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TRANSCRIPT
Effective January 1, 2015
Notes QL = Quantity Limits may applyB = Brand Drug PA = Prior Authorization may be requiredG = Generic Drug A = Age EditO = Over the Counter (OTC) ST = Step Therapy may be required
Preferred Drug Category
ACNE THERAPY
Acne Therapy - Oral
amnesteem G A; QL; PA
amoxicillin G
Claravis B A; QL; PA
clindamycin G
doxycycline G
erythromycin G
metronidazole G
minocycline G
myorisan G A; QL; PA
zenatane G A; QL; PA
Acne Treatment - Retinoids
adapalene G
tretinoin, cream, gel G A, QL
Acne Treatment Topical (Antibiotics)
Clinda-Derm B PA, QL
Clindamax B PA, QL
Clindamycin, gel, lotion, swab, sol G
erythromycin G
erythromycin-benzoyl peroxide G
metronidazole cream G
Acne Therapy Topical - Miscellaneous
benzoyl peroxide, 4-6%, gel, cr, lot G
This Formulary is a list of the most frequently prescribed medications and may not include all drugs covered under your pharmacy drug benefit. Inclusion of a drug does not guarantee coverage. Check your plan benefit materials for more information about your pharmacy benefit including copayment amounts. This list may change as new drugs are added or due to other factors.
HealthyU Managed Medicaid Formulary
Notes
1
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
Oscion B PA, QL
salicylic acid G
sodium sulfacetamide, cr, liq, G
sodium sulfacetamide/sulfur G
ALZHEIMER'S CHOLINOMIMETICS
Aricept B PA, QL
Aricept ODT B PA, QL
donepezil G QL
Exelon B PA,QL
Exelon Patch B PA, QL
galantamine G QL
Namenda B PA, QL
rivastigmine G QL
ANALGESICS (Non-Opioid)
acetaminophen O
aspirin O
ANAPHYLAXIS THERAPY AGENTS
Epipen B QL
Epipen-Jr B QL
Auvi-Q B QL
ANDROGENS
Androgenic Agents-Topical
Androderm B PA, QL
Androgel B PA, QL
Axiron B PA, QL
Testim B PA, QL
Androgenic Agents - Other
Android B PA, QL
Androxy B PA, QL
Delatestryl B PA, QL
Depo-Tesosterone B PA, QL
Methitest B PA, QL
testosterone cypionate G
testosterone enanthate G
ANESTHETICS-LOCAL
lidocaine gel G
2
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
lidocaine viscous G
ANTI-ANGINAL AGENTS
isosorbide dinitrate G
nitroglycerin sublingual G
nitroglycerin topical G
ANTIARRHYTHMICS
amiodarone G
disopyramide G
mexiletine G
propafenone IR G
quinidine gluconate G
cefdinir G
Suprax, liq, tabs B
cefpodoxime G
ANTIBIOTICS - QUINOLONES
Avelox B QL
Cipro Suspension B
ciprofloxacin G
ciprofloxacin ER G
Levaquin B PA; QL
levofloxacin G QL
ofloxacin G
ANTIBIOTICS - Misc.
amoxicillin G
amoxicillin/clavulanic acid G
azithromycin G
cefadroxil G QL
cephalexin G
clarithromycin G QL
dicloxacillin G
erythromycin G
metronidazole G
minocycline G
nitrofurantoin G
penicillin G
ANTIBIOTICS - CEPHALOSPORINS, 3rd GENERATION ORAL
3
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
rifampin G
sulfamethoxazole/trimethoprim G
tetracycline G
trimethoprim G
ANTIBIOTICS -Topical
mupirocin, oint G
neomycin/polymyxin/bacitracin O
ANTICOAGULANTS
ANTICOAGULANTS - Oral
warfarin G
Xarelto B PA
ANTICOAGULANTS - Injectable
Arixtra B PA; QL
enoxaparin sodium G PA; QL
fondaparinux G QL
Fragmin B QL
Lovenox B PA; QL
ANTIDIABETIC AGENTS – Oral
DPP-4 Inhibitors
Januvia B QL, ST
DPP-4 Inhibitor Combinations
Janumet B QL, ST
Janumet XR B QL, ST
Sulfonylureas
glimepiride G
glipizide G
glyburide G
Antidiabetic Agents - Misc.
glyburide/metformin G
metformin G QL
pioglitazone G QL, ST
pioglitazone/metformin G QL, ST
ANTIDIABETIC AGENTS – Injectable
GLP-1 Receptor Agonists
Bydureon B ST, QL
Byetta B ST, QL
4
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
Victoza B ST, QL
ANTIDIARRHEALS
loperamide AD O
ANTIEMETICS
granisetron G QL
ondansetron G QL
Antiemetics- Misc.
meclizine G
prochlorperazine G
promethazine G
ANTIFUNGALS
Antifungals (Oral)
clotrimazole G
Diflucan B PA, QL
fluconazole G QL
griseofulvin G QL
itraconazole G QL
ketoconazole G
nystatin G
Oravig B PA
terbinafine G QL
Vfend B QL
voriconazole G QL
Antifungals (Topical)
ciclopirox G QL
clotrimazole, cream, solution G
Lotrimin AF, cream, solution-Generic only O PA
econazole nitrate, cream G
ketoconazole, shampoo, cr., foam G
nystatin, powder, oint., cream G
Nystop, powder B
selenium sulfide G
Antifungals (Vaginal)
3-day vaginal cream O
clotrimazole 3, cream/applicator O
Antiemetics (5 HT-3 Antagonists, Neurokinin-1 Antagonists)
5
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
clotrimazole, cream/applicator O
miconazole 1-3 G
miconazole 7, cream/applicator G
miconazole nitrate G
terconazole G
ANTI-GOUT AGENTS
allopurinol G
colchicine G
probenecid G
ANTIHISTAMINE - Nasal Agents
Astelin B PA, QL; ST
azelastine HCL G QL
ANTIHISTAMINE - Ocular Agents
azelastine G
cromolyn G
epinastine G QL
ketotifen G QL
Optivar B ST
Patanol B PA, QL
ANTIHISTAMINE - Oral Agents
cetirizine O
diphenhydramine O
doxylamine O
hydroxyzine G
levocetirizine G
loratadine O
ANTIHYPERLIPIDEMIC AGENTS
Fibric Acid & Miscellaneous Derivatives
Antara B QL; ST
cholestyramine G
choline fenofibrate G QL
colestipol G
fenofibrate G QL
gemfibrozil G
Lovaza B QL; ST
niacin ER G ST, QL
6
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
Niacor B PA, QL
Tricor B ST; QL
Zetia B QL
atorvastatin G QL
Crestor B PA, QL; ST
Lipitor B PA, QL; ST
simvastatin G QL
Altoprev B PA, QL; ST
fluvastatin and fluvastatin XL G PA, QL
Lescol, and Lescol XL B PA, QL; ST
lovastatin G QL
Mevacor B PA, QL; ST
Pravachol G PA, QL; ST
pravastatin G QL
Cholesterol-Lowering Combinations
Vytorin B ST, QL
Statin-Hypotensive Combinations
Caduet B PA, QL
atorvastatin/amlodipine G PA, QL
ANTIHYPERTENSIVE AGENTS
Alpha/Beta-Adrenergic Blocking Agents
carvedilol G
labetalol G
Angiotensin Converting Enzyme (ACE) Inhibitors
benazepril G
captopril G
enalapril G
fosinopril G
lisinopril G
moexipril G
quinapril G
ramipril G QL
trandolapril G
benazepril / HCTZ (generic) G
Angiotensin Converting Enzyme (ACE) Inhibitor Combinations
HMG Co-A Reductase Inhibitors (“Statins”)
7
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
captopril / HCTZ (generic) G
enalapril / HCTZ (generic) G
fosinopril / HCTZ (generic) G
lisinopril / HCTZ (generic) G
moexipril / HCTZ (generic) G
quinapril / HCTZ (generic) G
Angiotensin Receptor Blockers (ARBs)
Avapro B PA, QL; ST
Benicar B ST, QL
Diovan B ST, QL
irbesartan G QL
losartan G QL
Avalide B PA, QL; ST
Benicar HCT B ST, QL
Diovan HCT B ST, QL
irbesartan/hctz G QL
losartan/hctz G QL
valsartan/hctz G ST, QL
Angiotensin Receptor Blocker (ARB) + Calcium Channel Blocker CombinationsAzor B PA, QL
Exforge HCT B PA, QL
Beta-Adrenergic Blocking Agents
acebutolol G
atenolol G
betaxolol G
bisoprolol G
metoprolol G
nadolol G
pindolol G
propranolol G
sotalol G
timolol G
Beta-Adrenergic Blocking Agent Combinations
atenolol/chlorthalidone G
Angiotensin Receptor Blocker (ARB) + Thiazide Combinations
8
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
bisoprolol/HCTZ G
metoprolol/HCTZ G
nadolol/bendroflumethiazide G
propranolol/HCTZ G
Calcium Channel Blocking Agents
amlodipine G QL
diltiazem G
felodipine G
isradipine G
nicardipine G
nifedipine G
nimodipine G
nisoldipine G QL
verapamil G
Direct Renin Inhibitors
Tekturna B ST, QL
Direct Renin Inhibitors/ Combinations
Tekamlo B ST, QL
Direct Renin Inhibitors/HCTZ
Tekturna HCT B ST, QL
ANTINEOPLASTICS
Antineoplastics PA
ANTI-VIRALS
Antiretrovirals Class Covered
acyclovir G
Tamiflu B QL
valacyclovir G
ASTHMA MEDICATIONS
Asthma Medication Chambers/Spacers
Aerochamber B
Arial O
Breatherite B
Easivent B
E-Z Spacer B
Inspirease B
9
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
LiteAire B
Microchamber B
Microspacer B
Nessi O
Optichamber B
Optihaler B
Pocket Chamber B
Pocket Spacer B
RiteFlo B
Valved Holding Chamber B
Vortex Valved Holding Chamber B
Watchhaler B
Beta Agonists (Long Acting ) – Solutions for Nebulizer
Brovana B PA
Perforomist B PA
Beta Agonists (Long Acting ) – Metered Dose Inhalers
Serevent Diskus B QL
Beta Agonists (Short Acting ) – Solution for Nebulizer
albuterol G
levalbuterol G PA
metaproterenol G
Xopenex Soln B PA
Beta Agonists (Short Acting ) – Metered Dose Inhalers
albuterol G
Ventolin HFA B QL
Xopenex HFA Inhalation B PA, QL
Combination Corticosteroid / LABA Inhalers
Advair Diskus B QL
Advair HFA B QL
Dulera B QL
Symbicort B QL
Corticosteroids – Metered Dose Inhalers
Asmanex B QL
Azmacort B QL
Flovent Discus B QL
Flovent HFA B QL
10
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
Qvar B QL
Corticosteroids – Solution for Nebulizer
budesonide ampules G QL
Leukotriene Medications
Accolate B PA, QL
montelukast G QL
zafirlukast G QL
Zyflo CR B ST, QL
BENIGN PROSTATIC HYPERPLASIA (BPH)
alfuzosin G
Avodart B PA, QL; ST
doxazosin G QL
finasteride G QL
Flomax B PA, QL; ST
prazosin G QL
tamsulosin G QL
terazosin G
Uroxatral B PA, QL; ST
BRONCHODILATOR - Inhaled Anticholinergic
Atrovent, HFA B QL
ipratropium G
Spiriva B QL
Combivent B QL
Combivent Respimat B QL
ipratropium/albuterol G
Tudorza B
CONTRACEPTIVES
Contraceptives - Low Dose and Mono-phasic
Altavera G QL
Amethyst G QL
Apri G QL
Aviane G QL
Balziva B QL
Beyaz B QL
BRONCHODILATOR - Inhaled Anticholinergic Combinations
BRONCHODILATOR - Long-acting Anticholinergic
11
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
Briellyn G QL
Cryselle G QL
Cyclafem G QL
Desogen B QL
Emoquette G QL
Femcon FE B QL
Generess FE B QL
Gianvi G QL
Gildess FE 1mg-20mcg only G QL
Jolessa G QL
Junel G QL
Junel FE G QL
Lessina G QL
Levlen 28 B QL
Levora-28 B QL
Loestrin G QL
Loestrin FE G QL
Loryna G QL
Low-Ogestrel G QL
Lutera G QL
Lybrel G QL
Microgestin G QL
Microgestin FE G QL
Modicon G QL
Mononessa G QL
Necon G QL
Nordette-28 G QL
Norgestrel-Ethinyl Estradiol G QL
Norinyl 1+35 G QL
Norinyl 1+50 G QL
Nortrel G QL
Ocella G QL
Ogestrel G QL
Ortho-Cept G QL
Ortho-Cyclen G QL
Ortho-Novum G QL
12
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
Ovcon-50 G QL
Portia G QL
Previfem G QL
Quasense G QL
Reclipsen G QL
Safyral G QL
Seasonale G QL
Solia G QL
Sprintec G QL
Sronyx G QL
Syeda G QL
Yasmin 28 G QL
Yaz G QL
Zarah G QL
Zenchent G QL
Zeosa G QL
Zovia G QL
Contraceptives - Bi-phasic
Amethia G QL
Azurette G QL
Camrese G QL
Camrese LO G QL
Kariva G QL
Loseasonique B QL
Mircette B QL
Necon 10-11 G QL
Seasonique B QL
Contraceptives - Tri-phasic/Multi-phasic
Aranelle G QL
Caziant G QL
Cyclafem G QL
Cyclessa B QL
Enpresse G QL
Estrostep FE B QL
Necon G QL
Nortrel G QL
13
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
Ortho Evra B QL
Ortho Tri-Cyclen B QL
Ortho Tri-Cyclen Lo B QL
Ortho-Novum 7 Days x 3 B QL
Tilia FE G QL
Tri-Legest FE G QL
Tri-Norinyl 7-9-5 B QL
Tri-Previfem G QL
Tri-Sprintec G QL
Trinessa G QL
Trivora-28 G QL
Velivet G QL
Contraceptives - Emergency
levonorgestrel G QL
Next Choice B QL
Plan B One-Step B QL
Contraceptives - Progestin Only
Camila G QL
Errin G QL
Heather G QL
Jolivette G QL
Micronor B QL
Nor-Q-D G QL
Nora-BE G QL
Norethindrone G QL
Contraceptives - Misc
Nuvaring B
Contraceptive creams, foams, tablets, sponges and condoms O
CORTICOSTEROIDS
Corticosteroids - Oral
dexamethasone G
methylprednisolone G
prednisolone G
prednisone G
Corticosteroids - Topical
betamethasone dipropionate G
14
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
betamethasone valerate G
fluocinolone G
hydrocortisone G
triamcinolone G
Antitussives
guaifenesin/codeine G
guaifenesin/DM O
promethazine/codeine G
Decongestants and Decongestant Combos
loratadine D O
pseudoephedrine O
Triaminic(s) O
Expectorants
guaifenesin O
guaifenesin SR O
Pulmozyme B PA;QL
Tobi B PA;QL
alcohol swabs O QL
Ascensia O
Breeze 2 O
Contour O
Bayer Products O
Freestyle Products O
Insulin syringes with needles-Disposable O QL
lancets O QL
TB Syringe B QL
Precision Products O
Abbott Products O
Urine Testing Products (Clinistix, Clinitest, Diastix, Ketostix) O
Diuretics
acetazolamide G
bumetanide G
DIURETICS
COUGH and COLD AGENTS
CYSTIC FIBROSIS AGENTS
DIABETIC TEST SUPPLIES and ADJUNCTS
15
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
chlorthalidone G
furosemide G
hydrochlorothiazide G
metolazone G
spironolactone G
Diuretic Combinations
spironolactone/hydrochlorothiazide G
triamterene/hydrochlorothizide G
Estrogens (Oral)
Cenestin B PA
estradiol G
estropipate G
Menest B PA
Estrogens (Combinations)
Combipatch B PA, QL
estradiol-norethindrone G
Jevantique G
Jinteli G
Mimvey G
Prempro B QL
Estrogens (Topical)
estradiol patch G
Vivelle-DOT B PA; QL
Estrogens (Vaginal)
Estring B QL
Premarin Cream B QL
Vagifem B QL
Alpha Adrenergic
Alphagan P B PA
apraclonidine G
brimonidine G
lopidine G
Beta Blocker
betaxolol G
EYEDROP
ESTROGENS
16
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
timolol G
Beta Blocker Combination
dorzolamide/timolol G
Misc.
dorzolamide G
pilocarpine G
Prostaglandin
latanoprost G QL
Travatan B ST
H2 Receptor Blockers
cimetidine G
famotidine O
ranitidine G
Proton Pump Inhibitors
lansoprazole G QL
omeprazole (generic) B QL
pantoprazole G QL
Prilosec OTC O QL
Gastrointestinal Agents-Misc.
calcium carbonate (antacid) O
calcium carbonate/mag. hydroxide (antacid) O
metoclopramide G
sucralfate G
Genotropin B PA; QL
Norditropin B PA; QL
Aranesp B PA; QL
Epogen B PA; QL
Procrit B PA; QL
Neulasta B PA; QL
Neupogen B PA; QL
Baraclude B PA; QL
HEPATITIS B AGENTS
GASTROINTESTINAL AGENTS
GROWTH HORMONES
GRANULOCYTE COLONY-STIMULATING FACTORS
HEMATOPOIETIC AGENTS - Erythropoietins
17
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
Hepsera B PA; QL
Viread B PA; QL
Interferons
Pegasys B PA; QL
Peg-Intron B PA; QL
Nucleoside Analogues
Rebetol B PA; QL
ribavirin G PA; QL
Polymerase Inhibitors
Sovaldi B PA; QL
Protease Inhibitors
Victrelis B PA; QL
temazepam G QL
zaleplon G QL
zolpidem G QL
Apriso B QL
Asacol / HD B QL
balsalazide G
Delzicol B
mesalamine G
sulfasalazine G
Cimzia B PA; QL
Enbrel B PA; QL
Humira B PA; QL
Rapid Acting Insulins
Apidra B QL
Novolin-R B QL
Novolog B QL
Intermediate Acting Insulins
Novolin-N B QL
Long Acting Insulins
INSULINS
HEPATITIS C AGENTS
HYPNOTICS
INFLAMMATORY BOWEL AGENTS
IMMUNOMODULATORS
18
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
Lantus B QL
Levemir B QL
Insulin Mixtures
Novolin 70/30 B QL
Novalog 70/30 B QL
bisacodyl O
citrate of magnesia O
docusate sodium O
Milk of Magnesia O
Miralax O
polyethylene glycol O
psyllium muciloid powder O
Senna O
sennosides/docusate O
Senokot 8.6 mg-Generic only O
calcitriol G
Sensipar B PA, QL
Axert B ST, QL
butalbital/apap/caffeine G QL
Cafergot G
Imitrex, Spray, Pen, Sub-Q vial B QL; ST
Maxalt (all dosage forms) B ST, QL
naratriptan G QL
rizatriptan G QL
sumatriptan G QL
zolmitriptan G QL
Avonex B PA, QL
Betaseron B PA, QL
Copaxone B PA, QL
Gilenya B PA, QL
Rebif B PA, QL
Tecfidera B PA
LAXATIVES
METABOLIC MODIFIERS
MIGRAINE AGENTS
MULTIPLE SCLEROSIS AGENTS
19
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Preferred Drug Category Notes
flunisolide G QL
fluticasone propionate G QL
Nasonex B ST, QL
triamcinolone spray G QL
Veramyst B ST, QL
Cox-2 Inhibitors
Celebrex B ST, QL
Non-Selective Non-Steroidal Anti-Inflamatories
Advil B QL
Anaprox DS B PA, QL
Cataflam B PA, QL
diclofenac potassium G QL
diclofenac sodium G QL
etodolac G
flurbiprofen G
ibuprofen G QL
Indocin B PA
Indocin Suppository B QL
indomethacin G
ketoprofen G
ketorolac injectable G
meloxicam G QL
Mobic B PA, QL
Motrin B PA, QL
nabumetone G
Nalfon G ST, QL
Naprosyn B PA, QL
naproxen G QL
naproxen sodium G
Oxaprozin B
sulindac G
tolmetin G
AK-POLY-BAC B
OPTHALMIC ANTIBIOTICS
NASAL CORTICOSTEROIDS
NON-STEROIDAL ANTI-INFLAMMATORIES
20
The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
bacitracin G
bacitracin/polymyxin B G
Ciloxan, drops, oint. B PA
ciprofloxacin G
erythromycin, oint G
Garamycin G
Gentak G
gentamicin oint G
gentamicin, drops G
Ilotycin G
levofloxacin G
neomycin-polymyxn B/Gramicidin G
Neosporin B PA
Ocuflox B PA
ofloxacin G
polymyxin B/trimethoprim G
Polytrim B PA
Terramycin/Polymyxin B B
Tobrex B
Vigamox B
Opthalmic Anti-Inflammatory Corticosteroid Agents
Alrex B
dexamethasone sodium phosphate G QL
Flarex B QL
fluorometholone G QL
FML, FML Forte, FML S.O.P. oint. B PA, QL
Lotemax B QL
Maxidex B QL
Pred Forte B PA, QL
Pred Mild B QL
prednisolone acetate G QL
prednisolone sodium phosphate G QL
Opthalmic Anti-Inflammatory NSAID Agents
Acular B PA
Acuvail B
OPHTHALMIC ANTI-INFLAMMATORY AGENTS
21
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Preferred Drug Category Notes
bromfenac sodium G
diclofenac sodium G
flurbiprofen sodium G
Ilevro B
ketorolac tromethamine G
Ocufen B PA
Opthalmic Anti-Inflammatory Combination Agents
Bleph-10 B PA, QL
Blephamide, Blephamide S.O.P. B QL
Maxitrol B PA, QL
neomycin-polymyxin-HC G
neomycin/bacitracin/polymyxin/hc G
neomycin/polymyxin/dexamethasone G
sulfacetamide sodium G
sulfacetamide-prednisolone G
Tobradex B PA (for drops), QL
tobramycin-dexamethasone G QL
Opioid Narcotics
apap/codeine G QL
Avinza B PA, QL; ST
fentanyl patch (generic) G QL
hydrocodone/APAP G QL
hydromorphone G QL
methadone (generic) G QL
morphine sulfate ER (generic) G QL
morphine sulfate IR G QL
Opana ER B QL
opioids (long / short acting) G QL
oxycodone G QL
oxycodone/APAP G QL
oxymorphone G QL
tramadol G QL
alendronate G QL
etidronate G QL
OPIOID NARCOTICS
OSTEOPOROSIS AGENTS
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Preferred Drug Category Notes
ibandronate G QL
antipyrine/benzocaine G
Ciprodex B
Cipro HC B
ofloxacin G
Creon B
Zenpep B
COMT Inhibitors & Combinations
carbidopa/levodopa G QL
MAO Inhibitors
selegiline G QL
Nonergot-Derived Dopamine Receptor Agonists
Mirapex B PA, QL
Mirapex ER B PA, QL
pramipexole G
ropinirole G
calcium acetate (phosphate binder) G
Fosrenol B
Renagel B
Renvela B
Aggrenox B PA
Agrylin B PA
anagrelide G PA
cilostazol G PA
clopidogrel 75mg G QL
dipyrimadole G PA
Effient B PA
pentoxifylline G PA
Pletal B PA
ticlopidine G
Trental B PA
PARKINSON'S AGENTS
PHOSPHATE BINDER AGENTS
PLATELET AGGREGATION INHIBITORS
OTIC AGENTS
PANCREATIC ENZYMES
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The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
potassium chloride G
17-alpha hydroxyprogesterone (compound) G
Makena B
Pulmonary Antihypertenives-Endothelin Antagonists
Letairis B PA
Tracleer B PA
Pulmonary Antihypertenives-Phosphodiesterase-5 Enzyme InhibitorsAdcirca B PA
Revatio B PA
sildenafil G
Pulmonary Antihypertenives-Prostacyclines
epoprostenol inj G PA
Ventavis B PA
lindane G QL
malathion G QL
Nix B/G QL
Rid B/G QL
Agents for Acute Injury Treatment
carisoprodol G QL
chlorzoxazone G QL
cyclobenzaprine G QL
metaxalone G QL
methocarbamol G QL
orphenadrine G QL
Skelaxin B PA, QL
Agents for Long Term Treatment
baclofen G QL
dantrolene G
Lioresal G PA
tizanidine G QL
POTASSIUM SUPPLEMENTS
PROGESTINS
PULMONARY ANTIHYPERTENSIVES
SCABICIDES
SKELETAL MUSCLE RELAXANTS
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The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
Combination Agents for Short Term Use
carisoprodol compound G QL
carisoprodol compound with codeine G QL
orphenadrine compound G QL
Chantix B PA; QL
Nicorette O
Nicoderm O
Nicorelief O
Commit O
Nicotine Gum O
Nicotine Patch O
Armour Thyroid B
levothyroxine G
liothyronine G
phenazopyridine G
Long Acting Agents
Ditropan XL B PA, QL; ST
Enablex B ST,QL
oxybutynin XL G
Toviaz B ST, QL
Vesicare B ST, QL
Short Acting Agents
flavoxate G
oxybutynin G
calcitriol G
calcium (oyster shell not covered) O
ferrous gluconate O
ferrous sulfate O
folic acid G
Inatal Advance B
Inatal GT B
URINARY ANALGESICS
URINARY ANTISPASMODICS
VITAMINS / MINERALS / SUPPLEMENTS
SMOKING DETERRENTS
THYROID AGENTS
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The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.
Preferred Drug Category Notes
Inatal Ultra B
M-Vit B
Marnatal-F B
Maxinate B
Mephyton B
O-Cal FA B
O-Cal Prenatal B
pediatric multiple vitamins G A
Prenatal Low Iron B
Prenatal Vitamins Plus B
prenatal vitamins with folic acid G PA
PureFe OB Plus B
PNV Folic Acid + Iron B
Se-Natal 19 B
Taron-Bc B
TriAdvance B
Trinatal GT B
Trinatal Rx 1 B
Trinatal Ultra B
Triveen-U B
Tri-Vi-Sol O
Tri-Vita O
Tri-Vitamin O
Vinate GT B
Vinate II B
Vinate M B
Vinate One B
Vinate Ultra B
Vol-nate B
Vol-Plus B
Vol-tab Rx B
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The contents of this document are confidential and proprietary and may not be reproduced, transmitted, published, or disclosed to others without prior authorization.