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The following is a list of the most commonly prescribed drugs. It representsan abbreviated version of the drug list (formulary) that is at the core of yourprescription-drug benefit plan. The list is not all-inclusive and does notguarantee coverage. In addition to using this list, you are encouraged to askyour doctor to prescribe generic drugs whenever appropriate.
OPEN ACCESS (2020)
PLEASE NOTE: Brand-name drugs may move to nonformulary status if ageneric version becomes available during the year. Not all the drugslisted are covered by all prescription-drug benefit programs; check yourbenefit materials for the specific drugs covered and the copayments foryour prescription-drug benefit program. For specific questions aboutyour coverage, please call the phone number printed on your member IDcard.
A .acetaminophen-codeineacycloviradapalene-benzoylperoxideAE
ADVAIR DISKUSQL
ADVAIR HFAQL
AFSTYLA†
AIMOVIGQL, PA, †
AJOVYQL, PA, †
albuterol sulfatealendronate sodiumalfuzosin hcl erallopurinolALPHAGAN PalprazolamambrisentanQL, PA, †
amiodarone hclAMITIZAQL, PA
amitriptyline hclamlodipine besy-benazepril hclST
amlodipine besylateamoxicillin-potclavulanateamoxicillinamphetamine sulfateQL,
AE
amphetamine-dextroamphetamineAE
anastrozoleANORO ELLIPTAQL
aprepitantQL
aripiprazoleQL
armodafinilQL, PA
ARMOUR THYROIDARNUITY ELLIPTAQL
ASMANEX HFAQL
atenolol-chlorthalidoneatenololatorvastatin calciumATRIPLAQL, †
ATROVENT HFAQL
AUBAGIOQL, PA, †
azathioprineazelaic acidAE
azelastine hclazithromycin
B .baclofenbenazepril hclbenazepril-hydrochlorothiazideBESIVANCEST
BETASERONQL, PA, †
bisoprolol-hydrochlorothiazidebosentanQL, PA, †
BREO ELLIPTAQL
BREVICON (28)BRILINTAQL
brimonidine tartratebudesonideQL
buprenorphine hcl-naloxone hclQL
bupropion hcl er(smoking det)QL
bupropion hcl er (sr)bupropion hcl er (xl)bupropion hclbuspirone hclbutalbital-apap-caffeineQL
butalbital-asa-caffeineQL
BYSTOLICQL, ST
C .cabergolinecalcitriolcarbamazepinecarbidopa-levodopacarvedilolcefadroxilcefdinircefuroxime axetilcelecoxibQL
cephalexinCETROTIDEPA, †
CHANTIXQL
chlorhexidine gluconateciclopiroxcinacalcet hclPA, †
CIPRODEXciprofloxacincitalopramhydrobromideQL
clarithromycinclindamycin hclclindamycin phos-benzoyl peroxAE
clindamycin phosphateclobetasol propionateclonazepamclonidine hclclopidogrel bisulfateclotrimazole-betamethasoneclotrimazolecolestipol hclCOMBIGANCOMBIPATCHQL
COMBIVENTRESPIMATQL
COSENTYXPA, †
CREONcyanocobalamin [INJ]cyclobenzaprine hclcyproheptadine hcl
D .dalfampridine erQL, PA, †
DESCOVYQL, †
desloratadineQL
dexamethasonediazepamdiclofenac sodiumdicyclomine hcldigoxindiltiazem hcl erdiphenoxylate-atropinedivalproex sodium erdivalproex sodiumdorzolamide hcl-timololmaldoxazosin mesylatedoxepin hcldoxycycline hyclatedoxycyclinemonohydrateDUAVEEQL
duloxetine hclQL
DUPIXENTQL, PA, †
dutasterideQL
DYMISTAQL
E .econazole nitrateELIQUISQL
ELMIRONEMGALITYQL, PA, †, AE
enalapril maleateenalapril-hydrochlorothiazideENBRELQL, PA, †
EPIDUO FORTEAE
epinephrineQL [INJ]EPIPEN 2-PAKQL [INJ]EPIPEN JR 2-PAKQL
[INJ]erythromycinescitalopram oxalateesomeprazolemagnesiumQL, ST
estradiolESTROSTEP FEeszopicloneQL, ST
etodolac
EUFLEXXAQL, PA, †
exemestaneezetimibeQL, ST
F .FARXIGAQL
febuxostatfenofibrate micronizedQL
finasterideFLOVENT DISKUSQL
FLOVENT HFAQL
fluconazolefludrocortisone acetatefluorometholonefluorouracil†
fluoxetine hclfluticasone-salmeterolQL
fluvoxamine maleatefolic acidFORTEOQL, PA, †
furosemide
G .gabapentingemfibrozilGENERESS FEGENOTROPINPA, †
gentamicin sulfateGENVOYAQL, †
glatiramer acetateQL, PA, †
glimepirideglipizide erglipizide xlglipizideGLUCAGONEMERGENCYQL [INJ]glyburideGLYXAMBIQL
guanfacine hcl erQL
guanfacine hcl
H .HUMIRAPA, †
hydralazine hclhydrochlorothiazidehydrocodone-acetaminophenhydrocodone-ibuprofenhydrocortisonehydromorphone hclhydroxychloroquinesulfatehydroxyzine hclhyoscyamine sulfate
I .ibandronate sodiumQL, PA,
†
imatinib mesylateQL, PA, †
indomethacinipratropium bromideipratropium-albuterolirbesartanisosorbide mononitrateerisotretinoinAE
J .JANUMET XRQL
JANUMETQL
JANUVIAQL
JARDIANCEQL
K .ketoconazoleketorolac tromethamineKOVALTRY†
L .labetalol hcllactuloselamotriginelansoprazoleLANTUSlatanoprostLATUDAQL
leflunomideletrozoleLEVEMIRlevetiracetamlevocetirizinedihydrochloridelevofloxacinlevothyroxine sodiumlidocaine viscous hclLINZESSQL, PA
liothyronine sodiumlisinoprillithium carbonate erlithium carbonateLIVALOQL, ST
LO LOESTRIN FElorazepamlosartan potassium-hctzlosartan potassiumloteprednol etabonatelovastatinLUMIGANST
M .MAVYRETQL, PA, †
meclizine hclmedroxyprogesteroneacetateQL
meloxicammemantine hclQL
mercaptopurinemesalamineQL
metformin hcl erQL
metformin hclmethadone hclmethimazolemethocarbamolmethotrexatemethylphenidate hclerQL, AE
methylphenidate hclQL, AE
methylprednisolonemetoclopramide hclmetoprolol succinate ermetoprolol tartratemetronidazoleMINIVELLEQL
minocycline hclmirtazapinemisoprostolmodafinilQL, PA
mometasone furoateMONOVISCQL, PA, †
montelukast sodiummorphine sulfate erQL
morphine sulfateMOVANTIKQL, PA
mupirocinmycophenolate mofetilMYRBETRIQQL, ST
N .nabumetonenaltrexone hclQL
naproxennaratriptan hclQL
neomycin-polymyxin-hcNEULASTAPA, †
NEUPOGENPA, † [INJ]nifedipine ernitrofurantoinnitroglycerinnortriptyline hclNOVOEIGHT†
NOVOLIN 70/30NOVOLIN NNOVOLIN R [INJ]NOVOLOG FLEXPENNOVOLOGNUCALAPA, †
NUCYNTA ERQL
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UPDATED ON 9/1/2019.THIS DOCUMENT LIST IS EFFECTIVE 1/1/2019 THROUGH 12/31/2019. THIS LIST IS SUBJECT TO CHANGE.©2019 All Rights Reserved
NUVARINGQL
nystatin
O .olmesartan medoxomil-hctzQL, ST
olmesartanmedoxomilQL, ST
olopatadine hclomega-3-acid ethylestersQL
ondansetronONETOUCH ULTRABLUEQL
ONETOUCH VERIOQL
OPDIVOPA, †
ORTHOVISCQL, PA, †
oseltamivir phosphateQL
OTEZLAQL, PA, †
oxcarbazepineoxybutynin chloride eroxybutynin chlorideoxycodone hcloxycodone-acetaminophenQL
OXYCONTINQL
OZEMPICQL, PA
P .pantoprazole sodiumparoxetine hclPAZEOpeg 3350/electrolytespenicillin v potassiumPENTASApermethrinphenazopyridine hclphenytoinpimecrolimuspioglitazone hclpolymyxin b-trimethoprimposaconazolePA
potassium chloride erpotassium citrate erpravastatin sodiumprazosin hclprednisoloneprednisonepregabalinQL, ST
PREMARINQL
PREMPROQL
PREPOPIKPROAIR HFAQL
PROAIR RESPICLICKQL
prochlorperazineprogesteronePROLENSApromethazine hclpromethazine-codeinepromethazine-dmpropranolol hcl erpropranolol hclPULMICORTFLEXHALERQL
Q .quetiapine fumarate erQL
quetiapine fumarateQL
quinapril hclQVAR REDIHALERQL
R .ramiprilranolazine erQL
REBIFQL, PA, †
REMICADEPA, †
REPATHAQL, PA, †
RESTASISQL, PA
REVLIMIDQL, PA, †
risperidoneritonavirQL, †
rizatriptan benzoateQL
ropinirole hcl erQL
ropinirole hclrosuvastatin calciumQL, ST
S .sertraline hclsevelamer carbonatesilodosinsimvastatinsodium fluoridesodium sulfacetamidesolifenacin succinateQL,
ST
sotalol hclSPIRIVA HANDIHALERQL
SPIRIVA RESPIMATQL
spironolactoneSPRYCELQL, PA, †
STELARAPA, †
STIOLTO RESPIMATQL
STRIBILDQL, †
SUBOXONEQL
sucralfatesulfamethoxazole-trimethoprimsulfasalazinesumatriptanQL
SYMBICORTQL
SYNJARDYQL
SYNTHROID
T .tacrolimustadalafil (pah)QL, PA, †
tadalafilQL
tamoxifen citratetamsulosin hclTECFIDERAQL, PA, †
temazepamtenofovir disoproxilfumarateQL, †
terbinafine hclterconazoletestosterone cypionatetestosteronePA
timolol maleateTIVICAYQL, †
tizanidine hclQL
tobramycin-dexamethasone
tobramycintolterodine tartratetopiramateTOUJEO SOLOSTARtramadol hcltramadol-acetaminophenTRAVATAN ZST
trazodone hclTRESIBA FLEXTOUCHtriamcinolone acetonidetriamterene-hctztriazolamTRIUMEQQL, †
TRULICITYQL, PA
TRUVADAQL, †
V .valacyclovir hclvalsartan-hydrochlorothiazidevalsartanvenlafaxine hcl ervenlafaxine hclverapamil hcl erVICTOZAQL, PA
VIIBRYDQL, ST
VIMPATQL
VIREADQL, †
VIVITROLPA, †
VYVANSEQL, AE
W .warfarin sodiumwixela inhubQL
X .XARELTOQL
XIFAXANQL, PA
XIGDUO XRQL
XIIDRAQL, PA
XOLAIRPA, †
XULTOPHYQL
Z .zaleplonZENPEPzolpidem tartrate erQL, ST
zolpidem tartrateQL
zonisamide
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UPDATED ON 9/1/2019.THIS DOCUMENT LIST IS EFFECTIVE 1/1/2019 THROUGH 12/31/2019. THIS LIST IS SUBJECT TO CHANGE.©2019 All Rights Reserved
(Continued)
Non-Preferred Medication(s) Selected Preferred Alternative(s) ACANYAPA and ONEXTONPA (clindamycin phosphate-benzoyl peroxide)
clindamycin and benzoyl peroxide (separate agents)
ADMELOGPA (insulin lispro) NOVOLOG
AEROSPANPA (flunisolide) ARNUITY ELLIPTAQL, ASMANEX HFAQL, ASMANEX TWISTHALERQL, FLOVENT DISKUSQL, FLOVENT HFAQL, PULMICORT FLEXHALERQL, QVAR REDIHALERQL
AIRDUOPA QL(fluticasone-salmeterol 55-14 mcg, 113-14 mcg, 232-14 mcg)
fluticasone-salmeterolQL (100-50 mcg, 250-50 mcg, 500-50 mcg), wixelaQL, ADVAIR DISKUSQL, ADVAIR HFAQL, BREO ELLIPTAQL, SYMBICORTQL
ALLZITALPA QL (butalbital-acetaminophen 25-325 mg) and butalbital-acetaminophen 50-300 mgPA QL
butalbital-acetaminophen 50-325 mgQL
ALVESCOPA (ciclesonide) ARNUITY ELLIPTAQL, ASMANEX HFAQL, ASMANEX TWISTHALERQL, FLOVENT DISKUSQL, FLOVENT HFAQL, PULMICORT FLEXHALERQL, QVAR REDIHALERQL
AMRIXPA QL (cyclobenzaprine ER) cyclobenzaprine 5 mg, cyclobenzaprine 10 mg
APIDRAPA (insulin glulisine) NOVOLOG
APIDRA SOLOSTARPA (insulin glulisine) NOVOLOG
AUVI-QPA QL (epinephrine solution) epinephrine 0.15 mgQL, epinephrine 0.3 mgQL, EPIPENQL, EPIPEN JRQL
BASAGLARPA (insulin glargine) LANTUS, LEVEMIR, TOUJEO, TRESIBA
BELSOMRAPA QL (suvorexant) zolpidem IRQL, zaleplon
BONJESTAPA QL and DICLEGISPA QL (doxylamine-pyridoxine) OTC doxylamine and OTC pyridoxine
BRAVELLE† PA (urofollitropin) GONAL-F†, GONAL-F RFF†
BYETTAPA QL (exenatide) OZEMPICPA QL, TRULICITYPA QL, VICTOZAPA QL
BYDUREONPA QL (exenatide extended-release) OZEMPICPA QL, TRULICITYPA QL, VICTOZAPA QL
CETRAXALPA QL (ciprofloxacin 0.2% otic soln) ofloxacin otic soln
DENAVIRPA (penciclovir) acyclovir ointment
DEXILANTQL (dexlansoprazole) lansoprazole, omeprazole, pantoprazole
DIABETES TEST STRIPSPA QL (e.g., Accu-Chek, Ascensia, Breeze, Contour, etc.)
ONETOUCHQL
DUEXISPA QL (famotidine-ibuprofen) OTC famotidine and OTC ibuprofen (separate agents)
DULERAPA QL (mometasone-formoterol) fluticasone-salmeterolQL (100-50 mcg, 250-50 mcg, 500-50 mcg), wixelaQL, ADVAIR DISKUSQL, ADVAIR HFAQL, BREO ELLIPTAQL, SYMBICORTQL
DUREZOLPA (difluprednate) prednisolone acetate ophth solution
EXTAVIA† PA QL BETASERON† PA QL, REBIF† PA QL
FOLLISTIM AQ† PA (follitropin beta) GONAL-F†, GONAL-F RFF†
FORFIVO XLPA QL (bupropion ER) bupropion ER
GLUMETZAPA QL and FORTAMETPA QL (metformin ER modified/osmotic)
metformin ER (generic Glucophage XR)
GRALISEPA QL (gabapentin) gabapentin
HORIZANTPA QL (gabapentin ER) gabapentin
HUMALOGPA (insulin lispro) NOVOLOG
HUMULIN NPA (insulin isophane), HUMULIN RPA (insulin regular), HUMULIN 70/30PA (insulin NPH and regular)
NOVOLIN N, NOVOLIN R, NOVOLIN 70/30
INCRUSE ELLIPTAPA (umeclidinium) SPIRIVAQL
INVOKANAPA QL (canagliflozin) FARXIGAQL, JARDIANCEQL
INVOKAMETPA QL (canagliflozin-metformin), INVOKAMET XRPA QL (canagliflozin-metformin ER)
SYNJARDYQL, SYNJARDY XRQL, XIGDUO XRQL
JENTADUETOPA QL,JENTADUETO XRPA QL (linagliptin and metformin) JANUMETQL, JANUMET XRQL
JUBLIAPA (eficonazole) ciclopirox
KAZANOPA QL (alogliptin-metformin) JANUMETQL, JANUMET XRQL
Examples of Non-Preferred Medications with Selected Formulary Alternatives The following is a list of some non-preferred brand-name medications with examples of selected covered formulary alternatives. This is not an all-inclusive list.
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UPDATED ON 9/1/2019.THIS DOCUMENT LIST IS EFFECTIVE 1/1/2019 THROUGH 12/31/2019. THIS LIST IS SUBJECT TO CHANGE.©2019 All Rights Reserved
Non-Preferred Medication(s) Selected Preferred Alternative(s) KOMBIGLYZE XRPA QL (saxagliptin-metformin ER) JANUMETQL, JANUMET XRQL
LASTACAFTPA QL (alcaftadine eye soln) OTC ketotifen eye soln
NASCOBALPA (cyanocobalamin nasal) OTC vitamin B12
NESINAPA QL (alogliptin) JANUVIAQL
NORDITROPIN†, PA (somatropin) GENOTROPIN†, PA
ONGLYZAPA QL (saxagliptin) JANUVIAQL
OSENIPA QL (alogliptin-pioglitazone) JANUVIAQL and pioglitazone
PANCREAZEPA (pancrelipase DR) CREON, ZENPEP
PERTZYEPA (pancrelipase DR) CREON, ZENPEP
PROVENTIL HFAPA QL (albuterol) PROAIR HFAQL
QTERNPA QL (dapagliflozin-saxagliptin) GLYXAMBIQL
SEGLUROMETPA QL (ertugliflozin-metformin) SYNJARDYQL, SYNJARDY XRQL, XIGDUO XRQL
STEGLATROPA QL (ertugliflozin) FARXIGAQL, JARDIANCEQL
STEGLUJANPA QL (ertugliflozin-sitagliptin) GLYXAMBIQL
SOLARAZEPA (diclofenac 3% gel) Fluorouracil 5% cream
SOLIQUAPA QL (insulin glargine-lixisenatide) XULTOPHYPA QL
SOLODYNPA QL (minocycline ER) minocycline
SOOLANTRAPA (ivermectin cream) metronidazole cream
TIROSINTPA QL (levothyroxine) levothyroxine, SYNTHROID
TRADJENTAPA QL (linagliptin) JANUVIAQL
TREXIMETPA QL (sumatriptan-naproxen) sumatriptanQL and naproxen (separate agents)
TUDORZA PRESSAIRPA QL (aclidinium) SPIRIVAQL
VENTOLIN HFAPA QL (albuterol sulfate) PROAIR HFAQL
VIMOVOPA QL (esomeprazole-naproxen) OTC esomeprazole and OTC naproxen
XOPENEX HFAPA QL (levalbuterol) PROAIR HFAQL
ZEGERIDPA QL (omeprazole-sodium bicarbonate) OTC omeprazole-sodium bicarbonate
ZIANAPA and VELTINPA (clindamycin phosphate-tretinoin) clindamycin and tretinoinAE (separate agents)
ZIOPTANPA QL (tafluprost) latanoprost
ZORVOLEXPA QL (diclofenac) diclofenac sodium DR
ZOVIRAX CREAMPA acyclovir ointment
ZYFLOPA QL (zileuton) and ZYFLO CRPA QL (zileuton ER) montelukast, zafirlukast
For the member: Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the US Food and Drug Administration (FDA) may not be covered upon release to market.
WellDyneRx may contact your provider after receiving a prescription to request consideration of a drug list product or generic equivalent. This may result in your provider prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of the original prescription. Generic medications contain the same active ingredi- ents as their corresponding brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards.
In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-pre- ferred or excluded option upon release of the generic product to the market.
For the physician: Generics should be considered the first-line of prescribing. Please prescribe preferred products and allow generic substitutions when medically appropriate. Brand-name drugs are listed in CAPITAL letters; generic drugs are listed in lower case letters.
This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to market.
[INJ] = Injectable Drug
ER = Extended-Release
DR = Delayed Release
AE = Age Edit
LD = Limited Distribution
PA = Prior Authorization
QL = Quantity Limits
ST = Step Therapy
† Indicates specialty
medications
KEY
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UPDATED ON 9/1/2019.THIS DOCUMENT LIST IS EFFECTIVE 1/1/2019 THROUGH 12/31/2019. THIS LIST IS SUBJECT TO CHANGE.©2019 All Rights Reserved