) clarithromycin
Generic Drug (Tier 1) erythromycin ethylsuccinate

BACTERIAL (MISCELLANEOUS ANTIBIOTICS)

Generic Drug (Tier 1) clindamycin
Generic Drug (Tier 1) metronidazole
Generic Drug (Tier 1) tobramycin

BACTERIAL (PENICILLINS)

Generic Drug (Tier 1) amoxicillin/clavulanate
Generic Drug (Tier 1) amoxicillin/pot.clavulanate

BACTERIAL (TETRACYCLINES)

Generic Drug (Tier 1) doxycycline monohydrate
Generic Drug (Tier 1) doxycycline

INFECTIONS

BACTERIAL (TETRACYCLINES)

Generic Drug (Tier 1) minocycline
Preferred Brand-name Drug (Tier 2) ORACEA

FUNGAL (ANTIFUNGAL DRUGS)

Generic Drug (Tier 1) fluconazole
Generic Drug (Tier 1) itraconazole
Generic Drug (Tier 1) ketoconazole
Generic Drug (Tier 1) terbinafine

MISCELLANEOUS ANTI-INFECTIVE DRUGS

Generic Drug (Tier 1) atovaquone/proguanil
Generic Drug (Tier 1) chloroquine phosphate
Generic Drug (Tier 1) hydroxychloroquine
Preferred Brand-name Drug (Tier 2) ZYVOX

TUBERCULOSIS (ANTITUBERCULOSIS DRUG)

Generic Drug (Tier 1) ethambutol
Generic Drug (Tier 1) isoniazid/rifampin (M)

URINARY TRACT

Generic Drug (Tier 1) nitrofurantoin (macrocrystals)
Generic Drug (Tier 1) nitrofurantoin exten. rel.

VIRAL (ANTIVIRAL DRUGS)

Generic Drug (Tier 1) acyclovir
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


INFECTIONS

VIRAL (ANTIVIRAL DRUGS)

Generic Drug (Tier 1) famciclovir
Generic Drug (Tier 1) valacyclovir
Preferred Brand-name Drug (Tier 2) VALCYTE

MENTAL HEALTH

ANTIDEPRESSANTS

Generic Drug (Tier 1) bupropion xl 150mg (M)
Generic Drug (Tier 1) bupropion (M)
Generic Drug (Tier 1) citalopram (M)
Generic Drug (Tier 1) clomipramine (M)
Generic Drug (Tier 1) desipramine (M)
Generic Drug (Tier 1) escitilopram (M)
Generic Drug (Tier 1) fluoxetine (M)
Generic Drug (Tier 1) imipramine (M)
Generic Drug (Tier 1) mirtapazine orally disintegrating (M)
Generic Drug (Tier 1) mirtazapine (M)
Generic Drug (Tier 1) nortriptyline (M)
Generic Drug (Tier 1) paroxetine controlled release (M)
Generic Drug (Tier 1) paroxetine (M)
Generic Drug (Tier 1) phenelzine (M)
Generic Drug (Tier 1) protriptyline (M)
Generic Drug (Tier 1) sertraline (M)
Generic Drug (Tier 1) tranylcypromine (M)
Generic Drug (Tier 1) venlafaxine (M)

ANTIPSYCHOTIC DRUGS

Generic Drug (Tier 1) olanzapine (M)

MENTAL HEALTH

ANTIPSYCHOTIC DRUGS

Generic Drug (Tier 1) quetiapine fumurate (M)
Generic Drug (Tier 1) risperidone (M)
Generic Drug (Tier 1) thiothixene (M)
Generic Drug (Tier 1) ziprasidone (M)

ANXIETY

Generic Drug (Tier 1) alprazolam
Generic Drug (Tier 1) diazepam

MANIC-DEPRESSION OR BIPOLAR DRUGS

Generic Drug (Tier 1) lithium carbonate ext. rel. (M)

MISCELLANEOUS DRUGS

MISCELLANEOUS DRUGS

Preferred Brand-name Drug (Tier 2) Novofine needles (M)
Preferred Brand-name Drug (Tier 2) Novotwist needles (M)

MUSCLE RELAXERS

MUSCLE RELAXERS

Generic Drug (Tier 1) carisoprodol
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


MUSCLE RELAXERS

MUSCLE RELAXERS

Generic Drug (Tier 1) cyclobenzaprine
Generic Drug (Tier 1) metaxalone
Generic Drug (Tier 1) methocarbamol
Generic Drug (Tier 1) tizanidine

NARCOLEPSY

NARCOLEPSY

Generic Drug (Tier 1) modafinil (P)

OB-GYN

BIRTH CONTROL PILLS (MONOPHASIC CONTRACEPTIVES)

Generic Drug (Tier 1) 0.03mg ethinyl estradiol/ 0.15mg levonorgestrel (M)
Generic Drug (Tier 1) 30 mcg ethinyl estradiol/0.15 mg levonorgestrel (M)
Generic Drug (Tier 1) drospirenone/ethinyl estradiol (M)
Generic Drug (Tier 1) drospirenone/ethinylestradiol (M)
Generic Drug (Tier 1) ethinyl estradiol/desogestrel (M)
Generic Drug (Tier 1) ethinyl estradiol/norethindrone (M)
Generic Drug (Tier 1) ethinyl estradiol/norgestimate (M)
Generic Drug (Tier 1) ethinylestradiol 30 mcg/desogestrel 0.15 mg (M)
Generic Drug (Tier 1) low-ogestrel (M)
Generic Drug (Tier 1) mestranol/norethindrone (M)
Generic Drug (Tier 1) necon (M)
Generic Drug (Tier 1) zovia (M)

BIRTH CONTROL PILLS (PROGESTIN ONLY)

Generic Drug (Tier 1) medroxyprogesterone injection (Q)

OB-GYN

BIRTH CONTROL PILLS (PROGESTIN ONLY)

Generic Drug (Tier 1) norethindrone 0.35 mg (M)

BIRTH CONTROL PILLS (TRIPHASIC CONTRACEPTIVES)

Generic Drug (Tier 1) desogestrel/ethinylestradiol (M)
Generic Drug (Tier 1) desogestril/ethinyl estradiol (M)
Generic Drug (Tier 1) ethinyl estradiol+norethindrone (M)
Generic Drug (Tier 1) ethinyl estradiol/norethindrone acetate (M)
Generic Drug (Tier 1) ethinyl estradiol/norethindrone (M)
Generic Drug (Tier 1) norgestinate-ethinyl estradiol (M)
Preferred Brand-name Drug (Tier 2) ORTHO TRI-CYCLEN LO (M)

BREAST CANCER (ANTI-ESTROGENS)

Preferred Brand-name Drug (Tier 2) FARESTON (M)
Generic Drug (Tier 1) tamoxifen (M)

FEMALE HORMONES (ESTROGENS)

Generic Drug (Tier 1) estradiol patch (M)
Generic Drug (Tier 1) estradiol (M)
Generic Drug (Tier 1) estropipate (M)
Preferred Brand-name Drug (Tier 2) PREMARIN VAGINAL CREAM (M)
Preferred Brand-name Drug (Tier 2) PREMARIN (M)

FEMALE HORMONES (PROGESTINS)

Generic Drug (Tier 1) medroxyprogesterone acetate (M)
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


OB-GYN

FEMALE HORMONES (PROGESTINS)

Generic Drug (Tier 1) micronized progesterone (M)

FEMALE HORMONES (REPLACEMENT COMBINATIONS)

Preferred Brand-name Drug (Tier 2) FEMHRT (M)
Preferred Brand-name Drug (Tier 2) PREMPHASE (M)
Preferred Brand-name Drug (Tier 2) PREMPRO (M)

FERTILITY

Preferred Brand-name Drug (Tier 2) BRAVELLE (P)
Generic Drug (Tier 1) chorionic gonadotropin (P)
Generic Drug (Tier 1) clomiphene
Preferred Brand-name Drug (Tier 2) CETROTIDE (P)
Generic Drug (Tier 1) ganirelix acetate (P)
Preferred Brand-name Drug (Tier 2) GONAL-F (P)
Preferred Brand-name Drug (Tier 2) MENOPUR (P)
Generic Drug (Tier 1) progesterone in oil (P)
Preferred Brand-name Drug (Tier 2) REPRONEX (P)

UTERINE CONTRACTIONS & BLEEDING

Generic Drug (Tier 1) methylergonovine

YEAST OR BACTERIAL INFECTIONS

Generic Drug (Tier 1) clindamycin
Generic Drug (Tier 1) metronidazole vaginal gel

OB-GYN

YEAST OR BACTERIAL INFECTIONS

Generic Drug (Tier 1) terconazole

PAIN MANAGEMENT (ANALGESICS)

PAIN MANAGEMENT (ANALGESICS)

Generic Drug (Tier 1) acetaminophen/codeine
Generic Drug (Tier 1) apap/dichloral-phenazone/isometheptene (M)
Generic Drug (Tier 1) butalbital/caffeine/aspirin
Generic Drug (Tier 1) butorphanol (Q)
Generic Drug (Tier 1) diclofenac sodium xr (M)
Generic Drug (Tier 1) diclofenac sodium (M)
Generic Drug (Tier 1) diclofenac/misoprostol (M)
Generic Drug (Tier 1) dihydroergotamine mesylate (M)
Generic Drug (Tier 1) ergotamine/caffeine (M)
Generic Drug (Tier 1) fentanyl lozenge (P)
Generic Drug (Tier 1) fentanyl transdermal
Generic Drug (Tier 1) hydromorphone
Generic Drug (Tier 1) ibuprofen/hydrocodone (M)
Generic Drug (Tier 1) ibuprofen
Generic Drug (Tier 1) indomethacin (M)
Generic Drug (Tier 1) ketorolac
Generic Drug (Tier 1) meloxicam (M)
Generic Drug (Tier 1) meperidine
Generic Drug (Tier 1) morphine sulfate
Generic Drug (Tier 1) morphine, sustained release
Generic Drug (Tier 1) nabumetone (M)
Generic Drug (Tier 1) naproxen (M)
Generic Drug (Tier 1) naratriptan (Q)
Generic Drug (Tier 1) oxaprozin (M)
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


PAIN MANAGEMENT (ANALGESICS)

PAIN MANAGEMENT (ANALGESICS)

Generic Drug (Tier 1) oxycodone/apap
Generic Drug (Tier 1) oxycodone/aspirin
Generic Drug (Tier 1) piroxicam (M)
Generic Drug (Tier 1) rizatriptan (Q)
Generic Drug (Tier 1) sulindac (M)
Generic Drug (Tier 1) sumatriptan (Q)
Generic Drug (Tier 1) tramadol (M)
Generic Drug (Tier 1) zolmitriptan (Q)

RESPIRATORY PROBLEMS

ASTHMA & COPD (MISCELLANEOUS INHALERS)

Preferred Brand-name Drug (Tier 2) ADVAIR (M)
Preferred Brand-name Drug (Tier 2) COMBIVENT (M)
Preferred Brand-name Drug (Tier 2) DULERA (M)
Generic Drug (Tier 1) ipratropium bromide (M)
Preferred Brand-name Drug (Tier 2) SPIRIVA (M)
Preferred Brand-name Drug (Tier 2) SYMBICORT (M)

ASTHMA (BRONCHODILATORS)

Generic Drug (Tier 1) levabuterol (M)
Preferred Brand-name Drug (Tier 2) PROAIR HFA (M)
Preferred Brand-name Drug (Tier 2) SEREVENT (M)
Preferred Brand-name Drug (Tier 2) TUDORZA (M)
Preferred Brand-name Drug (Tier 2) VENTOLIN HFA (M)

ASTHMA (STEROID INHALERS)

Preferred Brand-name Drug (Tier 2) ASMANEX (M)

RESPIRATORY PROBLEMS

ASTHMA (STEROID INHALERS)

Generic Drug (Tier 1) budesonide (M)
Preferred Brand-name Drug (Tier 2) FLOVENT DISKUS (M)
Preferred Brand-name Drug (Tier 2) FLOVENT HFA (M)
Preferred Brand-name Drug (Tier 2) PULMICORT FLEXHALER (M)

MISCELLANEOUS DRUGS

Preferred Brand-name Drug (Tier 2) EPIPEN JR. (Q)
Generic Drug (Tier 1) montelukast (M)
Generic Drug (Tier 1) zafirlukast (M)

SKIN

ACNE

Generic Drug (Tier 1) adapalene (P)
Generic Drug (Tier 1) benzoyl peroxide/erythromycin
Generic Drug (Tier 1) clindamycin phos/benzyl peroxide
Generic Drug (Tier 1) clindamycin/tretinoin (P)
Generic Drug (Tier 1) clindamycin
Generic Drug (Tier 1) tretinoin cream and gel (P)
Generic Drug (Tier 1) tretinoin (P)

ANTI-INFLAMMATORY OR CORTICOSTEROIDS

Generic Drug (Tier 1) alclometasone cream & oint.
Generic Drug (Tier 1) aug. betamethasone diprop. cream
Generic Drug (Tier 1) aug. betamethasone diprop. oint.
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


SKIN

ANTI-INFLAMMATORY OR CORTICOSTEROIDS

Generic Drug (Tier 1) betamethasone diprop.
Generic Drug (Tier 1) clobetasol propionate
Generic Drug (Tier 1) desonide
Generic Drug (Tier 1) halobetasol propionate
Generic Drug (Tier 1) hydrocortisone valerate
Generic Drug (Tier 1) mometasone furoate

DISEASES-ECZEMA & PSORIASIS

Generic Drug (Tier 1) calcipotriene cream
Preferred Brand-name Drug (Tier 2) PROTOPIC
Preferred Brand-name Drug (Tier 2) TAZORAC (P)

GENITAL WARTS

Generic Drug (Tier 1) imiquimod
Generic Drug (Tier 1) podofilox sol'n

LICE AND SCABIES TREATMENT

Generic Drug (Tier 1) permethrin cream

MISCELLANEOUS

Generic Drug (Tier 1) ciclopirox
Generic Drug (Tier 1) fluorouracil

TOPICAL ANTIBIOTICS

Generic Drug (Tier 1) clindamycin topical

SKIN

TOPICAL ANTIBIOTICS

Generic Drug (Tier 1) metronidazole topical gel
Generic Drug (Tier 1) mupirocin ointment
Generic Drug (Tier 1) silver sulfadiazine

TOPICAL ANTIFUNGAL DRUGS

Generic Drug (Tier 1) ciclopirox olamine
Generic Drug (Tier 1) clotrimazole/betamethasone
Generic Drug (Tier 1) nystatin
Preferred Brand-name Drug (Tier 2) ZOVIRAX CREAM

STEROIDS (ORAL ANTI-INFLAMMATORY DRUGS)

STEROIDS (ORAL ANTI-INFLAMMATORY DRUGS)

Generic Drug (Tier 1) methylprednisolone
Generic Drug (Tier 1) prednisolone sodium

STOMACH & DIGESTIVE DISORDERS

ACID & STOMACH ULCERS

Generic Drug (Tier 1) cimetidine
Preferred Brand-name Drug (Tier 2) DEXILANT (M)
Generic Drug (Tier 1) famotidine 40 mg (M)
Generic Drug (Tier 1) lansoprazole (M)
Generic Drug (Tier 1) misoprostol (M)
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


STOMACH & DIGESTIVE DISORDERS

ACID & STOMACH ULCERS

Generic Drug (Tier 1) nizatidine (M)
Generic Drug (Tier 1) omeprazole 10mg & 40mg (M)
Generic Drug (Tier 1) pantoprazole (M)
Generic Drug (Tier 1) ranitidine 300 mg (M)
Generic Drug (Tier 1) sucralfate

ANTI-DIARRHEAL DRUGS

Generic Drug (Tier 1) diphenoxylate/atropine

ANTI-NAUSEA

Generic Drug (Tier 1) dronabinol
Preferred Brand-name Drug (Tier 2) EMEND
Generic Drug (Tier 1) granisetron
Generic Drug (Tier 1) ondansetron

BOWEL & COLON DISEASE

Preferred Brand-name Drug (Tier 2) ASACOL HD (M)
Generic Drug (Tier 1) budesonide (micronized) (M)
Generic Drug (Tier 1) hydrocortisone/pramoxine
Generic Drug (Tier 1) hydrocortisone
Preferred Brand-name Drug (Tier 2) LIALDA
Generic Drug (Tier 1) mesalamine rectal susp (M)

IRRITABLE BOWEL SYNDROME

Generic Drug (Tier 1) dicyclomine

STOMACH & DIGESTIVE DISORDERS

MALABSORPTION DISEASE

Generic Drug (Tier 1) pancrelipase (M)

MISCELLANEOUS

Generic Drug (Tier 1) peg/electrolyte soln.
Generic Drug (Tier 1) sulfasalazine (M)
Generic Drug (Tier 1) ursodiol (M)

SEVERE HEARTBURN & REFLUX

Generic Drug (Tier 1) metoclopramide (M)

SUBSTANCE ABUSE

DRUG ADDICTION

Generic Drug (Tier 1) buprenorphine tab (P)
Generic Drug (Tier 1) buprenorphine/naloxone
Generic Drug (Tier 1) naltrexone

QUIT SMOKING AIDS

Generic Drug (Tier 1) bupropion sr

SUPPLEMENTS

VITAMIN D

Generic Drug (Tier 1) calcitriol capsules (M)
KEY: Preferred Brand-name Drugs (Tier 2) Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication


SUPPLEMENTS

VITAMIN D

Generic Drug (Tier 1) calcitriol suspension (M)
Generic Drug (Tier 1) doxercalciferol (M)

UROLOGY

BLADDER CONTROL (ANTISPASMODICS)

Preferred Brand-name Drug (Tier 2) DETROL LA (M)
Generic Drug (Tier 1) hyoscyamine (M)
Generic Drug (Tier 1) oxybutynin sr (M)
Generic Drug (Tier 1) oxybutynin (M)
Generic Drug (Tier 1) tolterodine (M)

BLADDER CONTROL (CHOLINERGIC AGENTS)

Generic Drug (Tier 1) bethanechol chloride (M)

IMPOTENCE (ERECTILE DYSFUNCTION)

Preferred Brand-name Drug (Tier 2) VIAGRA (Q)

PROSTATE DISEASE (BENIGN PROSTATIC HYPERTROPHY)

Preferred Brand-name Drug (Tier 2) AVODART (M)
Generic Drug (Tier 1) doxazosin (M)
Generic Drug (Tier 1) finasteride (M)
Preferred Brand-name Drug (Tier 2) JALYN (M)

UROLOGY

PROSTATE DISEASE (BENIGN PROSTATIC HYPERTROPHY)

Generic Drug (Tier 1) tamsulosin (M)
Generic Drug (Tier 1) terazosin (M)

URINARY TRACT PAIN (ANESTHETICS)

Generic Drug (Tier 1) phenazopyridine
KEY: Preferred Brand-name Drug (Tier 2) Preferred Brand-Name Drugs (Tier 2) Generic Drug (Tier 1) Generic Drugs (Tier 1)
P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication