Rx.com PBC Comprehensive Formulary

The list is subject to change at any time and coverage is based on your specific benefit plan.
Preferred Drug List
ANTI-INFECTIVES
ANTINEOPLASTIC &
IMMUNOSUPPRESANT
DRUGS
PENICILLINS
Autonomic & CNS Drugs,
Neurology & Psych (con't)
ALKYLATING AGENTS
NSAIDS (con't)
Brand medications not listed are non-preferred.
Updated April 2015
Autonomic & CNS Drugs,
Neurology & Psych (con't)
Cardiovascular, Hypertension
& Lipids (con't)
MISC. ANTIPSYCHOTICS
OTHER ANTIHYPERTENSIVE
COMBINATIONS (con't)
AMOXICILLIN
amoxicillin-clavulanate er
ampicillin [inj]
ampicillin/sulbactam [inj]
AUGMENTIN 125-31.25 MG/5ML
BICILLIN C-R [INJ]
BICILLIN L-A [INJ]
ALKERAN
BICNU [INJ]
BUSULFEX [INJ]
carboplatin [inj]
CEENU
cisplatin [inj]
CYCLOPHOSPHAMIDE CAPSULES
ibuprofen
indomethacin
indomethacin [inj]
indomethacin er
ketoprofen er
ketorolac tromethamine
ketorolac tromethamine [inj]
RISPERDAL
RISPERDAL CONSTA [INJ]
RISPERDAL M-TAB DISINTEGRATING
SEROQUEL XR
thiothixene
ziprasidone hcl
dicloxacillin sodium
nafcill in dextrose [inj]
cyclophosphamide tablets
cyclophosphamide [inj]
meclofenamate sodium
mefenamic acid
amphetamine salt combo,er
clonidine hcl er
nafcillin sodium [inj]
ifosfamide [inj]
meloxicam
DAYTRANA
oxacillin sodium [inj] 1g/50ml
oxacillin sodium [inj]
penicillin g potassium [inj]
penicillin g procaine
penicillin g sodium [inj]
ifosfamide-mesna
LEUKERAN
LOMUSTINE
melphalan hcl [inj]
MUSTARGEN [INJ]
nabumetone
NAPROSYN
naproxen sodium
naproxen del-rel
NEOPROFEN [INJ]
dexmethylphenidate hcl
dextroamphetamine sulfate
dextroamphetamine sulfate er
ERGOLOID MESYLATES
flumazenil [inj]
AMTURNIDE
BENICAR
BENICAR HCT
candesartan cilexetil
candesartan-hydrochlorothiazid
PENICILLIN GK-ISO-OSM DEXTROSE
MYLERAN
oxaprozin
FOCALIN XR 5, 10, 20, 25, 35MG
EDARBI
penicillin v potassium
piperacillin-tazobactam [inj]
TIMENTIN [INJ]
ZOSYN [INJ]
oxaliplatin
TEMODAR [INJ] [SP]
temozolomide [SP]
thiotepa [inj]
TREANDA [INJ] [SP]
VALCHLOR [SP]
ZANOSAR [INJ]
piroxicam
sulindac
tolmetin sodium
VIMOVO
VOLTAREN
ZORVOLEX
guanidine hcl
INTUNIV
lithium carbonate tab
lithium carbonate er
lithium carbonate caps
methamphetamine hcl
methylphenidate er
EDARBYCLOR
irbesartan
irbesartan-hydrochlorothiazide
losartan potassium
losartan-hydrochlorothiazide
TEKAMLO
TEKTURNA
methylphenidate hcl
modafinil
NUVIGIL
QUILLIVANT XR
VYVANSE
XYREM [SP]
TEKTURNA HCT
valsartan
valsartan-hydrochlorothiazide
TETRACYCLINES
demeclocycline hcl
doxycycline hyclate
doxycycline hyclate [inj]
doxycycline hyclate [inj]
doxycycline monohydrate
MINOCIN
minocycline hcl
minocycline hcl er
minocycline hcl tablet
ocudox
ORACEA
SOLODYN 115MG ER
SOLODYN 55MG ER
SOLODYN 45MG ER
SOLODYN 65MG ER
SOLODYN 80 ER
TETRACYCLINE
CEPHALOSPORINS
FIRST GENERATION CEPHALOSPORINS
cefazolin [inj]
cefazolin/dextrose [inj]
ANTIMETABOLITIES
ALIMTA [INJ]
ARRANON [INJ] [SP]
azacitidine [inj] [sp]
capecitabine [sp]
CLOLAR [INJ]
cytarabine [inj]
decitabine [inj] [sp]
DEPOCYT [INJ]
floxuridine [inj]
fludarabine phosphate [inj]
fluorouracil [inj]
FOLOTYN [INJ] [SP]
gemcitabine hcl [inj]
mercaptopurine
methotrexate
methotrexate [inj]
TABLOID
TREXALL
cephalexin
NSAIDS-SPECIFIC COX II INHIBITORS
celecoxib
Salicylates
choline mag trisalicylate
diflunisal
SALICYLAMIDE
salsalate
MISC. ANALGESICS
acetaminophen-diphenhydramine
butorphanol [inj]
butorphanol nasal
clonidine [inj]
EUFLEXXA [SP]
MONOVISC [INJ]
nalbuphine hcl [inj]
NUCYNTA
NUCYNTA ER
OFIRMEV [INJ]
ORTHOVISC [INJ] [SP]
PRIALT [INJ] [SP]
QUADRAMET[INJ]
HORMONES
SECOND GENERATION CEPHALOSPORINS
cefaclor
cefoxitin [inj]
cefoxitin/dextrose [INJ]
cefpodoxime proxetil
megestrol acetate
cefprozil
cefuroxime axetil
cefuroxime sodium
cefuroxime sodium [inj]
CEFUROXIME SODIUM 75 G [INJ]
THIRD GENERATION CEPHALOSPORINS
cefdinir
FARESTON
FASLODEX
letrozole
tamoxifen citrate
Antiandrogens
bicalutamide
flutamide
cefepime [inj]
NILANDRON
cefepime/dextrose [inj]
cefotaxime [INJ]
cefotetan [inj]
CEFTAZIDIME
ceftazidime [inj]
ceftibuten
ceftriaxone [inj]
ceftriaxone/dextrose [inj]
FORTAZ IN ISO-OSMOTIC DEXTROSE [INJ]
TEFLARO [INJ]
ZERBAXA
XTANDI [SP]
ZYTIGA [SP]
ANTIESTROGENS
anastrozole
exemestane
RADIOPHARMACEUTICALS
IODOPEN [INJ]
XOFIGO [INJ] [SP]
IMMUNOSUPPRESSANT DRUGS
AZASAN
azathioprine [sp]
azathioprine sodium [inj] [sp]
CELLCEPT [INJ] [SP]
CELLCEPT SUSPENSION [SP]
ERYTHROMYCINS & OTHER MACROLIDEScyclosporine [inj] [sp]
SYNVISC [INJ] [SP]
SYNVISC -ONE [INJ] [SP]
TALWIN [INJ]
tramadol hcl
TRAMADOL HCL ER
tramadol hcl-acetaminophen
NARCOTIC ANTAGONISTS
buprenorphine-naloxone
naloxone hcl [inj]
naltrexone hydrochloride
SUBOXONE
ZUBSOLV
HEADACHE THERAPY
dihydroergotamine mesylate
dihydroergotamine mesylate
ergotamine-caffeine
ISOMETHEPTENE MUCATE
naratriptan hcl
RELPAX
rizatriptan
rizatriptan disintegrating tablets
sumatriptan succinate
sumatriptan succinate spray non-aerosol
sumatriptan succinate [inj]
SUMAVEL DOSEPRO [INJ]
methyldopa/hydrochlorothiazide
metoprolol-hydrochlorothiazide
moexipril-hydrochlorothiazide
nadolol-bendroflumethiazide
propranolol hcl-hctz
quinapril-hydrochlorothiazide
MISC. PSYCHOTHERAPEUTIC AGENTS TARKA ER
ANXIOLYTICS
alprazolam
alprazolam er
alprazolam orally disintegrating tablet
buspirone hcl
chlordiazepoxide hcl
clorazepate dipotassium
diltiazem [inj]
lorazepam
lorazepam [inj]
MIDAZOLAM HCL
midazolam hcl [inj]
oxazepam
ANTIARRHYTHMIC AGENTS
LOVAZA
niacin er
pravastatin sodium
SIMCOR ER
adenosine [inj]
amiodarone hcl
amiodarone hcl [inj]
simvastatin
VASCEPA
VYTORIN
WELCHOL
ZETIA
propafenone hcl er
CATHFLO ACTIVASE [INJ]
quinidine gluconate [inj]
quinidine gluconate er
quinidine sulfate
quinidine sulfate er
sotalol
SOTALOL HCL [INJ]
TIKOSYN
dobutamine [inj]
dobutamine/dextrose [inj]
dopamine hcl [inj]
dopamine hcl in 5% dextrose
milrinone in 5% dextrose
milrinone lactate [inj]
NATRECOR [INJ]
norepinephrine bitartrate [inj]
phenylephrine hcl [inj]
RANEXA
RETAVASE
CARDIAC GLYCOSIDES
digoxin
digoxin
LANOXIN PEDIATRIC
RAPID ACTING NITRATES
nitroglycerin tablets
azithromycin
clarithromycin
clarithromycin er
ERYTHROCIN LACTOBIONATE [INJ]
erythromycin
erythromycin del-rel
erythromycin ethylsuccinate
erythromycin stearate
erythromycin w/sulfisoxazole
cyclosporine modified [sp]
mycophenolate mofetil [sp]
mycophenolic acid del-rel [sp]
mycophenolate acid del-rel
NULOJIX [INJ]
PROGRAF
RAPAMUNE 1 MG, 2 MG TABLETS [SP]
RAPAMUNE SOLUTION [SP]
SANDIMMUNE SOLUTION
SIMULECT [INJ] [SP]
VIVITROL [INJ]
zolmitriptan
zolmitriptan odt
ZOMIG
nitroglycerin [inj]
nitroglycerin in d5w [inj]
nitroglycerin spray
NITROLINGUAL
NITROSTAT
sirolimus [sp]
tacrolimus [sp]
ZORTRESS [SP]
carbidopa-levodopa-entacapone
isosorbide mononitrate er
carbidopa/levodopa
nitroglycerin
carbidopa/levodopa orally disintegrating tablets
nitroglycerin er
entacapone
ANTICOAGULANTS
AVELOX
AVELOX IV [INJ]
CIPRO SUSPENSION
ciprofloxacin
MISC. ANTINEOPLASTIC DRUGS
KEY:
[INJ], [inj] - Injectable Drug; [OTC], [otc] - Over the Counter; [SP], [sp] - Specialty Drug
Brand name drugs are list in CAPITAL letters Example: HUMIRA
Generic drugs are lister in lower-case letters. Example: azithromycin
lovastatin
flecainide acetate
ibutilide fumarate [inj]
lidocaine hcl in 7.5% dextrose [inj]
mexiletine hcl
NEXTERONE
procainamide hcl [inj]
propafenone hcl
TREXIMET
FLOUROQUINOLONES
LIPID/CHOLESTEROL LOWERING
AGENTS
amlodipine-atorvastatin
atorvastatin calcium
CHOLESTYRAMINE
cholestyramine light
colestipol hcl
CRESTOR
fenofibrate
fenofibrate caps
fenofibric acid
fenofibric acid delayed release
fluvastatin sodium
gemfibrozil
JUXTAPID [SP]
LIPOFEN
LIPTRUZET
cyclosporine [sp]
ANTIPARKINSONISM AGENTS
ANGIOTENSION II RECEPTOR
BLOCKERS & RENIN INHIBITOR
Cardiovascular,
Hypertension & Lipids
azithromycin [inj]
APOKYN [INJ] [SP]
AZILECT
benztropine [inj]
benztropine mesylate
carbidopa-levodopa er
TRIBENZOR
LONG ACTING NITRATES
DILATRATE-SR EXT-REL
isosorbide dinitrate
isosorbide dinitrate
isosorbide mononitrate
MISC. CARDIOVASCULAR AGENTS
ACTIVASE [INJ]
Dermatological/Topical
Therapy
TOPICAL CORTICOSTEROIDS
VERY HIGH POTENCY
clobetasol e
clobetasol propionate
diflorasone diacetate
diflorason diacetate/emollient
halobetasol propionate
TOPICAL CORTICOSTEROIDS
HIGH POTENCY
amcinonide
betamethasone dipropionate augmented
betamethasone valerate
desoximetasone
fluocinonide
Page 1
The list is subject to change at any time and coverage is based on your specific benefit plan.
Preferred Drug List
Brand medications not listed are non-preferred.
Updated April 2015
TOPICAL CORTICOSTEROIDS MEDIUM
POTENCY
ciprofloxacin er
ciprofloxacin/dextrose [inj]
levofloxacin hemihydrate
ABRAXANE [INJ] [SP]
ADCETRIS [INJ] [SP]
AFINITOR [SP]
MIRAPEX ER
pramipexole di-hcl
ARGATROBAN [INJ]
COUMADIN [INJ]
ELIQUIS
fluocinolone acetonide cream
fluocinolone acetonide ointment
levofloxacin hemihydrate [inj]
AFINITOR DISPERZ [SP]
ropinirole hcl
PRADAXA
fluticasone propionate
levofloxacin-d5w [inj]
moxifloxacin hcl
ofloxacin tablets
ARZERRA [INJ] [SP]
AVASTIN [INJ] [SP]
BEXXAR [INJ]
bleomycin [inj]
ropinirole hcl er
selegiline hcl
trihexyphenidyl hcl
REFLUDAN [INJ]
warfarin sodium
XARELTO
hydrocortisone butyrate
hydrocortisone butyrate/emoll
hydrocortisone valerate
mometasone furoate
sulfadiazine
sulfamethoxazole/trimethoprim
BOSULIF [SP]
CAPRELSA [SP]
BANZEL
carbamazepine
AGGRASTAT [INJ]
AGGRENOX ER
sulfamethoxazole/trimethoprim [inj]
cladribine [inj]
carbamazepine ext-release
BRILINTA
methenamine hippurate
CYRAMZA [SP]
dacarbazine [inj]
CELONTIN
clonazepam
cilostazol
clopidogrel
alclometasone dipropionate
methenamine mandelate
dactinomycin [inj]
clonazepam orally disintegrating tablets
dipyridamole [inj]
desonide
methylene blue [inj]
NITROFURANTOIN
nitrofurantoin
nitrofurantoin macrocrystal
daunorubicin [inj]
DAUNOXOME [INJ]
DOCEFREZ [INJ]
docetaxel [inj]
diazepam
diazepam rectal gel
DILANTIN
divalproex sodium
EFFIENT
INTEGRILIN [INJ]
REOPRO [INJ]
ZONTIVITY
hydrocortisone
hydrocortisone
hydrocortisone acetate
trimethoprim
doxorubicin hcl [inj]
divalproex sodium
acyclovir
doxorubicin hcl liposomal [inj]
DROXIA
divalproex sodium er
ethosuximide
enoxaparin sodium [inj] [sp]
fondaparinux sodium [sp]
bupivacaine hcl
bupivacaine/epinephrine [inj]
acyclovir [inj]
adefovir dipivoxil
amantadine hcl
cidofovir [inj]
entecavir
famciclovir
foscarnet sodium
ganciclovir
OLYSIO [SP]
RAPIVAB
RELENZA
ELIGARD [SP]
ELSPAR
EMCYT
epirubicin hcl [inj]
ERBITUX [INJ] [SP]
ERIVEDGE [SP]
ETOPOPHOS [INJ]
etoposide
etoposide [inj]
GAZYVA [INJ]
GILOTRIF [SP]
felbamate
fosphenytoin sodium
FYCOMPA
gabapentin
GABITRIL 12MG, 16 MG
GRALISE
LAMICTAL ODT
LAMICTAL XR
lamotrigine
lamotrigine er
levetiracetam
FRAGMIN [SP]
heparin lock flush [inj]
heparin sodium in 0.45% nacl [inj]
heparin sodium in 5% dextrose [inj]
HUMATE-P [INJ] [SP]
NOVOSEVEN RT [INJ] [SP]
NPLATE [INJ] [SP]
CARBOCAINE 2% [INJ]
chloroprocaine [inj]
cocaine hcl
ethyl chloride
LIDOCAINE
lidocaine
lidocaine hcl
lidocaine hcl jelly
lidocaine hcl w/epinephrine [inj]
lidocaine ointment
lidocaine-prilocaine
ribavirin [sp]
rimantadine hcl
SOVALDI [SP]
TYZEKA
valacyclovir
valganciclovir hcl
VICTRELIS [SP]
levetiracetam [inj]
levetiracetam er
LYRICA
ONFI
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital
phenobarbital sodium [inj]
phenytoin
phenytoin sodium
phenytoin sodium [inj]
POTIGA
primidone
SABRIL [SP]
PROMACTA [SP]
TRANEXAMIC ACID
tranexamic acid [inj]
WILATE [INJ] [SP]
MEPIVACAINE HCL
NAROPIN [INJ]
NESACAINE
sensorcaine [inj]
abacavir [sp]
abacavir/lamivudine/zidovudine [sp]
APTIVUS[SP]
ATRIPLA [SP]
COMPLERA [SP]
CRIXIVAN [SP]
didanosine
GLEEVEC [SP]
HALAVEN [INJ] [SP]
HERCEPTIN [INJ] [SP]
HEXALEN
HYCAMTIN CAPSULES [SP]
hydroxyurea
ICLUSIG [SP]
idarubicin hcl [inj]
INLYTA [SP]
irinotecan hcl [inj]
ISTODAX [INJ] [SP]
IXEMPRA [INJ] [SP]
JAKAFI [SP]
JEVTANA [INJ] [SP]
KADCYLA [INJ] [SP]
ADVATE [INJ] [SP]
ADVATE H [INJ] [SP]
ADVATE L [INJ] [SP]
ADVATE N [INJ] [SP]
ADVATE SH [INJ] [SP]
ADVATE UH [INJ] [SP]
ALPHANATE [INJ] [SP]
ALPHANINE SD [INJ] [SP]
ALPROLIX [INJ] [SP]
ANGIOMAX [INJ]
ABSORICA
ACZONE
adapalene
ATRALIN
benprox
benzoyl peroxide
clindamycin-benzoyl peroxide
clindamycin phosphate topical
clindamycin phos/benzoyl peroxide
DIFFERIN 0.1% LOTION
EDURANT [SP]
KEYTRUDA
TEGRETOL XR
ATRYN
EPIDUO
EMTRIVA [SP]
EPIVIR [SP]
EPIVIR SOLUTION
EPIVIR HBV SOLUTION
EPZICOM [SP]
FUZEON [INJ] [SP]
INTELENCE [SP]
INVIRASE [SP]
ISENTRESS [SP]
KALETRA [SP]
lamivudine [sp]
lamivudine hbv
lamivudine-zidovudine [sp]
LEXIVA [SP]
nevirapine, xr [sp]
NORVIR [SP]
PREZISTA [SP]
RESCRIPTOR [SP]
RETROVIR [INJ] [SP]
REYATAZ [SP]
SELZENTRY [SP]
stavudine [sp]
STRIBILD [SP]
SUSTIVA [SP]
KYPROLIS [INJ][SP]
leuprolide acetate [inj] [sp]
LUPRON DEPOT [INJ] [SP]
LUPRON DEPOT 11.25MG [INJ] [SP]
LUPRON DEPOT-PED [INJ] [SP]
LYNPARZA
LYSODREN
MARQIBO
MATULANE [SP]
MEKINIST [SP]
mitomycin [inj]
mitoxantrone [inj] [sp]
NEXAVAR [SP]
octreotide acetate [inj] [sp]
ONCASPAR
ONTAK [INJ]
OPDIVO
paclitaxel [inj]
PERJETA [INJ] [SP]
PHOTOFRIN [INJ]
POMALYST [SP]
PROVENGE [INJ] [SP]
PURIXAN
REVLIMID [SP]
tiagabine hcl
topiramate
VALPROATE SODIUM
valproate sodium [inj]
valproic acid
VIMPAT [INJ]
zonisamide
BEBULIN [INJ] [SP]
BEBULIN VH IMMUNO [INJ] [SP]
BENEFIX [INJ] [SP]
CEPROTIN [INJ] [SP]
CORIFACT [INJ] [SP]
ELOCTATE [INJ]
FEIBA NF [INJ] [SP]
HELIXATE FS [INJ] [SP]
HEMOFIL [INJ]
KOATE-DVI [INJ] [SP]
MONOCLATE-P [INJ]
MONONINE [INJ] [SP]
OBIZUR
pentoxifylline er
PROFILNINE SD [INJ] [SP]
protamine sulfate [inj]
RECOMBINATE [INJ] [SP]
RIASTAP [SP]
TRETTEN [SP]
THROMBATE III [INJ]
xyntha [inj] [sp]
erythromycin solution
erythromycin-benzoyl peroxide
FINACEA
FINACEA PLUS
isotretinoin
metronidazole cream
MIRVASO
ONEXTON
sodium sulfacetamide/sulfur
sulfacetamide sodium-sulfur
sulfacetamide sodium/sulfur 10-1
TAZORAC
TRETIN-X
tretinoin cream
tretinoin microsphere
VELTIN
ZIANA
TIVICAY [SP]
TRIUMEQ
TRUVADA
VIDEX [SP]
VIRACEPT [SP]
VIRAMUNE [SP]
VIREAD [SP]
RITUXAN [INJ] [SP]
SANDOSTATIN [INJ]
SIGNIFOR [INJ] [SP]
SOMATULINE DEPOT [INJ] [SP]
SPRYCEL [SP]
STIVARGA [SP]
SUTENT [SP]
ZIAGEN [SP]
zidovudine [sp]
SULFA'S & RELATED AGENT
URINARY TRACT AGENTS
ANTIVIRALS
HIV/AIDS THERAPY
ANTIFUNGAL AGENTS
AMBISOME [INJ]
amphotericin [inj]
CANCIDAS [INJ]
clotrimazole
fluconazole
fluconazole in dextrose
fluconazole in saline
FLUCYTOSINE
griseofulvin
griseofulvin ultramicrosize
ANTICONVULSANTS
MISC. NEUROLOGICAL THERAPY
AMPYRA [SP]
COPAXONE [INJ] [SP]
donepezil hcl
donepezil hcl
EXELON
EXELON
galantamine
GILENYA [SP]
LEMTRADA
NAMENDA
NAMENDA XR
NUEDEXTA
rivastigmine
TECFIDERA [SP]
TYSABRI [INJ] [SP]
XENAZINE [SP]
MUSCLE RELAXANTS &
ANTISPASMODIC
AGENTS
ANTIPLATELET DRUGS
prednicarbate
triamcinolone acetonide 0.1% cream
TOPICAL CORTICOSTEROIDS
LOW POTENCY
TOPICAL ANESTHETICS
HEPARIN
VITAMIN K
MEPHYTON
PHYTONADIONE
HEMOSTATICS
BENZOCAINE
MISC. COAGULATION AGENTS
THIAZIDE & RELATED DIURETICS
amiloride hcl
amiloride hcl w/hctz
THERAPY FOR ACNE
TOPICAL ANTIBACTERIALS
bacitracin eye ointment
bacitracin/polymyxin eye ointment
gentamicin sulfate cream
gentamicin sulfate ointment
mafenide acetate
mupirocin
sulfacetamide sodium topical
SULFAMYLON
anectine [inj]
baclofen
chlorzoxazone
cyclobenzaprine hcl
dantrolene sodium
bumetanide
bumetanide [inj]
chlorothiazide
chlorothiazide chlorothiazide sodium [inj]
chlorthalidone
EDECRIN[INJ]
eplerenone
SYLVANT [INJ]
GABLOFEN [INJ]
furosemide
ketoconazole cream
SYNRIBO [INJ] [SP]
LIORESAL [INJ]
furosemide [inj]
nystatin ointment
TAFINLAR [SP]
TARCEVA
TARGRETIN [SP]
TARGRETIN GEL [SP]
TASIGNA [SP]
TENIPOSIDE [INJ]
THALOMID [SP]
topotecan hcl [inj][sp]
TORISEL [INJ] [SP]
TRELSTAR
TRELSTAR DEPOT [INJ]
methocarbamol
orphenadrine citrate [inj]
orphenadrine citrate er
orphenadrine compound
ROBAXIN [INJ]
tizanidine hcl
Myasthenia Gravis
EDROPHONIUM CHLORIDE
MESTINON
MESTINON ER
neostigmine methylsulfate [inj]
hydrochlorothiazide
indapamide
mannitol
methyclothiazide
metolazone
RESECTISOL
spironolactone
spironolactone w/hctz
torsemide
torsemide [inj]
nystatin w/triamcinolone
KEY:
[INJ], [inj] - Injectable Drug; [OTC], [otc] - Over the Counter; [SP], [sp] - Specialty Drug
Brand name drugs are list in CAPITAL letters Example: HUMIRA
Generic drugs are lister in lower-case letters. Example: azithromycin
BETA BLOCKERS
TOPICAL ANTIFUNGALS
ciclopirox
clotrimazole
clotrimazole/betamethasone
econazole nitrate
TOPICAL ANTIVARALS
acyclovir ointment
DENAVIR
ZOVIRAX
BURN THERAPY
silver sulfadiazine
TOPICAL ENZYMES
SANTYL
KERATOLYTICS
salicylic acid
Page 2
The list is subject to change at any time and coverage is based on your specific benefit plan.
Preferred Drug List
itraconazole
ketoconazole
LAMISIL
MYCAMINE [INJ]
NOXAFIL
nystatin tablet
SPORANOX
terbinafine
TRELSTAR LA
tretinoin caps
TRISENOX [INJ]
TYKERB [SP]
VALSTAR [INJ] [SP]
VANTAS [SP]
VECTIBIX [INJ] [SP]
VELCADE [INJ] [SP]
pyridostigmine bromide
voriconazole
vinblastine sulfate
voriconazole [inj]
VOTRIENT [SP]
VUMON [INJ]
XALKORI [SP]
YERVOY [INJ] [SP]
ZALTRAP [INJ] [SP]
ZELBORAF [SP]
VANCOMYCIN
vancomycin hcl [inj]
VANCOMYCIN HCL 750 [INJ]
VIBATIV [INJ]
MISC. ANTI-INFECTIVES
Brand medications not listed are non-preferred.
Updated April 2015
ANTIPSORIATICS/ANTISEBORRHEIC
NEMBUTAL SODIUM [INJ]
acebutolol hcl
atenolol
betaxolol hcl
bisoprolol fumarate
BYSTOLIC
COREG CR ER
labetalol hcl
labetalol hcl [inj]
acitretin
ANTHRALIN
calcipotriene
calcitriol
PRAMOSONE 1% OINTMENT
PRAMOSONE 1% LOTION
PRAMOSONE E
ROZEREM
metoprolol succinate er
PRAMOSONE LOTION
seconal sodium
temazepam
triazolam
zaleplon
zolpidem tartrate
metoprolol tartrate
metoprolol tartrate [inj]
nadolol
pindolol
propranolol hcl
PRAMOSONE OINTMENT
selenium sulfide
STELARA [INJ] [SP]
TACLONEX SUSPENSION
zolpidem tartrate er
propranolol hcl
EURAX
propranolol hcl er
lindane
timolol maleate
malathion
HYPNOTIC AGENTS
AMYTAL [INJ]
diphenhydramine hcl
DOXYLAMINE SUCCINATE
flurazepam hcl
TRICYCLICS
TOPICAL SCABICIDES/PEDICULICIDES
AMIKACIN [INJ]
ZEVALIN
AZACTAM-ISO-OSMOTIC DEXTROSE [INJ]
ZOLADEX [SP]
amitriptyline hcl
aztreonam [inj]
ZOLINZA [SP]
amoxapine 150mg
bacitracin [inj]
BETHKIS
ZYDELIG
ZYKADIA
amoxapine 25mg
clomipramine hcl
diltiazem [inj]
desipramine hcl
doxepin hcl
imipramine hcl
imipramine pamoate
nortriptyline hcl
trimipramine maleate
diltiazem 24hr cd
diltiazem er
diltiazem er 24 hour
diltiazem hcl
nimodipine
verapamil er
alphaquin hp
aluminum chloride 20% topical
ammonium lactate 12% topical
avo cream
CARAC
CHLORHEXIDINE GLUCONATE
verapamil er pm
CONDYLOX GEL
verapamil hcl [inj]
DEXPANTHENOL
diclofenac sodium gel
ADJUNCTIVE AGENTS
CALCIUM CHANNEL BLOCKERS/
NON-DIHYDROPYRIDINES
permethrin
spinosad
MISC. DERMATOLOGICALS
CAYSTON [SP]
chloramphenicol [INJ]
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate [inj]
clindamycin phosphate/dextrose [inj]
amifostine [inj]
calcium folinate [inj]
dexrazoxane [inj]
ELITEK [INJ]
FUSILEV [INJ]
colistimethate [inj]
KEPIVANCE [INJ] [SP]
CUBICIN [INJ]
DALVANCE [INJ]
leucovorin calcium
leucovorin calcium [inj]
amitriptyline/chlordiazepoxide
bupropion ext-release (12 hour)
DAPSONE
DORIBAX
gentamicin sulfate [inj]
gentamicin sulfate in ns
mesna [inj]
MESNEX
VORAXAZE [INJ]
XGEVA [INJ] [SP]
bupropion hcl
bupropion hcl xl er
bupropion sr er
duloxetine
amlodipine besylate
CLEVIPREX [INJ]
felodipine er
eletone
ELIDEL
emulsion sb
ETHYL ALCOHOL
GAZYVA [SP]
isradipine
fluorouracil
IMBRUVICA [SP]
nicardipine hcl
hpr
maprotiline hcl
mirtazapine
nicardipine hcl [inj]
hpr plus
hydroquinone cream
benazepril hcl
captopril
enalapril maleate
enalaprilat [inj]
fosinopril sodium
lisinopril
moexipril hcl
hydroquinone er
imiquimod
lactic acid
lustra-ultra
mb hydrogel
nuquin hp
OXSORALEN 1% LOTION
perindopril erbumine
quinapril
podofilox
pr cream
ramipril
PROTOPIC
trandolapril
pruclair
prumyx
gentamicin sulfate in ns 100mg/0.1l
imipenem-cilastatin [inj]
Autonomic & CNS Drugs,
Neurology & Phych
NARCOTIC ANALGESICS
MISC. ANTIDEPRESSANTS
CALCIUM CHANNEL
BLOCKERS/DIHYDROPYRIDINES
INVANZ [INJ]
kanamycin sulfate [inj]
alfentanil hcl [inj]
meropenem [inj]
neomycin sulfate
ORABACTIV [INJ]
polymyxin b sulfate [inj]
SIVEXTRO [INJ]
SYNERCID [INJ] [SP]
TOBI PODHALER [SP]
buprenorphine [inj]
buprenorphine hydrochloride
BUTRANS
codeine sulfate
DILAUDID-HP 250 MG [INJ]
fentanyl
FENTANYL CITRATE
mirtazapine disintegrating
perphenazine/amitriptyline
PRISTIQ ER
trazodone hcl
venlafaxine hcl
venlafaxine hcl er
tobramycin nebulization solution [sp]
tobramycin sulfate [inj]
fentanyl citrate [inj]
fentanyl citrate lozenge
phenelzine sulfate
tranylcypromine sulfate
tobramycin sulfate in ns
hydromorphone hcl 4mg
TYGACIL [INJ]
XIFAXAN
hydromorphone hcl rectal
hydromorphone hcl [inj]
ZYVOX
INFUMORPH
BRISDELLE
citalopram hbr
ZYVOX [INJ]
ALBENZA
ALINIA
atovaquone
metronidazole
levorphanol tartrate
meperidine hcl [inj]
methadone hcl
methadone hcl [inj]
morphine sulfate, [inj]
morphine sulfate cr
escitalopram oxalate
fluoxetine dr
FLUOXETINE HCL
fluvoxamine maleate er 24 hr
paroxetine hcl
paroxetine hcl er
clonidine hcl
clonidine/chlorthalidone
doxazosin mesylate
guanfacine hcl
methyldopa
methyldopate hcl [inj]
REGRANEX
sonafine
tl-cermide
urea
urea
urea
metronidazole [inj]
NEBUPENT [INJ]
morphine sulfate er
morphine sulfate tablet
VIIBRYD
prazosin hcl
reserpine
urea
ZYCLARA
paromomycin sulfate
OPANA ER
chlorpromazine [inj]
STROMECTOL
oxycodone hcl
chlorpromazine hcl
tinidazole
OXYCONTIN ER
oxymorphone hcl
oxymorphone hcl er
sufentil [inj]
ULTIVA [INJ]
ANTIPARASITICS
ANTIMALARIALS
atovaquone-proguanil hcl
chloroquine phosphate
COARTEM
DARAPRIM
hydroxychloroquine sulfate
mefloquine hcl
PRIMAQUINE
quinine sulfate
ANTIMYCOBACTERIALS
CAPASTAT SULFATE [INJ]
ethambutol hcl
isoniazid
isoniazid [inj]
PRIFTIN
pyrazinamide
rifabutin
RIFADIN
RIFADIN[INJ]
SIRTURO
STREPTOMYCIN SULFATE [INJ]
MAO INHIBITORS
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS
PHENOTHIAZINES
ACE INHIBITORS
ADRENERGIC ANTAGONISTS &
RELATED DRUGS
terazosin hcl
AGENTS FOR PHEOCHROMOCYTOMA
fluphenazine decanoate [inj]
fluphenazine hcl
fluphenazine hcl
perphenazine
thioridazine hcl
COMBINATION NARCOTIC/ANAGESICS trifluoperazine hcl
acetaminophen w/codeine
BUTYROPHENONES
DEMSER
DIBENZYLINE
PHENTOLAMINE MESYLATE [INJ]
butalbital compound
butalbital compound w/codeine
butalbital-asp-caffeine
butalbital/apap/caffeine
butalbital/caff/apap/codeine
hydrocodone bit-ibuprofen
hydrocodone w/acetaminophen
oxycodone hcl-ibuprofen
oxycodone w/acetaminophen
oxycodone w/aspirin
minoxidil
papaverine hcl [inj]
papaverine hcl er
REMODULIN [INJ] [SP]
NSAIDS
calcium-folic acid plus d
diclofenac potassium
diclofenac sodium
diclofenac sodium-misoprostol del-rel
etodolac/etodolac er
fenoprofen calcium
flurbiprofen
KEY:
[INJ], [inj] - Injectable Drug; [OTC], [otc] - Over the Counter; [SP], [sp] - Specialty Drug
Brand name drugs are list in CAPITAL letters Example: HUMIRA
Generic drugs are lister in lower-case letters. Example: azithromycin
haloperidol
haloperidol [inj]
haloperidol decanoate [inj]
haloperidol lactate [inj]
MISC. ANTIPSYCHOTICS
ABILIFY
ABILIFY DISCMELT
ABILIFY MANTENA, ER
clozapine
clozapine odt
LATUDA
loxapine succinate
olanzapine
olanzapine [inj]
olanzapine odt
olanzapine-fluoxetine hcl
quetiapine fumarate
VIMIZIM
VASODILATORS
epoprostenol [inj] [sp]
epoprostenol diluent [inj] [sp]
hydralazine hcl
OTHER ANTIHYPERTENSIVE
COMBINATIONS
atenolol w/chlorthalidone
AZOR
benazepril hcl-hctz
bisoprolol fumarate/hctz
captopril/hydrochlorothiazide
enalapril maleate/hctz
EXFORGE
EXFORGE HCT
fosinopril-hydrochlorothiazide
lisinopril-hctz
prutect
EAR, NOSE & THROAT
MEDICATIONS
MISCELLANEOUS OTIC
PREPARATIONS
acetic acid ear solution
acetic acid/aluminum ear solution
acetic acid/hydrocortisone ear solution
antipyrine w/benzocaine ear solution
antipyrine w/benzocaine/poly ear solution
chloroxylenol/benzocaine/hydrocortisone
acetate ear suspension
ciprofloxacin hcl
ofloxacin otic drops
OTIC STEROID / ANTIBIOTIC
CIPRODEX
neomycin/polymyxin/hc
neomycin/polymyxin/hc drops
MISCELLANEOUS AGENTS
ASTEPRO
ATROVENT SPRAY
azelastine hcl nasal spray
FIRST-BXN
FIRST-MOUTHWASH BLM
ipratropium bromide spray
MYALEPT [SP]
oxymetazoline hcl 12 hour
sodium fluoride
sodium fluoride cream
Page 3
The list is subject to change at any time and coverage is based on your specific benefit plan.
Preferred Drug List
ENDOCRINE/DIABETES
ANTITHYROID AGENTS
methimazole
propylthiouracil
MUSCULOSKELETAL &
RHEUMATOLOGY (con't)
GASTROENTEROLOGY (con't)
MISCELLANEOUS GASTROINTESTINAL
AGENTS (con't)
MONOPHASIC /BIPHASIC /TRIPHASIC
AGENTS (con't)
Brand medications not listed are non-preferred.
Updated April 2015
RESPIRATORY, ALLERGY,
COUGH & COLD (con't)
INHALED CORTICOSTEROIDS
VITAMINS, HEMATINICS &
ELECTROLYTES (con't)
VITAMINS & HEMATINICS (con't)
ARMOUR THYROID
levothroid
levothyroxine sodium
levothyroxine sodium [inj]
cromolyn sodium oral solution
CYSTADANE [SP]
DELZICOL DEL-REL
ENTYVIO
ENTYVIO [INJ]
hydrocortisone
hydrocortisone acetate
sronyx
syeda
tilia fe
tri-estarylla
tri-legest fe
tri-linyah
trinessa
ASMANEX, HFA
budesonide
FLOVENT HFA
FLOVENT DISKUS
PULMICORT
PULMICORT FLEXHALER
QVAR
liothyronine sodium
liothyronine sodium tablet
KRISTALOSE
lactulose
trivora
velivet
DYMISTA
triveen-duo dha
triveen-one
THYROID
LIALDA
vestura
flunisolide
triveen-prx rnf
LINZESS
LOTRONEX
mesalamine
metoclopramide hcl
metoclopramide hcl [inj]
viorele
wera
wymzya fe
zarah
zenchent
fluticasone propionate
NASONEX
QNASL
triamcinolone acetonide spray
VERAMYST
triveen-ten
triveen-u
trust natal dha
ultimate ob dha
ultimatecare one
THYROID HORMONES
ADRENAL HORMONES
A-HYDROCORT [INJ]
ARISTOSPAN [INJ]
BETAMETHASONE
BETAMETHASONE ACETATE
betamethasone acetate/betamethasone
sodium phosphate [inj]
INTRANASAL STEROIDS
MISCELLANEOUS PULMONARY
AGENTS
PENTASA
zenchent fe
BETAMETHASONE SODIUM PHOSPHATE
cortisone acetate
cosyntropin [INJ]
DEPO-MEDROL 20 MG/ML [INJ]
dexamethasone
dexamethasone sodium phosphate
fludrocortisone acetate
PROCTOFOAM-HC
RECTIV
RELISTOR [INJ]
REMICADE [INJ] [SP]
sodium bicarbonate [in]
sodium chloride/sodium bicarb [inj]
sulfasalazine
zeosa
zovia
KENALOG [INJ]
MEDROL
methylprednisolone
methylprednisolone acetate [inj]
methylprednisolone sod succ [inj]
prednisolone
prednisolone sodium phosphate
prednisone
SOLU-CORTEF [INJ]
SOLU-MEDROL [INJ]
veripred 20
sulfasalazine dr
UCERIS
oxytocin [inj]
OXYTOCICS
ERGONOVINE MALEATE
HEMABATE [INJ]
methylergonovine maleate
METHYLERGONOVINE MALEATE [INJ]
trinatal gt
trinatal rx 1
trinatal ultra
trinate
triphrocaps
TROPHAMINE [INJ]
VITACIRC-B
ultimatecare one nf
acetylcysteine
ADCIRCA [SP]
ADEMPAS [SP]
ADVAIR DISKUS
ADVAIR HFA
ANORO ELLIPTA
v-c forte
v-natal
vemavite-prx 2
vena-bal dha
venatal complete dha
venatal-fa
VENOFER [INJ]
vinacal
vinate az
vinate c
vinate calcium
vinate dha
vinate gt
vinate ic
vinate ii
vinate one
vinate ultra
vinate-m
virt-bal dha
virt-bal dha plus
virt-pn
virt-pn dha
virt-pn plus
virt-select
virt-vite
virt-vite forte
ANDRODERM
ANDROGEL
AXIRON
danazol
FLUOXYMESTERONE
METHITEST
oxandrolone
ALOXI [INJ]
dimenhydrinate [inj]
dronabinol
droperidol [inj]
EMEND
EMEND [INJ]
granisetron hcl
granisetron hcl [inj]
meclizine hcl
ondansetron hcl
ondansetron hcl [inj]
ondansetron hcl in dextrose [inj]
ondansetron in sodium chloride[inj]
ondansetron odt
prochlorperazine edisylate [inj]
CENESTIN
BREO ELLIPTA
CINRYZE [INJ] [SP]
COMBIVENT RESPIMAT
cromolyn sodium nebulization solution
DALIRESP
DULERA
FIRAZYR [INJ] [SP]
ipratropium bromide
ipratropium-albuterol nubulization
KALBITOR [INJ] [SP]
LETAIRIS [SP]
montelukast sodium
OPSUMIT [SP]
PULMOZYME [SP]
REVATIO [INJ] [SP]
sildenafil citrate [sp]
sodium chloride nebulizer(ml)
SPIRIVA, RESPIMAT
SYMBICORT
testosterone cypionate [inj]
prochlorperazine maleate
DEPO-ESTRADIOL [INJ]
TRACLEER [SP]
vitafol-ob
testosterone enanthate [inj]
prochlorperazine maleate
DIVIGEL
TUDORZA PRESSAIR
vitafol-pn
BRAVELLE [INJ]
clomiphene citrate
FOLLISTIM AQ [INJ] [SP]
SANCUSO
SCOPOLAMINE HYDROBROMIDE
TRANSDERM-SCOP
trimethobenzamide hcl
ENJUVIA
ESTRACE CREAM
ESTRACE TABLET
estradiol
TYVASO [SP]
VENTAVIS [SP]
XOLAIR [INJ] [SP]
zafirlukast
vitamin a
vitaspire
vol-care rx
vol-nate
MENOPUR [INJ] [SP]
trimethobenzamide hcl [inj]
estradiol patch
estradiol valerate [inj]
ESTRING
estropipate
EVAMIST
MINIVELLE
PREMARIN
ANDROGENS
OVULATORY STIMULANTS
MISCELLANEOUS AGENTS
ACTHREL [INJ]
ALDURAZYME [INJ] [SP]
cabergoline
calcitonin salmon nasal
calcitriol [inj]
CERDELGA [SP]
CEREZYME [INJ] [SP]
desmopressin acetate nasal [sp]
desmopressin acetate [inj] [sp]
doxercalciferol
ELAPRASE [INJ] [SP]
ELELYSO [INJ] [SP]
FABRAZYME [INJ] [SP]
HECTOROL
HECTOROL [INJ]
KALYDECO [SP]
KUVAN [SP]
ANTIVERTIGO & ANTIEMETIC
AGENTS
BOWEL EVACUANTS
MOVIPREP
peg 3350-electrolyte
polyethylene glycol
SUCLEAR
SUPREP
IMMUNOLOGY, VACCINES
& BIOTECHNOLOGY
ERYTHROID STIMULANTS
ARANESP [INJ] [SP]
PROCRIT [INJ] [SP]
MYELOID STIMULANTS
LEUKINE [INJ] [SP]
MOZOBIL [INJ] [SP]
NEULASTA [INJ] [SP]
NEUPOGEN [INJ] [SP]
INTERFERONS
PROGESTINS
caldolor [inj]
CRINONE [SP]
DEPO-PROVERA 400 MG/ML [INJ]
ENDOMETRIN [SP]
errin
heather
jencycla
jolivette
lyza
MAKENA [INJ] [SP]
medroxyprogesterone acetate [inj]
nora-be
norethindrone acetate
progesterone in oil [inj] [sp]
progersterone: micronized
ESTROGENS
flavoxate hcl
GELNIQUE
vol-plus
vol-tab rx
vp-ch plus
vp-ch-pnv
vp-era ob plus
vp-ggr-b6
vp-heme one
PREMARIN [INJ]
MYRBETRIQ ER 24 HR
vynatal-fa
VAGIFEM
VIVELLE PATCH
oxybutynin chloride
oxybutynin chloride er
OXYTROL PATCH
tolterodine tartrate
TOVIAZ
trospium chloride er
VESICARE
zatean-ch
zatean-pn
zatean-pn dha
zatean-pn plus
zingiber
ESTROGEN COMBINATIONS
COMBIPATCH
DUAVEE
estradiol-norethindrone acetat
estrogen & methyltestosterone
PREMPHASE
PREMPRO
VAGINAL CLEANSER /ANTIINFECTIVES
ACTIMMUNE [INJ] [SP]
clindamycin phosphate vaginal
LUMIZYME [INJ] [SP]
ALFERON N [INJ]
metronidazole gel
MIACALCIN [INJ]
AVONEX [INJ] [SP]
MYOZYME [INJ] [SP]
NAGLAZYME [INJ] [SP]
pamidronate disodium [inj]
paricalcitol
SAMSCA
SENSIPAR
SOMAVERT [INJ][SP]
STIMATE SPRAY [SP]
SYNAREL
vasopressin [inj]
BETASERON
INFERGEN [INJ]
INTRON A [INJ]
PEGASYS [INJ]
PEGASYS PROCLICK [INJ]
PLEGRIDY
REBIF
REBIF REBIDOSE
SYLATRON
VPRIV [INJ]
ZAVESCA [SP]
ZEMPLAR [INJ]
GROWTH HORMONES
EGRIFTA [INJ]
GENOTROPIN
HUMATROPE [INJ] [SP]
NORDITROPIN
KEY:
[INJ], [inj] - Injectable Drug; [OTC], [otc] - Over the Counter; [SP], [sp] - Specialty Drug
Brand name drugs are list in CAPITAL letters Example: HUMIRA
Generic drugs are lister in lower-case letters. Example: azithromycin
UROLOGICALS
VAGINAL ANTIFUNGALS
MICONAZOLE 1
terconazole
SPECIALIZED OB/GYN DRUGS
isoxsuprine hcl
DIAPHRAGMS AND OTHER
NON-ORAL CONTRACEPTIVES
IMPLANON [SP]
MIRENA [SP]
NEXPLANON [SP]
NUVARING
OPHTHALMOLOGY
BETA-BLOCKERS
betaxolol eye solution
BETOPTIC S
CHOLINERGIC STIMULANTS
bethanechol chloride
ANTICHOLINERGICS &
ANTISPASMODICS
URINARY ANESTHETICS
phenazopyridine hcl
phenazopyridine plus
MISCELLANEOUS UROLOGICALS
alprostadil [inj]
POTASSIUM
pot chloride/dextrose/ns [inj]
potassium acetate [inj]
potassium bicarbonate
potassium chloride
potassium chloride/dextrose [inj]
OTHER ELECTROLYTES
AMINOACETIC ACID
ADDAMEL N [INJ]
aminoacetic acid [inj]
AMMONIUM CHLORIDE [INJ]
CAVERJECT [INJ]
CIALIS
CYSTAGON [SP]
ELMIRON
glycine
hyophen
k-phos neutral
K-PHOS ORIGINAL
calcium acetate
calcium chloride [inj]
calcium gluconate [inj]
chromium chloride [inj]
copper chloride [inj]
CUPRIC SULFATE [INJ]
eliphos
GLYCOPHOS [INJ]
k-phos neutral
magnesium chloride [inj]
MUSE
phosphasal
potassium citrate er
RENACIDIN
magnesium sulfate [inj]
MAGNESIUM SULFATE IN DEXTROSE [INJ]
manganese [inj]
manganese sulfate [inj]
Page 4
The list is subject to change at any time and coverage is based on your specific benefit plan.
Preferred Drug List
zoledronic acid [inj] [sp]
zoledronic acid/mannitol [inj] [sp]
ZOMETA [INJ] [SP]
GONADOTROPIN & RELATED
AGENTS
CETROTIDE [INJ] [SP]
chorionic gonadotropin [inj] [sp]
GANIRELIX ACETATE [SP]
INSULIN THERAPY
OMNITROPE
SEROSTIM [INJ]
Brand medications not listed are non-preferred.
Updated April 2015
carteolol hcl
levobunolol hcl drops
metipranolol drops
tricitrates
uretron d-s
urimar-t
MULTITRACE-4 [INJ]
MULTITRACE-5 [INJ]
NEUT [INJ]
ARCALYST [INJ] [SP]
timolol maleate drops
urin d.s.
NORMOSOL-R AND DEXTROSE [INJ]
ILARIS [INJ] [SP]
NEUMEGA [INJ] [SP]
PROLEUKIN [INJ] [SP]
PHOSPHOLINE IODIDE DROPS
urogesic
ustell
VIAGRA
nutrilyte [inj]
nutrilyte ii [inj]
PEDITRACE [INJ]
potassium chl-normal saline [inj]
INTERLEUKINS
VACCINES & MISCELLANEOUS
IMMUNOLOGICALS
CHOLINESTERASE INHIBITOR MIOTICS
DIRECT ACTING MIOTICS
pilocarpine hcl drops
BENIGN PROSTATIC HYPERPLASIA
(BPH) THERAPY
HUMALOG [INJ]
ACTHIB [INJ]
alfuzosin hcl er
ringers [inj]
selenium [inj]
HUMULIN KWIKPEN [INJ] [OTC]
ADACEL [INJ]
carbachol [INJ]
finasteride
sodium acetate [inj]
HUMULIN R 500 UNITS [IINJ] [OTC]
HUMULIN 70/30, KWIKPEN [INJ] [OTC]
AFLURIA [INJ]
APLISOL [INJ]
COMBIGAN
dorzolamide hcl
RAPAFLO
tamsulosin hcl er 24 hr
sodium chloride 3% [inj]
sodium chloride 0.45% [inj]
LANTUS [INJ]
ATGAM [INJ]
dorzolamide-timolol
LANTUS SOLOSTAR [INJ]
LEVEMIR, FLEXTOUCH
LEVEMIR [INJ]
NOVOLOG [INJ]
BIOTHRAX [INJ]
BOOSTRIX [INJ]
BOTOX [INJ] [SP]
candin
ISOPTO CARBACHOL
latanoprost drops
LUMIGAN
physostigmine salicylate [inj]
advanced am/pm
AQUASOL A [INJ]
NOVOLOG FLEXPEN
CERVARIX [INJ]
TRAVATAN Z
ascorbic acid [inj]
NOVOLOG MIX 70-30
COMVAX [INJ]
CROFAB [INJ]
travoprost
b-complex
bal-care dha
ALZ-NAC
acarbose
ACTOPLUS MET XR
BYDUREON [INJ]
BYDUREON PEN
BYETTA [INJ]
glimepiride
glipizide
glipizide er
glyburide
glyburide micronized
CYTOGAM [INJ] [SP]
ENGERIX-B [INJ]
FLUARIX [INJ]
FLULAVAL [INJ]
FLULAVAL QUAD [INJ]
FLUMIST
FLUVIRIN [INJ]
FLUZONE [INJ]
FLUZONE INTRADERM QUAD 2014-15
fomepizole
GAMASTAN S-D [INJ] [SP]
acetazolamide
acetazolamide er
acetazolamide [inj]
methazolamide
cavan-alpha kit
cavan-ec sod dha
CENOLATE [INJ]
centratex
choice-ob + dha
choice-tabs
complete natal dha
CONCEPTION XR MOTILITY
corvita
NASCOBAL [INJ]
DAILYVITE
amino acid [inj] [
AMINOSYN [INJ]
BAL IN OIL [INJ]
CLINIMIX [INJ]
FREAMINE HBC
FREAMINE III
HEPATAMINE [INJ]
HEPATASOL [INJ]
hetastarch w/sodium chloride [inj]
intralipid
IONOSOL B WITH DEXTROSE 5%
glyburide-metformin hcl
INVOKAMET
INVOKANA
JANUMET
JANUMET XR
JANUVIA
JENTADUETO
JUVISYNC
KOMBIGLYZE XR
metformin hcl
metformin hcl er
nateglinide
ONGLYZA
pioglitazone hcl
pioglitazone-glimepiride
GAMMAGARD LIQUID [INJ] [SP]
GAMMAGARD S-D [INJ] [SP]
GAMUNEX [INJ] [SP]
GAMUNEX-C [INJ]
GARDASIL, 9 [INJ]
GRASTEK
HAVRIX [INJ]
HEPAGAM B [INJ]
HIZENTRA [INJ] [SP]
HYPERHEP B S-D [INJ]
HYPERRAB S-D [INJ]
HYPERRHO S-D
HYPERTET S-D
IMOGAM RABIES-HT [INJ]
IMOVAX RABIES VACCINE [INJ]
AZASITE
BESIVANCE
ciprofloxacin eye solution
dexferrum
DIALYVITE 800
DULEEK-MET NEW
elite ob
elite-ob
elite-ob 400
fabb
fe 90 plus
fe c
FERAHEME
ferocon
ferotrinsic
ferraplus 90
ferrex 150 forte
ferrex 150 forte plus
ISOLYTE S [INJ]
L-METHYLFOLATE-MECOBALAMIN-NAC
metafolbic plus
METHYLFOLATE MECOBALAMIN-NAC
NEPHRAMINE [INJ]
NORMOSOL-M AND DEXTROSE [INJ]
NORMOSOL-R PH 7.4 [INJ]
PLASMA-LYTE 148 [INJ]
premasol [inj]
PROCALAMINE
PROSOL
travasol [inj]
vp-zel
pioglitazone-metformin
INFANRIX [INJ]
NON-INSULIN HYPOGLYCEMIC
AGENTS
PILOPINE HS
OTHER GLAUCOMA DRUGS
ORAL DRUGS FOR GLAUCOMA
CYCLOPLEGIC MYDRIATICS
atropine sulfate eye solution
atropine sulfate eye ointment
cyclopentolate eye solution
homatropine hydrobromide
tropicamide
NON-STEROIDAL
ANTI-INFLAMMATORY AGENTS
bromfenac eye solution
diclofenac sodium
flurbiprofen sodium
ILEVRO
ketorolac tromethamine drops
NEVANAC
PROLENSA
VASOCONSTRICTOR DECONGESTANTS
naphazoline hcl
phenylephrine hcl
ANTIBIOTICS
VITAMINS, HEMATINICS &
ELECTROLYTES
VITAMINS & HEMATINICS
sodium lactate [inj]
TPN ELECTROLYTES [INJ]
TRACE ELEMENTS [INJ]
zinc chloride
zinc sulfate
MISCELLANEOUS NUTRITION
PRODUCTS
BLOOD DERIVATIVES
albumin human [inj]
DIAGNOSTICS &
MISCELLANEOUS AGENTS
erythromycin ointment
ferrex 28
IPOL [INJ]
IXIARO [INJ]
M-M-R II VACCINE W/DILUENT [INJ]
MENACTRA [INJ]
MENOMUNE-A-C-Y-W-135 [INJ]
MYOBLOC [INJ] [SP]
PEDIARIX [INJ]
PEDVAXHIB [INJ]
PNEUMOVAX 23 [INJ]
GLUCOSE ELEVATING AGENTS
PREVNAR 13
GLUCAGEN [INJ]
PRIVIGEN [INJ] [SP]
GLUCAGON
PROQUAD [INJ]
PROGLYCEM
RABAVERT
INSULIN
RAGWITEK
SYRINGES/MISCELLANEOUS DME RECOMBIVAX HB [INJ]
1ST CHOICE LANCETS
ROTATEQ
ACCU-CHEK SOFTCLIX LANCETS DEVICE [OTC] SYNAGIS [INJ] [SP]
ACCU-CHEK FASTCLIX, MULTICLIX, SOFTCLIX, LANCETS
TETANUS
[OTC]
DIPHTHERIA TOXOIDS [INJ]
DEXCOM G4 SENSOR
tetanus toxoid
FEMCAP
THERACYS [INJ]
FORA LANCING DEVICE
THYMOGLOBULIN [INJ] [SP]
FREESTYLE FREEDOM LITE
TICE BCG [INJ]
MINIMED
TRUMENBA
MINIMED RESERVOIR
TUBERSOL [INJ]
gatifloxacin
gentasol
levofloxacin hemihydrate rops
MOXEZA
NATACYN
neomycin/polymyxin/gramicidin
ofloxacin
tobramycin sulfate drops
VIGAMOX
neo/polymyxin/dexamethasone
ferrocite plus
ferrogels forte
folbecal
folbee
folbee plus
folbic
folbic rf
folcaps
folcaps omega-3
folic acid
folic acid [inj]
folic acid-cyancobal-pyridoxin
FOLIC ACID-VIT B12
folivane-f
folivane-ob
folivane-plus
folivane-prx dha nf
folplex 2.2
foltanx
hematinic plus
hematinic with folic acid
hematogen
hematogen fa
hematogen forte
acamprosate calcium
acetic acid irrigation
ADAGEN [INJ] [SP]
AMMONUL [INJ]
anagrelide hydrochloride
ARALAST NP [INJ] [SP]
BREVITAL [INJ]
BROMHEXINE HYDROCHLORIDE
BUPHENYL TABLETS
bupivacaine/dextrose [inj]
caffeine citrated
caffeine citrated [inj]
CARBAGLU [SP]
cevimeline hcl
CHEMET
citric acid
CLINIMIX E [INJ]
deferoxamine [inj]
DELFLEX W/DEXTROSE
dextrose in lactated ringers
dextrose in water
dextrose with sodium chloride
NOVOFINE
NOVOFINE AUTOCOVER
ONE TOUCH ULTRA 2
ONE TOUCH ULTRA SMART
ONE TOUCH ULTRA SYSTEM
ONE TOUCH ULTRAMINI
ONE TOUCH VERIO
neo/polymyxin/dexamethasone
neomycin-polymyxin-dexamethaso
neomycin-polymyxin-dexamethaso drops
neomycin/bacitracin/poly/hc
TOBRADEX
TOBRADEX ST
tobramycin-dexamethasone
hemenatal ob
hemenatal ob + dha
hemetab
hydroxocobalamin
iferex 150 forte
inatal advance
inatal gt
disulfiram
EOVIST [INJ]
ETHAMOLIN
etidronate disodium
etomidate [inj]
EXJADE [SP]
EXTRANEAL ICODEXTRIN DIALYSIS
ZYLET
inatal ultra
FERRIPROX [SP]
infed [inj]
FOSRENOL
INFUVITE [INJ]
L-MEFOLATE-PYRIDOX-MECOBALAMIN
L-METHYL-B6-B12
L-METHYLFOLATE CALCIUM
m.v.i. adult [inj]
M.V.I. PEDIATRIC [INJ]
M.V.I.-12 [INJ]
macnatal cn dha
MEFOLATE-PYRIDOX-MECOBALAMIN
metafolbic
multigen
HEXTEND LACTATED ELECTROLYTE
INCRELEX [INJ][SP]
ISOVUE [INJ]
ISOVUE-M [INJ]
ketamine hcl [inj]
levocarnitine
levocarnitine [inj]
LEXISCAN
MAGNEVIST [INJ]
md-gastroview
midodrine hcl
PRANDIMET
repaglinide
RIOMET
SYMLINPEN 60 [INJ]
tolazamide
tolbutamide
TRADJENTA
VICTOZA [INJ]
XIGDUO XR
ONE TOUCH VERIO IQ
ONE TOUCH VERIO SYNC
ORTHO-DIAPHRAGM
ORTHO-DIAPHRAGM
PARADIGM INFUSION
PARADIGM INSULIN PUMP
PARADIGM SILHOUETTE
POLYFIN QR
PRODIGY INSULIN SYRINGE
PRODIGY PEN NEEDLE
QUICK RELEASE SOFT TEFLON
SILHOUETTE
SILHOUETTE [INJ]
TWINRIX [INJ]
TYPHIM VI [INJ]
VAQTA
VARIVAX VACCINE [INJ]
VARIZIG [INJ]
VIVOTIF BERNA DEL-REL
YF-VAX [INJ]
MUSCULOSKELETAL &
RHEUMATOLOGY
GOUT THERAPY
allopurinol
allopurinol sodium
colchicine
COLCRYS
KRYSTEXXA [INJ]
probenecid
ULORIC
OTHER RHEUMATOLOGICALS
ACTEMRA [INJ] [SP]
BENLYSTA [INJ] [SP]
KEY:
[INJ], [inj] - Injectable Drug; [OTC], [otc] - Over the Counter; [SP], [sp] - Specialty Drug
Brand name drugs are list in CAPITAL letters Example: HUMIRA
Generic drugs are lister in lower-case letters. Example: azithromycin
SULFONAMIDES
sulfacetamide sodium ointment
sulfacetamide sodium drops
STEROIDS
ALREX
dexamethasone sodium phosphate
DUREZOL
fluorometholone
FML S.O.P.
LOTEMAX
PRED MILD
prednisolone acetate
prednisolone sodium phosphate drops
STEROID-ANTIBIOTIC COMBINATIONS
STEROID-SULFONAMIDE
COMBINATIONS
sulfacetamide w/prednisolone
SYMPATHOMIMETICS
ALPHAGAN P 0.1%
apraclonidineeye solution
brimonidine eye solution
MISCELLANEOUS OPHTHALMOLOGICS
azelastine hcl eye solution
balanced salt eye irrigation
BEPREVE
cromolyn sodium eye solution
MISCELLANEOUS AGENTS
Page 5
The list is subject to change at any time and coverage is based on your specific benefit plan.
Preferred Drug List
SOF-SET
SOF-SET MICRO
SOFT TOUCH
SOLOSITE
SURE-T PARADIGM
VGO 20
VGO 30
VGO 40
CYSTARAN [SP]
epinastine hcl
EYLEA [INJ] [SP]
FLUORESCEIN SODIUM
JETREA [INJ] [SP]
LUCENTIS [INJ] [SP]
PATADAY
PATANOL
multigen folic
multigen plus
multitrace-4 ped [inj]
multivitamin w/fluoride & iron
multivitamin with fluoride
mynatal
mynatal caps
mynatal advance
OMNIPAQUE
ORFADIN [SP]
PANHEMATIN [INJ]
pilocarpine hcl
PROHANCE [INJ]
PROLASTIN C [INJ] [SP]
propofol
PROSTAMEN
proparacaine hcl
mynatal plus
RAVICTI [SP]
proparacaine-fluorescein
RESTASIS
sodium chloride drops
tetcaine drops
VISUDYNE [INJ]
mynatal-z
mynate 90 plus er
mynephrocaps
METHYL-B6-B12
NATAL-V RX
RENVELA
riluzole
SEROTONIN HCL
sodium chloride
sodium chloride [inj]
natalvirt 90 dha
sodium chloride irrigation
natalvirt ca
sodium phosphate [inj]
natalvirt flt
sodium polystyrene sulfonate
nephplex rx
sodium thiosulfate [inj]
arbinoxa
nephro-vite rx
nutri-tab ob
SOLIRIS [INJ] [SP]
SOTRADECOL [INJ][SP]
carbinoxamine
cetirizine syrup
clemastine fumarate
cyproheptadine hcl
desloratadine
desloratadine disintegrating tablets
obstetrix dha
pnv ob+dha
pnv-dha
pnv-first
pnv-omega
pnv-select
THALLOUS CHLORIDE TL-201
THYROGEN [INJ] [SP]
TRYPSIN
VIMIZIM [INJ] [SP]
VISIPAQUE [INJ]
water [inj]
azurette
dexchlorpheniramine maleate er
pnv-total
water intravenous solution
cimetidine
balziva
BEYAZ
diphenhydramine [inj]
hydroxyzine hcl
poly-iron 150 forte
polysaccharide iron forte
water solution; irrigation
XIAFLEX [INJ] [SP]
famotidine
famotidine [inj]
famotidine 20 [inj]
nizatidine
briellyn
camrese
camrese lo
caziant
hydroxyzine hcl
hydroxyzine pamoate
levocetirizine dihydrochloride
promethazine hcl
pr natal 400
pr natal 400 ec
pr natal 430
pr natal 430 ec
ZEMAIRA [INJ] [SP]
ranitidine hcl
chateal
promethazine hcl sup
prefol-dha
benzphetamine hcl
ranitidine hcl [inj]
cryselle
promethazine hcl tablets
prena1
diethylpropion hcl
ZANTAC RX
cyclafem
dasetta
promethazine hcl [inj]
promethegan
prena1 chew
prena1 plus
diethylpropion hcl
phendimetrazine tartrate
AUVI-Q
epinephrine
epinephrine [inj]
EPIPEN
EPIPEN JR.
prenaissance
prenaissance 90 dha
prenaissance balance
prenaissance dha
prenaissance harmony dha
prenaissance next
prenaissance plus
phendimetrazine tartrate er
phentermine hcl
FIRST-LANSOPRAZOLE
daysee
elinest
emoquette
enpresse
enskyce
estarylla
falmina
FIRST-OMEPRAZOLE
lansoprazole del-rel
gianvi
gildagia
NEXIUM
NEXIUM [INJ]
omeprazole del-rel
BLOOD GLUCOSE MONITORING
DEVICES & SUPPLIES
CUPRIMINE
ENBREL [INJ]
HUMIRA [INJ] [SP]
leflunomide
ORENCIA [INJ]
RIDAURA
SAVELLA
Brand medications not listed are non-preferred.
Updated April 2015
OSTEOPOROSIS THERAPY
alendronate sodium
ATELVIA
FREESTYLE FREEDOM KIT [OTC]
FORTEO [INJ]
FREESTYLE FREEDOM LITE METER [OTC]
ibandronate sodium
FREESTYLE INSULINX
IBANDRONATE, [INJ]
FREESTYLE INSULINX GLUCOSE SYSTEM [OTC] risedronate, sodium
FREESTYLE INSULINX TEST STRIPS [OTC]
OBSTETRICS & GYNECOLOGY
MONOPHASIC /BIPHASIC
FREESTYLE LITE METER [OTC]
/TRIPHASIC AGENTS
FREESTYLE LITE TEST STRIPS [OTC]
FREESTYLE TEST STRIPS [OTC]
altavera
ONE TOUCH ULTRA TEST STRIPS
ONE TOUCH VERIO
alyacen
amethia
OPTIUM
amethia lo
OPTIUM EZ
amethyst
PRECISION PCX, PCX PLUS, POINT OF CARE, Q-I-D
apri
PRECISION XTRA B-KETONE STRIPS [OTC]
aranelle
PRECISION XTRA MONITOR [OTC]
aubra [inj]
PRECISION XTRA TEST STRIPS [OTC]
aviane
GASTROENTEROLOGY
H2 ANTAGONISTS
PROSTAGLANDINS
misoprostol
OTHER ULCER THERAPY
carafate
lansoprazol-amoxicil-clarithro
sucralfate
PROTON PUMP INHIBITORS
ANTIVIRALS
TRIFLURIDINE
RESPIRATORY, ALLERGY,
COUGH & COLD
ANTIHISTAMINES
ADRENERGICS
ANTITUSSIVE COMBINATIONS
SMOKING DETERRENTS
CHANTIX
ANOREXIANTS
NEUTRACEUTICALS
UVA URSI LEAF FLUID EXTRACT
IRRIGATING SOLUTIONS
neomycin-polymyxin b [inj]
ringers irrigation
ANTIDOTES
prenaplus
prenatabs fa
atropen [inj]
gildess
benzonatate
chlorphen-pse-dm tannate
D-CHLORPHENIRA/PSE/CHLOPHEDIAN 12.5CPD1DCPM-30PSE
prenatabs rx
PROTOPAM CHLORIDE [INJ]
gildess fe
introvale
DEXTROMETHORPHAN HBR
dihydrocodeine-bpm-pe
prenatal ad
prenatal low iron
OMEPRAZOLE-SODIUM BICARBONATE
jolessa
junel
junel fe
kariva
kelnor 1-35
kurvelo
leena
dihydrocodeine/aspirin/caffeine
DM/PHENYLEPH/CHLORPHENIRAMINE 10PEH4CPM-20DM
guaifenesin with codeine
hydrocodone-chlorpheniramine er
HYDROCODONE/HOMATROPINE
promethazine vc w/codeine
promethazine w/dm
PSEUDOEPH/CHLOPHEDIANOL/GG 12.5CPD100GFN-30PSE
prenatal plus
pantoprazole sodium
ANTIDIARRHEALS
diphenoxylate w/atropine
loperamide hcl
opium
paregoric
ANTISPASMODICS
dicyclomine hcl
lessina
levonorgestrel
glycopyrrolate
levora
glycopyrrolate [inj]
LO LOESTRIN FE
hyoscyamine sulfate
hyoscyamine sulfate disinegrating tablets
hyoscyamine sulfate er
LEVSIN
LO MINASTRIN FE
loryna
low-ogestrel
lutera
marlissa
microgestin
microgestin fe
BILE ACIDS
CHENODAL [SP]
KINEVAC [INJ]
ursodiol
TUSSICAPS
DECONGESTANT / ANTIHISTAMINES
brompheniramine w/pseudoephed
phenylephrine/chlorpheniramine
4cpm
XANTHINES
AMITIZA
ANALPRAM ADVANCED CREAM KIT
ANALPRAM 2.5% LOTION
ANALPRAM-HC 1% CREAM SINGLES
ASACOL HD
balsalazide disodium
budesonide ec
CANASA
CITRA PH
CORTIFOAM
orsythia
philith
pirmella
portia
quasense
reclipsen
SAFYRAL
sprintec
albuterol sulfate
ARCAPTA NEOHALER
FORADIL
levalbuterol hcl
PERFOROMIST [INJ]
PROAIR HFA
SEREVENT DISKUS
VENTOLIN HFA
MISC. GASTROINTESTINAL AGENTS
KEY:
[INJ], [inj] - Injectable Drug; [OTC], [otc] - Over the Counter; [SP], [sp] - Specialty Drug
Brand name drugs are list in CAPITAL letters Example: HUMIRA
Generic drugs are lister in lower-case letters. Example: azithromycin
se-tan dha pernatal
se-tan plus
aminophylline [inj]
caffeine/sodium benzoate [inj]
difil-g
theophylline anhydrous elixir
theophylline anhydrous drops er 12 hr
reno caps
se-natal 19
10peh-
pseudoephedrine hcl 12 hour er
pseudoephedrine hcl-d 12 hour
pseudoephedrine sulfate er
mono-linyah
mononessa
myzilra
NATAZIA
necon
norethindrone-e.estradiol iron
norethindrone-ethin estradiol
nortrel
ocella
ogestrel
DIGESTIVE ENZYMES
CREON
pancrelipase
SUCRAID [SP]
VIOKACE
ZENPEP DEL-REL
prenatal-u
pyridoxine hcl
RENA-VITE RX
relnate dha
renal caps
renalpren
BETA AGONISTS ORAL
ALBUTEROL
albuterol sulfate
ephedrine sulfate
metaproterenol sulfate
terbutaline sulfate
BETA AGONISTS INHALERS
setonet
setonet-ec
strovite
STUART ONE
taron forte
taron prenatal
taron-bc
taron-c dha
taron-duo ec
therapeutic hematinic
therapeutic vitamin w-minerals
thiamine hcl
tl g-fol os
tl gard rx
tl icon
tl-care dha
tl-fol 500 er
tl-hem 150 er 24 hr
tl-select
tri rx
triadvance
tricon
trigels-f forte
Page 6