TIER 1Acebutolol HCl (Sectral)

Acetaminophen/Butalbital (Phrenilin) Acetaminophen/Caffeine/Butalbital (Fioricet)

Acetylcysteine Vial (Mucomyst)Aciclovir Ointment (Zovirax)Adapalene (Differin)Albuterol Sulfate (Accuneb, Proventil, Ventolin)Alendronate Sodium (Fosamax)Amiloride (Midamor)Amiloride HCL/Hydrochlorothiazide (Moduretic)Amlodipine Besylate (Norvasc)Amoxicillin Trihydrate/Potassium Clavulanate ql (Amoxil,

Augmentin Suspension, Augmentin ES) Aspirin/Caffeine/Butalbital (Fiorinal) Atenolol (Tenormin) Atenolol/Chlorthalidone (Tenoretic)

Atorvastatin (Lipitor qd)Azelastine Nasal Spray (Astelin)Azithromycin (Zithromax ql)Benazepril (Lotensin)Benzphetamine HCl (Didrex)Betamethasone Dipropionate (Diprosone 0.05 %, Maxivate 0.05%)Betaxolol (Kerlone)Bisoprolol (Zebeta)Bisoprolol Fumarate/HCTZ (Ziac)Bumetanide (Bumex)Cabergoline (Dostinex)Calcitonin, Salmon, Synthetic Aerosol, Spray w/Pump

(Miacalcin ql)Candesartan (Atacand, Atacand HCTZ)Capecitabine (Xeloda) Captopril (Capoten)

Captopril/Hydrochlorothiazide (Capozide)Carvedilol (Coreg)Cefaclor (Ceclor)Cefaclor Extended Release ql (Ceclor CD)Cefadroxil (Duricef Tablet, Capsule, Suspension)Cefdinir (Omnicef )Cefpodoxime (Vantin)Cefprozil (Cefzil)Cefuroxime Axetil (Ceftin)Cephalexin Monohydrate (Keflex)Chlorothiazide (Diuril)Chlorpropamide (Diabinese)Chlorthalidone (Hygroton)Cholestyramine (Questran, Questran Light)Cilostazol (Pletal)Cimetidine, Cimetidine OTC (Tagamet)Ciprofloxacin HCl (Cipro)Clindamycin/Benzoyl Peroxide (Benzaclin)Clindamycin HCl (Cleocin HCl 150, 300mg)Clindamycin Phosphate (Cleocin T)Clonidine HCl (Catapres, Catapres-TTS)Clotrimazole Cream, Solution, Non-Oral (Lotrimin AF)

Indomethacin (Indocin) Indomethacin Capsule, Sustained Action (Indocin SR)

Ipratropium Bromide Solution, Non-Oral (Atrovent)Irbesartan (Avapro)

Irbesartan/HCTZ(Avalide)Isosorbide Dinitrate, Tab, SA, SL (Isordil)Isosorbide Mononitrate (ISMO)Isosorbide Mononitrate Tablet, Sustained Release 24 hr (Imdur)Itraconazole (Sporanox qd)Ketoconazole Cream ql, Tablet (Nizoral)Labetalol HCl (Normodyne)Levofloxacin (Levaquin)Levothyroxine Sodium (Levoxyl)Lisinopril ql (Prinivil, Zestril)

Lisinopril/Hydrochlorothiazide (Prinzide, Zestoretic)Losartan qd (Cozaar)Losartan/HCTZ qd (Hyzaar)Lovastatin (Mevacor qd)Megestrol Acetate (Megace)Meloxicam (Mobic ql)Metformin HCl, ER (Glucophage, Glucophage XR)Methenamine Mandelate (Mandelamine)Methyldopa (Aldomet)Methyldopa/Hydrochlorothiazide (Aldoril)Metoazone (Zaroxolyn)Metoprolol HCT (Lopressor HCT)

Metoprolol Tartrate (Lopressor, Toprol XL) Metronidazole (Metrogel)

Miconazole (Micatin)Minocycline HCl (Dynacin, Minocin)Misoprostol (Cytotec)Moexipril (Univasc)Montelukast ql ST (Singulair)Mupropirocin Ointment (Bactroban)Nabumetone (Relafen)Nadolol (Corgard)

Naproxen (EC-Naprosyn) Naproxen (Naprosyn) Naproxen Sodium (Anaprox 275, 550 mg) Neomycin Sulfate (Neomycin Sulfate)

Niacin (Niacor, Niaspan)Niacin SA (Niaspan)Nifedipin ER ql (Procardia, Procardia XL)Nimodipine (Nimotop)Nitrofurantoin Macrocrystal (Macrodantin 50, 100mg)Nitrofurantoin/Nitrofurantoin Macrocrystal (Macrobid)Nitroglycerin Capsule, Sustained Action (Nitro-Bid)Nitroglycerin Patch, Transdermal 24 Hours (Transderm-Nitro)Nitroglycerin Spray (Nitromist)Nystatin (Mycostatin)Ofloxacin (Floxin)Oxaprozin (Daypro)Oxybutynin Chloride (Ditropan, Ditropan XL)Pantoprazole (Protonix) Penicillin V Potassium (Pen-Vee K)Permethrin ql (Elimite)Phenylephrine HCl/Promethazine HCl (Phenergan VC)Pindolol (Visken)

Piroxicam (Feldene)Polyethylene Glycol/Electrolyte (Colyte, Golytely)Potassium Chloride ER (Micro-K, K-Dur)Pravastatin (Pravachol qd)Prazosin HCl (Minipress)

This information pertains to:

Prescription ID Card Number:

Benefit Information:

2015 Sparrow PHPMember Guide

Clotrimazole Troche (Fulvicin P/G)Clotrimazole/Betamethasone Dipropionate Cream ql (Lotrisone)Colestipol (Colestid)Cromolyn Sodium Ampul for Nebulization (Intal)Cyproheptadine HCl (Periactin)Dexchlorpheniramine Maleate Syrup (Polaramine)Dexchlorpheniramine Maleate Tablet, Sustained Action

(Polaramine)Diclofenac Potassium (Cataflam)

Diclofenac Sodium, XR (Voltaren) Diclofenac 3% Gel (Solaraze)

Dicloxacillin Sodium Capsule (Dynapen)Diflorasone Diacetate (Psorcon-E)Diltiazem HCl (Cardizem, Tiazac)Diltiazem HCl Capsule, Sustained Release (Cardizem SR,

Cardizem CD)Donepezil ql qd (Aricept)Doxazosin Mesylate (Cardura)

Doxycycline Hyclate (Vibra-Tabs, Vibramycin)Enalapril (Vasotec)

Enalapril Maleate/Hydrochlorothiazide (Vaseretic)Erythromycin Base (Eryc)Erythromycin Base Tablet, Enteric Coated (E-Mycin)Erythromycin/Benzoyl Peroxide (Benzamycin) Erythromycin Ethylsuccinate (E.E.S., EryPed)Erythromycin Ethylsuccinate/Sulfisoxazole Acetyl (Pediazole)Erythromycin Stearate (Erythrocin Stearate)

Estradiol (Estrace) Estradiol Patch, Transdermal Weekly ql (Climara) Estropipate Tablet ql (Ogen) Etodolac, Etodolac ER (Lodine)

Famciclovir (Famvir)Famotidine (Pepcid 40mg)Felodipine (Plendil)Fenofibrate Micronized (Lofibra, Antara)Fenofibric Acid (Fibricor)

Fenoprofen Calcium Tablet (Nalfon) Finasteride ql N A (Proscar A)

Fluconazole (Diflucan ql) Flurbiprofen (Ansaid)

Fluticasone Propionate ql (Flonase ql)Fosinopril Sodium (Monopril, Monopril HCT)Furosemide (Lasix)Galantamine HBr ql (Razadyne)Gama Benzene Hexachloride (Lindane)Gemfibrozil (Lopid)Glipizide (Glucotrol)Glipizide Extended Release Tablet (Glucotrol XL)Glipizide/Metformin (Metaglip)Glyburide (DiaBeta, Micronase)Glyburide, Micronized (Glynase)Glyburide/Metformin HCl (Glucovance)Griseofulvin Ultramicrosize Tablet (Mycelex)Guanfacine HCl (Tenex)Hydralazine HCl/Hydrochlorothiazide (Apresazide)Hydrochlorothiazide (HydroDIURIL)Hydrocortisone Cream, Ointment, Lotion (Hytone 2.50%)Hydrocortisone Valerate Cream, Ointment (Westcort 0.20%)Hydroxyzine (Atarax)Hydroxyzine Pamoate Capsule (Vistaril)Hyoscyamine Sulfate (Levsin, Levsin/SL, Levbid)Hyoscyamine Sulfate Capsule, Sustained Release 12 hr (Levsinex)

Indapamide (Lozol)

FORM# FF45932I (Ed. 5/15)

How to use: Please copy this original sheet and place in your patient’s file, to reference when prescribing for patients whose plans use the PHP 2015 Sparrow PHP Prescription Drug List Formulary.Please note: Parentheses indicate a medication’s trade name or generic. Coverage is determined by the member’s prescription drug benefit.

This file sheet does not contain a complete list of formulary drugs. It only lists the most commonly prescribed drugs.

Effective May 1, 2015

KEY:

= Weigh risk of birth defects or other adverse outcomes.

= Do not use in pregnancy.N = Prior Notification is required to be eligible for coverage.

Contact PHP Customer Service to determine request procedure.

A = Prior Notification may be required to be eligible for coveragedepending on patient’s age. Contact PHP Customer Service todetermine request procedure.

ql = Quantity limit.qd = Quantity per duration limit.ST = Quantity per duration limit.OTC = Over-the-counter (non-prescription) drug. Written prescription

required. Mandatory generic substitution required.

NovoLog Mix 70/30 (Insulin Aspart Protamine Human/InsulinAspart Vial)

Premarin (Estrogens, Conjugated Cream, Tabs) Premphase (Estrogens, Conjugated/Medroxyprogesterone Acetate) Prempro (Estrogens, Conjugated/Medroxyprogesterone Acetate)

Pulmozyme (Dornase Alfa Solution, Non-Oral)Qvar (Beclomethasone Dipropionate ql)Serevent Diskus

(Salmeterol Xinafoate Disk, with Inhalation Device ql)Spiriva ql (Tiotropium)Symbicort (Budesonide/Formoterol)Tekturna (Aliskiren)Tykerb N (Lapatinib)

Vivelle-Dot ql (Estradiol Patch, Transdermal Biweekly)Xopenex HFA (Levalbuterol)

NO CO-PAYMENTClemastine Fumarate (Tavist) OTCClotrimazole (Clotrimazole) OTC

Desogestrel-Ethinyl Estradiol (Apri, Desogen, Mircette) Desogestrel-Ethinyl Estradiol (Ortho-Cept) Ethynodiol D-Ethinyl Estradiol (Demulen) Ethynodiol D-Ethinyl Estradiol (Zovia)

Famotidine (Pepcid 10, 20mg) OTCHydrocortisone OTC

Ibuprofen (Motrin, Rufen, Children’s Advil) Ibuprofen Suspension, Oral (Final Dose Form) (Children’s Advil) Kariva (Desogestrel-Ethinyl Estradiol/Ethinyl Estradiol)

Ketoconazole ql (Nizoral-AD) OTC Levonorgestrel-Ethinyl Estradiol (Alesse, Aviane, Levora, Levlen,

Levlite, Lybrel, Nordette, Seasonale,Tri-Levlen, Triphasil, Trivora)Loratadine (Loratadine + Alavert) OTCLoratadine D (Alavert-D) OTC

Low-Ogestrel (Norgestrel-Ethinyl Estradiol) Microgestin FE (Noreth A-ET Estra/FE Fumarate) Naproxen Sodium (Aleve) Norethindrone (Camila, Ortho Micronor) Norethindrone A-E Estradiol (Loestrin) Norethindrone A-E Estradiol/Ferrous Fumarate (Loestrin Fe) Norethindrone-Ethinyl Estradiol (Brevicon, Nelova, Necon, Ovcon,

Genora, Modicon, Norinyl, Nortrel) Norethindrone-Ethinyl Estradiol (Ortho-Novum 1-0.035mg,

Ortho-Novum 10/11, Ortho-Novum 7/7/7) Norethindrone-Mestranol (Norinyl, Nelova, Necon, Genora 1/50) Norethindrone-Mestranol (Ortho-Novum 1-0.05mg) Norgestimate-Ethinyl Estradiol (Ortho-Cyclen, Ortho Tri-Cyclen) Norgestrel-Ethinyl Estradiol (Lo/Ovral, Ovral, Ogestrel) Ortho Tri-Cyclen Lo (Norgestimate-Ethinyl Estradiol)

Triamcinolone Acetonide (Aristocort 0.03, 0.10%, Kenalog 0.03,0.10%)

Triamcinolone Nasal Spray (Nasacort AQ)Triamterene/Hydrochlorothiazide (Dyazide, Maxzide)Trimethoprim (Proloprim)

Valsartan ql (Diovan) Valsartan/Hydrochlorothiazide qd (Diovan HCT)

Verapamil HCl (Calan, SR, Verelan 120, 180mg)Zolmitriptan ql qd (Zomig, Zomig ODT)

TIER 2

Actos ql (Pioglitazone HCl)Advair Diskus ql (Fluticasone Propionate/Salmeterol Xinafoate Disk,

with Inhalation Device)Alphagan P (Brimonide)Androgel (Testosterone)Apidra (Insulin glulisine)Atrovent HFA (Ipratropium Bromide)Avandamet ql (Rosiglitazone/Metformin)Avandia ql (Rosiglitazone Maleate)Azmacort ql (Triamcinolone Acetonide Aerosol w/Adapter)

Cafergot (Ergotamine Tartrate/Caffeine Suppository, Rectal)Chantix (Varenicline)Dapsone (Dapsone)Ergomar (Ergotamine Tartrate)Exelon (Rivastigmine Tartrate ql)Flovent HFA ql (Fluticasone Propionate Disk, with Inhalation

Device)Flovent Rotadisk ql (Fluticasone Propionate Aerosol w/Adapter)Foradil (Formoterol Fumarate ql)Fosamax D ql (Alendronate Sodium Cholecalciferol)Fragmin syringes (Dalteparin ql)Humalog (Insulin Lispro, Human Recombinant Analog Vial)Humalog Mix 75/25 (Insulin Lispro Humulin 70/30, Novolin 70/30 (Insulin NPH Human

Recombinant/Insulin Regular Human Recombinant Vial)Humulin N, Novolin N (Insulin NPH Human Recombinant Vial)Humulin R, Novolin R (Insulin Regular Human Recombinant Vial)Intal ql (Cromolyn Sodium)Janumet (Sitagliptin/Metformin)Januvia (Sitagliptin Phosphate)Lantus (Insulin Glargine, Human Recombinant Analog)Levemir (Insulin Detemir)Menest (Esterified Estrogens)Nasonex ql (Mometasone Furoate Spray, Non-Aerosol)NovoLog (Insulin Aspart Vial)

ProAir HFA (Albuterol)Progesterone, Micronized (Prometrium)Promethazine HCl (Phenergan)Propranolol (Inderal)Propranolol HCl/Hydrochlorothiazide (Inderide)Pseudoephedrine HCl/Brompheniramine Maleate (Bromfed,

Bromfed-PD)Pseudoephedrine HCl/Carbinoxamine Maleate Tablet (Rondec,

Deconamine, Deconamine SR)Pseudoephedrine Sulfate/Dexbrompheniramine Maleate (Drixoral)Rabeprazole (Aciphex)Ramipril (Altace)Ranitidine HCl Syrup, Tabs (Zantac)Repaglinide ql (Prandin)Rizatriptan Benzoate qd (Maxalt, MLT)Silver Sulfadiazine (Silvadene)Simvastatin (Zocor qd)Sodium Chloride for Inhalation (Sodium Chloride)Sotalol (Betapace)

Spironolactone (Aldactone) Spironolactone/Hydrochlorothiazide (Aldactazide 25-25mg)

Sucralfate (Carafate)Sulfamethoxazole/Trimethoprim (Bactrim, Bactrim DS, Septra,

Septra DS)Sulfisoxazole (Sulfisoxazole)

Sulindac (Clinoril)Sumatriptan Spray, Non-Aerosol, Tab, Vial qd (Imitrex)Tamsulosin (Flomax) Telmisartin/Telmisartan HCTZ (Micardis/Micardis HCT)Temozolomide (Temodar) Terazosin HCl (Hytrin) Terbinafine HCl N qd (Lamisil)Terbutaline Sulfate (Brethine)

Tetracycline HCl (Achromycin V)Timolol Maleate (Blocadren)Tizanidine (Zanaflex) Tobramycin/Dexamethasone Susp (Tobradex)Tolazamide (Tolinase)Tolbutamide (Orinase)

Tolmetin Sodium (Tolectin, Tolectin DS)Tolterodine/Tolterodine ER (Detrol/Detrol LA)Torsemide (Demadex)Tramadol/Tramadol ER (Ultram/Ultram ER)Trandolapril (Mavik)Trandolapril/Verapamil (Tarka)Tretinoin (Retin-A)

Note:This Sparrow PHP prescription drug list (PDL) consists of but is not limited to the following plans for Physicians Health Plan FamilyCare and Healthy Michigan.