Providence Health & Services - Alaska/media/files...latest and best information about effective, quality medications that also provide value. Providence Health Plan’s prescription

Providence Health & Services - Alaska Formulary List of Covered Prescription Drugs

www.providence.org/healthplans

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Prescription drug benefits from Providence

Providence Health Plan wants you to get the most from all of your covered benefits and for you to have information to make smart decisions about medications. Our pharmacy benefit plan is designed to provide resources to assist you and your doctor to become knowledgeable about the latest and best information about effective, quality medications that also provide value.

Providence Health Plan’s prescription drug Program

Your prescription drug coverage provides benefits for medications listed on the Providence Health Plan formulary. The Formulary is a list of Food and Drug Administration (FDA)-approved prescription generic, brand name and specialty medications. Providence consults with a team of physicians and pharmacists to develop the Formulary which is designed to offer drug treatment choices for covered medical conditions. The Formulary can help you and your physician choose effective medications that minimize your out-of-pocket expense. There are effective generic drug choices to treat most medical conditions. Medications included in the Formulary can be purchased at participating retail, mail order and specialty pharmacies. The Providence Health Plan Formulary is available at our website: www.providence.org/ healthplans/ under “Members”, “Pharmacy resources”.

Retail Pharmacies

You have broad access to over 22,000 participating pharmacies and their services nationwide at discounted rates. You can search the online directory to locate participating pharmacies near you.

Mail Order Pharmacies

A 90-day supply of maintenance medication is available through the mail order participating pharmacies. Maintenance drugs are typically prescribed to treat long-term or chronic conditions, such as diabetes, high blood pressure and high cholesterol. Maintenance drugs are those that you have received under our plan for at least 30-days and you anticipate continuing to use in the future. Your 90-day supply copayment or coinsurance applies. Not all covered prescription drugs are available in a 90-day supply. Mail order pharmacies include:

• Postal Prescription Services • Walgreens Pharmacy • Wellpartner Pharmacy

In addition, you have access to a 90-day supply of maintenance medications at preferred retail stores, such as Albertsons/Sav-On, Costco, Florence Pharmacy, Fred Meyer, OHSU Outpatient and Clinic Pharmacies, Providence (all pharmacy locations), QFC, Safeway, SUPERVALU Inc., Walgreens and Yokes Food pharmacies.

http://providence.org/healthplans/members/pharmacy/postalrx.aspx

http://providence.org/healthplans/members/pharmacy/walgreens.aspx

http://providence.org/healthplans/members/pharmacy/wellpartner.aspx

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Specialty drugs

Specialty drugs are prescriptions that require special delivery, handling, administration and monitoring by your pharmacist. These drugs are available through Providence Specialty Pharmacy Services and are listed in the Providence Health Plan formulary with a status of “Specialty.” To order your specialty medication contact Providence Specialty Pharmacy at 503-215-4535 or 1- 800-772-7053 ext. 54535.

Know More. Save More.

1. Become smarter about your prescription drug benefits - refer to the “Pharmacy Benefit Tips” section on our Web site.

2. Ask your physician if there’s a generic medication available on the Formulary to treat your medical condition.

Generic drugs

Why should you consider switching to generic drugs? Generic drugs have the same active-ingredient formula as the brand name drug. Generic drugs are tested by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs. Generic drugs are only available after the brand name patent expires. The bonus: They save you and your employer money. Refer to our list of “Effective Generic Options for Common Medical Conditions” available on our website: www.providence.org/ healthplans/ under “Members”, “Pharmacy resources”. There are two types of generic drugs:

• Generic Equivalent

A generic equivalent means the exact same medication in generic form is substituted for the brand name. A generic manufacturer makes it and charges less than the brand manufacturer. The FDA assures equivalence through testing. More than 50% of the time the same company makes the brand and the generic! They then license it to be distributed under a generic manufacturing company (e.g. for high cholesterol: Zocor® (simvastatin) made by Merck is now as available in generic form as simvastatin).

• Generic Alternative

A generic alternative is not the same medication. According to the evidence that includes medical studies, the generic alternative can be expected to treat the same condition as well as or better than the brand name alternative (e.g. for high cholesterol: simvastatin is prescribed instead of LIPITOR®

) Generic alternatives are an important option for drugs not available in generic form yet. Visit the Consumer Reports Best Buy Drug website http://www.consumerreports.org/health/best-buy-drugs/index.htm for more information on safe and effective drug treatment options.

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Formulary Brand drugs

Brand name drugs are protected by US patent laws for up to 17 years. Only the pharmaceutical company holds the patent and has exclusive rights to produce and sell the drug; however, there are effective generic equivalents or alternatives to treat most common ailments. If there is not a generic option, Providence has identified formulary brand name drugs that evidence shows they can be used safely, are effective, and offer value.

Prior Authorization

Some prescription drugs require prior authorization for medical necessity, place of therapy, length of therapy, step therapy, or number of doses. A limited number of medications need prior authorization (PA) review by physicians and pharmacists at Providence Health Plan in order to be approved for coverage. We consider many factors before requiring PA of a prescription medication including: serious risks, Food and Drug Administration (FDA) approved indications, cost-effectiveness, and new medications on the market that have not been widely used or evaluated. If your medication requires prior authorization, contact your doctor or other medical provider to submit an authorization request or to consider changing your prescription to an effective formulary alternative medication covered by your pharmacy benefits. The Formulary and prior authorization form are available on our website: www.providence.org/ healthplans/ under “Members”, “Pharmacy resources”.

Step Therapy

Step therapy uses Providence Health Plan pharmacy claims history to confirm if certain drugs have been tried first and if they have, the drug requiring prior authorization will automatically be approved. In the event these drugs are not tried first, cannot be tried first or the drug history is not part of Providence Health Plan claims, prior authorization is required.

Quantity Limit

For certain drugs, Providence Health Plans limits the amount of the drug covered for a specified time frame [e.g. Providence Health Plans provides 2 inhalers per 30 days for Proair® or Proventil® HFA (Albuterol HFA)].

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How to search the Formulary

There are two ways to search the Formulary:

1. The first section of the Formulary lists prescription medications by medical condition category that the drug treats (e.g., drugs used to treat heart conditions are listed under the category, Cardiovascular Agents).

2. The Index, which provides an alphabetical listing of the drugs included in the Formulary.

Changes to the Formulary

Our pharmacy & therapeutics committee (comprised of community doctors and pharmacists who practice in the communities we serve) continue to review the latest evidence to identify opportunity to promote safe, effective and affordable drug therapy. The formulary is updated every two months. Generally, formulary status for a formulary drug you are taking with your Providence Health Plans pharmacy benefit coverage will not change during the year unless:

• The same medication is now available in generic form, or • Safety or effectiveness concerns are raised about the prescription drug, or • The pharmacy & therapeutics committee determines that changes to the formulary would

“overall” be in the best interest of PHP’s health plan members. In such cases, impacted individuals are always notified in writing if the formulary change results in a reduction of benefits or an increase in copayment.

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Providence Health Plan Commercial Formulary[To help find a drug see the back of the document for an alphabetical listing]

Drug Name CommentStatus*^

Analgesics ‐ Drugs to treat pain

Non‐opioid Analgesics

CELEBREX® 400MG BRAND PA, QL (30 CAPSULES PER 30 DAYS)

CELEBREX® 50MG, 100MG, 200MG BRAND PA, QL (60 CAPSULES PER 30 DAYS)

DICLOFENAC POTASSIUM GENERIC

DIFLUNISAL GENERIC

ETODOLAC GENERIC

FENOPROFEN GENERIC

FLURBIPROFEN GENERIC

IBUPROFEN GENERIC

INDOMETHACIN GENERIC

KETOPROFEN GENERIC

KETOROLAC TROMETHAMINE TABLET GENERIC

MECLOFENAMATE GENERIC

MELOXICAM GENERIC

NAPROXEN GENERIC

NAPROXEN SODIUM GENERIC

OXAPROZIN GENERIC

PIROXICAM GENERIC

SULINDAC GENERIC

TOLMETIN SODIUM GENERIC

VOLTAREN® GEL BRAND

Opioid Analgesics

ACETAMINOPHEN‐CODEINE GENERIC

BUPRENORPHINE GENERIC

BUTORPHANOL TARTRATE GENERIC

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PA ‐ Prior Authorization, QL ‐ Quantity Limits, ST ‐ Step Therapy

*Specialty medications are only available through the Providence specialty network. See introduction.

^A formulary brand drug becomes non‐formulary when it becomes available as a generic drug.

Updated 03/12/2012




Opioid Analgesics

CODEINE SULFATE GENERIC

CO‐GESIC GENERIC

ENDOCET GENERIC

FENTANYL GENERIC QL (15 PATCHES PER 30 DAYS)

FENTANYL CITRATE GENERIC QL (120 LOZENGES PER 30 DAYS)

HYDROCODONE BIT‐IBUPROFEN GENERIC

HYDROCODONE‐ACETAMINOPHEN GENERIC

HYDROMORPHONE HCL GENERIC

LEVORPHANOL TARTRATE GENERIC

MARGESIC H GENERIC

MEPERIDINE GENERIC

METHADONE HCL GENERIC

METHADOSE GENERIC

MORPHINE SULFATE ER GENERIC

MORPHINE SULFATE IR GENERIC

OXYCODONE 20MG/ML SOLUTION GENERIC

OXYCODONE ER GENERIC PA, QL (90 TABLETS PER 30 DAYS)

OXYCODONE IR GENERIC

OXYCODONE‐ACETAMINOPHEN GENERIC

OXYCODONE‐ASPIRIN GENERIC

OXYCODONE‐IBUPROFEN GENERIC

OXYCONTIN® BRAND PA, QL (90 TABLETS PER 30 DAYS)

OXYMORPHONE GENERIC PA

RMS‐SUPPOSITORY GENERIC

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Updated 03/12/2012




Opioid Analgesics

ROXICET GENERIC

STAGESIC GENERIC

SUBOXONE® TABLETS & FILM BRAND

TRAMADOL ER GENERIC

TRAMADOL HCL GENERIC

TRAMADOL HCL‐ACETAMINOPHEN GENERIC QL (240 TABLETS PER 30 DAYS)

VANACET GENERIC

ZERLOR GENERIC

Anesthetics

Local Anesthetics

LIDOCAINE HCL GENERIC

LIDOCAINE‐PRILOCAINE GENERIC

LIDODERM® BRAND

LIDOMAR VISCOUS GENERIC

Antibacterials ‐ Drugs to treat bacterial infections

Aminoglycosides

NEOMYCIN SULFATE GENERIC

Antibacterials, Other

BACITRACIN OINTMENT GENERIC

BACITRACIN ZINC OINTMENT GENERIC

CLINDAMYCIN HCL GENERIC

DAPSONE GENERIC

METHENAMINE HIPPURATE GENERIC

METRONIDAZOLE TABLETS GENERIC

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Updated 03/12/2012




Antibacterials, Other

NITROFURANTOIN MACROCRYSTALS GENERIC

NITROFURANTOIN SUSPENSION GENERIC

UREX GENERIC

VANCOCIN® BRAND

VANDAZOLE GENERIC

XIFAXAN® 200MG BRAND PA, QL (90 TABS PER 30 DAYS)

XIFAXAN® 550MG BRAND PA, QL (60 TABS PER 30 DAYS)

ZYVOX® BRAND PA

Beta‐lactam, Cephalosporins

CEDAX® BRAND

CEFACLOR GENERIC

CEFADROXIL GENERIC

CEFDINIR GENERIC

CEFPODOXIME PROXETIL GENERIC

CEFPROZIL GENERIC

CEFUROXIME GENERIC

CEFUROXIME AXETIL GENERIC

CEPHALEXIN GENERIC

Beta‐lactam, Penicillins

AMOX TR‐POTASSIUM CLAVULANATE GENERIC

AMOX TR‐POTASSIUM CLAVULANATE ER GENERIC

AMOXICILLIN GENERIC

AMPICILLIN GENERIC

DICLOXACILLIN GENERIC

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Updated 03/12/2012




Beta‐lactam, Penicillins

PENICILLIN V POTASSIUM GENERIC

Macrolides

AZITHROMYCIN GENERIC

CLARITHROMYCIN GENERIC

CLARITHROMYCIN ER GENERIC

ERY‐TAB® BRAND

ERYTHROMYCIN GENERIC

ERYTHROMYCIN ETHYLSUCCINATE GENERIC

ERYTHROMYCIN‐SULFISOXAZOLE GENERIC

Quinolones

AVELOX® BRAND

CIPRO HC® BRAND

CIPRODEX® BRAND

CIPROFLOXACIN ER GENERIC

CIPROFLOXACIN HCL GENERIC

LEVOFLOXACIN TABLETS & SOLUTION GENERIC

Sulfonamides

GANTRISIN® BRAND

SULFAMETHOXAZOLE‐TRIMETHOPRIM GENERIC

TRIMETHOPRIM GENERIC

Tetracyclines

DEMECLOCYCLINE HCL GENERIC

DOXYCYCLINE HYCLATE GENERIC

ED DOXY‐CAPS GENERIC

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Updated 03/12/2012




Tetracyclines

MINOCYCLINE HCL GENERIC

MYRAC GENERIC

TETRACYCLINE HCL GENERIC

Anticonvulsants ‐ Drugs to treat or prevent seizures

Anticonvulsants, Other

BANZEL® BRAND PA

DIASTAT® BRAND

DIAZEPAM RECTAL KIT BRAND

LEVETIRACETAM GENERIC

LEVETIRACETAM ER GENERIC

TOPIRAMATE CAP SPRINKLE GENERIC

TOPIRAMATE TABLETS GENERIC

VIMPAT® BRAND PA

Calcium Channel Modifying Agents

ETHOSUXIMIDE GENERIC

LYRICA® BRAND PA

ZONISAMIDE GENERIC

Gamma‐aminobutyric Acid (GABA) Augmenting Agents

DIVALPROEX CAP SPRINKLE GENERIC

DIVALPROEX SODIUM GENERIC

DIVALPROEX SODIUM ER GENERIC

GABAPENTIN GENERIC

GABAPENTIN SOLUTION GENERIC

GABITRIL® BRAND

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Updated 03/12/2012



Anticonvulsants ‐ Drugs to treat or prevent seizures

Gamma‐aminobutyric Acid (GABA) Augmenting Agents

PRIMIDONE GENERIC

SABRIL® BRAND

VALPROATE SODIUM GENERIC

VALPROIC ACID GENERIC

Glutamate Reducing Agents

FELBAMATE GENERIC

LAMOTRIGINE GENERIC

Sodium Channel Inhibitors

CARBAMAZEPINE GENERIC

CARBAMAZEPINE XR CAPSULES GENERIC

CARBAMAZEPINE XR TABLETS GENERIC

DILANTIN INFATAB® BRAND

OXCARBAZEPINE GENERIC

PHENYTOIN GENERIC

PHENYTOIN SODIUM ER GENERIC

TRILEPTAL SUSPENSION® BRAND

Antidementia Agents ‐ Drugs to treat dementia

Cholinesterase Inhibitors

DONEPEZIL GENERIC QL (30 CAPSULES PER 30 DAYS)

DONEPEZIL ODT GENERIC QL (30 CAPSULES PER 30 DAYS)

EXELON® PATCH & SOLUTION BRAND

RIVASTIGMINE CAPSULES GENERIC QL (60 CAPSULES PER 30 DAYS)

Glutamate Pathway Modifiers

NAMENDA SOLUTION® BRAND PA, QL (300 ML PER 30 DAYS)

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Updated 03/12/2012



Antidementia Agents ‐ Drugs to treat dementia

Glutamate Pathway Modifiers

NAMENDA® BRAND PA, QL (60 TABLETS PER 30 DAYS)

Antidepressants ‐ Drugs to treat depression

Antidepressants, Other

BUDEPRION SR GENERIC DEDUCTIBLE WAIVED

BUDEPRION XL GENERIC DEDUCTIBLE WAIVED

BUPROPION HCL GENERIC DEDUCTIBLE WAIVED

BUPROPION HCL SR GENERIC DEDUCTIBLE WAIVED

BUPROPION HCL XL GENERIC DEDUCTIBLE WAIVED

MAPROTILINE GENERIC DEDUCTIBLE WAIVED

MIRTAZAPINE GENERIC DEDUCTIBLE WAIVED

NEFAZODONE GENERIC DEDUCTIBLE WAIVED

TRAZODONE HCL GENERIC DEDUCTIBLE WAIVED

Monoamine Oxidase Inhibitors

EMSAM® BRAND PA

MARPLAN® BRAND

PHENELZINE SULFATE GENERIC

TRANYLCYPROMINE SULFATE GENERIC DEDUCTIBLE WAIVED

Serotonin/ Norepinephrine Reuptake Inhibitors

CITALOPRAM HBR GENERIC DEDUCTIBLE WAIVED

CITALOPRAM SOLUTION GENERIC DEDUCTIBLE WAIVED

CYMBALTA® BRAND PA, QL (60 CAPSULES PER 30 DAYS)

FLUOXETINE HCL GENERIC DEDUCTIBLE WAIVED

FLUVOXAMINE MALEATE GENERIC DEDUCTIBLE WAIVED

PAROXETINE HCL GENERIC DEDUCTIBLE WAIVED

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Updated 03/12/2012



Antidepressants ‐ Drugs to treat depression

Serotonin/ Norepinephrine Reuptake Inhibitors

SERTRALINE HCL GENERIC DEDUCTIBLE WAIVED

VENLAFAXINE ER (150MG) GENERIC

VENLAFAXINE ER (37.5MG OR 75MG) GENERIC QL (30 CAPSULES PER 30 DAYS)

VENLAFAXINE HCL GENERIC

Tricyclics

AMITRIPTYLINE HCL GENERIC DEDUCTIBLE WAIVED

AMOXAPINE GENERIC DEDUCTIBLE WAIVED

CLOMIPRAMINE HCL GENERIC DEDUCTIBLE WAIVED

DESIPRAMINE HCL GENERIC

DOXEPIN HCL GENERIC

IMIPRAMINE HCL GENERIC DEDUCTIBLE WAIVED

IMIPRAMINE PAMOATE GENERIC DEDUCTIBLE WAIVED

NORTRIPTYLINE HCL GENERIC DEDUCTIBLE WAIVED

PROTRIPTYLINE HCL GENERIC

TRIMIPRAMINE MALEATE GENERIC DEDUCTIBLE WAIVED

Antidotes, Deterrents, and Toxicologic Agents

Antidotes

BUPHENYL® SPECIALTY

CARBAGLU® SPECIALTY PA

EXJADE® SPECIALTY

LEUCOVORIN CALCIUM GENERIC

SPS GENERIC

SYPRINE® BRAND

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Updated 03/12/2012



Antidotes, Deterrents, and Toxicologic Agents

Deterrents

BUPROBAN GENERIC

BUPROPION HCL SR GENERIC

CAMPRAL® BRAND PA

DISULFIRAM GENERIC

NALTREXONE HCL GENERIC

Antiemetics ‐ Drugs to treat or prevent nausea

Antiemetics

EMEND TRIFOLD PACK® BRAND QL (1 PACK PER 15 DAYS)

EMEND® 80MG BRAND QL (4 TABLETS PER 28 DAYS)

GRANISETRON TABLETS GENERIC PA,QL (8 TABLETS PER 30 DAYS, 30ML PER 30 DAYS)

HYDROXYZINE PAMOATE GENERIC

METOCLOPRAMIDE HCL GENERIC

ONDANSETRON HCL (24 MG) TABS GENERIC QL (16 TABLETS PER 30 DAYS)

ONDANSETRON HCL (4 OR 8MG) TABS GENERIC QL (48 TABLETS PER 30 DAYS)

ONDANSETRON HCL SOLUTION GENERIC QL (480 ML PER 30 DAYS)

ONDANSETRON ODT (4 OR 8 MG) TABS GENERIC QL (48 TABLETS PER 30 DAYS)

PROCHLORPERAZINE EDISYLATE GENERIC

PROMETHAZINE GENERIC

PROMETHEGAN GENERIC

TRANSDERM‐SCOP® BRAND

TRIMETHOBENZAMIDE GENERIC

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Updated 03/12/2012



Antifungals ‐ Drugs to treat fungal infections

Antifungals

FLUCONAZOLE GENERIC

FLUCYTOSINE GENERIC QL (120 CAPSULES PER 30 DAYS)

GRISEOFULVIN GENERIC

GRISEOFULVIN ULTRA GENERIC

ITRACONAZOLE GENERIC PA

KETOCONAZOLE GENERIC

KURIC GENERIC

NOXAFIL® BRAND PA

TERBINAFINE HCL GENERIC

TERCONAZOLE GENERIC

VORICONAZOLE GENERI

Antigout Agents ‐ Drugs to treat or prevent gout

Antigout Agents

ALLOPURINOL GENERIC

COLCRYS® BRAND

PROBENECID GENERIC

PROBENECID‐COLCHICINE GENERIC

Anti‐inflammatory Agents ‐ Drugs to treat inflammation

Glucocorticoids

BUDENOSIDE GENERIC

CELESTONE® BRAND

CORTISONE GENERIC

METHYLPREDNISOLONE GENERIC

ORAPRED ODT® BRAND

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Updated 03/12/2012



Anti‐inflammatory Agents ‐ Drugs to treat inflammation

Glucocorticoids

PREDNISOLONE GENERIC

PREDNISOLONE SOD PHOSPHATE GENERIC

PREDNISONE GENERIC

Nonsteroidal Anti‐inflammatory Drugs

CELEBREX® 400MG BRAND PA, QL (30 CAPSULES PER 30 DAYS)

CELEBREX® 50MG, 100MG, 200MG BRAND PA, QL (60 CAPSULES PER 30 DAYS)

CHOLINE MAG TRISAL GENERIC

DICLOFENAC POTASSIUM GENERIC

DICLOFENAC SODIUM GENERIC

ETODOLAC GENERIC

FENOPROFEN GENERIC

IBUPROFEN GENERIC

INDOMETHACIN GENERIC

KETOPROFEN GENERIC

KETOROLAC TROMETHAMINE TABLET GENERIC

MECLOFENAMATE GENERIC

MELOXICAM GENERIC

NABUMETONE GENERIC

NAPROXEN GENERIC

NAPROXEN SODIUM GENERIC

OXAPROZIN GENERIC

PIROXICAM GENERIC

TOLMETIN SODIUM GENERIC

VOLTAREN® GEL BRAND

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Updated 03/12/2012



Antimigraine Agents ‐ Drugs to treat or prevent migraines

Abortive

APAP‐BUTALBITAL GENERIC

ASCOMP WITH CODEINE GENERIC

BUTALBITAL COMPOUND GENERIC

BUTALBITAL‐APAP‐CAFFEINE GENERIC

BUTALBITAL‐CAFF‐APAP‐COD GENERIC

ERGOTAMINE‐CAFFEINE GENERIC

MAXALT MLT® BRAND QL (2 PACKAGES PER 30 DAYS)

MAXALT® BRAND QL (2 PACKAGES PER 30 DAYS)

MIGERGOT GENERIC

MIGRANAL® BRAND QL (1 PACKAGE PER 30 DAYS)

NARATRIPTAN HCL GENERIC QL (2 PACKAGES PER 30 DAYS)

SUMATRIPTAN SUCCINATE GENERIC QL (2 PACKAGES PER 30 DAYS)

ZOMIG ZMT® BRAND QL (2 PACKAGES PER 30 DAYS)

ZOMIG® BRAND QL (2 PACKAGES PER 30 DAYS)

Prophylactic

DIVALPROEX SODIUM ER GENERIC

TOPIRAMATE CAP SPRINKLE GENERIC

TOPIRAMATE TABLETS GENERIC

Antimyasthenic Agents ‐ Drugs to treat Myasthenia Gravis

Parasympathomimetics

MESTINON® 180 MG BRAND

PYRIDOSTIGMINE BROMIDE GENERIC

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Updated 03/12/2012



Antimycobacterials ‐ Drugs to treat tuberculosis

Antituberculars

ETHAMBUTOL HCL GENERIC

ISONARIF GENERIC

ISONIAZID GENERIC

PRIFTIN® BRAND

RIFAMPIN GENERIC

RIFATER® BRAND

TRECATOR® BRAND

Antineoplastics ‐ Drugs to treat cancer

Alkylating Agents

CEENU® BRAND

HEXALEN® SPECIALTY

LEUKERAN® BRAND

MATULANE® SPECIALTY

Antiangiogenic Agents

REVLIMID® SPECIALTY PA

THALOMID® SPECIALTY

Antiestrogens/Modifiers

EMCYT® SPECIALTY

EVISTA® BRAND

FARESTON® BRAND

TAMOXIFEN CITRATE GENERIC

Antimetabolites

DROXIA® BRAND

HYDROXYUREA GENERIC

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Updated 03/12/2012




Antimetabolites

MERCAPTOPURINE GENERIC

XELODA® BRAND

Antineoplastics

AFINITOR® SPECIALTY PA, QL (30 TABLETS PER 30 DAYS)

ANASTROZOLE GENERIC

CYCLOPHOSPHAMIDE GENERIC

EXEMESTANE GENERIC

GLEEVEC® SPECIALTY PA

HYCAMTIN® CAPSULES BRAND PA

IRESSA® SPECIALTY PA

JAKAFI® SPECIALTY PA

LETROZOLE GENERIC

MESNEX® BRAND

NEXAVAR® SPECIALTY PA

PANRETIN® SPECIALTY

SPRYCEL® SPECIALTY PA

SUTENT® SPECIALTY PA

TARCEVA® SPECIALTY PA

TARGRETIN® CAPSULES SPECIALTY PA

TASIGNA® SPECIALTY PA

TEMODAR® SPECIALTY PA

TRETINOIN CAPSULES SPECIALTY PA

TYKERB® SPECIALTY PA

VANDETANIB BRAND PA

21




Updated 03/12/2012




Antineoplastics

VIDAZA® SPECIALTY PA

VOTRIENT® SPECIALTY PA

ZELBORAF® SPECIALTY PA

ZOLINZA® SPECIALTY PA

Antiparasitics ‐ Drugs to treat parasites

Antiprotozoals

ALINIA® BRAND PA

CHLOROQUINE PHOSPHATE GENERIC PA

DARAPRIM® BRAND PA

FANSIDAR® BRAND PA

HYDROXYCHLOROQUINE SULFATE GENERIC

MEFLOQUINE HCL GENERIC PA

MEPRON® BRAND

TINDAMAX® BRAND PA

Pediculicides/Scabicides

PERMETHRIN GENERIC

ULESFIA® BRAND

Antiparkinson Agents ‐ Drugs to treat Parkinsonism

Antiparkinson Agents

AMANTADINE GENERIC

APOKYN® SPECIALTY PA

AZILECT® BRAND

BENZTROPINE MESYLATE GENERIC

BROMOCRIPTINE MESYLATE GENERIC

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Updated 03/12/2012



Antiparkinson Agents ‐ Drugs to treat Parkinsonism

Antiparkinson Agents

CARBIDOPA‐LEVODOPA GENERIC

COMTAN® BRAND

LODOSYN® BRAND

PRAMIPEXOLE GENERIC

ROPINIROLE GENERIC

SELEGILINE HCL GENERIC

TRIHEXYPHENIDYL GENERIC

Antipsychotics ‐ Drugs used in psychotherapy

Atypicals

ABILIFY DISCMELT® BRAND

ABILIFY® BRAND

CLOZAPINE GENERIC

FANAPT® BRAND PA

FAZACLO® BRAND

INVEGA® BRAND PA

LATUDA® BRAND PA, QL (30 TABLETS PER 30 DAYS)

OLANZAPINE GENERIC

OLANZAPINE ODT GENERIC

RISPERIDONE GENERIC QL (90 TABLETS PER 30 DAYS)

SAPHRIS® BRAND PA

SEROQUEL® BRAND

SYMBYAX® BRAND PA

Conventional

CHLORPROMAZINE GENERIC

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Updated 03/12/2012



Antipsychotics ‐ Drugs used in psychotherapy

Conventional

COMPRO GENERIC

HALOPERIDOL GENERIC

LOXAPINE GENERIC

MOBAN® BRAND

ORAP® BRAND

PERPHENAZINE GENERIC

PERPHENAZINE‐AMITRIPTYLINE GENERIC

PROCHLORPERAZINE MALEATE GENERIC

THIORIDAZINE GENERIC

THIOTHIXENE GENERIC

TRIFLUOPERAZINE HCL GENERIC

Antispasticity Agents ‐ Drugs to treat muscle spasms

Antispasticity Agents

BACLOFEN GENERIC

TIZANIDINE HCL GENERIC

Antivirals ‐ Drugs to treat viral infections

Anti‐cytomegalovirus (CMV) Agents

GANCICLOVIR GENERIC

VALCYTE® SOLUTION BRAND QL (18 ML PER DAY)

VALCYTE® TABLETS BRAND QL (2 TABLETS PER DAY)

Antihepatitis Agents

BARACLUDE® SPECIALTY PA

HEPSERA® SPECIALTY QL (30 TABLETS PER 30 DAYS)

INCIVEK® SPECIALTY PA

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Updated 03/12/2012




Antihepatitis Agents

INFERGEN® SPECIALTY

PEGASYS® SPECIALTY PA, QL (4 SYRINGES PER 30 DAYS)

PEGINTRON REDIPEN® SPECIALTY PA, QL (4 PENS PER 30 DAYS)

PEGINTRON® SPECIALTY PA, QL (4 KITS PER 30 DAYS)

REBETOL® BRAND PA

RIBAPAK® SPECIALTY PA

RIBASPHERE® SPECIALTY PA

RIBAVIRIN® SPECIALTY PA

TYZEKA® BRAND PA, QL (30 TABLETS PER 30 DAYS)

VICTRELIS® SPECIALTY PA

Antiherpetic Agents

ACYCLOVIR GENERIC

FAMCICLOVIR GENERIC

VALACYCLOVIR GENERIC

Anti‐HIV Agents, Fusion Inhibitors

FUZEON® BRAND

Anti‐HIV Agents, Integrase Inhibitors

ISENTRESS® BRAND

Anti‐HIV Agents, Non‐nucleoside Reverse Transcriptase Inhibitors

EDURANT® BRAND

INTELENCE® BRAND

SUSTIVA® BRAND

VIRAMUNE XR® BRAND

VIRAMUNE® BRAND

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Updated 03/12/2012




Anti‐HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitor

DIDANOSINE CAPS GENERIC

EMTRIVA® BRAND

EPIVIR HBV® BRAND

EPIVIR® SOLUTION BRAND

EPZICOM® BRAND

LAMIVUDINE TABLETS GENERIC

LAMIVUDINE‐ZIDOVUDINE GENERIC

STAVUDINE GENERIC

TRIZIVIR® BRAND

TRUVADA® BRAND

VIREAD® BRAND

ZIAGEN® BRAND

ZIDOVUDINE GENERIC

Anti‐HIV Agents, Protease Inhibitors

APTIVUS® BRAND

ATRIPLA® BRAND

COMPLERA® BRAND

CRIXIVAN® BRAND

INVIRASE BRAND

KALETRA® BRAND

LEXIVA® BRAND

NORVIR® BRAND

PREZISTA® BRAND

REYATAZ® BRAND

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Updated 03/12/2012




Anti‐HIV Agents, Protease Inhibitors

VIRACEPT® BRAND

Anti‐influenza Agents

RELENZA® BRAND QL (1 DISKHALER PER 10 DAYS)

RIMANTADINE HCL GENERIC

TAMIFLU® BRAND QL (20 CAPSULES PER 10 DAYS)

Chemokine Receptor Antagonist

SELZENTRY® BRAND

Anxiolytics ‐ Drugs to treat anxiety

Antidepressants

CITALOPRAM HBR GENERIC DEDUCTIBLE WAIVED

CITALOPRAM SOLUTION GENERIC DEDUCTIBLE WAIVED

CYMBALTA® BRAND PA, QL (60 CAPSULES PER 30 DAYS)

FLUOXETINE HCL GENERIC DEDUCTIBLE WAIVED

FLUVOXAMINE MALEATE GENERIC DEDUCTIBLE WAIVED

LEXAPRO® BRAND ST (LOOKS FOR TRIAL OF CITALOPRAM AND ONE OTHER GENERIC SSRI ANTIDEPRESSANT)

PAROXETINE HCL GENERIC DEDUCTIBLE WAIVED

SERTRALINE HCL GENERIC DEDUCTIBLE WAIVED

VENLAFAXINE ER (150MG) GENERIC

VENLAFAXINE ER (37.5MG OR 75MG) GENERIC QL (30 CAPSULES PER 30 DAYS)

VENLAFAXINE HCL GENERIC

Anxiolytics

ALPRAZOLAM GENERIC

ALPRAZOLAM ER GENERIC

27




Updated 03/12/2012



Anxiolytics ‐ Drugs to treat anxiety

Anxiolytics

CHLORDIAZEPOXIDE GENERIC

CLONAZEPAM GENERIC

CLORAZEPATE GENERIC

DIAZEPAM GENERIC

FLURAZEPAM GENERIC

LORAZEPAM GENERIC

LORAZEPAM INTENSOL GENERIC

OXAZEPAM GENERIC

TEMAZEPAM GENERIC

TRIAZOLAM GENERIC

Anxiolytics, Other

BUSPIRONE HCL GENERIC

MEPROBAMATE GENERIC

Bipolar Agents ‐ Drugs to treat bipolar disorders

Bipolar Agents

GEODON® BRAND

LITHIUM CARBONATE GENERIC

LITHIUM CITRATE GENERIC

LITHIUM ER GENERIC

Blood Glucose Regulators ‐ Drugs to treat diabetes

Antidiabetic Agents

ACARBOSE GENERIC

ACTOPLUS MET XR® BRAND

ACTOPLUS MET® BRAND

28




Updated 03/12/2012




Antidiabetic Agents

ACTOS® BRAND

BYETTA® BRAND PA

CHLORPROPAMIDE GENERIC DEDUCTIBLE WAIVED

DUETACT® BRAND

GLIMEPIRIDE GENERIC DEDUCTIBLE WAIVED

GLIPIZIDE GENERIC DEDUCTIBLE WAIVED

GLIPIZIDE ER GENERIC DEDUCTIBLE WAIVED

GLIPIZIDE‐METFORMIN GENERIC

GLYBURIDE GENERIC DEDUCTIBLE WAIVED

GLYBURIDE MICRONIZED GENERIC DEDUCTIBLE WAIVED

GLYBURIDE‐METFORMIN HCL GENERIC

GLYSET® BRAND

JANUMET® BRAND PA

JANUVIA® BRAND PA

KOMBIGLYZE XR® BRAND PA

METFORMIN HCL GENERIC DEDUCTIBLE WAIVED

METFORMIN HCL ER GENERIC DEDUCTIBLE WAIVED

NATEGLINIDE GENERIC

ONGLYZA® BRAND PA

RIOMET® BRAND

SYMLIN® BRAND PA

VICTOZA BRAND PA

Glycemic Agents

GLUCAGEN BRAND QL (2 KITS PER 30 DAYS)

29




Updated 03/12/2012




Glycemic Agents

GLUCAGON® BRAND QL (2 KITS PER 30 DAYS)

PROGLYCEM® BRAND

Insulins

HUMALOG MIX 50‐50® BRAND DEDUCTIBLE WAIVED

HUMALOG MIX 75‐25® BRAND DEDUCTIBLE WAIVED

HUMALOG® BRAND DEDUCTIBLE WAIVED

HUMULIN 50‐50® BRAND DEDUCTIBLE WAIVED

HUMULIN MIX 70‐30® BRAND DEDUCTIBLE WAIVED

HUMULIN N® BRAND DEDUCTIBLE WAIVED

HUMULIN R® BRAND DEDUCTIBLE WAIVED

LANTUS SOLOSTAR® BRAND DEDUCTIBLE WAIVED

LANTUS® BRAND DEDUCTIBLE WAIVED

LEVEMIR® BRAND DEDUCTIBLE WAIVED

NOVOLIN MIX 70‐30 INNOLET® BRAND DEDUCTIBLE WAIVED

NOVOLIN N INNOLET® BRAND DEDUCTIBLE WAIVED

NOVOLIN N® BRAND DEDUCTIBLE WAIVED

NOVOLIN R® BRAND DEDUCTIBLE WAIVED

NOVOLOG MIX 70‐30® BRAND DEDUCTIBLE WAIVED

NOVOLOG® BRAND DEDUCTIBLE WAIVED

Blood Glucose Testing

Meters & Strips

ACCU‐CHECK (METERS & TEST STRIPS) DME BENEFIT QL

LIFESCAN (METERS & TEST STRIPS) DME BENEFIT QL

30




Updated 03/12/2012



Blood Products/Modifiers/ Volume Expanders

Anticoagulants

ENOXAPARIN SODIUM INJECTABLE GENERIC

FONDAPARINUX GENERIC

FRAGMIN® SPECIALTY

INNOHEP® SPECIALTY

JANTOVEN GENERIC

PRADAXA® BRAND

WARFARIN SODIUM GENERIC

XARELTO® BRAND

Antifibrinolytics

LYSTEDA® BRAND

Blood Formation Products

ARANESP® SPECIALTY PA

EPOGEN® SPECIALTY PA

LEUKINE® SPECIALTY PA

NEULASTA® SPECIALTY PA

NEUMEGA® SPECIALTY PA

NEUPOGEN® SPECIALTY PA

PROCRIT® SPECIALTY PA

PROMACTA® 25 MG SPECIALTY PA, QL (90 TABLETS PER 30 DAYS)

PROMACTA® 50 MG SPECIALTY PA, QL (30 TABLETS PER 30 DAYS)

Blood Products/Modifiers/Volume Expanders

ANAGRELIDE HCL GENERIC

Platelet Aggregation Inhibitors

AGGRENOX® BRAND

31




Updated 03/12/2012



Blood Products/Modifiers/ Volume Expanders

Platelet Aggregation Inhibitors

BRILINTA® BRAND

CILOSTAZOL GENERIC

DIPYRIDAMOLE GENERIC

EFFIENT® BRAND

PENTOXIFYLLINE SA GENERIC

PLAVIX® BRAND

TICLOPIDINE GENERIC

Bradykinin B2 Receptor Antagonist

Bradykinin B2 Receptor Antagonist

FIRAZYR® SPECIALTY PA, QL 9 SYRINGES/30 DAYS

Cardiovascular Agents ‐ Drugs to treat blood pressure, cholesterol & the heart

Alpha‐adrenergic Agonists

CLONIDINE HCL GENERIC

CLONIDINE TRANSDERMAL PATCH GENERIC

GUANFACINE HCL GENERIC

METHYLDOPA GENERIC

METHYLDOPA‐HCTZ GENERIC

MIDODRINE HCL GENERIC

Alpha‐adrenergic Blocking Agents

GUANABENZ ACETATE GENERIC

PRAZOSIN HCL GENERIC

TERAZOSIN HCL GENERIC

Antiarrhythmics

AMIODARONE HCL GENERIC

32




Updated 03/12/2012




Antiarrhythmics

DISOPYRAMIDE PHOSPHATE GENERIC

DISOPYRAMIDE PHOSPHATE ER 150 MG GENERIC

FLECAINIDE ACETATE GENERIC

MEXILETINE GENERIC

MULTAQ® BRAND

NORPACE CR® 100 MG BRAND

PROPAFENONE HCL GENERIC

QUINIDINE GLUCONATE GENERIC

QUINIDINE SULFATE GENERIC

TIKOSYN® BRAND

Beta‐adrenergic Blocking Agents

ACEBUTOLOL HCL GENERIC DEDUCTIBLE WAIVED

ATENOLOL GENERIC DEDUCTIBLE WAIVED

ATENOLOL‐CHLORTHALIDONE GENERIC DEDUCTIBLE WAIVED

BETAXOLOL HCL GENERIC

BISOPROLOL FUMARATE GENERIC DEDUCTIBLE WAIVED

CARVEDILOL GENERIC DEDUCTIBLE WAIVED

COREG CR® BRAND

LABETALOL HCL GENERIC DEDUCTIBLE WAIVED

LEVATOL® BRAND

METOPROLOL SUCCINATE ER GENERIC DEDUCTIBLE WAIVED

METOPROLOL TARTRATE GENERIC DEDUCTIBLE WAIVED

METOPROLOL‐HYDROCHLOROTHIAZIDE GENERIC

NADOLOL GENERIC DEDUCTIBLE WAIVED

33




Updated 03/12/2012




Beta‐adrenergic Blocking Agents

NADOLOL‐BENDROFLUMETHIAZIDE GENERIC

PINDOLOL GENERIC DEDUCTIBLE WAIVED

PROPRANOLOL GENERIC DEDUCTIBLE WAIVED

PROPRANOLOL ER GENERIC DEDUCTIBLE WAIVED

PROPRANOLOL‐HCTZ GENERIC

SOTALOL GENERIC

SOTALOL AF GENERIC

TIMOLOL MALEATE TABS GENERIC DEDUCTIBLE WAIVED

Calcium Channel Blocking Agents

AFEDITAB CR GENERIC

AMLODIPINE BESYLATE GENERIC

CARTIA XT GENERIC

DILTIAZEM ER CAPSULES GENERIC

DILTIAZEM ER TABLETS GENERIC

DILTIAZEM HCL GENERIC

FELODIPINE ER GENERIC

ISRADIPINE GENERIC

NICARDIPINE HCL GENERIC

NIFEDIAC CC GENERIC

NIFEDICAL XL GENERIC

NIFEDIPINE ER GENERIC

NISOLDIPINE GENERIC

TAZTIA XT GENERIC

VERAPAMIL ER GENERIC

34




Updated 03/12/2012




Calcium Channel Blocking Agents

VERAPAMIL ER PM GENERIC

VERAPAMIL HCL GENERIC

Cardiovascular Agents, Other

AMLODIPINE BESYLATE‐BENAZEPRIL GENERIC

DIGITEK GENERIC

DIGOXIN GENERIC

NIMODIPINE GENERIC

PENTOXIFYLLINE GENERIC

RANEXA® BRAND

Diuretics

ACETAZOLAMIDE GENERIC

AMILORIDE HCL GENERIC

AMILORIDE HCL‐HCTZ GENERIC

BUMETANIDE GENERIC

CHLOROTHIAZIDE GENERIC

CHLORTHALIDONE GENERIC

DYRENIUM® BRAND

EDECRIN® BRAND

FUROSEMIDE GENERIC

HYDROCHLOROTHIAZIDE GENERIC

INDAPAMIDE GENERIC

METHAZOLAMIDE GENERIC

METOLAZONE GENERIC

SPIRONOLACTONE‐HCTZ GENERIC

35




Updated 03/12/2012




Diuretics

TORSEMIDE GENERIC

TRIAMTERENE‐HCTZ GENERIC

Dyslipidemics

AMLODIPINE‐ATORVASTATIN GENERIC

ATORVASTATIN GENERIC

CHOLESTYRAMINE GENERIC

CHOLESTYRAMINE LIGHT GENERIC

COLESTIPOL HCL GENERIC

FENOFIBRATE GENERIC

FENOFIBRIC ACID GENERIC

GEMFIBROZIL GENERIC

LOVASTATIN GENERIC DEDUCTIBLE WAIVED

LOVAZA® BRAND PA

NIASPAN® BRAND

PRAVASTATIN SODIUM GENERIC DEDUCTIBLE WAIVED

PREVALITE GENERIC

SIMVASTATIN 20MG AND LOWER GENERIC DEDUCTIBLE WAIVED

SIMVASTATIN 40MG GENERIC QL (30 TABLETS PER 30 DAYS), DEDUCTIBLE WAIVED

TRICOR® BRAND

ZETIA® BRAND PA

Renin‐angiotensin‐aldosterone System Inhibitors

BENAZEPRIL HCL GENERIC DEDUCTIBLE WAIVED

BENAZEPRIL‐HYDROCHLOROTHIAZIDE GENERIC DEDUCTIBLE WAIVED

CAPTOPRIL GENERIC DEDUCTIBLE WAIVED

36




Updated 03/12/2012




Renin‐angiotensin‐aldosterone System Inhibitors

CAPTOPRIL‐HYDROCHLOROTHIAZIDE GENERIC DEDUCTIBLE WAIVED

DIOVAN HCT® BRAND ST (LOOKS FOR TRIAL OF LOSARTAN OR LOSARTAN‐HCTZ)

DIOVAN® BRAND ST (LOOKS FOR TRIAL OF LOSARTAN OR LOSARTAN‐HCTZ)

ENALAPRIL MALEATE GENERIC DEDUCTIBLE WAIVED

ENALAPRIL‐HYDROCHLOROTHIAZIDE GENERIC DEDUCTIBLE WAIVED

EPLERENONE GENERIC

EPROSARTAN MESYLATE GENERIC

FOSINOPRIL SODIUM GENERIC DEDUCTIBLE WAIVED

FOSINOPRIL‐HYDROCHLOROTHIAZIDE GENERIC DEDUCTIBLE WAIVED

LISINOPRIL GENERIC DEDUCTIBLE WAIVED

LISINOPRIL‐HYDROCHLOROTHIAZIDE GENERIC DEDUCTIBLE WAIVED

LOSARTAN GENERIC

LOSARTAN‐HYDROCHLOROTHIAZIDE GENERIC

MOEXIPRIL HCL GENERIC DEDUCTIBLE WAIVED

MOEXIPRIL‐HYDROCHLOROTHIAZIDE GENERIC DEDUCTIBLE WAIVED

PERINDOPRIL ERBUMINE GENERIC

QUINAPRIL HCL GENERIC DEDUCTIBLE WAIVED

QUINAPRIL‐HYDROCHLOROTHIAZIDE GENERIC DEDUCTIBLE WAIVED

RAMIPRIL GENERIC DEDUCTIBLE WAIVED

SPIRONOLACTONE GENERIC

TRANDOLAPRIL GENERIC DEDUCTIBLE WAIVED

Vasodilators

DILATRATE‐SR® BRAND

37




Updated 03/12/2012




Vasodilators

HYDRALAZINE GENERIC

ISOSORBIDE DINITRATE GENERIC

ISOSORBIDE MONONITRATE GENERIC

NITRO‐BID GENERIC

NITROGLYCERIN PATCH GENERIC

NITROGLYCERIN SA TABLETS GENERIC

NITROGLYCERIN SL GENERIC

TRACLEER® SPECIALTY PA

Central Nervous System Agents ‐ Drugs that affect the brain

Amphetamines, ADHD

ADDERALL XR® BRAND

AMPHETAMINE SALT COMBO GENERIC

AMPHETAMINE SALT COMBO ER GENERIC

DEXTROAMPHETAMINE SULFATE SA GENERIC

DEXTROSTAT GENERIC

Non‐amphetamines, ADHD

CONCERTA® BRAND

DAYTRANA® BRAND PA

DEXMETHYLPHENIDATE HCL GENERIC

METADATE CD® BRAND

METHYLIN ER GENERIC

METHYLIN® CHEWABLE TABLETS BRAND

METHYLPHENIDATE CPMP 50‐50 GENERIC

38




Updated 03/12/2012



Central Nervous System Agents ‐ Drugs that affect the brain

Non‐amphetamines, ADHD

METHYLPHENIDATE ER 18MG, 27MG, 36MG, 54MG

BRAND

METHYLPHENIDATE ER 20MG GENERIC

METHYLPHENIDATE TABLET & SOLUTION GENERIC

STRATTERA® BRAND PA

VYVANSE® BRAND

Non‐amphetamines, Other

PROVIGIL® BRAND PA, QL (60 TABLETS PER 30 DAYS)

RILUTEK® SPECIALTY

XENAZINE® SPECIALTY PA

XYREM® SPECIALTY

Potassium Channel Inhibitor

AMPYRA® SPECIALTY PA, QL (60 TABLETS PER 30 DAYS)

Pseudobulbar Affect Agent

NUEDEXTA® BRAND PA

Serotonin/Norepinephrine Reuptake Inhibitors

SAVELLA® TABLETS BRAND PA, QL (60 TABLETS PER 30 DAYS)

SAVELLA® TITRATION PACK BRAND PA, QL (1 PACK PER 28 DAYS)

Dental and Oral Agents

Dental and Oral Agents

CHLORHEXIDINE GLUCONATE GENERIC

PILOCARPINE TABLETS GENERIC

39




Updated 03/12/2012



Dermatological Agents ‐ Drugs to treat skin conditions

Dermatological Agents

ADAPALENE 0.1% CREAM/GEL GENERIC

AMNESTEEM GENERIC

APEXICON E GENERIC

CALCIPOTRIENE SOLUTION GENERIC

CARAC® BRAND

CICLOPIROX GENERIC

CLARAVIS GENERIC

CLINDAMYCIN PHOSPHATE GENERIC

CLINDAMYCIN PHOSPHATE 1% FOAM GENERIC

CLINDAMYCIN/BENZOYL PEROXIDE GEL GENERIC

DEL‐BETA GENERIC

DENAVIR® BRAND PA

DIFFERIN® 0.3% GEL BRAND

DOVONEX® CREAM AND OINTMENT BRAND

ECONAZOLE NITRATE GENERIC

ELIDEL® BRAND ST

ERYTHROMYCIN‐BENZOYL PEROXIDE GENERIC

FINACEA PLUS® BRAND PA

FINACEA® BRAND PA

FLUOCINOLONE‐E GENERIC

FLUOROPLEX® BRAND

FLUOROURACIL GENERIC

HYPERCARE 20% SOLUTION GENERIC

IMIQUIMOD 5% CREAM GENERIC

40




Updated 03/12/2012





LOKARA GENERIC

METRONIDAZOLE 0.75% TOPICAL GENERIC

MUPIROCIN OINTMENT GENERIC

NYAMYC GENERIC

NYSTATIN GENERIC

NYSTOP GENERIC

OXSORALEN GENERIC

OXSORALEN‐ULTRA® SPECIALTY

PEDI‐DRI GENERIC

PODOFILOX GENERIC

PRAMOXINE 1% FOAM GENERIC

PROTOPIC BRAND ST

REGRANEX® SPECIALTY PA

SANTYL® BRAND QL (30 GRAMS PER 30 DAYS)

SILVER SULFADIAZINE GENERIC

SOTRET GENERIC

SSD AF CREAM GENERIC

SSD CREAM GENERIC

SULFACETAMIDE SODIUM LOTION GENERIC

TAZORAC® BRAND

THERMAZENE CREAM GENERIC

TRETINOIN CREAM, GEL, OR SOLUTION GENERIC

TRIAMCINOLONE GENERIC

TRIAMCINOLONE ACETONIDE GENERIC

41




Updated 03/12/2012





TRIDERM GENERIC

Enzyme Replacements/ Modifiers

Digestive Enzymes

CREON® BRAND

LIPRAM‐PN GENERIC

PANCRELIPASE GENERIC

PANCRELIPASE MT GENERIC

PANGESTYME EC GENERIC

PANGESTYME MT GENERIC

PANGESTYME UL GENERIC

PANOCAPS GENERIC

PANOCAPS MT GENERIC

VIOKASE® BRAND

ZENPEP® BRAND

Other

ADAGEN® SPECIALTY

CYSTAGON® SPECIALTY

KUVAN® SPECIALTY PA

ORFADIN® SPECIALTY

SUCRAID® SPECIALTY

ZAVESCA® SPECIALTY

Gastrointestinal Agents ‐ Drugs to treat acid, digestion and bowel conditions

Antispasmodics, Gastrointestinal

CUVPOSA® BRAND PA

42




Updated 03/12/2012




Antispasmodics, Gastrointestinal

DICYCLOMINE GENERIC

GLYCOPYRROLATE GENERIC

Gastrointestinal Agents, Other

DIPHENOXYLATE‐ATROPINE GENERIC

LACTULOSE GENERIC

LONOX GENERIC

MOVIPREP POWDER KIT® BRAND

PEG 3350‐ELECTROLYTE GENERIC

PROCTOCREAM‐HC GENERIC

PROCTO‐PAK GENERIC

PROCTOSOL‐HC GENERIC

PROCTOZONE‐HC GENERIC

TRILYTE GENERIC

URSODIOL GENERIC

Histamine 2 (H2) Blocking Agents

CIMETIDINE GENERIC

FAMOTIDINE 40MG GENERIC

NIZATIDINE CAPSULES GENERIC

RANITIDINE HCL 300 mg GENERIC

RANITIDINE SYRUP GENERIC

Irritable Bowel Syndrome Agents

LOTRONEX® BRAND PA

Protectants

MISOPROSTOL GENERIC

43




Updated 03/12/2012




Protectants

SUCRALFATE GENERIC

Proton Pump Inhibitors

LANSOPRAZOLE 30 MG GENERIC QL (60 CAPSULES PER 30 DAYS)

OMEPRAZOLE GENERIC QL (60 CAPSULES PER 30 DAYS)

PANTOPRAZOLE SODIUM TABLETS GENERIC QL (60 TABLETS PER 30 DAYS)

PROTONIX® SUSPENSION BRAND

Genitourinary Agents ‐ Drugs to treat genitourinary conditions

Analgesics

ELMIRON® BRAND QL (120 CAPSULES PER 30 DAYS)

Antispasmodics, Urinary

BETHANECHOL CHLORIDE GENERIC

DETROL LA® BRAND QL (30 TABLETS PER 30 DAYS)

DETROL® BRAND

FLAVOXATE HCL GENERIC

OXYBUTYNIN GENERIC

OXYBUTYNIN ER GENERIC

OXYTROL® BRAND

TROSPIUM CHLORIDE GENERIC

Benign Prostatic Hypertrophy Agents

ALFUZOSIN GENERIC

DOXAZOSIN MESYLATE GENERIC

FINASTERIDE GENERIC

TAMSULOSIN GENERIC

TERAZOSIN HCL GENERIC

44




Updated 03/12/2012



Genitourinary Agents ‐ Drugs to treat genitourinary conditions

Genitourinary Agents, Other

CUPRIMINE® BRAND

DEPEN® BRAND

THIOLA® BRAND

Phosphate Binders

CALCIUM ACETATE GENERIC

RENAGEL® BRAND PA

RENVELA® BRAND PA

Hormonal Agents, Modifying

Androgens

ANADROL‐50® SPECIALTY

ANDROGEL® BRAND

TESTIM® BRAND

TESTOSTERONE CYPIONATE INJECTABLE GENERIC

TESTOSTERONE ENANTHATE INJECTABLE GENERIC

Contraceptives

AMETHYST GENERIC

APRI® GENERIC

ARANELLE® GENERIC

AVIANE® GENERIC

BALZIVA® GENERIC

BREVICON® GENERIC

CRYSELLE® GENERIC

ENPRESSE® GENERIC

GIANVI GENERIC

45




Updated 03/12/2012




Contraceptives

JOLESSA® GENERIC

JUNEL FE® GENERIC

JUNEL® GENERIC

KARIVA® GENERIC

KELNOR® GENERIC

LEENA® GENERIC

LEVORA® GENERIC

LOESTRIN 24 FE® BRAND

LOW‐OGESTREL® GENERIC

LUTERA® GENERIC

MICROGESTIN FE GENERIC

MICROGESTIN® GENERIC

MONONESSA® GENERIC

NECON® GENERIC

NORINYL® GENERIC

NORTREL® GENERIC

NUVARING® BRAND

OCELLA® GENERIC

OGESTREL® GENERIC

ORTHO EVRA® BRAND

ORTHO TRI‐CYCLEN LO® BRAND

PORTIA® GENERIC

QUASENSE® GENERIC

RECLIPSEN® GENERIC

46




Updated 03/12/2012




Contraceptives

TRI‐LEGEST® GENERIC

TRINESSA® GENERIC

TRI‐PREVIFEM® GENERIC

TRI‐SPRINTEC® GENERIC

ZOVIA® GENERIC

Estrogens

CESIA® GENERIC

COMBIPATCH® BRAND

ESTRADIOL GENERIC

ESTRADIOL‐NORETHINDRONE 1.0‐0.5 MG TAB

GENERIC

ESTRING® BRAND

ESTROPIPATE GENERIC

JINTELI GENERIC

ORTHO‐EST® GENERIC

PREMARIN VAGINAL CREAM® BRAND

PREMARIN® BRAND QL (30 TABLETS PER 30 DAYS)

PREMPHASE® BRAND

PREMPRO® BRAND

SOLIA® GENERIC

VAGIFEM® BRAND

VELIVET® GENERIC

VIVELLE‐DOT® BRAND

Glucocorticoids/Mineralocorticoids

ALCLOMETASONE DIPROPIONATE GENERIC

47




Updated 03/12/2012




Glucocorticoids/Mineralocorticoids

BETAMETHASONE DIPROPIONATE GENERIC

CLOBETASOL EMOLLIENT GENERIC

CLOBETASOL PROPIONATE GENERIC

CLOTRIMAZOLE‐BETAMETHASONE GENERIC

CORMAX GENERIC

DESONIDE GENERIC

DESOXIMETASONE GENERIC

DEXAMETHASONE GENERIC

FLUDROCORTISONE ACETATE GENERIC

FLUOCINOLONE ACETONIDE GENERIC

FLUOCINONIDE GENERIC

HALOBETASOL PROPIONATE GENERIC

HYDROCORTISONE GENERIC

HYDROCORTISONE BUTYRATE GENERIC

MOMETASONE FUROATE GENERIC

Other

ACTHAR H.P. GEL® SPECIALTY PA

Pituitary

DESMOPRESSIN ACETATE GENERIC PA

EGRIFTA® SPECIALTY PA

GENOTROPIN® SPECIALTY PA

HUMATROPE® SPECIALTY PA

INCRELEX® SPECIALTY PA

NUTROPIN AQ® SPECIALTY PA

48




Updated 03/12/2012




Pituitary

NUTROPIN® SPECIALTY PA

Progestins

CAMILA GENERIC

ERRIN GENERIC

JOLIVETTE GENERIC

MEDROXYPROGESTERONE GENERIC

MEDROXYPROGESTERONE ACETATE GENERIC

MEGESTROL ACETATE GENERIC

NORA‐BE GENERIC

NORETHINDRONE ACETATE GENERIC

PROMETRIUM® BRAND

Selective Estrogen Receptor Modifying Agents

EVISTA® BRAND

Thyroid

LEVOTHROID GENERIC

LEVOTHYROXINE SODIUM GENERIC

LEVOXYL GENERIC

LIOTHYRONINE GENERIC

UNITHROID GENERIC

Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/Modifi

Ergot Alkaloids

METHYLERGONOVINE MALEATE GENERIC

49




Updated 03/12/2012



Hormonal Agents, Suppressant

Adrenal

LYSODREN® BRAND

Antiandrogens

BICALUTAMIDE GENERIC

NILANDRON® BRAND

ZYTIGA® BRAND PA

Parathyroid

SENSIPAR® (30 OR 60MG) SPECIALTY QL (60 TABLETS PER 30 DAYS)

SENSIPAR® (90 MG) SPECIALTY QL (120 TABLETS PER 30 DAYS)

Pituitary

CABERGOLINE GENERIC

DANAZOL GENERIC

ELIGARD® BRAND PA

LEUPROLIDE ACETATE GENERIC PA

OCTREOTIDE ACETATE SPECIALTY PA

SOMAVERT® SPECIALTY PA

Thyroid

METHIMAZOLE GENERIC

PROPYLTHIOURACIL GENERIC

Immunological Agents ‐ Drugs to stimulate, suppress or regulate the immune s

Immune Suppressants

AZATHIOPRINE GENERIC

CELLCEPT® SOLUTION BRAND

CYCLOSPORINE GENERIC

ENBREL® SPECIALTY PA

50




Updated 03/12/2012




Immune Suppressants

GENGRAF GENERIC

HUMIRA® SPECIALTY PA

METHOTREXATE GENERIC

METHOTREXATE INJECTABLE GENERIC

MYCOPHENOLATE MOFETIL GENERIC

MYFORTIC® BRAND

RAPAMUNE® BRAND

TACROLIMUS CAPSULE GENERIC

ZORTRESS® 0.25MG BRAND

ZORTRESS® 0.5MG & 0.75MG SPECIALTY

Immunological Agents

KINERET® SPECIALTY PA, QL (1 SYRINGE PER DAY)

Immunomodulators

ACTIMMUNE® SPECIALTY PA

ALFERON N® SPECIALTY

ARCALYST® SPECIALTY PA, QL (1 VIAL PER WEEK)

AVONEX® SPECIALTY QL (4 INJECTIONS PER 30 DAYS)

BETASERON® SPECIALTY PA, QL (14 VIALS PER 28 DAYS)

COPAXONE® SPECIALTY QL (30 INJECTIONS PER 30 DAYS)

EXTAVIA® SPECIALTY PA, QL (15 SYRINGES PER 30 DAYS)

GILENYA® SPECIALTY PA, QL (30 TABLETS PER 30 DAYS)

INTRON A® SPECIALTY PA

LEFLUNOMIDE GENERIC

REBIF® SPECIALTY QL (12 INJECTIONS PER 30 DAYS)

51




Updated 03/12/2012




Immunomodulators

SYLATRON® SPECIALTY PA

Inflammatory Bowel Disease Agents ‐ Drugs to treat the inflammatory bowel

Salicylates

APRISO® BRAND

ASACOL® BRAND

BALSALAZIDE DISODIUM GENERIC

CANASA® BRAND

DIPENTUM® BRAND

LIALDA BRAND

MESALAMINE GENERIC

PENTASA® BRAND

Sulfonamides

SULFASALAZINE GENERIC

SULFASALAZINE DR GENERIC

SULFAZINE GENERIC

SULFAZINE EC GENERIC

Metabolic Bone Disease Agents ‐ Drugs to treat metabolic bone disorders

Metabolic Bone Disease Agents

ACTONEL® (5,30,35 MG) BRAND ST (LOOKS FOR TRIAL OF ALENDRONATE)

ALENDRONATE SODIUM GENERIC

CALCITONIN NASAL SPRAY GENERIC

CALCITRIOL GENERIC

ETIDRONATE DISODIUM GENERIC

52




Updated 03/12/2012



Metabolic Bone Disease Agents ‐ Drugs to treat metabolic bone disorders

Metabolic Bone Disease Agents

FORTEO® SPECIALTY PA

FOSAMAX 70 MG ORAL SOLUTION® BRAND

HECTOROL® BRAND ST

ZEMPLAR® BRAND PA

Ophthalmic Agents ‐ Drugs to treat eye conditions

Ophthalmic Anti‐allergy Agents

ALOMIDE® BRAND

CROMOLYN EYE DROPS GENERIC

EPINASTINE HCL GENERIC

Ophthalmic Antibacterial Agents

AKTOB GENERIC

AZASITE® BRAND

BACITRACIN‐POLYMYXIN EYE OINT GENERIC

GENTAMICIN SULFATE GENERIC

GENTASOL GENERIC

LEVOFLOXACIN 0.50 % DROPS GENERIC

NEOMYCIN‐BACITRACIN‐POLYMYXIN GENERIC

NEOMYCIN‐POLYMYXIN‐DEXAMETH GENERIC

NEOMYCIN‐POLYMYXIN‐GRAMICIDIN GENERIC

OCUSULF‐10 GENERIC

OFLOXACIN GENERIC

POLY‐DEX GENERIC

POLYMYXIN B SUL‐TRIMETHOPRIM GENERIC

TOBRADEX® OINTMENT BRAND

53




Updated 03/12/2012




Ophthalmic Antibacterial Agents

TOBRAMYCIN SULFATE GENERIC

TOBRASOL GENERIC

VIGAMOX® BRAND

ZYLET® BRAND

ZYMAXID® BRAND

Ophthalmic Antifungal Agents

NATACYN® BRAND

Ophthalmic Antiglaucoma Agents

AZOPT® BRAND

BETAXOLOL HCL 0.5% EYE DROP GENERIC

BETIMOL® BRAND

BETOPTIC S® BRAND

BRIMONIDINE GENERIC

CARTEOLOL HCL GENERIC

DIPIVEFRIN HCL GENERIC

DORZOLAMIDE GENERIC

DORZOLAMIDE/TIMOLOL GENERIC

ISTALOL® BRAND

LEVOBUNOLOL HCL GENERIC

METIPRANOLOL GENERIC

PILOPINE HS® BRAND

TIMOLOL MALEATE OPHTH DROPS GENERIC

Ophthalmic Antiherpetic Agents

TRIFLURIDINE GENERIC

54




Updated 03/12/2012




Ophthalmic Antiherpetic Agents

ZIRGAN® BRAND

Ophthalmic Anti‐inflammatories

ALREX® BRAND

BROMFENAC SODIUM GENERIC

DEXAMETHASONE EYE OINT/DROP GENERIC

DICLOFENAC EYE DROPS GENERIC

FLAREX® BRAND

FLUOROMETHOLONE GENERIC

FLUOR‐OP GENERIC

FLURBIPROFEN SODIUM GENERIC

FML FORTE® BRAND

FML S.O.P.® BRAND

KETOROLAC TROMETHAMINE OPHTH DROPS GENERIC

LOTEMAX® BRAND

PREDNISOLONE ACETATE GENERIC

VEXOL® BRAND

Ophthalmic Other Agents

AK‐CON GENERIC

BLEPHAMIDE® BRAND

LACRISERT® BRAND

MYDRAL GENERIC

NAPHAZOLINE HCL GENERIC

NEOMYC‐POLYM‐DEXAMETH EYE GENERIC

RESTASIS® BRAND PA, QL (60 VIALS PER 30 DAYS)

55




Updated 03/12/2012




Ophthalmic Other Agents

TROPICACYL GENERIC

TROPICAMIDE GENERIC

Ophthalmic Prostaglandins and Prostamide Analogs

ALPHAGAN P® 0.1% BRAND

LATANOPROST GENERIC

LUMIGAN® BRAND

TRAVATAN Z® BRAND

TRAVATAN® BRAND

Otic Agents ‐ Drugs to treat ear conditions

Otic Agents

BOROFAIR EAR DROPS GENERIC

DERMOTIC® BRAND

NEOMYCIN‐POLYMYXIN‐HC GENERIC

Respiratory Tract Agents ‐ Drugs to treat allergies or breathing conditions

Antihistamines

AZELASTINE GENERIC

CLEMASTINE FUMARATE GENERIC

CYPROHEPTADINE GENERIC

HYDROXYZINE HCL GENERIC

Anti‐inflammatories, Inhaled Corticosteroids

ALVESCO® BRAND

ASMANEX® BRAND

BUDESONIDE NEB SUSPENSION GENERIC

FLOVENT HFA® BRAND DEDUCTIBLE WAIVED

56




Updated 03/12/2012




Anti‐inflammatories, Inhaled Corticosteroids

FLOVENT® DISKUS BRAND DEDUCTIBLE WAIVED

QVAR® BRAND

Anti‐inflammatories, Nasal Corticosteroids

FLUNISOLIDE NASAL GENERIC

FLUTICASONE PROPIONATE NASAL INHALER GENERIC QL (16 ML PER 30 DAYS)

NASONEX® BRAND QL (17 GRAMS PER 30 DAYS)

RHINOCORT AQUA NASAL SPRAY® BRAND

TRIAMCINOLONE ACETONIDE NASAL SPRAY GENERIC

Antileukotrienes

SINGULAIR® BRAND ST

ZAFIRLUKAST GENERIC QL (60 TABLETS PER 30 DAYS)

Antitussives (Cough Suppressants)

BENZONATATE GENERIC

CHERATUSSIN AC GENERIC

CHERATUSSIN DAC GENERIC

GUAIFENESIN‐CODEINE GENERIC

PROMETHAZINE VC GENERIC

PROMETHAZINE VC‐CODEINE GENERIC

PROMETHAZINE‐CODEINE GENERIC

PROMETHAZINE‐DM GENERIC

Bronchodilators, Anticholinergic

ATROVENT HFA® BRAND

IPRATROPIUM BROMIDE GENERIC

SPIRIVA® BRAND QL (1 HANDIHALER PER 30 DAYS)

57




Updated 03/12/2012




Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)

THEOPHYLLINE ANHYDROUS GENERIC

THEOPHYLLINE ER GENERIC

Bronchodilators, Sympathomimetic

ALBUTEROL SULFATE NEBULIZER SOLUTION GENERIC

COMBIVENT® BRAND

LEVALBUTEROL 1.25 MG/0.5 ML GENERIC

PROAIR® HFA GENERIC QL (2 INHALERS PER 30 DAYS), DEDUCTIBLE WAIVED

PROVENTIL® HFA GENERIC QL (2 INHALERS PER 30 DAYS), DEDUCTIBLE WAIVED

SEREVENT DISKUS® BRAND

TERBUTALINE SULFATE GENERIC

TWINJECT® BRAND QL (1.1 ML PER 180 DAYS)

XOPENEX HFA® (EXCEPT 1.25 MG/0.5 ML) BRAND

XOPENEX® BRAND

Mast Cell Stabilizers

CROMOLYN NEBULIZER SOLN GENERIC

GASTROCROM® BRAND

INTAL® BRAND

Pulmonary Antihypertensives

ADCIRCA® SPECIALTY PA, QL (60 TABLETS PER 30 DAYS)

LETAIRIS® SPECIALTY PA

REVATIO® SPECIALTY PA, QL (90 TABLETS PER 30 DAYS)

VENTAVIS® SPECIALTY PA

58




Updated 03/12/2012




Respiratory Tract Agents

ADVAIR DISKUS® BRAND

ADVAIR HFA® BRAND

EPIPEN JR® BRAND QL (1 "2‐PAK" PER 90 DAYS)

EPIPEN® BRAND QL (1 "2‐PAK" PER 90 DAYS)

IPRATROPRIUM‐ALBUTEROL GENERIC

PULMOZYME® SPECIALTY

SYMBICORT® BRAND

TYZINE® BRAND

Sedatives/Hypnotics ‐ Drugs to treat sleep disorders

Sedatives/Hypnotics

ESTAZOLAM GENERIC

ROZEREM® BRAND PA, QL (30 TABLETS PER 30 DAYS)

ZALEPLON GENERIC QL (30 TABLETS PER 30 DAYS)

ZOLPIDEM TARTRATE GENERIC QL (30 TABLETS PER 30 DAYS)

Skeletal Muscle Relaxants ‐ Drugs to treat muscle spasms

Skeletal Muscle Relaxants

CARISOPRODOL GENERIC

CARISOPRODOL COMPOUND GENERIC

CARISOPRODOL CPD/CODEINE GENERIC

CHLORZOXAZONE GENERIC

CYCLOBENZAPRINE HCL TABLET GENERIC

METAXALONE GENERIC

METHOCARBAMOL GENERIC

ORPHENADRINE GENERIC

59




Updated 03/12/2012



Skeletal Muscle Relaxants ‐ Drugs to treat muscle spasms

Skeletal Muscle Relaxants

ORPHENADRINE COMP FORTE GENERIC

Therapeutic Nutrients/Minerals/Electrolytes

Nutrients/Minerals/Electrolytes ‐ Prescription

ED K+10 GENERIC

KAON‐CL TAB GENERIC

KLOR‐CON® M DISPERSIBLE TABLET GENERIC

KLOTRIX GENERIC

POTASSIUM CHLORIDE CAPSULE GENERIC

POTASSIUM CHLORIDE TABLET SA GENERIC

POTASSIUM CITRATE GENERIC

POTASSIUM CITRATE ER GENERIC

Prenatal Vitamins ‐ Prescription

PRENATABS RX® BRAND

PRENATAL 19® GENERIC

PRENATAL PLUS® GENERIC

VINATE ONE® GENERIC

VINATE‐M® GENERIC

Vitamins ‐ Prescription

CYANOCOBALAMIN 1,000 MCG/ML INJ. GENERIC

FLUORABON GENERIC

FOLIC ACID GENERIC

MULTIVIT‐FLUORIDE GENERIC

MULTIVIT‐IRON‐FL GENERIC

POLY‐IRON‐FL GENERIC

60




Updated 03/12/2012



Therapeutic Nutrients/Minerals/Electrolytes

Vitamins ‐ Prescription

TRI‐VIT‐FLUOR GENERIC

TRI‐VIT‐FLUOR‐IRON GENERIC

VITAMIN D 1.25 MG (50,000 IU) GENERIC

61




Updated 03/12/2012

61

Alphabetical Listing

Drug Name Page ABILIFY DISCMELT® 23 ABILIFY® 23 ABSTRAL® is non-formulary and requires PA

ACARBOSE 28 ACCOLATE® - generic on formulary as ZAFIRLUKAST

ACCU-CHECK (METERS & TEST STRIPS) 30 ACCUNEB® - generic on formulary as ALBUTEROL SULFATE NEBULIZER SOLUTION

ACCUPRIL® - generic on formulary as QUINAPRIL HCL

ACCURETIC® - generic on formulary as QUINAPRIL-HYDROCHLOROTHIAZIDE

ACCUTANE® - generic on formulary as AMNESTEEM

ACEBUTOLOL HCL 33 ACEON® - generic on formulary as PERINDOPRIL ERBUMINE

ACETAMINOPHEN-CODEINE 7 ACETAZOLAMIDE 35 ACIPHEX® is non-formulary and requires PA, a formulary alternative is OMEPRAZOLE

ACTHAR H.P. GEL® 48 ACTIGALL® - generic on formulary as URSODIOL

ACTIMMUNE® 51 ACTIQ® - generic on formulary as FENTANYL CITRATE

ACTIVELLA® - generic on formulary as ESTRADIOL-NORETHINDRONE

ACTONEL 150MG is non-formulary and requires PA

ACTONEL® (5,30,35 MG) 52 ACTOPLUS MET XR® 28 ACTOPLUS MET® 28 ACTOS® 29 ACULAR® - generic on formulary as KETOROLAC TROMETHAMINE OPHTH DROPS

ACULAR® LS - generic on formulary as KETOROLAC TROMETHAMINE OPHTH

Drug Name Page DROPS ACYCLOVIR 25 ACZONE® is non-formulary and requires PA

ADAGEN® 42 ADALAT CC® - generic on formulary as NIFEDIAC CC

ADAPALENE 0.1% CREAM/GEL 39 ADCIRCA® 58 ADDERALL XR® 38 ADDERALL® - generic on formulary as AMPHETAMINE SALT COMBO

ADVAIR DISKUS® 58 ADVAIR HFA® 58 ADVICOR® is non-formulary, a generic alternative is SIMVASTATIN + NIASPAN®

AFEDITAB CR 34 AFINITOR® 21 AGGRENOX® 31 AGRYLIN® - generic on formulary as ANAGRELIDE HCL

AK-CON 55 AKTOB 53 ALBALON® - generic on formulary as NAPHAZOLINE HCL

ALBUTEROL SULFATE NEBULIZER SOLUTION 57 ALCLOMETASONE DIPROPIONATE 47 ALDACTAZIDE® - generic on formulary as SPIRONOLACTONE-HCTZ

ALDACTONE® - generic on formulary as SPIRONOLACTONE

ALDARA® - generic on formulary as IMIQUIMOD CREAM 5%

ALENDRONATE SODIUM 52 ALFERON N® 51 ALFUZOSIN 44 ALINIA® 22 ALLOPURINOL 17 ALOMIDE® 53 ALPHAGAN P® 0.15% - generic on formulary as BRIMONIDINE

ALPHAGAN P® 0.1% 55 ALPRAZOLAM 27

62

Drug Name Page ALPRAZOLAM ER 27 ALREX® 54 ALTABAX® is non-formulary and requires PA, a formulary alternative is MUPIROCIN

ALTACE® - generic on formulary as RAMIPRIL

ALVESCO® 56 AMANTADINE 22 AMARYL® - generic on formulary as GLIMEPIRIDE

AMBIEN CR® is non-formulary and requires PA, a formulary alternative is ZOLPIDEM TARTRATE

AMBIEN® - generic on formulary as ZOLPIDEM TARTRATE

AMERGE® is non-formulary, a generic alternative is SUMATRIPTAN

AMETHYST 45 AMIDRIN® - is not FDA approved and therefore not a covered benefit, formulary alternatives are BULTALBITAL-APAP-CAFFEINE, BUTALBITAL COMPOUND

AMILORIDE HCL 35 AMILORIDE HCL-HCTZ 35 AMIODARONE HCL 32 AMITIZA® is non-formulary and requires PA, an alternative is OTC MIRALAX

AMITRIPTYLINE HCL 15 AMLODIPINE BESYLATE 34 AMLODIPINE BESYLATE-BENAZEPRIL 35 AMLODIPINE-ATORVASTATIN 36 AMNESTEEM 39 AMOX TR-POTASSIUM CLAVULANATE 10 AMOX TR-POTASSIUM CLAVULANATE ER 10 AMOXAPINE 15 AMOXICILLIN 10 AMOXIL® - generic on formulary as AMOXICILLIN

AMPHETAMINE SALT COMBO 38 AMPHETAMINE SALT COMBO ER 38 AMPICILLIN 10 AMPYRA® 39 AMRIX® is non-formulary and requires PA, a formulary alternative is CYCLOBENZAPRINE

Drug Name Page AMTURNIDE® is non-formulary and requires PA

ANADROL-50® 45 ANAFRANIL® - generic on formulary as CLOMIPRAMINE HCL

ANAGRELIDE HCL 31 ANALPRAM HC® - is not FDA approved and therefore not a covered benefit, an OTC alternative is PREPARATION H® and/or SITZ BATH, a formulary alternative is HYDROCORTISONE CREAM

ANASTROZOLE 21 ANCOBON - generic on formulary as FLUCYTOSINE

ANDROGEL® 45 ANSAID® - generic on formulary as FLURBIPROFEN

ANTABUSE® - generic on formulary as DISULFRAM

ANUCORT HC® - is not FDA approved and therefore not a covered benefit, an OTC alternative is PREPARATION H® and/or SITZ BATH, a formulary alternative is HYDROCORTISONE CREAM

ANUSOL-HC® - generic on formulary as PROCTOCREAM-HC

APAP-BUTALBITAL 19 APEXICON E 40 APLENZIN® is non-formulary and requires PA, a formulary alternative is BUPROPION HCL XL

APOKYN® 22 APRI® 45 APRISO® 52 APTIVUS® 26 ARALEN® is non-formulary and requires PA

ARANELLE® 45 ARANESP® 31 ARCALYST® 51 ARCAPTA® is non-formulary and requires PA, a formulary alternative is SEREVENT®

ARICEPT® - generic on formulary as DONEPEZIL

ARICEPT® 23MG is non-formulary and requires PA

ARICEPT® ODT - generic on formulary as

63

Drug Name Page DONEPEZIL ODT ARIMIDEX® - generic on formulary as ANASTROZOLE

ARISTOCORT® - generic on formulary as TRIAMCINOLONE ACETONIDE

ARIXTRA® - generic on formulary as FONDAPARINUX

AROMASIN® - generic on formulary as EXEMESTANE

ARTHROTEC® is non-formulary and requires PA, a formulary alternative is MELOXICAM

ASACOL® 52 ASACOL® HD is non-formulary and requires PA, a formulary alternative is ASACOL®

ASCOMP WITH CODEINE 19 ASMANEX® 56 ASTELIN® - generic on formulary as AZELASTINE

ASTEPRO® is non-formulary and requires PA, a formulary alternative is AZELASTINE

ATACAND HCT® is non-formulary and requires PA, a formulary alternative is LOSARTAN-HYDROCHLOROTHIAZIDE

ATACAND® is non-formulary and requires PA, a formulary alternative is LOSARTAN

ATELVIA is non-formulary and requires PA, a formulary alternative is ALENDRONATE

ATENOLOL 33 ATENOLOL-CHLORTHALIDONE 33 ATIVAN® - generic on formulary as LORAZEPAM

ATORVASTATIN 36 ATRALIN® is non-formulary and requires PA

ATRIPLA® 26 ATROVENT HFA® 57 ATROVENT® - generic on formulary as IPRATROPIUM BROMIDE

AUGMENTIN XR® - generic on formulary as AMOX TR-POTASSIUM CLAVULANATE ER

AUGMENTIN® - generic on formulary as AMOX TR-POTASSIUM CLAVULANATE

AVALIDE® is non-formulary and requires

Drug Name Page PA, a formulary alternative is LOSARTAN-HYDROCHLOROTHIAZIDE AVAPRO® is non-formulary and requires PA, a formulary alternative is LOSARTAN

AVELOX® 11 AVIANE® 45 AVINZA® is non-formulary and requires PA, a formulary alternative is MORPHINE SULFATE ER

AVONEX® 51 AXERT® is non-formulary, a generic alternative is SUMATRIPTAN

AXID® - generic on formulary as NIZATIDINE

AXID® SOLUTION is non-formulary and requires PA, a formulary alternative is RANITIDINE or FAMOTIDINE

AZASITE® 53 AZATHIOPRINE 50 AZELASTINE 56 AZILECT® 22 AZITHROMYCIN 11 AZOPT® 54 AZULFIDINE® - generic on formulary as SULFASALAZINE

BACITRACIN OINTMENT 9 BACITRACIN ZINC OINTMENT 9 BACITRACIN-POLYMYXIN EYE OINT 53 BACLOFEN 24 BACTRIM® - generic on formulary as SULFAMETHOXAZOLE-TRIMETHOPRIM

BACTROBAN® - generic on formulary as MUPIROCIN OINTMENT

BALSALAZIDE DISODIUM 52 BALZIVA® 45 BANZEL® 12 BARACLUDE® 24 BENAZEPRIL HCL 36 BENAZEPRIL-HYDROCHLOROTHIAZIDE 36 BENICAR HCT® is non-formulary and requires PA, a formulary alternative is LOSARTAN-HYDROCHLOROTHIAZIDE

BENICAR® is non-formulary and requires PA, a formulary alternative is LOSARTAN

BENTYL® - generic on formulary as DICYCLOMINE

BENZACLIN CK® is non-formulary and

64

Drug Name Page requires PA, a formulary alternative is CLINDAMYCIN/BENZOYL PEROXIDE GEL BENZACLIN GEL® - generic on formulary as CLINDAMYCIN/BENZOYL PEROXIDE GEL

BENZACLIN PUMP® is non-formulary and requires PA, a formulary alternative is CLINDAMYCIN/BENZOYL PEROXIDE GEL

BENZAMYCIN® - generic on formulary as ERYTHROMYCIN-BENZOYL PEROXIDE

BENZONATATE 57 BENZTROPINE MESYLATE 22 BEPREVE® is non-formulary and requires PA

BESIVANCE®is non-formulary, a generic alternative is OFLOXACIN

BETAGAN® - generic on formulary as LEVOBUNOLOL HCL

BETAMETHASONE DIPROPIONATE 47 BETAPACE AF® - generic on formulary as SOTALOL AF

BETAPACE® - generic on formulary as SOTALOL

BETASERON® 51 BETAXOLOL HCL 33 BETAXOLOL HCL 0.5% EYE DROP 54 BETHANECHOL CHLORIDE 44 BETIMOL® 54 BETOPTIC S® 54 BIAXIN XL® - generic on formulary as CLARITHROMYCIN ER

BICALUTAMIDE 50 BIDIL® is non-formulary and requires PA, a formulary alternative is ISOSORBIDE DINITRATE + HYDRALAZINE

BIONECT® is non-formulary and requires PA, a formulary alternative is REGRANEX® which also requires PA

BISOPROLOL FUMARATE 33 BLEPH-10® - generic on formulary as OCUSULF-10

BLEPHAMIDE® 55 BONIVA® is non-formulary and requires PA, a formulary alternative is ALENDRONATE

BOROFAIR EAR DROPS 56 BOROFAIR® - generic on formulary as BOROFAIR EAR DROPS

Drug Name Page BREVICON® 45 BRILINTA® 31 BRIMONIDINE 54 BROMFENAC SODIUM 54 BROMOCRIPTINE MESYLATE 22 BUDENOSIDE 17 BUDEPRION SR 14 BUDEPRION XL 14 BUDESONIDE NEB SUSPENSION 56 BUMETANIDE 35 BUMEX® - generic on formulary as BUMETANIDE

BUPHENYL® 15 BUPRENORPHINE 7 BUPROBAN 16 BUPROPION HCL 14 BUPROPION HCL SR 14, 16 BUPROPION HCL XL 14 BUSPAR® - generic on formulary as BUSPIRONE HCL

BUSPIRONE HCL 28 BUTALBITAL COMPOUND 19 BUTALBITAL-APAP-CAFFEINE 19 BUTALBITAL-CAFF-APAP-COD 19 BUTORPHANOL TARTRATE 7 BUTRANS® is non-formulary and requires PA

BYETTA® 29 BYSTOLIC® is non-formulary and requires PA, a formulary alternative is CARVEDILOL

CABERGOLINE 50 CALCIPOTRIENE SOLUTION 40 CALCITONIN NASAL SPRAY 52 CALCITRIOL 52 CALCIUM ACETATE 45 CAMBIA® is non-formulary and requires PA, a formulary alternative is DICLOFENAC

CAMILA 49 CAMPRAL® 16 CANASA® 52 CAPOTEN® - generic on formulary as CAPTOPRIL

CAPOZIDE® - generic on formulary as CAPTOPRIL-HYDROCHLOROTHIAZIDE

CAPRELSA® 21

65

Drug Name Page CAPTOPRIL 36 CAPTOPRIL-HYDROCHLOROTHIAZIDE 36

CARAC® 40 CARAFATE® - generic on formulary as SUCRALFATE

CARBAGLU® 15 CARBAMAZEPINE 13 CARBAMAZEPINE XR CAPSULES 13 CARBAMAZEPINE XR TABLETS 13 CARBATROL® - generic on formulary as CARBAMAZEPINE XR CAPSULES

CARBIDOPA-LEVODOPA 23 CARDIZEM CD® - generic on formulary as DILTIAZEM CD

CARDIZEM LA® - generic on formulary as DILTIAZEM ER TABLETS

CARDIZEM LA® 120mg is non-formulary and requires PA

CARDIZEM® - generic on formulary as DILTIAZEM HCL

CARDURA® - generic on formulary as DOXAZOSIN MESYLATE

CARDURA® XL is non-formulary and requires PA, formulary alternatives are TAMSULOSIN, DOXAZOSIN, and TERAZOSIN

CARISOPRODOL 59 CARISOPRODOL COMPOUND 59 CARISOPRODOL CPD/CODEINE 59 CARTEOLOL HCL 54 CARTIA XT 34 CARVEDILOL 33 CASODEX® - generic on formulary as BICALUTAMIDE

CATAFLAM® - generic on formulary as DICLOFENAC POTASSIUM

CATAPRES® - generic on formulary as CLONIDINE HCL

CATAPRES-TTS® - generic on formulary as CLONIDINE TRANSDERMAL PATCH

CEDAX® 10 CEENU® 20 CEFACLOR 10 CEFADROXIL 10 CEFDINIR 10 CEFPODOXIME PROXETIL 10 CEFPROZIL 10

Drug Name Page CEFTIN® - generic on formulary as CEFUROXIME

CEFUROXIME 10 CEFUROXIME AXETIL 10 CEFZIL® - generic on formulary as CEFPROZIL

CELEBREX® 400MG 7, 18 CELEBREX® 50MG, 100MG, 200MG 7, 18 CELESTONE® 17 CELEXA® - generic on formulary as CITALOPRAM HBR

CELLCEPT® SOLUTION 50 CENESTIN® is non-formulary, a formulary alternative is PREMARIN®

CENTANY KIT® is non-formulary and requires PA, a formulary alternative is MUPIROCIN OINTMENT

CEPHALEXIN 10 CESAMET® is non-formulary and requires PA, a formulary alternative is ONDANSETRON

CESIA® 47 CETRAXAL®is non-formulary, a generic alternative is OFLOXACIN

CHERATUSSIN AC 57 CHERATUSSIN DAC 57 CHLORDIAZEPOXIDE 28 CHLORHEXIDINE GLUCONATE 39 CHLOROQUINE PHOSPHATE 22 CHLOROTHIAZIDE 35 CHLORPROMAZINE 23 CHLORPROPAMIDE 29 CHLORTHALIDONE 35 CHLORZOXAZONE 59 CHOLESTYRAMINE 36 CHOLESTYRAMINE LIGHT 36 CHOLINE MAG TRISAL 18 CIALIS® is non-formulary and requires PA, formulary alternatives are TAMSULOSIN, DOXAZOSIN, and TERAZOSIN

CICLOPIROX 40 CILOSTAZOL 32 CIMETIDINE 43 CIMZIA® is non-formulary, specialty, and requires PA

CIPRO HC® 11 CIPRO XR® - generic on formulary as

66

Drug Name Page CIPROFLOXACIN ER CIPRO® - generic on formulary as CIPROFLOXACIN HCL

CIPRODEX® 11 CIPROFLOXACIN ER 11 CIPROFLOXACIN HCL 11 CITALOPRAM HBR 14, 27 CITALOPRAM SOLUTION 14, 27 CLARAVIS 40 CLARIFOAM® is non-formulary and requires PA, a formulary alternative is SULFACETAMIDE

CLARINEX® is non-formulary and requires PA, an OTC alternative is ZYRTEC OTC, CLARITIN OTC or ALLEGRA OTC

CLARINEX-D® is non-formulary and requires PA, an OTC alternative is ZYRTEC OTC, CLARITIN OTC or ALLEGRA OTC

CLARITHROMYCIN 11 CLARITHROMYCIN ER 11 CLEMASTINE FUMARATE 56 CLEOCIN HCL® - generic on formulary as CLINDAMYCIN HCL

CLEOCIN T® - generic on formulary as CLINDAMYCIN PHOSPHATE

CLIMARA® - generic on formulary as ESTRADIOL

CLINDAMYCIN HCL 9 CLINDAMYCIN PHOSPHATE 40 CLINDAMYCIN PHOSPHATE 1% FOAM 40 CLINDAMYCIN/BENZOYL PEROXIDE GEL 40 CLINDAREACH KIT® is non-formulary and requires PA, a formulary alternative is CLINDAMYCIN HCL

CLINORIL® - generic on formulary as SULINDAC

CLOBETASOL EMOLLIENT 47 CLOBETASOL PROPIONATE 48 CLOBEX® SPRAY is non-formulary and requires PA, a formulary alternative is CLOBETASOL PROPIONATE

CLOMIPRAMINE HCL 15 CLONAZEPAM 28 CLONIDINE HCL 32 CLONIDINE TRANSDERMAL PATCH 32 CLORAZEPATE 28 CLOTRIMAZOLE-BETAMETHASONE 48

Drug Name Page CLOZAPINE 23 CLOZARIL® - generic on formulary as CLOZAPINE

COARTEM® is non-formulary and requires PA

CODEINE SULFATE 8 CO-GESIC 8 COLAZAL® - generic on formulary as BALSALAZIDE DISODIUM

COLCRYS® 17 COLESTID® - generic on formulary as COLESTIPOL HCL

COLESTIPOL HCL 36 COLYTE® - generic on formulary as PEG 3350-ELECTROLYTE

COMBIGAN® is non-formulary and requires PA, a formulary alternative is BRIMONIDINE 2% + TIMOLOL 0.5%

COMBIPATCH® 47 COMBIVENT® 57 COMBUNOX® - generic on formulary as OXYCODONE-IBUPROFEN

COMPLERA® 26 COMPRO 24 COMTAN® 23 CONCERTA® 38 CONDYLOX® - generic on formulary as PODOFILOX

CONZIP® is non-formulary and requires PA, a formulary alternative is TRAMADOL ER

COPAXONE® 51 COPEGUS® - generic on formulary as RIBAVIRIN

COREG CR® 33 COREG® - generic on formulary as CARVEDILOL

CORGARD® - generic on formulary as NADOLOL

CORMAX 48 CORTEF® - generic on formulary as HYDROCORTISONE

CORTISONE 17 CORTISPORIN® - generic on formulary as NEOMYCIN-POLYMYXIN-HC

CORZIDE® - generic on formulary as NADOLOL-BENDROFLUMETHIAZIDE

67

Drug Name Page COSOPT® - generic on formulary as DORZOLAMIDE/TIMOLOL

COUMADIN® - generic on formulary as WARFARIN SODIUM

COZAAR® - generic on formulary as LOSARTAN

CREON® 42 CRESTOR® is non-formulary and requires PA, a formulary alternative is SIMVASTATIN

CRIXIVAN® 26 CROMOLYN EYE DROPS 53 CROMOLYN NEBULIZER SOLN 58

CRYSELLE® 45 CUPRIMINE® 44 CUVPOSA® 42 CYANOCOBALAMIN 1,000 MCG/ML INJ. 60 CYCLESSA® - generic on formulary as CESIA®

CYCLOBENZAPRINE HCL TABLET 59 CYCLOPHOSPHAMIDE 21 CYCLOSET® is non-formulary and requires PA

CYCLOSPORINE 50 CYMBALTA® 14, 27 CYPROHEPTADINE 56 CYSTAGON® 42 CYTOMEL® - generic on formulary as LIOTHYRONINE

CYTOTEC® - generic on formulary as MISOPROSTOL

CYTOXAN® - generic on formulary as CYCLOPHOSPHAMIDE

DALIRESP® is non-formulary and requires PA, a formulary alternative is SEREVENT®

DALMANE® - generic on formulary as FLURAZEPAM

DANAZOL 50 DAPSONE 9 DARAPRIM® 22 DARVOCET® - generic on formulary as PROPOXYPHENE NAPSYLATE/APAP

DAYPRO® - generic on formulary as OXAPROZIN

DAYTRANA® 38 DDAVP TABLETS® - generic on formulary as DESMOPRESSIN ACETATE

Drug Name Page DECLOMYCIN® - generic on formulary as DEMECLOCYCLINE HCL

DEL-BETA 40 DELTASONE® - generic on formulary as PREDNISONE

DEMADEX® - generic on formulary as TORSEMIDE

DEMECLOCYCLINE HCL 11 DENAVIR® 40 DEPACON® - generic on formulary as VALPROATE SODIUM

DEPAKENE® - generic on formulary as VALPROIC ACID

DEPAKOTE ER® - generic on formulary as DIVALPROEX SODIUM ER

DEPAKOTE SPRINKLE® - generic on formulary as DIVALPROEX CAP SPRINKLE

DEPAKOTE® - generic on formulary as DIVALPROEX SODIUM

DEPEN® 44 DERMOTIC® 56 DESIPRAMINE HCL 15 DESMOPRESSIN ACETATE 48 DESOGEN® - generic on formulary as RECLIPSEN®

DESONATE GEL® is non-formulary and requires PA, a formulary alternative is DESONIDE CREAM

DESONIDE 48 DESOWEN® - generic on formulary as DESONIDE

DESOXIMETASONE 48 DESYREL® - generic on formulary as TRAZODONE HCL

DETROL LA® 44 DETROL® 44 DEXAMETHASONE 48 DEXAMETHASONE EYE OINT/DROP 54 DEXEDRINE® - generic on formulary as DEXTROAMPHETAMINE SULFATE SA

DEXMETHYLPHENIDATE HCL 38 DEXTROAMPHETAMINE SULFATE SA 38 DEXTROSTAT 38 DIABETA® - generic on formulary as GLYBURIDE

DIAMOX SEQUELS® - generic on formulary as ACETAZOLAMIDE

68

Drug Name Page DIASTAT® 12 DIAZEPAM 28 DIAZEPAM RECTAL KIT 12 DICLOFENAC EYE DROPS 54 DICLOFENAC POTASSIUM 7, 18

DICLOFENAC SODIUM 18 DICLOXACILLIN 10 DICYCLOMINE 42 DIDANOSINE CAPS 26 DIDRONEL® - generic on formulary as ETIDRONATE DISODIUM

DIFFERIN® 0.1% - generic on formulary as ADAPALENE 0.1% CREAM/GEL

DIFFERIN® 0.1% LOTION is non-formulary and requires PA, a formulary alternative is ADAPALENE 0.1% CREAM/GEL

DIFFERIN® 0.3% GEL 40 DIFLUCAN® - generic on formulary as FLUCONAZOLE

DIFLUNISAL 7 DIGITEK 35 DIGOXIN 35 DILACOR XR® - generic on formulary as DILTIAZEM ER

DILANTIN INFATAB® 13 DILANTIN KAPSEALS® - generic on formulary as PHENYTOIN SODIUM ER

DILANTIN® - generic on formulary as PHENYTOIN

DILATRATE-SR® 37 DILAUDID® - generic on formulary as HYDROMORPHONE HCL

DILTIAZEM ER CAPSULES 34 DILTIAZEM ER TABLETS 34 DILTIAZEM HCL 34 DIOVAN HCT® 37 DIOVAN® 37 DIPENTUM® 52 DIPHENOXYLATE-ATROPINE 43 DIPIVEFRIN HCL 54 DIPROLENE AF® - generic on formulary as BETAMETHASONE DIPROPIONATE

DIPYRIDAMOLE 32 DISOPYRAMIDE PHOSPHATE 32 DISOPYRAMIDE PHOSPHATE ER 150 MG 33 DISULFIRAM 16

Drug Name Page DITROPAN XL® - generic on formulary as OXYBUTYNIN ER

DITROPAN® - generic on formulary as OXYBUTYNIN

DIVALPROEX CAP SPRINKLE 12 DIVALPROEX SODIUM 12 DIVALPROEX SODIUM ER 12, 19 DONEPEZIL 13 DONEPEZIL ODT 13 DORYX® is non-formulary and requires PA, a formulary alternative is DOXYCYCLINE HYCLATE

DORZOLAMIDE 54 DORZOLAMIDE/TIMOLOL 54 DOVONEX® CREAM AND OINTMENT 40 DOXAZOSIN MESYLATE 44 DOXEPIN HCL 15 DOXYCYCLINE HYCLATE 11 DROXIA® 20 DUAC GEL® is non-formulary and requires PA, a formulary alternative is CLINDAMYCIN/BENZOYL PEROXIDE GEL

DUETACT® 29 DURAGESIC® - generic on formulary as FENTANYL

DYNACIRC CR® is non-formulary, a generic alternative is ISRADIPINE or AMLODIPINE

DYRENIUM® 35 E.E.S.®, ERYPRED® - generic on formulary as ERYTHROMYCIN ETHYLSUCCINATE

EC-NAPROSYN® - generic on formulary as NAPROXEN

ECONAZOLE NITRATE 40

ED DOXY-CAPS 11 ED K+10 59 EDARBI® is non-formulary and requires PA, a formulary alternative is LOSARTAN

EDECRIN® 35 EDLUAR® is non-formulary and requires PA, a formulary alternative is ZOLPIDEM TARTRATE

EDURANT® 25 EEMT DS - is not FDA approved and therefore not a covered benefit, formulary alternatives are ESTRADIOL,

69

Drug Name Page PREMARIN® EEMT HS - is not FDA approved and therefore not a covered benefit, formulary alternatives are ESTRADIOL, PREMARIN®

EFFEXOR XR® - generic on formulary as VENLAFAXINE ER

EFFEXOR® - generic on formulary as VENLAFAXINE HCL

EFFIENT® 32 EFUDEX® - generic on formulary as FLUOROURACIL

EGRIFTA® 48 ELAVIL® - generic on formulary as AMITRIPTYLINE HCL

ELDEPRYL® - generic on formulary as SELEGILINE HCL

ELESTAT® - generic on formulary as EPINASTINE HCL

ELIDEL® 40 ELIGARD® 50 ELIMITE® - generic on formulary as PERMETHRIN

ELMIRON® 44 ELOCON® - generic on formulary as MOMETASONE FUROATE

EMBEDA® is non-formulary and requires PA, a formulary alternative is MORPHINE SULFATE ER

EMCYT® 20 EMEND TRIFOLD PACK® 16 EMEND® 80MG 16 EMLA® - generic on formulary as LIDOCAINE-PRILOCAINE

EMSAM® 14 EMTRIVA® 26 ENABLEX® is non-formulary and requires PA, formulary alternatives are OXYBUTYNIN ER and DETROL LA

ENALAPRIL MALEATE 37 ENALAPRIL-HYDROCHLOROTHIAZIDE 37 ENBREL® 50 ENDOCET 8 ENJUVIA® is non-formulary, a generic alternative is ESTRADIOL or PREMARIN®

ENOXAPARIN SODIUM INJECTABLE 31 ENPRESSE® 45

Drug Name Page ENTOCORT EC® - generic on formulary as BUDENOSIDE

EPIDREN® - is not FDA approved and therefore not a covered benefit, formulary alternatives are BULTALBITAL-APAP-CAFFEINE, BUTALBITAL COMPOUND

EPIDUO® is non-formulary and requires PA

EPINASTINE HCL 53 EPIPEN JR® 58 EPIPEN® 58 EPIPEN® - generic on formulary as EPINEPHRINE PEN

EPIVIR HBV® 26 EPIVIR® - generic on formulary as LAMIVUDINE TABLETS

EPIVIR® SOLUTION 26 EPLERENONE 37 EPOGEN® 31 EPROSARTAN MESYLATE 37 EPZICOM® 26 EQUETRO® is non-formulary and requires PA, a formulary alternative is CARBAMEZAPINE

ERGOTAMINE-CAFFEINE 19 ERRIN 49 ERY-TAB® 11 ERYTHROMYCIN 11 ERYTHROMYCIN ETHYLSUCCINATE 11 ERYTHROMYCIN-BENZOYL PEROXIDE 40 ERYTHROMYCIN-SULFISOXAZOLE 11 ESSIAN DS - is not FDA approved and therefore not a covered benefit, formulary alternatives are ESTRADIOL, PREMARIN®

ESTAZOLAM 59 ESTRACE® - generic on formulary as ESTRADIOL

ESTRACE® TABLET - generic on formulary as ESTRADIOL

ESTRADIOL 47 ESTRADIOL-NORETHINDRONE 1.0-0.5 MG TAB 47 ESTRATEST® - is not FDA approved and therefore not a covered benefit, formulary alternatives are ESTRADIOL,

70

Drug Name Page PREMARIN® ESTRING® 47 ESTROGENS METHYLTESTOSTERONE DS - is not FDA approved and therefore not a covered benefit, formulary alternatives are ESTRADIOL, PREMARIN®

ESTROGENS METHYLTESTOSTERONE HS - is not FDA approved and therefore not a covered benefit, formulary alternatives are ESTRADIOL, PREMARIN®

ESTROPIPATE 47 ESTROSTEP FE® - generic on formulary as TRI-LEGEST®

ETHAMBUTOL HCL 20 ETHOSUXIMIDE 12 ETIDRONATE DISODIUM 52 ETODOLAC 7, 18 EVISTA® 20, 49 EVOCLIN® - generic on formulary as CLINDAMYCIN PHOSPHATE 1% FOAM

EXALGO® is non-formulary and requires PA

EXELON® - generic on formulary as RIVASTIGMINE CAPSULES

EXELON® PATCH & SOLUTION 13 EXEMESTANE 21 EXFORGE HCT® is non-formulary and requires PA, formulary alternatives are AMLODIPINE + LOSARTAN-HYDROCHLOROTHIAZIDE

EXFORGE® is non-formulary, formulary alternatives are AMLODIPINE + LISINOPRIL or LOSARTAN or DIOVAN®

EXJADE® 15 EXTAVIA® 51 EXTINA FOAM® is non-formulary and requires PA, a formulary alternative is KETOCONAZOLE CREAM

FAMCICLOVIR 25 FAMOTIDINE 40MG 43 FAMVIR® - generic on formulary as FAMCICLOVIR

FANAPT® 23 FANSIDAR® 22 FARESTON® 20 FAZACLO® 23 FELBAMATE 13

Drug Name Page FELBATOL® - generic on formulary as FELBAMATE

FELDENE® - generic on formulary as PIROXICAM

FELODIPINE ER 34 FEMARA® - generic on formulary as LETROZOLE

FEMTRACE® is non-formulary and requires PA, a formulary alternative is ESTRADIOL

FENOFIBRATE 36 FENOFIBRIC ACID 36 FENOPROFEN 7, 18 FENTANYL 8 FENTANYL CITRATE 8 FENTORA® is non-formulary and requires PA, a formulary alternative is MORPHINE SULFATE ER

FEXMID® is non-formulary and requires PA, a formulary alternative is CYCLOBENZAPRINE

FEXOFENADINE - is OTC and therefore not a covered benefit. Please consult with a pharmacist about this medication.

FIBRICOR® - generic on formulary as FENOFRIBIC ACID

FINACEA PLUS® 40 FINACEA® 40 FINASTERIDE 44 FIORICET WITH CODEINE® - generic on formulary as BUTALBITAL-CAFF-APAP-COD

FIORICET® - generic on formulary as BUTALBITAL-APAP-CAFFEINE

FIORINAL WITH CODEINE #3® - generic on formulary as BUTALBITAL COMP/COD

FIRAZYR® 32 FLAREX® 55 FLAVOXATE HCL 44 FLECAINIDE ACETATE 33 FLECTOR® is non-formulary and requires PA, a formulary alternative is DICLOFENAC TABLETS

FLEXERIL® - generic on formulary as CYCLOBENZAPRINE HCL

FLOMAX® - generic on formulary as TAMSULOSIN

71

Drug Name Page FLONASE® - generic on formulary as FLUTICASONE PROPIONATE NASAL INHALER

FLOVENT HFA® 56 FLOVENT® DISKUS 56 FLUCONAZOLE 17 FLUCYTOSINE 17 FLUDROCORTISONE ACETATE 48 FLUMADINE® - generic on formulary as RIMANTADINE HCL

FLUNISOLIDE NASAL 56 FLUOCINOLONE ACETONIDE 48 FLUOCINOLONE-E 40 FLUOCINONIDE 48 FLUORABON 60 FLUOROMETHOLONE 55 FLUOR-OP 55 FLUOROPLEX® 40 FLUOROURACIL 40 FLUOXETINE HCL 14, 27 FLURAZEPAM 28 FLURBIPROFEN 7 FLURBIPROFEN SODIUM 55 FLUTICASONE PROPIONATE NASAL INHALER 56 FLUVOXAMINE MALEATE 14, 27 FML FORTE® 55 FML S.O.P.® 55 FML® - generic on formulary as FLUOROMETHOLONE

FOCALIN XR® is non-formulary and requires PA, a formulary alternative is METHYLPHENIDATE

FOCALIN® - generic on formulary as DEXMETHYLPHENIDATE HCL

FOLIC ACID 60 FONDAPARINUX 31 FORTAMET® is non-formulary and requires PA, a formulary alternative is METFORMIN

FORTEO® 52 FOSAMAX 70 MG ORAL SOLUTION® 52 FOSAMAX PLUS D® is non-formulary and requires PA, a formulary alternative is ALENDRONATE + OTC Vitamin D

FOSAMAX® - generic on formulary as ALENDRONATE SODIUM

Drug Name Page FOSINOPRIL SODIUM 37 FOSINOPRIL-HYDROCHLOROTHIAZIDE 37 FOSRENOL® is non-formulary and requires PA, a formulary alternative is CALCIUM ACETATE (PHOSLO) OR OTC CALCIUM CARBONATE

FRAGMIN® 31 FURADANTIN® - generic on formulary as NITROFURANTOIN SUSPENSION

FUROSEMIDE 35 FUZEON® 25 GABAPENTIN 12 GABAPENTIN SOLUTION 12 GABITRIL® 12 GANCICLOVIR 24 GANTRISIN® 11 GASTROCROM® 58 GELNIQUE® is non-formulary and requires PA, formulary alternatives are OXYBUTYNIN ER and DETROL LA

GEMFIBROZIL 36 GENGRAF 50 GENOPTIC® - generic on formulary as GENTASOL

GENOTROPIN® 48 GENTAK® - generic on formulary as GENTAMICIN SULFATE

GENTAMICIN SULFATE 53 GENTASOL 53 GEODON® 28 GIANVI 45 GILENYA® 51 GLEEVEC® 21 GLIMEPIRIDE 29 GLIPIZIDE 29 GLIPIZIDE ER 29 GLIPIZIDE-METFORMIN 29 GLUCAGEN 29 GLUCAGON® 30 GLUCOPHAGE XR® - generic on formulary as METFORMIN HCL ER

GLUCOPHAGE® - generic on formulary as METFORMIN HCL

GLUCOTROL XL® - generic on formulary as GLIPIZIDE ER

GLUCOTROL® - generic on formulary as GLIPIZIDE

72

Drug Name Page GLUCOVANCE® - generic on formulary as GLYBURIDE-METFORMIN HCL

GLUMETZA® is non-formulary and requires PA, a formulary alternative is METFORMIN

GLYBURIDE 29 GLYBURIDE MICRONIZED 29 GLYBURIDE-METFORMIN HCL 29 GLYCOPYRROLATE 42 GLYNASE® - generic on formulary as GLYBURIDE MICRONIZED

GLYSET® 29 GOLYTELY® - generic on formulary as PEG 3350-ELECTROLYTE

GRALISE® is non-formulary and requires PA, a formulary alternative is GABAPENTIN IR

GRANISETRON TABLETS 16 GRIFULVIN V® - generic on formulary as GRISEOFULVIN

GRISEOFULVIN 17 GRISEOFULVIN ULTRA 17 GRIS-PEG® - generic on formulary as GRISEOFULVIN ULTRA

GUAIFENESIN-CODEINE 57 GUANABENZ ACETATE 32 GUANFACINE HCL 32 HALCION® - generic on formulary as TRIAZOLAM

HALFLYTELY® is non-formulary, generic alternative are PEG 3350-ELECTROLYTE and TRILYTE

HALOBETASOL PROPIONATE 48 HALOPERIDOL 24 HECTOROL® 52 HEPSERA® 24 HEXALEN® 20 HIPREX® - generic on formulary as METHENAMINE HIPPURATE

HORIZANT® is non-formulary and requires PA, a formulary alternative is PRAMIPEXOLE

HUMALOG MIX 50-50® 30 HUMALOG MIX 75-25® 30 HUMALOG® 30 HUMATROPE® 48 HUMIRA® 50

Drug Name Page HUMULIN 50-50® 30 HUMULIN MIX 70-30® 30 HUMULIN N® 30 HUMULIN R® 30 HYCAMTIN® CAPSULES 21 HYDRALAZINE 37 HYDREA® - generic on formulary as HYDROXYUREA

HYDROCHLOROTHIAZIDE 35 HYDROCODONE BIT-IBUPROFEN 8 HYDROCODONE-ACETAMINOPHEN 8 HYDROCORTISONE 48 HYDROCORTISONE BUTYRATE 48 HYDROMORPHONE HCL 8 HYDROXYCHLOROQUINE SULFATE 22 HYDROXYUREA 20 HYDROXYZINE HCL 56 HYDROXYZINE PAMOATE 16 HYOSCYAMINE- is not FDA approved and therefore not a covered benefit, a formulary alternative is dicyclomine

HYPERCARE 20% SOLUTION 40 HYTRIN® - generic on formulary as TERAZOSIN HCL

HYZAAR® - generic on formulary as LOSARTAN-HYDROCHLOROTHIAZIDE

IBUPROFEN 7, 18 IMDUR® - generic on formulary as ISOSORBIDE MONONITRATE

IMIPRAMINE HCL 15 IMIPRAMINE PAMOATE 15 IMIQUIMOD 5% CREAM 40 IMITREX® - generic on formulary as SUMATRIPTAN SUCCINATE

IMURAN® - generic on formulary as AZATHIOPRINE

INCIVEK® 24 INCRELEX® 48 INDAPAMIDE 35 INDERAL LA® - generic on formulary as PROPRANOLOL ER

INDERAL® - generic on formulary as PROPRANOLOL

INDOCIN SR® - generic on formulary as INDOMETHACIN

INDOMETHACIN 7, 18 INFERGEN® 25

73

Drug Name Page INNOHEP® 31 INNOPRAN XL® is non-formulary, a generic alternative is PROPRANOLOL XL

INSPRA® - generic on formulary as EPLERENONE

INTAL® 58 INTELENCE® 25 INTRON A® 51 INTUNIV ® is non-formulary and requires PA

INVEGA® 23 INVIRASE 26 IPRATROPIUM BROMIDE 57 IPRATROPRIUM-ALBUTEROL 58 IPRIVASK® is non-formulary and requires PA, formulary alternatives are ENOXAPARIN or FONDAPARINUX

IRESSA® 21 ISENTRESS® 25 ISONARIF 20 ISONIAZID 20 ISORDIL® - generic on formulary as ISOSORBIDE DINITRATE

ISOSORBIDE DINITRATE 38 ISOSORBIDE MONONITRATE 38 ISRADIPINE 34 ISTALOL® 54 ITRACONAZOLE 17 JAKAFI® 21 JALYN® is non-formulary and requires PA

JANTOVEN 31 JANUMET® 29 JANUVIA® 29 JINTELI 47 JOLESSA® 45 JOLIVETTE 49 JUNEL FE® 45 JUNEL® 46 KALETRA® 26 KAON-CL TAB 59 KAPIDEX® is non-formulary and requires PA, formulary alternatives are OMEPRAZOLE and PANTOPRAZOLE

KAPVAY® is non-formulary and requires PA

KARIVA® 46 K-DUR® - generic on formulary as

Drug Name Page POTASSIUM CHLORIDE KEFLEX® - generic on formulary as CEPHALEXIN

KELNOR® 46 KENALOG® - generic on formulary as TRIDERM

KEPPRA XR® - generic on formulary as LEVETIRACETAM ER

KEPPRA® - generic on formulary as LEVETIRACETAM

KERLONE® - generic on formulary as BETAXOLOL HCL

KETEK® is non-formulary and requires PA KETOCONAZOLE 17

KETOPROFEN 7, 18 KETOROLAC TROMETHAMINE OPHTH DROPS 55 KETOROLAC TROMETHAMINE TABLET 7, 18 KINERET® 51 KLARON® - generic on formulary as SULFACETAMIDE SODIUM

KLONOPIN WAFER® is non-formulary, a generic alternative is CLONAZEPAM

KLONOPIN® - generic on formulary as CLONAZEPAM

KLOR-CON POWDER - is not FDA approved and therefore not a covered benefit, a formulary alternative is KLOR-CON® M DISPERSIBLE TABLET

KLOR-CON SOLUTION - is not FDA approved and therefore not a covered benefit, a formulary alternative is KLOR-CON® M DISPERSIBLE TABLET

KLOR-CON® M DISPERSIBLE TABLET 60 KLOTRIX 60 KOMBIGLYZE XR® 29 K-TAB® - generic on formulary as KAON-CL

KURIC 17 KUVAN® 42 LABETALOL HCL 33 LACRISERT® 55 LACTULOSE 43 LAMICTAL® - generic on formulary as LAMOTRIGINE

LAMICTAL® ODT is non-formulary and requires PA, formulary alternatives are

74

Drug Name Page LAMOTRIGINE TABLETS and LAMOTRIGINE CHEWABLE TABLETS LAMICTAL® XR is non-formulary and requires PA, formulary alternatives are LAMOTRIGINE TABLETS and LAMOTRIGINE CHEWABLE TABLETS

LAMISIL® - generic on formulary as TERBINAFINE HCL

LAMIVUDINE TABLETS 26 LAMIVUDINE-ZIDOVUDINE 26 LAMOTRIGINE 13 LANOXIN® - generic on formulary as DIGOXIN

LANSOPRAZOLE 30 MG 43 LANTUS SOLOSTAR® 30 LANTUS® 30 LARIAM® - generic on formulary as MEFLOQUINE HCL

LASIX® - generic on formulary as FUROSEMIDE

LASTACAFT® is non-formulary and requires PA

LATANOPROST 55 LATUDA® 23 LEENA® 46 LEFLUNOMIDE 51 LESCOL XL® is non-formulary, a generic alternative is SIMVASTATIN

LESCOL® is non-formulary, a generic alternative is SIMVASTATIN

LETAIRIS® 58 LETROZOLE 21 LEUCOVORIN CALCIUM 15 LEUKERAN® 20 LEUKINE® 31 LEUPROLIDE ACETATE 50 LEVALBUTEROL 1.25 MG/0.5 ML 58 LEVAQUIN® - generic on formulary as LEVOFLOXACIN TABLETS & SOLUTION

LEVATOL® 33 LEVEMIR® 30 LEVETIRACETAM 12 LEVETIRACETAM ER 12 LEVOBUNOLOL HCL 54 LEVOCETERIZINE is non-formulary and requires PA, an OTC alternative is ZYRTEC OTC, CLARITIN OTC or ALLEGRA OTC

Drug Name Page LEVO-DROMORAN® - generic on formulary as LEVORPHANOL TARTRATE

LEVOFLOXACIN 0.50 % DROPS 53 LEVOFLOXACIN TABLETS & SOLUTION 11 LEVORA® 46 LEVORPHANOL TARTRATE 8 LEVOTHROID 49 LEVOTHYROXINE SODIUM 49 LEVOXYL 49 LEXAPRO® 27 LEXIVA® 26 LIALDA 52 LIBRIUM® - generic on formulary as CHLORDIAZEPOXIDE

LIDEX® - generic on formulary as FLUOCINONIDE

LIDOCAINE HCL 9 LIDOCAINE-PRILOCAINE 9 LIDODERM® 9 LIDOMAR VISCOUS 9 LIFESCAN (METERS & TEST STRIPS) 30 LIORESAL® - generic on formulary as BACLOFEN

LIOTHYRONINE 49 LIPITOR® - generic on formulary as ATORVASTATIN

LIPOFEN® is non-formulary and requires PA, a formulary alternative is FENOFIBRATE

LIPRAM® - generic on formulary as PANCRELIPASE

LIPRAM-PN 42 LISINOPRIL 37 LISINOPRIL-HYDROCHLOROTHIAZIDE 37 LITHIUM CARBONATE 28 LITHIUM CITRATE 28 LITHIUM ER 28 LITHOBID® - generic on formulary as LITHIUM CARBONATE

LIVALO® is non-formulary and requires PA, formulary alternatives are SIMVASTATIN or LOVASTATIN

LOCOID® - generic on formulary as HYDROCORTISONE BUTYRATE

LODINE® - generic on formulary as ETODOLAC

LODOSYN® 23

75

Drug Name Page LOESTRIN 24 FE® 46 LOESTRIN FE® - generic on formulary as JUNEL FE®

LOESTRIN® - generic on formulary as JUNEL®

LOKARA 40 LOMOTIL® - generic on formulary as DIPHENOXYLATE-ATROPINE

LONOX 43 LO-OVRAL® - generic on formulary as CRYSELLE®

LOPID® - generic on formulary as GEMFIBROZIL

LOPRESSOR HCT® - generic on formulary as METOPROLOL-HYDROCHLOROTHIAZIDE

LOPRESSOR® - generic on formulary as METOPROLOL TARTRATE

LORAZEPAM 28 LORAZEPAM INTENSOL 28 LORTAB® - generic on formulary as VANACET

LOSARTAN 37 LOSARTAN-HYDROCHLOROTHIAZIDE 37 LOTEMAX® 55 LOTENSIN HCT® - generic on formulary as BENAZEPRIL-HYDROCHLOROTHIAZIDE

LOTENSIN® - generic on formulary as BENAZEPRIL HCL

LOTREL® - generic on formulary as AMLODIPINE BESYLATE-BENAZEPRIL

LOTRISONE® - generic on formulary as CLOTRIMAZOLE-BETAMETHASONE

LOTRONEX® 43 LOVASTATIN 36 LOVAZA® 36 LOVENOX® - generic on formulary as ENOXAPARIN SODIUM INJECTABLE

LOW-OGESTREL® 46 LOXAPINE 24 LOXITANE® - generic on formulary as LOXAPINE

LUMIGAN® 55 LUNESTA® is non-formulary and requires PA, formulary alternatives are ZOLPIDEM or ZALEPLON

LUPRON® is non-formulary and requires

Drug Name Page PA, a formulary alternative is LEUPROLIDE ACETATE which also requires PA LUTERA® 46 LUVOX CR® is non-formulary and requires PA, a formulary alternative is FLUVOXAMINE MALEATE

LYBREL® - generic on formulary as AMETHYST

LYRICA® 12 LYSODREN® 49 LYSTEDA® 31 MACRODANTIN® - generic on formulary as NITROFURANTOIN MACROCRYSTALS

MAGNACET® is non-formulary and requires PA

MALARONE® is non-formulary and requires PA

MAPROTILINE 14 MARGESIC H 8 MARINOL® is non-formulary and requires PA, a formulary alternative is ONDANSETRON

MARPLAN® 14 MATULANE® 20 MAVIK® - generic on formulary as TRANDOLAPRIL

MAXALT MLT® 19 MAXALT® 19 MAXIDEX® - generic on formulary as DEXAMETHASONE EYE OINT/DROP

MAXIPIME® - generic on formulary as CEFEPIME HCL

MAXITROL® - generic on formulary as NEOMYCIN-POLYMYXIN-DEXAMETH

MAXZIDE® - generic on formulary as TRIAMTERENE-HCTZ

MECLIZINE 12.5mg & 25mg - is OTC and therefore not a covered benefit. Please consult with a pharmacist about this medication.

MECLOFENAMATE 7, 18 MEDROL® - generic on formulary as METHYLPREDNISOLONE

MEDROXYPROGESTERONE 49 MEDROXYPROGESTERONE ACETATE 49 MEFLOQUINE HCL 22

76

Drug Name Page MEGESTROL ACETATE 49 MELOXICAM 7, 18 MEPERIDINE 8 MEPROBAMATE 28 MEPRON® 22 MERCAPTOPURINE 21 MESALAMINE 52 MESNEX® 21 MESTINON® - generic on formulary as PYRIDOSTIGMINE BROMIDE

MESTINON® 180 MG 19 METADATE CD® 38 METADATE ER® - generic on formulary as METHYLIN ER

METAXALONE 59 METFORMIN HCL 29 METFORMIN HCL ER 29 METHADONE HCL 8 METHADOSE 8 METHAZOLAMIDE 35 METHENAMINE HIPPURATE 9 METHERGINE® - generic on formulary as METHYLERGONOVINE MALEATE

METHIMAZOLE 50 METHOCARBAMOL 59 METHOTREXATE 51 METHOTREXATE INJECTABLE 51 METHYLDOPA 32 METHYLDOPA-HCTZ 32 METHYLERGONOVINE MALEATE 49 METHYLIN ER 38 METHYLIN® CHEWABLE TABLETS 38 METHYLPHENIDATE CPMP 50-50 38 METHYLPHENIDATE ER 18MG, 27MG, 36MG, 54MG 38 METHYLPHENIDATE ER 20MG 39 METHYLPHENIDATE TABLET & SOLUTION 39 METHYLPREDNISOLONE 17 METIPRANOLOL 54 METOCLOPRAMIDE HCL 16 METOLAZONE 35 METOPROLOL SUCCINATE ER 33 METOPROLOL TARTRATE 33 METOPROLOL-HYDROCHLOROTHIAZIDE 33 METOZOLV ODT® is non-formulary and requires PA, a formulary alternative is

Drug Name Page METOCLOPRAMIDE HCL METROCREAM® - generic on formulary as METRONIDAZOLE

METROGEL 1% GEL® is non-formulary, a generic alternative is METRONIDAZOLE 0.75% GEL

METRONIDAZOLE 0.75% TOPICAL 40 METRONIDAZOLE TABLETS 9 MEVACOR® - generic on formulary as LOVASTATIN

MEXILETINE 33 MICARDIS® is non-formulary and requires PA, a formulary alternative is LOSARTAN

MICROGESTIN FE 46 MICROGESTIN® 46 MICRO-K® - generic on formulary as POTASSIUM CHLORIDE

MICRONASE® - generic on formulary as GLYBURIDE

MICRONOR® - generic on formulary as NORETHINDRONE ACETATE

MICROZIDE® - generic on formulary as HYDROCHLOROTHIAZIDE

MIDODRINE HCL 32 MIDRIN® - is not FDA approved and therefore not a covered benefit, formulary alternatives are BULTALBITAL-APAP-CAFFEINE, BUTALBITAL COMPOUND

MIGERGOT 19 MIGRANAL® 19 MINIPRESS® - generic on formulary as PRAZOSIN HCL

MINITRAN® - generic on formulary as NITROGLYCERIN PATCH

MINOCYCLINE HCL 12 MIRAPEX ER® is non-formulary and requires PA, a formulary alternative is PRAMIPEXOLE

MIRAPEX® - generic on formulary as PRAMIPEXOLE

MIRTAZAPINE 14 MISOPROSTOL 43 MOBAN® 24 MOBIC® - generic on formulary as MELOXICAM

MODICON® - generic on formulary as

77

Drug Name Page BREVICON® MOEXIPRIL HCL 37 MOEXIPRIL-HYDROCHLOROTHIAZIDE 37 MOMETASONE FUROATE 48 MONONESSA® 46 MONOPRIL HCT® - generic on formulary as FOSINOPRIL-HYDROCHLOROTHIAZIDE

MONOPRIL® - generic on formulary as FOSINOPRIL SODIUM

MORPHINE SULFATE CONCENTRATE (20MG/ML) - is not FDA approved and therefore not a covered benefit, a formulary alternative may be MORPHINE SOLUTION (10MG/5ML OR 20MG/5ML) or discussion with the physician about alternate ways of treating the pain.

MORPHINE SULFATE ER 8 MORPHINE SULFATE IR 8 MOTRIN® - generic on formulary as IBUPROFEN

MOVIPREP POWDER KIT® 43 MOXATAG® is non-formulary, a generic alternative is AMOXICILLIN

MOZOBIL® is non-formulary and requires PA

MS CONTIN® - generic on formulary as MORPHINE SULFATE ER

MULTAQ® 33 MULTIVIT-FLUORIDE 60 MULTIVIT-IRON-FL 60 MUPIROCIN OINTMENT 41 MYAMBUTOL® - generic on formulary as ETHAMBUTOL HCL

MYCOPHENOLATE MOFETIL 51 MYCOSTATIN® - generic on formulary as NYSTOP

MYDRAL 55 MYDRIACYL® - generic on formulary as TROPICAMIDE

MYFORTIC® 51 MYRAC 12 MYSOLINE® - generic on formulary as PRIMIDONE

NABUMETONE 18 NADOLOL 33 NADOLOL-BENDROFLUMETHIAZIDE 33

Drug Name Page NALTREXONE HCL 16 NAMENDA SOLUTION® 13 NAMENDA® 14 NAPHAZOLINE HCL 55 NAPRELAN® - generic on formulary as NAPROXEN SODIUM

NAPROSYN® - generic on formulary as NAPROXEN

NAPROXEN 7, 18 NAPROXEN SODIUM 7, 18 NARATRIPTAN HCL 19 NARDIL® - generic on formulary as PHENELZINE SULFATE

NASACORT AQ® - generic on formulary as TRIAMCINOLONE ACETONIDE NASAL SPRAY

NASONEX® 56 NATACYN® 54 NATEGLINIDE 29 NATROBA® is non-formulary and requires PA, a formulary alternative is ULESFIA®

NECON® 46 NEFAZODONE 14 NEOMYCIN SULFATE 9 NEOMYCIN-BACITRACIN-POLYMYXIN 53 NEOMYCIN-POLYMYXIN-DEXAMETH 53 NEOMYCIN-POLYMYXIN-GRAMICIDIN 53 NEOMYCIN-POLYMYXIN-HC 56 NEOMYC-POLYM-DEXAMETH EYE 55 NEORAL® - generic on formulary as GENGRAF

NEOSPORIN® - generic on formulary as NEOMYCIN-POLYMYXIN-GRAMICIDIN

NEULASTA® 31 NEUMEGA® 31 NEUPOGEN® 31 NEURONTIN® - generic on formulary as GABAPENTIN

NEURONTIN® SOLUTION - generic on formulary as GABAPENTIN SOLUTION

NEXAVAR® 21 NEXICLON XR® is non-formulary and requires PA

NEXIUM® is non-formulary and requires PA, a formulary alternative is OMEPRAZOLE

NIASPAN® 36

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Drug Name Page NICARDIPINE HCL 34 NIFEDIAC CC 34 NIFEDICAL XL 34 NIFEDIPINE ER 34 NILANDRON® 50 NIMODIPINE 35 NISOLDIPINE 34 NITRO-BID 38 NITRO-DUR® - generic on formulary as NITROGLYCERIN PATCH

NITROFURANTOIN MACROCRYSTALS 10 NITROFURANTOIN SUSPENSION 10 NITROGLYCERIN PATCH 38 NITROGLYCERIN SA TABLETS 38 NITROGLYCERIN SL 38 NITROSTAT® - generic on formulary as NITROQUICK SL

NIZATIDINE CAPSULES 43 NIZATIDINE SOLUTION is non-formulary, a generic alternative is RANITIDINE SYRUP or CIMETIDINE SOLUTION

NIZORAL® - generic on formulary as KETOCONAZOLE

NOLVADEX® - generic on formulary as TAMOXIFEN

NORA-BE 49 NORCO® - generic on formulary as HYDROCODONE-ACETAMINOPHEN

NORDETTE® - generic on formulary as PORTIA®

NORDITROPIN® is non-formulary and requires PA

NORDITROPIN® NORDIFLEX is non-formulary and requires PA

NORETHINDRONE ACETATE 49 NORINYL® 46 NORPACE CR® 100 MG 33 NORPACE® - generic on formulary as DISOPYRAMIDE PHOSPHATE

NORPRAMIN® - generic on formulary as DESIPRAMINE HCL

NOR-Q-D® - generic on formulary as CAMILA

NORTREL® 46 NORTRIPTYLINE HCL 15 NORVASC® - generic on formulary as AMLODIPINE BESYLATE

Drug Name Page

NORVIR® 26 NOVOLIN MIX 70-30 INNOLET® 30 NOVOLIN N INNOLET® 30 NOVOLIN N® 30 NOVOLIN R® 30 NOVOLOG MIX 70-30® 30 NOVOLOG® 30 NOXAFIL® 17 NUCYNTA ER® is non-formulary and requires PA, a formulary alternative is TRAMADOL ER

NUCYNTA® is non-formulary and requires PA, a formulary alternative is TRAMADOL

NUEDEXTA® 39 NULYTELY® - generic on formulary as TRILYTE

NUTROPIN AQ® 48 NUTROPIN® 48 NUVARING® 46 NUVIGIL® is non-formulary and requires PA

NYAMYC 41 NYSTATIN 41 NYSTOP 41 OCELLA® 46 OCTREOTIDE ACETATE 50 OCUFEN® - generic on formulary as FLURBIPROFEN SODIUM

OCUFLOX® - generic on formulary as OFLOXACIN

OCUSULF-10 53 OFLOXACIN 53 OGEN® - generic on formulary as ESTROPIPATE

OGESTREL® 46 OLANZAPINE 23 OLANZAPINE ODT 23 OLEPTRO® is non-formulary and requires PA, a formulary alternative is TRAZADONE

OLUX-E® is non-formulary and requires PA, a formulary alternative is CLOBETASOL PROPIONATE

OMEPRAZOLE 44 OMNARIS® is non-formulary and requires PA, a formulary alternative is FLUTICASONE PROPIONATE NASAL INHALER

79

Drug Name Page OMNICEF® - generic on formulary as CEFDINIR

ONDANSETRON HCL (24 MG) TABS 16 ONDANSETRON HCL (4 OR 8MG) TABS 16 ONDANSETRON HCL SOLUTION 16 ONDANSETRON ODT (4 OR 8 MG) TABS 16 ONGLYZA® 29 ONSOLIS® is non-formulary and requires PA, a formulary alternative is MORPHINE SULFATE ER

OPANA ER® is non-formulary and requires PA, a formulary alternative is MORPHINE SULFATE ER

OPANA® - generic on formulary as OXYMORPHONE

OPTIPRANOLOL® - generic on formulary as METIPRANOLOL

ORACEA® is non-formulary and requires PA, a formulary alternative is DOXYCYCLINE HYCLATE

ORAP® 24 ORAPRED ODT® 17 ORAPRED® - generic on formulary as PREDNISOLONE SOD PHOSPHATE

ORBIVAN® is non-formulary and requires PA

ORFADIN® 42 ORPHENADRINE 59 ORPHENADRINE COMP FORTE 59 ORTHO EVRA® 46 ORTHO MICRONOR® - generic on formulary as CAMILA

ORTHO TRI-CYCLEN LO® 46 ORTHO TRI-CYCLEN® - generic on formulary as TRINESSA®

ORTHO-CEPT® - generic on formulary as RECLIPSEN®

ORTHO-EST® 47 OVCON® - generic on formulary as BALZIVA®

OXAPROZIN 7, 18 OXAZEPAM 28 OXCARBAZEPINE 13 OXSORALEN 41 OXSORALEN-ULTRA® 41 OXYBUTYNIN 44 OXYBUTYNIN ER 44

Drug Name Page OXYCODONE 20MG/ML SOLUTION 8 OXYCODONE ER 8 OXYCODONE IR 8 OXYCODONE SOLUTION - is not FDA approved and therefore not a covered benefit, a formulary alternative is MORPHINE SOLUTION (10MG/5ML OR 20MG/5ML)

OXYCODONE-ACETAMINOPHEN 8 OXYCODONE-ASPIRIN 8 OXYCODONE-IBUPROFEN 8 OXYCONTIN® 8 OXYMORPHONE 8

OXYTROL® 44 PACERONE® - generic on formulary as AMIODARONE HCL

PAMELOR® - generic on formulary as NORTRIPTYLINE HCL

PANCREASE MT® - generic on formulary as LIPRAM-PN

PANCRELIPASE 42 PANCRELIPASE MT 42 PANGESTYME EC 42 PANGESTYME MT 42 PANGESTYME UL 42 PANLOR SS® - generic on formulary as ZERLOR

PANOCAPS 42 PANOCAPS MT 42 PANRETIN® 21 PANTOPRAZOLE SODIUM TABLETS 44 PARAFON FORTE DSC® - generic on formulary as CHLORZOXAZONE

PARLODEL® - generic on formulary as BROMOCRIPTINE MESYLATE

PARNATE® - generic on formulary as TRANYLCYPROMINE SULFATE

PAROXETINE CR® is non-formulary and requires PA, a formulary alternative is PAROXETINE HCL

PAROXETINE HCL 14, 27 PATADAY® is non-formulary and requires PA, an alternative is KETOTIFEN FUMARATE OTC

PATANASE® is non-formulary and requires PA, a formulary alternative is FLUTICASONE OR FLUNISOLIDE nasal

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Drug Name Page spray PAXIL CR® is non-formulary and requires PA, a formulary alternative is PAROXETINE

PAXIL® - generic on formulary as PAROXETINE HCL

PEDIAZOLE® - generic on formulary as ERYTHROMYCIN-SULFISOXAZOLE

PEDI-DRI 41 PEG 3350-ELECTROLYTE 43 PEGASYS® 25 PEGINTRON REDIPEN® 25 PEGINTRON® 25 PENICILLIN V POTASSIUM 11 PENLAC® is non-formulary and requires PA, a formulary alternative is TERBINAFINE

PENNSAID is non-formulary and requires PA, a formulary alternative is oral DICLOFENAC

PENTASA® 52 PENTOXIFYLLINE 35 PENTOXIFYLLINE SA 32 PEPCID® - generic on formulary as FAMOTIDINE

PERCOCET® - generic on formulary as OXYCODONE-APAP

PERIDEX® - generic on formulary as CHLORHEXIDINE GLUCONATE

PERINDOPRIL ERBUMINE 37 PERMETHRIN 22 PERPHENAZINE 24 PERPHENAZINE-AMITRIPTYLINE 24 PERSANTINE® - generic on formulary as DIPYRIDAMOLE

PEXEVA® is non-formulary and requires PA, a formulary alternative is PAROXETINE

PHENELZINE SULFATE 14 PHENYTOIN 13 PHENYTOIN SODIUM ER 13 PHOSLO® - generic on formulary as CALCIUM ACETATE

PHRENLIN®, PHRENLIN FORTE® - generic on formulary as APAP-BUTALBITAL

PILOCARPINE TABLETS 39 PILOPINE HS® 54

Drug Name Page PINDOLOL 34 PIROXICAM 7, 18 PLAQUENIL® - generic on formulary as HYDROXYCHLOROQUINE SULFATE

PLAVIX® 32 PLENDIL® - generic on formulary as FELODIPINE ER

PLETAL® - generic on formulary as CILOSTAZOL

PODOFILOX 41 POLY-DEX 53 POLYETHYLENE GLYCOL - is OTC and therefore not a covered benefit. Please consult with a pharmacist about this medication.

POLY-IRON-FL 60 POLYMYXIN B SUL-TRIMETHOPRIM 53 POLYTRIM® - generic on formulary as POLYMYXIN B SUL-TRIMETHOPRIM

PORTIA® 46 POTASSIUM CHLORIDE CAPSULE 60 POTASSIUM CHLORIDE POWDER - is not FDA approved and therefore not a covered benefit, a formulary alternative is KLOR-CON® M DISPERSIBLE TABLET

POTASSIUM CHLORIDE SOLUTION - is not FDA approved and therefore not a covered benefit, a formulary alternative is KLOR-CON® M DISPERSIBLE TABLET

POTASSIUM CHLORIDE TABLET SA 60 POTASSIUM CITRATE 60 POTASSIUM CITRATE ER 60 PRADAXA® 31 PRAMIPEXOLE 23 PRAMOSONE® - is not FDA approved and therefore not a covered benefit, an OTC alternative is PREPARATION H® and/or SITZ BATH, a formulary alternative is HYDROCORTISONE CREAM

PRAMOXINE 1% FOAM 41 PRAVACHOL® - generic on formulary as PRAVASTATIN SODIUM

PRAVASTATIN SODIUM 36 PRAVIGARD PAC® is non-formulary and requires PA, a formulary alternative is PRAVASTATIN + OTC ASPIRIN

PRAZOSIN HCL 32

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Drug Name Page PRECOSE® - generic on formulary as ACARBOSE

PRED FORTE® - generic on formulary as PREDNISOLONE ACETATE

PREDNISOLONE 18 PREDNISOLONE ACETATE 55 PREDNISOLONE SOD PHOSPHATE 18 PREDNISONE 18 PRELONE® - generic on formulary as PREDNISOLONE

PREMARIN VAGINAL CREAM® 47 PREMARIN® 47 PREMPHASE® 47 PREMPRO® 47 PRENATABS RX® 60 PRENATAL 19® 60 PRENATAL PLUS® 60 PREVACID NAPRAPAC® is non-formulary and requires PA, a formulary alternative is OMEPRAZOLE + NAPROXEN

PREVACID® - generic on formulary as LANSOPRAZOLE

PREVALITE 36 PREZISTA® 26 PRIFTIN® 20 PRILOSEC® - generic on formulary as OMEPRAZOLE

PRILOSEC® suspension is non-formulary, a generic alternative is OMEPRAZOLE

PRIMAQUINE is non-formulary and requires PA

PRIMIDONE 13 PRINIVIL® - generic on formulary as LISINOPRIL

PRINIZIDE® - generic on formulary as LISINOPRIL-HYDROCHLOROTHIAZIDE

PRISTIQ® is non-formulary and requires PA, a formulary alternative is VENLAFAXINE HCL or EFFEXOR XR®

PROAIR® HFA 58 PROAMATINE® - generic on formulary as MIDODRINE HCL

PROBENECID 17 PROBENECID-COLCHICINE 17 PROCARDIA XL® - generic on formulary as NIFEDIPINE ER

PROCHLORPERAZINE EDISYLATE 16

Drug Name Page PROCHLORPERAZINE MALEATE 24 PROCRIT® 31 PROCTOCREAM-HC 43 PROCTO-PAK 43 PROCTOSOL-HC 43 PROCTOZONE-HC 43 PROGLYCEM® 30 PROGRAF® - generic on formulary as TACROLIMUS CAPSULE

PROMACTA® 31 PROMETHAZINE 16 PROMETHAZINE VC 57 PROMETHAZINE VC-CODEINE 57 PROMETHAZINE-CODEINE 57 PROMETHAZINE-DM 57 PROMETHEGAN 16 PROMETRIUM® 49 PROPAFENONE HCL 33 PROPINE® - generic on formulary as DIPIVEFRIN HCL

PROPRANOLOL 34 PROPRANOLOL ER 34 PROPRANOLOL-HCTZ 34 PROPYLTHIOURACIL 50 PROQUIN XR® is non-formulary and requires PA, a formulary alternative is CIPROFLOXACIN HCL

PROSCAR® - generic on formulary as FINASTERIDE

PROTONIX® - generic on formulary as PANTOPRAZOLE

PROTONIX® SUSPENSION 44 PROTOPIC 41 PROTRIPTYLINE HCL 15 PROTROPIN® is non-formulary and requires PA

PROVENTIL® HFA 58 PROVERA® - generic on formulary as MEDROXYPROGESTERONE ACETATE

PROVIGIL® 39 PROZAC WEEKLY® - generic on formulary as FLUOXETINE HCL

PROZAC® - generic on formulary as FLUOXETINE HCL

PULMICORT RESPULE® - generic on formulary as BUDESONIDE NEB SUSPENSION

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Drug Name Page PULMOZYME® 58 PURINETHOL® - generic on formulary as MERCAPTOPURINE

PYRIDOSTIGMINE BROMIDE 19 QUALAQUIN® is non-formulary and requires PA

QUASENSE® 46 QUESTRAN® - generic on formulary as CHOLESTYRAMINE

QUINAPRIL HCL 37 QUINAPRIL-HYDROCHLOROTHIAZIDE 37 QUINIDINE GLUCONATE 33 QUINIDINE SULFATE 33 QUIXIN® - generic on formulary as LEVOFLOXACIN 0.50% DROPS

QVAR® 56 RAMIPRIL 37 RANEXA® 35 RANITIDINE HCL 300 mg 43 RANITIDINE SYRUP 43 RAPAFLO® is non-formulary and requires PA, formulary alternatives are TAMSULOSIN, DOXAZOSIN, and TERAZOSIN

RAPAMUNE® 51 REBETOL® 25 REBETRON® is non-formulary and requires PA

REBIF® 51 RECLIPSEN® 46 REGLAN® - generic on formulary as METOCLOPRAMIDE HCL

REGRANEX® 41 RELAFEN® - generic on formulary as NABUMETONE

RELENZA® 27 RELISTOR® is non-formulary and requires PA

REMERON® - generic on formulary as MIRTAZAPINE

RENAGEL® 45 RENOVA® is non-formulary and requires PA, a formulary alternative is TRETINOIN GEL OR CREAM

RENVELA® 45 REQUIP XL® is non-formulary and requires PA, a formulary alternative is

Drug Name Page ROPINIROLE REQUIP® - generic on formulary as ROPINIROLE

RESTASIS® 55 RESTORIL® - generic on formulary as TEMAZEPAM

RETIN-A MICRO® is non-formulary and requires PA

RETIN-A® - generic on formulary as TRETINOIN CREAM, GEL, OR SOLUTION

REVATIO® 58 REVLIMID® 20 REYATAZ® 26 RHEUMATREX® - generic on formulary as METHOTREXATE

RHINOCORT AQUA NASAL SPRAY® 57 RIBAPAK® 25 RIBASPHERE® 25 RIBAVIRIN® 25 RIFAMATE® - generic on formulary as ISONARIF

RIFAMPIN 20 RIFATER® 20 RILUTEK® 39 RIMANTADINE HCL 27 RIOMET® 29 RISPERDAL® - generic on formulary as RISPERIDONE

RISPERIDONE 23 RITALIN LA® - generic on formulary as METHYLPHENIDATE CPMP 50-50

RITALIN® - generic on formulary as METHYLPHENIDATE HCL

RITALIN-SR® - generic on formulary as METHYLPHENIDATE ER

RIVASTIGMINE CAPSULES 13 RMS-SUPPOSITORY 8 ROBAXIN® - generic on formulary as METHOCARBAMOL

ROBINUL® - generic on formulary as GLYCOPYRROLATE

ROPINIROLE 23 ROSAC WASH® is non-formulary and requires PA, a formulary alternative is SULFACETAMIDE

ROSANIL® - is not FDA approved and therefore not a covered benefit, a

83

Drug Name Page formulary alternative is SULFACETAMIDE LOTION ROXANOL INTENSOL(20MG/ML)® - is not FDA approved and therefore not a covered benefit, a formulary alternative may be MORPHINE SOLUTION (10MG/5ML OR 20MG/5ML) or discussion with the physician about alternate ways of treating the pain.

ROXICET 9 ROXICODONE® - generic on formulary as OXYCODONE

ROZEREM® 59 RYBIX ODT® is non-formulary and requires PA, a formulary alternative is TRAMADOL TABLETS

RYTHMOL® - generic on formulary as PROPAFENONE HCL

RYZOLTL® is non-formulary and requires PA, a formulary alternative is TRAMADOL

SABRIL® 13 SAIZEN® is non-formulary and requires PA

SAMSCA® is non-formulary and requires PA, a formulary alternative is FUROSEMIDE

SANCTURA® - generic on formulary as TROSPIUM CHLORIDE

SANCTURA® XR is non-formulary and requires PA, formulary alternatives are OXYBUTYNIN ER and DETROL LA

SANCUSO® is non-formulary and requires PA, a formulary alternative is ONDANSETRON

SANDIMMUNE® - generic on formulary as CYCLOSPORINE

SANDOSTATIN® - generic on formulary as OCTREOTIDE ACETATE

SANTYL® 41 SAPHRIS® 23 SARAFEM® - generic on formulary as FLUOXETINE HCL

SAVELLA® TABLETS 39 SAVELLA® TITRATION PACK 39 SEASONALE® - generic on formulary as JOLESSA®

SECTRAL® - generic on formulary as

Drug Name Page ACEBUTOLOL HCL SELEGILINE HCL 23 SELZENTRY® 27 SENSIPAR® (30 OR 60MG) 50 SENSIPAR® (90 MG) 50 SEREVENT DISKUS® 58 SEROQUEL XR® is non-formulary and requires PA, a formulary alternative is RISPERIDONE or SEROQUEL®

SEROQUEL® 23 SEROSTIM® is non-formulary and requires PA

SERTRALINE HCL 15, 27 SILENOR® is non-formulary and requires PA, a formulary alternative is ZOLPIDEM TARTRATE

SILVADENE® - generic on formulary as SSD CREAM

SILVER SULFADIAZINE 41 SIMPONI® is non-formulary, specialty, and requires PA

SIMVASTATIN 20MG AND LOWER 36 SIMVASTATIN 40MG 36 SIMVASTATIN 80MG is non-formulary and requires PA

SINEMET® - generic on formulary as CARBIDOPA-LEVODOPA

SINGULAIR® 57 SKELAXIN® - generic on formulary as METAXALONE

SOLIA® 47 SOMA® - generic on formulary as CARISOPRODOL

SOMAVERT® 50 SONATA® - generic on formulary as ZALEPLON

SOTALOL 34 SOTALOL AF 34 SOTRET 41 SPIRIVA® 57 SPIRONOLACTONE 37 SPIRONOLACTONE-HCTZ 35 SPORANOX® - generic on formulary as ITRACONAZOLE CAPSULES

SPRYCEL® 21 SPS 15 SSD AF CREAM 41

84

Drug Name Page SSD CREAM 41 STAGESIC 9 STARLIX® - generic on formulary as NATEGLINIDE

STAVOR® is non-formulary and requires PA, a formulary alternative is VALPROIC ACID

STAVUDINE 26 STRATTERA® 39 SUBOXONE® TABLETS & FILM 9 SUBUTEX® - generic on formulary as BUPRENORPHINE

SUCRAID® 42 SUCRALFATE 43 SULF-10® - generic on formulary as OCUSULF-10

SULFACETAMIDE SODIUM LOTION 41 SULFAMETHOXAZOLE-TRIMETHOPRIM 11 SULFASALAZINE 52 SULFASALAZINE DR 52 SULFAZINE 52 SULFAZINE EC 52 SULINDAC 7 SUMATRIPTAN SUCCINATE 19 SUMAVEL® is non-formulary and requires PA, a formulary alternative is SUMATRIPTAN SUCCINATE

SUMYCIN® - generic on formulary as TETRACYCLINE HCL

SURMONTIL® - generic on formulary as TRIMIPRAMINE MALEATE

SUSTIVA® 25 SUTENT® 21 SYLATRON® 51 SYMBICORT® 59 SYMBYAX® 23 SYMLIN® 29 SYNTHROID® - generic on formulary as LEVOTHYROXINE SODIUM

SYPRINE® 15 TACLONEX OINTMENT® is non-formulary and requires PA, a formulary alternative is DOVONEX® AND BETAMETHASONE DIPROPIONATE CREAM

TACLONEX® is non-formulary and requires PA, formulary alternatives are BETAMETHASONE, DOVONEX®, and

Drug Name Page TAZORAC® TACROLIMUS CAPSULE 51 TAGAMET® - generic on formulary as CIMETIDINE

TAMBOCOR® - generic on formulary as FLECAINIDE ACETATE

TAMIFLU® 27 TAMOXIFEN CITRATE 20 TAMSULOSIN 44 TAPAZOLE® - generic on formulary as METHIMAZOLE

TARCEVA® 21 TARGRETIN® CAPSULES 21 TASIGNA® 21 TAZORAC® 41 TAZTIA XT 34 TEGRETOL XR® - generic on formulary as CARBAMAZEPINE XR TABLETS

TEGRETOL® - generic on formulary as CARBAMAZEPINE

TEKTURNA HCT® is non-formulary and requires PA, a formulary alternative is LISINOPRIL-HYDROCHLOROTHIAZIDE or LOSARTAN-HYDROCHLOROTHIAZIDE

TEKTURNA® is non-formulary and requires PA, a formulary alternative is LISINOPRIL or LOSARTAN

TEMAZEPAM 28 TEMODAR® 21 TEMOVATE EMOLLIENT® - generic on formulary as CLOBETASOL EMOLLIENT

TEMOVATE® - generic on formulary as CLOBETASOL PROPIONATE

TENEX® - generic on formulary as GUANFACINE HCL

TENORETIC® - generic on formulary as ATENOLOL-CHLORTHALIDONE

TENORMIN® - generic on formulary as ATENOLOL

TERAZOL® - generic on formulary as TERCONAZOLE

TERAZOSIN HCL 32, 44 TERBINAFINE HCL 17 TERBUTALINE SULFATE 58 TERCONAZOLE 17 TESSALON PEARLS® - generic on formulary as BENZONATATE

85

Drug Name Page TESTIM® 45 TESTOSTERONE CYPIONATE INJECTABLE 45 TESTOSTERONE ENANTHATE INJECTABLE 45 TETRACYCLINE HCL 12 TEV-TROPIN® ZORBTIVE is non-formulary and requires PA

THALOMID® 20 THEOPHYLLINE ANHYDROUS 57 THEOPHYLLINE ER 57 THERMAZENE CREAM 41 THIOLA® 45 THIORIDAZINE 24 THIOTHIXENE 24 TIAZAC® - generic on formulary as TAZTIA XT

TICLOPIDINE 32 TIKOSYN® 33 TIMOLOL MALEATE OPHTH DROPS 54 TIMOLOL MALEATE TABS 34 TIMOPTIC® - generic on formulary as TIMOLOL MALEATE

TINDAMAX® 22 TIZANIDINE HCL 24 TOBRADEX® OINTMENT 53 TOBRAMYCIN SULFATE 53 TOBRASOL 53 TOBREX® - generic on formulary as TOBRAMYCIN SULFATE

TOFRANIL® - generic on formulary as IMIPRAMINE HCL

TOFRANIL-PM® - generic on formulary as IMIPRAMINE PAMOATE

TOLMETIN SODIUM 7, 18 TOPAMAX SPRINKLE® - generic on formulary as TOPIRAMATE CAP SPRINKLE

TOPAMAX® - generic on formulary as TOPIRAMATE TABLETS

TOPICORT LP® - generic on formulary as DESOXIMETASONE

TOPIRAMATE CAP SPRINKLE 12, 19 TOPIRAMATE TABLETS 12, 19 TOPROL XL® - generic on formulary as METOPROLOL SUCCINATE ER

TORADOL® - generic on formulary as KETOROLAC TROMETHAMINE

TORSEMIDE 35 TOVIAZ® is non-formulary and requires

Drug Name Page PA, formulary alternatives are OXYBUTYNIN ER and DETROL LA TRACLEER® 38 TRADJENTA® is non-formulary and requires PA, formulary alternatives are ONGLYZA® and JANUVIA®

TRAMADOL ER 9 TRAMADOL HCL 9 TRAMADOL HCL-ACETAMINOPHEN 9 TRANDATE® - generic on formulary as LABETALOL HCL

TRANDOLAPRIL 37 TRANSDERM-SCOP® 16 TRANXENE® - generic on formulary as CLORAZEPATE

TRANYLCYPROMINE SULFATE 14 TRAVATAN Z® 56 TRAVATAN® 56 TRAZODONE HCL 14 TRECATOR® 20 TRENTAL® - generic on formulary as PENTOXIFYLLINE SA

TRETINOIN CAPSULES 21 TRETINOIN CREAM, GEL, OR SOLUTION 41 TRETIN-X® is non-formulary and requires PA, a formulary alternative is TRETINOIN GEL OR CREAM

TREXIMET® is non-formulary and requires PA, a formulary alternative is SUMATRIPTAN and OTC Naproxen

TRIAMCINOLONE 41 TRIAMCINOLONE ACETONIDE 41 TRIAMCINOLONE ACETONIDE NASAL SPRAY 57 TRIAMTERENE-HCTZ 36 TRIAZOLAM 28 TRIBENZOR® is non-formulary and requires PA, a formulary alternative is LOSARTAN and AMLODIPINE

TRICOR® 36 TRIDERM 41 TRIFLUOPERAZINE HCL 24 TRIFLURIDINE 54 TRIHEXYPHENIDYL 23 TRI-LEGEST® 46 TRILEPTAL SUSPENSION® 13 TRILEPTAL® - generic on formulary as

86

Drug Name Page OXCARBAZEPINE TRI-LEVLEN® - generic on formulary as ENPRESSE®

TRILIPIX® is non-formulary and requires PA, formulary alternatives are FENOFIBRATE and GEMFIBROZIL

TRILYTE 43 TRILYTE WITH FLAVOR PACKETS® - generic on formulary as TRILYTE

TRIMETHOBENZAMIDE 16 TRIMETHOPRIM 11 TRIMIPRAMINE MALEATE 15

TRINESSA® 46 TRI-NORINYL® - generic on formulary as ARANELLE®

TRIPHASIL® - generic on formulary as ENPRESSE®

TRI-PREVIFEM® 47 TRI-SPRINTEC® 47 TRI-VIT-FLUOR 60 TRI-VIT-FLUOR-IRON 60 TRIVORA® - generic on formulary as ENPRESSE®

TRIZIVIR® 26 TROPICACYL 55 TROPICAMIDE 55 TROSPIUM CHLORIDE 44 TRUSOPT® - generic on formulary as DORZOLAMIDE

TRUVADA® 26 TWINJECT® 58 TWYNSTA® is non-formulary and requires PA, a formulary alternative is LOSARTAN and AMLODIPINE

TYKERB® 21 TYLOX® - generic on formulary as OXYCODONE-ACETAMINOPHEN

TYZEKA® 25 TYZINE® 59 ULESFIA® 22 ULORIC® is non-formulary and requires PA, a formulary alternative is ALLOPURINOL

ULTRACET® - generic on formulary as TRAMADOL HCL-ACETAMINOPHEN

ULTRAM ER® - generic on formulary as TRAMADOL ER

Drug Name Page ULTRAM® - generic on formulary as TRAMADOL HCL

ULTRAVATE® - generic on formulary as HALOBETASOL PROPIONATE

UNIPHYL® - generic on formulary as THEOPHYLLINE ER

UNIRETIC® - generic on formulary as MOEXIPRIL-HYDROCHLOROTHIAZIDE

UNITHROID 49 UNIVASC® - generic on formulary as MOEXIPRIL HCL

URECHOLINE® - generic on formulary as BETHANECHOL CHLORIDE

UREX 10 URISPAS® - generic on formulary as FLAVOXATE HCL

UROCIT-K® - generic on formulary as POTASSIUM CITRATE ER

UROXATRAL® - generic on formulary as ALFUZOSIN

URSODIOL 43 VAGIFEM® 47 VALACYCLOVIR 25 VALCYTE® SOLUTION 24 VALCYTE® TABLETS 24 VALIUM® - generic on formulary as DIAZEPAM

VALPROATE SODIUM 13 VALPROIC ACID 13 VALTREX® - generic on formulary as VALACYCLOVIR

VALTURNA ® is non-formulary and requires PA, a formulary alternative is LOSARTAN and LISINOPRIL

VANACET 9 VANCOCIN® 10 VANDAZOLE 10 VASERETIC® - generic on formulary as ENALAPRIL-HYDROCHLOROTHIAZIDE

VASOTEC® - generic on formulary as ENALAPRIL MALEATE

VECTICAL® is non-formulary and requires PA, formulary alternatives are BETAMETHASONE, DOVONEX®, and TAZORAC®

VEETIDS® - generic on formulary as PENICILLIN V POTASSIUM

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Drug Name Page VELIVET® 47 VENLAFAXINE ER (150MG) 15, 27 VENLAFAXINE ER (37.5MG OR 75MG) 15, 27 VENLAFAXINE HCL 15, 27 VENTAVIS® 58 VENTOLIN HFA® - generic on formulary as PROVENTIL HFA

VERAMYST® is non-formulary and requires PA, a formulary alternative is FLUTICASONE OR FLUNISOLIDE nasal spray

VERAPAMIL ER 34 VERAPAMIL ER PM 34 VERAPAMIL HCL 35 VERDESO FOAM® is non-formulary and requires PA, a formulary alternative is DESONIDE CREAM

VERELAN PM® - generic on formulary as VERAPAMIL ER PM

VERELAN® - generic on formulary as VERAPAMIL HCL

VESANOID® - generic on formulary as TRETINOIN CAPSULES

VESICARE® is non-formulary and requires PA, formulary alternatives are OXYBUTYNIN ER and DETROL LA

VEXOL® 55 VIBRAMYCIN® - generic on formulary as ED DOXY-CAPS

VICODIN® - generic on formulary as HYDROCODONE-APAP

VICOPROFEN® - generic on formulary as HYDROCODONE BIT-IBUPROFEN

VICTOZA 29 VICTRELIS® 25 VIDAZA® 22 VIDEX EC® - generic on formulary as DIDANOSINE

VIGAMOX® 53 VIIBRYD® is non-formulary and requires PA, formulary alternatives are GENERIC SSRIs (citalopram, fluoxetine, sertraline, paroxetine)

VIMOVO® is non-formulary and requires PA

VIMPAT® 12 VINATE ONE® 60

Drug Name Page VINATE-M® 60 VIOKASE® 42 VIRACEPT® 27 VIRAMUNE XR® 25 VIRAMUNE® 25 VIREAD® 26 VIROPTIC® - generic on formulary as TRIFLURIDINE

VITAMIN D 1.25 MG (50,000 IU) 60 VIVACTIL® - generic on formulary as PROTRIPTYLINE HCL

VIVELLE-DOT® 47 VOLTAREN® GEL 7, 18 VOLTAREN-XR® - generic on formulary as DICLOFENAC SODIUM

VORICONAZOLE 17 VOTRIENT® 22 VYTORIN® is non-formulary and requires PA, a formulary alternative is SIMVASTATIN

VYVANSE® 39 WARFARIN SODIUM 31 WELCHOL® is non-formulary and requires PA, a formulary alternative is COLESTIPOL HCL

WELLBUTRIN SR® - generic on formulary as BUDEPRION SR

WELLBUTRIN XL® - generic on formulary as BUDEPRION XL

WELLBUTRIN® - generic on formulary as BUPROPION HCL

XALATAN® - generic on formulary as LATANOPROST

XANAX XR® - generic on formulary as ALPRAZOLAM ER

XANAX® - generic on formulary as ALPRAZOLAM

XARELTO® 31 XELODA® 21 XENAZINE® 39 XERESE® is non-formulary and requires PA, a formulary alternative is ACYCLOVIR TABLETS and OTC HYDROCORTISONE 1% CREAM

XIBROM® - generic on formulary as BROMFENAC SODIUM

XIFAXAN® 200MG 10

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Drug Name Page XIFAXAN® 550MG 10 XOLEGEL® is non-formulary and requires PA, a formulary alternative is KETOCONAZOLE CREAM or A TOPICAL STEROID

XOPENEX HFA® (EXCEPT 1.25 MG/0.5 ML) 58 XOPENEX® 58 XYLOCAINE® - generic on formulary as LIDOCAINE HCL

XYREM® 39 YASMIN® - generic on formulary as OCELLA®

YAZ® - generic on formulary as GIANVI ZAFIRLUKAST 57

ZALEPLON 59 ZANAFLEX® TABLETS - generic on formulary as TIZANIDINE TABLETS

ZANTAC® - generic on formulary as RANITIDINE HCL

ZARONTIN® - generic on formulary as ETHOSUXIMIDE

ZAROXOLYN® - generic on formulary as METOLAZONE

ZAVESCA® 42 ZEBETA® - generic on formulary as BISOPROLOL FUMARATE

ZEGERID® CAPSULE 40mg is non-formulary, a generic alternative is OMEPRAZOLE

ZELAPAR® is non-formulary and requires PA

ZELBORAF® 22 ZEMPLAR® 52 ZENPEP® 42 ZERIT® - generic on formulary as STAVUDINE

ZERLOR 9 ZESTORETIC® - generic on formulary as LISINOPRIL-HYDROCHLOROTHIAZIDE

ZESTRIL® - generic on formulary as LISINOPRIL

ZETIA® 36 ZIAGEN® 26 ZIANA® is non-formulary and requires PA

ZIDOVUDINE 26 ZIPSOR ® is non-formulary and requires PA, a formulary alternative is

Drug Name Page DICLOFENAC ZIRGAN® 54 ZITHROMAX® - generic on formulary as AZITHROMYCIN

ZMAX® is non-formulary and requires PA, a formulary alternative is AZITHROMYCIN

ZOCOR® - generic on formulary as SIMVASTATIN

ZOLINZA® 22 ZOLOFT® - generic on formulary as SERTRALINE HCL

ZOLPIDEM TARTRATE 59 ZOLPIDEM TARTRATE ER is non-formulary and requires PA, a formulary alternative is ZOLPIDEM TARTRATE

ZOLPIMIST® is non-formulary and requires PA

ZOMIG ZMT® 19 ZOMIG® 19 ZONEGRAN® - generic on formulary as ZONISAMIDE

ZONISAMIDE 12 ZORTRESS® 0.25MG 51 ZORTRESS® 0.5MG & 0.75MG 51 ZOVIA® 47 ZOVIRAX® - generic on formulary as ACYCLOVIR

ZOVIRAX® CREAM OR OINTMENT is non-formulary and requires PA, a formulary alternative is ACYCLOVIR TABLETS

ZUPLENZ® is non-formulary and requires PA, a formulary alternative is ONDANSETRON ODT

ZYCLARA® is non-formulary and requires PA, a formulary alternative is IMIQUIMOD 5% CREAM

ZYLET® 53 ZYLOPRIM® - generic on formulary as ALLOPURINOL

ZYMAXID® 53 ZYPREXA ZYDIS® - generic on formulary as OLANZAPINE ODT

ZYPREXA® - generic on formulary as OLANZAPINE

ZYTIGA® 50 ZYVOX® 10

Category Listing Category Name Page Analgesics - Drugs to treat pain 7 Anesthetics 9 Antibacterials - Drugs to treat bacterial infections 9 Anticonvulsants - Drugs to treat or prevent seizures 12 Antidementia Agents - Drugs to treat dementia 13 Antidepressants - Drugs to treat depression and anxiety 14 Antidotes, Deterrents, and Toxicolgic Agents 15 Antiemetics - Drugs to treat nausea 16 Antifungals - Drugs to treat fungal infections 17 Antigout Agents - Drugs to treat or gout 17 Anti-inflammatory Agents - Drugs to treat inflammation 17 Antimigraine Agents - Drugs to treat migraines 19 Antimyasthenic Agents - Drugs to treat Myasthenia Gravis 19 Antimycobacterials - Drugs to treat tuberculosis 20 Antineoplastics - Drugs to treat cancer 20 Antiparasitics - Drugs to treat parasites 22 Antiparkinson Agents - Drugs to treat Parkinsonism 22 Antipsychotics - Drugs used in psychotherapy 23 Antispasticity Agents – Drugs to treat muscle spasms 24 Antivirals - Drugs to treat viral infections 24 Anxiolytics - Drugs to treat anxiety (also see antidepressants) 27 Bipolar Agents - Drugs to treat bipolar disorders 28 Blood Glucose Regulators - Drugs to treat Diabetes 28 Blood Glucose Testing – Meters & Test Strips (DME Benefit Reference) 30 Blood Products/Modifiers/Volume Expanders 31 Bradykinin B2 Receptor Atagonist 32 Cardiovascular Agents – Drugs to treat the blood pressure, cholesterol or the heart 32 Central Nervous System Agents - Drugs that affect the brain 38 Dental and Oral Agents 39 Dermatological Agents - Drugs to treat skin conditions 39 Enzyme Replacements/ Modifiers 42 Gastrointestinal Agents - Drugs to treat acid, digestion and bowel conditions 42 Genitourinary Agents - Drugs to treat genitourinary conditions 44 Hormonal Agents, Modifying 45 Hormonal Agents, Suppressant (Adrenal, Parathyroid, Pituitary, Sex Hormones, Thyroid) 49 Immunological Agents - Drugs to stimulate, suppress or regulate the immune system 50 Inflammatory Bowel Disease Agents - Drugs to treat inflammatory bowel disorders 52 Metabolic Bone Disease Agents – Drugs to treat metabolic bone disorders 52 Ophthalmic Agents - Drugs to treat eye conditions 53 Otic Agents - Drugs to treat ear conditions 56 Respiratory Tract Agents - Drugs to treat allergy or breathing conditions 56 Sedatives/Hypnotics - Drugs to treat sleep disorders 59 Skelatal Muscle Relaxants - Drugs to treat muscle spasms 59 Therapeutic Nutrients/Minerals/Electrolytes 59

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Providence Health & Services - Alaska/media/files...latest and best information about effective, quality medications that also provide value. Providence Health Plan’s prescription