February1, 2008
Help to stretch your prescription dollar
RegenceRx Preferred Medication List/Formulary
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
2
Your Preferred
Medication List/Formulary
3
Common Questions and Answers
Preferred/Formulary Medications
4-11
12-17
18-22
• By Category
• A to Z Listing
– Generics
– P
referred/Formulary Brands
Non-Preferred/Non-Formulary Brands
Table of Contents
23-27
• G
eneric and Preferred
Brand Alternatives
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
RegenceRx is dedicated to provide the tools you need to
understand your options and be a more informed consumer.
This preferred medication list/formulary will help—with the
answers you need to access affordable prescription benefits.
Determining Cost
How much you pay for a prescription
depends on whether it’s a:
• Generic
• Preferred/formulary brand name
•Non-preferred/non-formulary
brand name (brand name
medication not on the list)
Newly-introduced
generic medications
When a generic is introduced to the
marketplace, it immediately becomes
available at the lowest copay. After a
generic is available, the brand name
medication will only be available at the
non-preferred/non-formulary copay.
Your cost is lowest for generic
medications and highest for nonpreferred/non-formulary brand name
medications. You can find specific
coverage and copay information in
your summary of benefits.
Preferred/formulary
brand name medications
Brand name medications on the
preferred medication list (PML)
have been chosen because our
professional review has shown each
of them to be high-quality, effective,
and affordable. Preferred/formulary
brand name medications are either
more effective or equally effective—at
a lower cost—than other brand name
medications not listed.
Generic medications
Generics provide the same
therapeutic benefits of their brand
name counterparts, without the
brand name price. In fact, generic
medications are generally 20-60%
less expensive. The U.S. Food and
Drug Administration assures both
generic and brand name medications
meet the same high standards for
strength, quality, and purity.
Non-preferred/non-formulary
brand name medications
Non-preferred/non-formulary brand
name medications are those that do
not appear on the PML due to side
effects, therapeutic performance,
or higher cost. You may still opt
for these medications, but your
copay will be higher than any other
prescription type.
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
How can I use the PML/formulary
to get the best benefit?
What if my medication needs
prior authorization?
Ask your doctor to prescribe
generic medications whenever
possible. If a generic is not available,
ask your doctor to choose a
preferred/formulary brand name
medication. Take this list when you
go to the doctor so you can discuss
your options.
Certain medications may need prior
authorization. This means that we
will need to review information from
your doctor before the medication
can be approved for coverage. For a
list of medications that need prior
authorization, please visit our Web
site at www.regencerx.com or
contact our Customer Service
Department at the phone number
listed on your member card.
How can I tell if a listed medication
is a generic?
Generic medications are listed
in lower case bold, like this:
fluconazole.
How can I tell if a listed medication
is a brand?
Brand name medications start with
a capital letter and are followed by
a registered trademark symbol like
this: ®.
Brand name medications listed in
parentheses after a generic are:
• non-preferred/non-formulary
• o
nly listed as a reference for a
generically available medication
Please remember that not all brands
are preferred/formulary.
If you decide to purchase the
medication without authorization, you
will be responsible for the total cost of
the prescription.
What resources were used to
determine what medications would
be on the PML/formulary?
Information from the US Food and
Drug Administration (FDA), medical
literature (including scientific studies),
and national treatment guidelines
were reviewed by the RegenceRx
Pharmacy and Therapeutics (P&T)
Committee. This committee includes
practicing doctors and pharmacists.
When there are choices, medications
with the best value were included on
the PML/formulary.
What if my medication is not on
the PML/formulary?
Q and A
First, check with your doctor. There
are preferred/formulary alternatives
in most cases, and your doctor
can determine an acceptable
alternative for your medical
condition. If you remain on a
non-preferred/non-formulary brand
name medication, your benefit will
depend on your coverage.
If you have questions, please
contact our Customer Service
Department at the phone number
listed on your member card. Or
visit us at www.regencerx.com.
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Preferred/Formulary Medications: By Category
Effective February 1, 2008
This list can be used to assist you and your doctor in choosing a generic or preferred/formulary medication.
•
Generic medications are listed in lower case bold. Example: fluconazole.
•
Brand name medications start with a capital letter and are followed by a registered trademark symbol like this ®.
Example: Ancobon®.
•
Brand name medications listed in parenthesis after a generic are:
- Non-preferred/non-formulary.
- Only listed as a reference for a generically available medication. Example: fluconazole (Diflucan® )
Additional Information:
-
-
-
-
Preferred/formulary medications are limited to the dosage form and strength listed; if no strength is listed,
all strengths for the listed dosage form are preferred/formulary.
Sustained action/release (SA/SR), extended release (ER/XR), long-acting (LA), and enteric coated (EC) medications
are only preferred/formulary if listed.
Occasionally, preferred/formulary medications may be contract exclusions and, therefore, are not covered.
Some medications may require prior authorization or have quantity limits.
Please note that the PML/formulary list may change. To view the most current list, visit our Web site at www.regencerx.com.
For more detailed prescription benefit information, please refer to your benefits booklet.
ANTIFUNGALS (Systemic)
fluconazole tablet, oral suspension (Diflucan®)
griseofulvin microsize oral suspension (Grifulvin V®)
griseofulvin microsize tablet (Fulvicin® U/F)
griseofulvin ultramicrosize tablet (Fulvicin® P/G)
itraconazole capsule (Sporanox®)*
ketoconazole tablet (Nizoral®)
nystatin suspension, tablet (Mycostatin®)
terbinafine HCL tablet (Lamisil®)*
Ancobon® capsule
Mycelex® Troche
Sporanox solution*
Vfend® tablet, oral suspension
ANTI-INFECTIVES (cont.)
erythromycin ethyl suc tablet, suspension (EES®)
erythromycin/sulfisox suspension (Pediazole®)
ethambutol tablet (Myambutol®)
hydroxychloroquine tablet (Plaquenil®)
isoniazid tablet
mebendazole chewtabs (Vermox®)
metronidazole tablet (Flagyl®)
minocycline capsule (Minocin®)
nitrofurantoin capsule (Macrodantin®, Macrobid®)
ofloxacin tablet (Floxin®)
penicillin V potassium tablet, suspension (Veetids®)
pyrazinamide tablet
rifampin capsule (Rifadin®)
rifampin/isoniazid capsule (Rifamate®)
sulfamethoxazole/trimethoprim tablet, suspension
(Bactrim®, Septra®)
sulfadiazine tablet (Microsulfon®)
sulfisoxazole tablet, suspension (Gantrisin®)
tetracycline capsule (Achromycin®)
trimethoprim tablet (Proloprim®)
Albenza® tablet
Alinia® tablet, suspension
Augmentin ES-600® oral suspension
Avelox® tablet
Biltricide® tablet
Dapsone® tablet
Daraprim® tablet
Fansidar® tablet
Furadantin® oral suspension
Furoxone® tablet, oral suspension
Humatin® capsule
Lamprene® capsule
Lariam® tablet
Mepron® oral suspension
ANTI-INFECTIVES
amoxicillin capsule, suspension, tablet,
chews, drops (Amoxil®)
amoxicillin/pot. clavulanate tabs, chews,
suspension (Augmentin®)
azithromycin tablet, packet, suspension (Zithromax®)
cefaclor capsule, suspension (Ceclor®)
cefadroxil capsule, tablet, suspension (Duricef®)
cefdinir capsule, suspension (Omnicef®)
cefprozil tablet, suspension (Cefzil®)
cefuroxime tablet (Ceftin®)
cephalexin capsule (Keflex®)
cephradine capsule (Velosef®)
chloroquine tablet (Aralen®)
ciprofloxacin tablet, suspension (Cipro®)
clarithromycin tablet (Biaxin®)
clindamycin capsule (Cleocin®)
dicloxacillin capsule (Dynapen®)
doxycycline capsule, tablet (Vibramycin®)
doxycycline hyclate tablet (Periostat®)
erythromycin base EC tablet (Emycin®)
*May not be a covered benefit under some plans.
4
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
ANTI-INFECTIVES (cont.)
Mintezol® oral suspension, chewable
Mycobutin® capsule
Primaquine tablet
Seromycin® capsule
Stromectal® tablet
Yodoxin® tablet
Zyvox® tablet, oral suspension
ANTI-VIRALS/HIV/AIDS (cont.)
Kaletra® capsule, oral solution
Lexiva® tablet
Norvir® capsule, oral solution
Prezista™ tablet
Rebetol® oral solution
Rescriptor® tablet
Reyataz® capsule
Sustiva® capsule, tablet
Tamiflu® capsule, suspension for reconstitution
Trizivir® tablet
Valtrex® tablet
Videx® chew tab, solution, packet
Viracept® tablet, powder for oral solution
Viramune® tablet, oral suspension
Viread® tablet
Zerit® capsule, oral solution
Ziagen® tablet, oral solution
ANTINEOPLASTICS
cyclophosphamide tablet (Cytoxan®)
etoposide capsule (Toposar®, Vepesid®)
flutamide capsule (Eulexin®)
hydroxyurea capsule (Hydrea®)
leucovorin tablet (Wellcovorin®)
megestrol tablet, syrup (Megace®)
tamoxifen tablet (Nolvadex®)
tretinoin capsule (Vesanoid®)
Alkeran® tablet
Arimidex® tablet
Aromasin® tablet
Casodex® tablet
CeeNu® capsule
Droxia capsule
Emcyt® capsule
Fareston® tablet
Femara® tablet
Gleevec® tablet, capsule
Hexalen® capsule
Leukeran® tablet
Lysodren® tablet
Matulane® capsule
Mesnex® tablet
Myleran® tablet
Nolvadex® tablet
Purinethol® tablet
Tarceva® tablet
Temodar® capsule
Thioguanine® tablet
Xeloda® tablet
BEHAVIOR MODIFICATION
amphetamine/dextroamphetamine tablet (Adderall®)
dextroamphetamine SR capsule
(Dexedrine Spansule®)
dextroamphetamine tablet (Dexedrine®)
methylphenidate tablet (Ritalin®)
methylphenidate ER tablet (Ritalin® SR)
Adderall XR™ capsule
Antabuse® tablet
Metadate® CD capsule
BLOOD MODIFIERS
aminocaproic acid tablet (Amicar®)
anagrelide capsule (Agrylin®)
cilostazol tablet (Pletal®)
dipyridamole tablet (Persantine®)
pentoxifylline tablet (Trental®)
ticlopidine tablet (Ticlid®)
warfarin tablet (Coumadin®)
Coumadin® tablet
Mephyton® tablet
Plavix® tablet
BONE & JOINT
allopurinol tablet (Zyloprim®)
colchicine tablet
leflunomide tablet (Arava®)
methotrexate tablet (Rheumatrex®)
probenecid tablet
sulfasalazine tablet (Azulfidine® EN-tabs®)
Actonel® tablet
Actonel® with Calcium tablet
Cuprimine® capsule
Depen® tablet
Didronel® tablet
Evista® tablet
Fosamax® tablet, oral solution
Fosamax Plus D™ tablet
Ridaura® capsule
Miacalcin® nasal spray
ANTI-VIRALS/HIV/AIDS
acyclovir tablet, capsule, suspension (Zovirax®)
amantadine capsule, syrup (Symmetrel®)
didanosine capsule (Videx EC®)
famciclovir tablet (Famvir®)
ganciclovir capsule (Cytovene®)
ribavirin capsule (Rebetol)
ribavirin tablet (Copegus)
rimantadine tablet (Flumadine®)
zidovudine capsule, tablet, syrup (Retrovir®)
Agenerase® capsule, oral solution
Atripla™ tablet
Baraclude® tablet, oral solution
Combivir® tablet
Crixivan® capsule
Emtriva® capsule
Epivir® tablet, oral solution
Epivir HBV® tablet, oral solution
Epzicom® tablet
Fortovase® capsule
Hepsera® tablet
Hivid® tablet
Invirase® capsule, tablet
CARDIOVASCULAR
acebutolol capsule (Sectral®)
amiloride tablet (Midamor®)
amiloride/HCTZ tablet (Moduretic®)
amiodarone tablet (Cordarone®)
amlodipine besylate (Norvasc®)
5
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
CARDIOVASCULAR (cont.)
amlodipine besylate/benazepril capsule (Lotrel®)
atenolol tablet (Tenormin®)
atenolol/chlorthalidone tablet (Tenoretic®)
benazepril HCL tablet (Lotensin®)
benazepril HCL/HCTZ tablet (Lotensin® HCT)
betaxolol tablet (Kerlone®)
bumetanide tablet (Bumex®)
captopril tablet (Capoten®)
captopril/HCTZ tablet (Capozide®)
carvedilol tablet (Coreg®)
chlorothiazide tablet (Diuril®)
chlorthalidone tablet (Thalitone®)
clonidine tablet (Catapres®)
digoxin tablet, elixir (Lanoxin)
diltiazem tablet (Cardizem®)
diltiazem SR capsule (Cardizem® SR)
diltiazem SR capsule (Cardizem® CD)
diltiazem SR capsule (Dilacor® XR)
disopyramide & ER capsule (Norpace®, Norpace CR®)
doxazosin tablet (Cardura®)
enalapril tablet (Vasotec®)
enalapril/HCTZ tablet (Vaseretic®)
felodipine tablet (Plendil)
flecainide tablet (Tambocor®)
fosinopril tablet (Monopril®)
fosinopril/HCTZ tablet (Monopril HCT®)
furosemide tablet (Lasix®)
guanfacine tablet (Tenex®)
hydralazine tablet (Apresoline®)
hydralazine/HCTZ tablet (Apresazide®)
hydrochlorothiazide tablet (Oretic®)
indapamide tablet (Lozol®)
isosorbide dinitrate & ER tablet
(Isordil® & Dilatrate® SR)
isosorbide mononitrate & ER tablet
(Ismo® & Imdur®)
labetalol tablet (Trandate®)
lisinopril tablet (Zestril®, Prinivil®)
lisinopril/HCTZ tablet (Zestoretic®)
methyclothiazide tablet (Enduron®)
methyldopa tablet (Aldomet®)
metolazone tablet (Zaroxolyn®)
metoprolol tablet (Lopressor®)
metoprolol succinate tablet (Toprol XL®)
mexiletine capsule (Mexitil®)
midodrine tablet (Proamatine®)
minoxidil tablet (Loniten®)
moexipril/HCTZ tablet (Uniretic®)
moexipril HCL tablet (Univasc®)
nadolol tablet (Corgard®)
nicardipine capsule (Cardene®)
nifedipine capsule (Procardia®)
nifedipine SA tablet (Adalat® CC)
nimodipine capsule (Nimotop®)
nitroglycerin patch (Minitran®, Nitro-Dur®)
nitroglycerin capsule (NitroTime®)
pindolol tablet (Visken®)
potassium chloride tablet (K-Dur®)
prazosin capsule (Minipress®)
procainamide capsule (Pronestyl®)
procainamide SA tablet (Pronestyl SR®)
propafenone tablet (Rythmol®)
propranolol tablet (Inderal®)
propranolol/HCTZ tablet (Inderide®)
quinapril tablet (Accupril®)
quinapril/HCTZ tablet (Accuretic®)
CARDIOVASCULAR (cont.)
quinidine gluconate tablet (Quinaglute®)
quinidine sulfate tablet (Quinidex®)
ramipril capsule (Altace®)
sotalol tablet (Betapace®)
spironolactone tablet (Aldactone®)
spironolactone/HCTZ tablet (Aldactazide®)
terazosin capsule (Hytrin®)
timolol maleate tablet (Blocadren®)
trandolapril tablet (Mavik®)
triamterene/HCTZ tablet (Maxzide®)
verapamil tablet (Calan®)
verapamil SR tablet (Calan SR®)
Benicar™ tablet
Benicar HCT™ tablet
Catapres-TTS® patch
Cordarone® tablet
Inderal® LA capsule
Innopran XL™ capsule
Kaon-CL-10® tablet
K-Dur® tablet
K-Lyte® DS tablet
Lanoxicaps®
Lanoxin® tablet, elixir
Micardis® tablet
Micardis HCT® tablet
Micro-K® capsule
Norpace® CR capsule
Procanbid® tablet
Revatio™ tablet
Sular® tablet
Tikosyn® capsule
Tracleer® tablet
CHOLESTEROL LOWERING
cholestyramine/sucrose powder (Questran®)
colestipol HCL granules, tablet (Colestid®)
fenofibrate microsphere capsule, tablet (Lofibra®)
gemfibrozil capsule (Lopid®)
lovastatin tablet (Mevacor®)
pravastatin tablet (Pravachol®)
simvastatin tablet (Zocor®)
Colestid® packet
Crestor® tablet
Niaspan® tablet
Vytorin® tablet
DIABETES
acetohexamide tablet (Dymelor®)
chlorpropamide tablet (Diabinese®)
glimepiride tablet (Amaryl®)
glipizide tablet (Glucotrol®)
glipizide ER tablet (Glucotrol® XL)
glipizide-metformin (Metaglip™)
glyburide tablet (Diabeta®)
glyburide, micronized tablet (Glynase®)
metformin tablet (Glucophage®)
metformin ER tablet (Glucophage® XR)
tolazamide tablet (Tolinase®)
tolbutamide tablet (Orinase®)
Actos® tablet
Avandia® tablet
GlucaGen® injection
Glucagon® injection
Humalog® insulins
Humulin® insulins
Lantus® insulin
6
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
DIABETES (cont.)
Lantus® SoloSTAR® insulin
Novolin® insulins
Novolog® insulins
Prandin® tablet
Precose® tablet
Proglycem® capsule, oral suspension
GASTROINTESTINAL (cont.)
Anzemet® tablet
Asacol®tablet, oral solution
Canasa® rectal suppository
Colyte® powder for reconstitution
Compro® rectal suppository
Cortifoam® rectal foam
Creon® capsule
Dipentum® capsule
Epifoam® topical foam
Golytely® powder for reconstitution, packets
Helidac® combopak
Kristalose® packet
Kutrase® capsule
Ku-zyme® capsule
Ku-zyme® HP capsule
Kytril® tablet, solution
NuLytely® powder for reconstitution
Pancrease® capsule
Pancrease® MT capsule
Pancrecarb MS® capsule
Pentasa® capsule
Prevacid® capsule, suspension, tablet
PrevPac®
Prilosec OTC™ - Available at the generic copay.
ProctoFoam®-HC rectal foam
Ultrase® capsule
Ultrase® MT capsule
URSO® tablet
Viokase® tablet, powder
Visicol® tablet
DIABETIC SUPPLIES
- Please check if these are covered by your prescription benefit:
Ascensia® test strips*
Ascensia Breeze® 2 test strips*
Ascensia Contour® test strips*
Novofine® needles*
Lancets, needles, syringes (all products)*
EAR/NOSE/THROAT
acetic acid otic (Acetasol®)
acetic acid/hydrocortisone otic (Acetasol®-HC)
benzocaine/antipyrine otic (Aurodex®)
benzonatate capsule (Tessalon®)
clemastine tablet (Tavist®)
fexofenadine tablet (Allegra®)
flunisolide nasal spray (Nasalide®)
fluticasone propionate nasal spray (Flonase®)
hydrocodone/homatropine tablet, syrup (Hycodan®)
hydrocort/polymyx/neomycin otic
(Cortisporin® Otic)
ipratropium nasal spray (Atrovent®)
Astelin®nasal spray
BromHist® oral solution
Carboxine-PSE® liquid
Cerumenex® otic solution
Ciprodex® otic suspension
Cipro® HC otic suspension
Nasacort® AQ nasal spray
Nasonex® nasal spray
Relacon-HC® syrup
Rescon JR® capsule
Rhinocort® Aqua® nasal spray
HORMONE/ENDOCRINE (ALSO SEE WOMEN’S HEALTH)
calcitriol capsule (Rocaltrol®)
cortisone acetate tablet (Cortone®)
desmopressin tablet, nasal spray, nasal solution (DDAVP®)
dexamethasone tablet, elixir (Decadron®)
fludrocortisone tablet (Florinef®)
folic acid tablet (Folvite®)
levothyroxine sodium tablet
methimazole tablet (Tapazole®)
methylprednisolone tablet (Medrol®)
prednisolone 15mg/5ml syrup (Prelone®)
prednisolone sod phosphate oral solution (Orapred®)
prednisone tablet, solution (Deltasone®)
propylthiouracil tablet
thyroid dessicated tablet
triamcinolone tablet (Aristocort®)
unithroid tablet
Armour® Thyroid tablet
Cytomel® tablet
DDAVP® nasal spray, nasal solution
Dexamethasone Intensol® oral solution
Levothroid® tablet
Levoxyl® tablet
Methitest® tablet
Nilandron® tablet
Pediapred® oral solution
Prednisone Intensol® oral concentrate
Stimate® nasal spray
Synthroid® tablet
Teslac® tablet
Testred® tablet
Thyrolar® tablet
Westhroid® tablet
Winstrol® tablet
GASTROINTESTINAL
cimetidine tablet, liquid (Tagamet®)
dicyclomine capsule, tablet (Bentyl®)
diphenoxylate/atropine tablet (Lomotil®)
famotidine tablet (Pepcid®)
hyoscyamine capsule (Levsin®)
lactulose syrup (Enulose®)
loperamide capsule, liquid (Imodium®)
meclizine tablet (Antivert®)
mesalamine enema (Rowasa®)
metoclopramide tablet, syrup (Reglan®)
misoprostil tablet (Cytotec®)
omeprazole capsule (Prilosec® )
ondansetron tablet (Zofran ODT® )
ondansetron HCL tablet, oral solution (Zofran® )
pantoprazole sodium tablet (Protonix® )
polyethylene glycol/electrolyte solution
prochlorperazine tablet (Compazine®)
promethazine tablet, suppository (Phenergan®)
ranitidine tablet, syrup (Zantac®)
sucralfate tablet (Carafate®)
sulfasalazine tablet (Azulfidine® EN-tabs®)
trimethobenzamide capsule, suppository
(Tigan®)
ursodiol capsule (Actigall®)
Analpram HC® rectal cream, rectal lotion
*May not be a covered benefit under some plans.
7
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
IMMUNOSUPPRESSANTS
azathioprine tablet (Imuran®)
cyclosporine, modified capsule, solution (Neoral®)
cyclosporine capsule, solution (Sandimmune®)
CellCept® tablet, capsule, suspension
Myfortic® ER tablet
Prograf® capsule
Rapamune® tablet, solution
Sandimmune® capsule, solution
MENTAL HEALTH (cont.)
Nardil® tablet
Orap® tablet
Risperdal® tablet, solution
Seroquel® tablet
Zyprexa® tablet
Zyprexa Zydis® tablet
MUSCLE RELAXANTS
baclofen tablet (Lioresal®)
carisoprodol tablet (Soma®)
carisoprodol/ASA tablet (Soma® Compound)
cyclobenzaprine tablet (Flexeril®)
dantrolene capsule (Dantrium®)
methocarbamol tablet (Robaxin®)
methocarbamol/ASA tablet (Robaxisal®)
tizanidine tablet (Zanaflex®)
MENTAL HEALTH
alprazolam tablet (Xanax®)
amitriptyline tablet (Elavil®)
amoxapine tablet (Asendin®)
bupropion SR tablet (Wellbutrin SR®)
buspirone tablet (BuSpar®)
chloral hydrate capsule
chlordiazepoxide capsule (Librium®)
chlorpromazine tablet, drops, syrup
(Thorazine®)
citalopram tablet (Celexa)
clomipramine capsule (Anafranil®)
clonazepam tablet (Klonopin®)
clorazepate tablet (Tranxene®)
clozapine tablet (Clozaril®)
desipramine tablet (Norpramin®)
diazepam tablet, solution (Valium®)
doxepin capsule (Sinequan®)
estazolam tablet (Prosom®)
fluoxetine capsule (Prozac®)
fluphenazine tablet, concentrate, elixir
(Prolixin®)
flurazepam capsule (Dalmane®)
fluvoxamine tablet (Luvox®)
haloperidol tablet, solution (Haldol®)
hydroxyzine HCL tablet (Atarax®)
hydroxyzine pamoate capsule (Vistaril)
imipramine tablet (Tofranil®)
lithium carbonate capsule (Eskalith®)
lithium citrate syrup
lorazepam tablet (Ativan®)
loxapine succinate capsule (Loxitane®)
maprotiline tablet (Ludiomil®)
mirtazapine tablet (Remeron®)
nefazodone tablet (Serzone®)
nortriptyline capsule (Pamelor®)
oxazepam capsule (Serax®)
paroxetine tablet (Paxil®)
perphenazine tablet (Trilafon®)
protriptyline tablet (Vivactil®)
sertraline tablet (Zoloft®)
temazepam capsule (Restoril®)
thioridazine tablet, solution (Mellaril®)
thiothixene capsule (Navane®)
tranylcypromine sulfate tablet (Parnate®)
trazodone tablet (Desyrel®)
triazolam tablet (Halcion®)
trifluoperazine tablet (Stelazine®)
venlafaxine HCL tablet (Effexor®)
zolpidem tartrate tablet (Ambien®)
Effexor XR® capsule
Eskalith® capsule, tablet
Eskalith CR® tablet
Lithobid® tablet
Lorazepam Intensol® oral concentrate
Moban® tablet, oral concentrate
NEUROLOGICAL
benztropine tablet (Cogentin®)
bromocriptine capsule, tablet (Parlodel®)
cabergoline tablet (Dostinex®)
carbamazepine tablet, chews, suspension (Tegretol®)
carbidopa/levodopa tablet (Sinemet®)
ethosuximide syrup (Zarontin)
gabapentin tablet, capsule (Neurontin®)
lamotrigine tablet (Lamictal®)
oxcarbazepine tablet (Trileptal®)
phenobarbital tablet, elixir
phenytoin sodium capsule (Dilantin®)
primidone tablet (Mysoline®)
selegiline tablet, capsule (Eldepryl®)
trihexyphenidyl tablet (Artane®)
valproic acid capsule, syrup (Depakene®)
valproate sodium syrup (Depakene®)
zonisamide capsule (Zonegran®)
Aricept® tablet
Aricept ODT® tablet
Carbatrol® capsule
Celontin® tablet, capsule
Cognex® capsule
Comtan® tablet
Depakote® tablet
Depakote® ER tablet
Depakote Sprinkle® capsule
Diastat® rectal gel
Diastat® AcuDial™ rectal gel
Dilantin® capsule, chews, suspension
Epitol® tablet
Exelon® capsule, solution
Felbatol® tablet, oral suspension
Gabitril® tablet
Kemadrin® tablet
Keppra® tablet, solution
Lamictal® tablet
Mebaral® tablet
Mestinon® tablet, syrup
Mirapex® tablet
Mysoline® tablet, oral suspension
Phenytek® capsule
Razadyne™ tablet, solution
Requip® tablet
Rilutek® tablet
Stalevo® tablet
Tegretol® XR tablet
Topamax® tablet, sprinkle
Zarontin® capsule, syrup
8
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
OPHTHALMIC
acetazolamide tablet (Diamox®)
atropine ophthalmic solution (Atropair®)
bacitracin ophthalmic solution
betaxolol ophthalmic solution
brimonidine ophthalmic solution (Alphagan®)
carteolol ophthalmic solution
cromolyn ophthalmic solution (Crolom)
dexamethasone sod phos ophthalmic suspension
diclofenac sod ophthalmic solution
dipivefrin ophthalmic solution (Propine)
erythromycin base ophthalmic ointment
fluorometholone ophthalmic suspension (Fluor-Op®)
flurbiprofen ophthalmic solution (Ocufen®)
gentamicin ophthalmic solution (Genoptic®)
homatropine ophthalmic solution
(Isopto® Homatropine)
ketotifen fumarate ophthalmic solution (Zaditor®)
levobunolol ophthalmic solution (Betagan®)
methazolamide tablet (Neptazane®)
naphazoline ophthalmic solution (Vasocon®)
neo/polymyx/dexamethasone ophthalmic suspension,
ointment
phenylephrine ophthalmic solution
pilocarpine ophthalmic solution (Adsorbocarpine®)
prednisolone acetate ophthalmic suspension
(Pred Forte®)
prednisolone sod phosphate ophthalmic solution
(Inflamase Forte®)
sulfacetamide ophthalmic solution (Bleph®-10)
timolol maleate ophthalmic solution (Timoptic®)
tobramycin ophthalmic solution (Tobrex®)
trifluridine ophthalmic solution (Viroptic®)
Acular® ophthalmic solution
Acular LS™ ophthalmic solution
Acular® PF ophthalmic droperette
Alocril® ophthalmic solution
Alphagan® P ophthalmic solution
Alrex® ophthalmic suspension
Azopt® ophthalmic suspension
Betimol® ophthalmic solution
Betoptic S® ophthalmic suspension
Blephamide S.O.P. ophthalmic ointment
Ciloxan® ophthalmic solution, ointment
Cosopt® ophthalmic solution
Cyclogyl® ophthalmic solution
Diamox Sequels® capsule
FML® S.O.P. ophthalmic ointment
Isopto® Atropine ophthalmic solution
Isopto® Homatropine ophthalmic solution
Lotemax® ophthalmic suspension
Lumigan® ophthalmic solution
Ocuflox® ophthalmic solution
Patanol® ophthalmic solution
Pilopine HS® ophthalmic gel
Pred-Mild® ophthalmic suspension
Timoptic-XE® ophthalmic sol-gel
TobraDex® ophthalmic suspension, ointment
Travatan® ophthalmic solution
Travatan Z® ophthalmic solution
Trusopt® ophthalmic solution
PAIN & INFLAMMATORY DISEASE (cont.)
ergotamine/caffeine tablet, suppository (Cafergot®)
etodolac capsule (Lodine®)
fenoprofen tablet, capsule (Nalfon®)
fentanyl citrate lollipop (Actiq®)
fentanyl patch (Duragesic®)
flurbiprofen tablet (Ansaid®)
hydrocodone/APAP tablet (Vicodin®)
hydrocodone/ibuprofen tablet (Vicoprofen®)
hydromorphone tablet (Dilaudid®)
ibuprofen tablet (Motrin®)
indomethacin capsule (Indocin®)
ketoprofen capsule (Orudis®)
ketoprofen ER capsule (Oruvail® SR)
meclofenamate capsule (Meclomen®)
meloxicam tablet (Mobic®)
meperidine tablet, syrup (Demerol®)
methadone tablet, solution, concentrate
(Dolophine®)
morphine sulfate tablet, capsule, solution
morphine SR tablet (MS Contin®)
nabumetone tablet (Relafen®)
naproxen tablet (Naprosyn®)
oxaprozin tablet (Daypro®)
oxycodone capsule (OxyIR®)
oxycodone SR tablets (OxyContin®)
oxycodone/APAP tablet (Percocet®)
oxycodone/ASA tablet (Percodan®)
piroxicam capsule (Feldene®)
propoxyphene/APAP tablet (Darvocet N®-100)
salsalate tablet (Disalcid®)
sulindac tablet (Clinoril®)
tolmetin tablet (Tolectin®)
tramadol tablet (Ultram®)
tramadol/APAP tablet (Ultracet®)
Ergomar® tablet
Imitrex® tablet, nasal spray, injection
Kadian® capsule
Maxalt® tablet
Maxalt®-MLT tablet
Migranal® nasal spray
Phrenalin® with caffeine/codeine capsule
Relpax® tablet
Zomig® tablet, nasal spray
Zomig-ZMT™ tablet
RESPIRATORY
acetylcysteine solution (Mucomyst®)
albuterol oral inhaler, inhalation solution,
tablet, syrup (Proventil®)
aminophylline tablet, liquid
cromolyn sodium solution (Intal®)
dyphylline tablet (Lufyllin®)
ipratropium bromide solution (Atrovent®)
ipratropium/albuterol inhalation solution (Duoneb®)
metaproterenol tablet, syrup, inhalation solution
(Alupent®)
theophylline tablet, capsule, elixir
Accolate® tablet
Asmanex® twisthaler
Atrovent® oral inhaler
Atrovent HFA® oral inhaler
Azmacort® oral inhaler
Beclovent® oral inhaler
Combivent® oral inhaler
PAIN & INFLAMMATORY DISEASE
choline mag trisalicylate tablet (Trilisate®)
codeine/APAP tablet (Tylenol® #3)
diclofenac tablet (Voltaren®)
diflunisal tablet (Dolobid®)
9
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
RESPIRATORY (cont.)
Flovent® Diskus® oral inhaler
Flovent HFA® oral inhaler
Foradil® oral inhaler
Intal® oral inhaler
Nebupent® powder for inhalation
Peak Flow Meters
ProAir® HFA oral inhaler
Proventil HFA® oral inhaler
Pulmicort Respules®
Pulmicort® oral inhaler
Pulmozyme® inhalation solution
QVAR® oral inhaler
Serevent Diskus® oral inhaler
Singulair® tablet, granules, chews
Spacer devices
Spiriva® oral inhaler
Tilade® oral inhaler
Tobi® oral inhalation solution
Uniphyl® tablet
SKIN/TOPICAL
amcinonide cream, ointment, lotion (Cyclocort®)
bacitracin/polymyxin ointment (Polysporin®)
betamethasone dipropionate cream, gel, lotion, ointment
(Diprolene®)
betamethasone dipropionate augmented cream
(Diprolene AF®)
betamethasone valerate liquid, lotion (Beta-val®)
betamethasone/clotrimazole cream (Lotrisone®)
ciclopirox cream, gel, topical suspension (Loprox®)
ciclopirox topical solution (Penlac®)*
clindamycin topical gel, lotion, solution (Cleocin®)
clobetasol propionate cream, lotion, ointment
(Temovate®)
desonide/petrolatum cream (Desonide®)
desoximetasone gel, ointment, cream (Topicort®)
diflorasone diacetate ointment, cream (Psorcon®)
erythromycin base/benzoyl peroxide gel
(Benzamycin®)
fluocinolone acetonide cream, ointment
(Synalar®)
fluocinonide cream, ointment, solution, gel
(Lidex®)
fluorouracil cream, solution (Efudex®)
gentamicin cream, ointment (Garamycin®)
hydrocortisone cream, ointment, lotion
(Ala-cort®)
hydrocortisone butyrate cream, ointment, solution (Locoid®)
isotretinoin (amnesteem, claravis, sotret) capsule (Accutane®)
ketoconazole shampoo (Nizoral®)
lidocaine viscous solution (Xylocaine®)
lindane lotion, shampoo (Kwell®)
mometasone cream, lotion, ointment (Elocon®)
mupirocin ointment (Bactroban®)
permethrin 5% cream (Elimite®)
podofilox solution (Condylox®)
silver sulfadiazine cream (Silvadene®)
sulfacetamide sodium/sulfur emulsion, medicated pad
(Plexion®)
tretinoin cream, gel, lotion (Retin A®)*
triamcinolone acetonide cream, ointment (Aristocort®)
urea cream, gel, lotion (Keralac®)
Aclovate® cream, ointment
Azelex® cream
Bactroban® cream
Bactroban® nasal ointment
*May not be a covered benefit under some plans.
10
SKIN/TOPICAL (cont.)
Benzac W® gel
Capex® shampoo
Carac® cream
Centany® ointment
Cloderm® cream
Condylox® gel, solution
Cordran® lotion, tape, ointment, cream
Cutivate® cream, lotion, ointment
Derma-Smooth/FS® oil
Differin® gel, cream, solution, swab
Dovonex® ointment, cream, solution
Eurax® cream, lotion
Fluoroplex® cream, solution
Loprox® shampoo
Luxiq® foam
MetroCream®
MetroGel®
Phisohex® liquid
MetroLotion®
Noritate® cream
Ovide® lotion
Retin A Micro® gel*
Soriatane® capsule
Soriatane® CK kit
Tazorac® cream, gel
Topicort LP® cream
Ultravate® cream, ointment
UROLOGY
citric acid/sodium citrate solution (Bicitra®)
bethanechol tablet (Urecholine®)
finasteride tablet (Proscar®)
methenamine hippurate tablet (Hiprex®)
methenamine mandelate tablet (Mandelamine®)
oxybutynin tablet (Ditropan®)
oxybutynin chloride ER tablet (Ditropan® XL)
phenazopyridine tablet (Pyridium®)
potassium citrate tablet (Urocit-K®)
Detrol® LA capsule
Elmiron® capsule
Uroxatral® tablet
WOMEN’S HEALTH
clomiphene citrate tablet (Clomid®)*
cryselle tablet*
danazol capsule (Danocrine®)
estradiol tablet (Estrace)
estradiol transdermal patch
estropipate tablet (Ogen)
medroxyprogesterone acetate tablet
menest tablet
metronidazole vaginal gel (MetroGel-Vaginal®)
nora-BE tablet*
previfem tablet*
tilia FE tablet* (Estrostep® FE)
tri-legest FE tablet* (Estrostep® FE)
Alesse® tablet*
Anemagen® capsule
Cenestin® tablet
Demulen® tablet*
Desogen® tablet*
Diaphragms*
Esclim® patch
Estraderm® patch
FemHRT® tablet
Gynazole®-1 vaginal cream
Loestrin® tablet*
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
OTHER
chlorhexidine gluconate oral rinse (Peridex®)
fluoride drops
pilocarpine tablet (Salagen®)
Buphenyl® tablet, powder
Carnitor® tablet, liquid
Chemet® capsule
Cystadane® oral powder
Dialyvite® tablet
Evoxac® tablet
Galzin® capsule
PerioGard® oral liquid
PhosLo® capsule, tablet
Radiogardase® capsule
Sensipar® tablet
Syprine® capsule
WOMEN’S HEALTH (cont.)
Loestrin® FE tablet*
Loestrin® 24 FE tablet*
LoOvral® tablet*
Methergine® tablet
Micronor® tablet*
Modicon® tablet*
Nestab FA® tablet
Nordette® tablet*
Norinyl® tablet*
Nor-QD® tablet*
Ortho Cept® tablet*
Ortho Cyclen® tablet*
Ortho Evra® patch*
Ortho Novum® tablet*
Ortho Prefest® tablet
Ortho Tri-Cyclen® tablet*
Ortho Tri-Cyclen® Lo tablet*
Ovral® tablet*
Ovrette® tablet*
Plan B® tablet*
Premarin® tablet
Premarin® vaginal cream
Premphase® tablet
Prempro® tablet
Serophene® tablet*
Terazol® vaginal cream
Tri-Levlen® tablet*
Tri-Norinyl® tablet*
Triphasil® tablet*
Vagifem® vaginal tablet
Vivelle® patch
Vivelle-DOT® patch
SELF-INJECTED
cyanocobalamin injection
heparin sodium injection
leuprolide non-depot injection
octreotide acetate injection (Sandostatin®)
Apokyn® injection
Aranesp® injection
Avonex® injection
Copaxone® injection
Enbrel® injection
Epipen® injection
Epipen® Jr injection
Epogen® injection
Fragmin® injection
Fuzeon® injection
Increlex™ injection
Innohep® injection
Intron® A injection
Leukine® injection
Lovenox® injection
Miacalcin® injection
Neupogen® injection
Nutropin AQ® injection*▼
Nutropin Depot® injection*▼
Nutropin® injection*▼
Pegasys® injection
Peg-Intron® injection
Peg-Intron® Redipen injection
Procrit® injection
Rebetron® injection
Rebif® injection
Saizen® injection*▼
*May not be a covered benefit under some plans.
▼
Obtain from a designated Specialty Pharmacy.
11
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
A to Z Listing: Generics
Effective February 1, 2008
This list can be used to assist you and your doctor in choosing a generic.
• Generic medications are listed in lower case bold.
• Non-preferred/non-formulary brands are listed only as a reference for generically available medications.
• Not all generics are listed. Those listed are examples of some of the generic medications available.
Additional Information:
- Occasionally, generic medications may be contract exclusions and, therefore, are not covered.
- Some medications may require prior authorization or have quantity limits.
Please note that the PML/formulary list may change. To view the most current list, visit our Web site at www.regencerx.com.
For more detailed prescription benefit information, please refer to your benefits booklet.
Generic
A
acebutolol capsule
acetazolamide tablet
acetic acid otic
acetic acid/hydrocortisone otic
acetohexamide tablet
acetylcysteine solution
acyclovir tablet, capsule,
suspension
albuterol oral inhaler,
inhalation solution, tablet,
syrup
allopurinol tablet
alprazolam tablet
amantadine capsule, syrup
amcinonide cream, ointment,
lotion
amiloride tablet
amiloride/HCTZ tablet
aminocaproic acid tablet
aminophylline tablet, liquid
amiodarone tablet
amitriptyline tablet
amlodipine besylate tablet
amlodipine besylate/benazepril
capsule
amoxapine tablet
amoxicillin capsule, tablet,
suspension, chews, drops
amoxicillin/pot. clavulanate
tabs, chews, suspension
amphetamine/
dextroamphetamine tablet
anagrelide capsule
atenolol tablet
atenolol/chlorthalidone tablet
atropine ophthalmic solution
**This brand is preferred/formulary.
Non-Preferred/NonFormulary Brand Name
azathioprine tablet
Sectral®
Diamox®
Acetasol®
Acetasol®-HC
Dymelor®
Mucomyst®
Imuran®
azithromycin tablet, packet,
suspension
B
bacitracin ophthalmic solution
bacitracin/polymyxin ointment
baclofen tablet
benazepril tablet
benzocaine/antipyrine otic
benzonatate capsule
benztropine tablet
betamethasone dipropionate
cream, gel, lotion, ointment
betamethasone dipropionate
augmented cream
betamethasone valerate liquid,
lotion
betamethasone/clotrimazole
cream
betaxolol ophthalmic solution
betaxolol tablet
bethanechol tablet
brimonidine ophthalmic
solution
bromocriptine capsule, tablet
bumetanide tablet
bupropion SR tablet
buspirone tablet
C
cabergoline tablet
calcitriol capsule
captopril tablet
Zovirax®
Proventil®
Zyloprim®
Xanax®
Symmetrel®
Cyclocort®
Midamor®
Moduretic®
Amicar®
Cordarone®**
Elavil®
Norvasc®
Lotrel®
Asendin
Non-Preferred/NonFormulary Brand Name
Generic
®
Amoxil®
Augmentin®
Adderall®
Agrylin®
Tenormin®
Tenoretic®
Atropair®
captopril/HCTZ tablet
carbamazepine tablet, chews,
suspension
carbidopa/levodopa tablet
12
Zithromax®
Polysporin®
Lioresal®
Lotensin®
Aurodex®
Tessalon®
Cogentin®
Diprolene®
Diprolene AF®
Beta-val®
Lotrisone®
Kerlone®
Urecholine®
Alphagan®
Parlodel®
Bumex®
Wellbutrin SR®
BuSpar®
Dostinex®
Rocaltrol®
Capoten®
Capozide®
Tegretol®
Sinemet®
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Generic
carisoprodol tablet
carisoprodol/ASA tablet
carteolol ophthalmic solution
carvedilol tablet
cefaclor capsule, suspension
cefadroxil capsule, tablet,
suspension
cefdinir capsule, suspension
cefprozil tablet, suspension
cefuroxime tablet
cephalexin capsule
cephradine capsule
chloral hydrate capsule
chlordiazepoxide capsule
chlorhexidine gluconate oral
rinse
chloroquine tablet
chlorothiazide tablet
chlorpromazine tablet, drops,
syrup
chlorpropamide tablet
chlorthalidone tablet
cholestyramine/sucrose
powder
choline mag trisalicylate tablet
ciclopirox cream, gel, topical
suspension
ciclopirox topical solution*
cilostazol tab
cimetidine tablet, liquid
ciprofloxacin tablet,
suspension
citalopram tablet
citric acid/sodium citrate
solution
clarithromycin tablet
clemastine tablet
clindamycin capsule
clindamycin topical gel, lotion,
solution
clobetasol propionate cream,
lotion, ointment
clomiphene citrate tablet*
clomipramine capsule
clonazepam tablet
clonidine tablet
clozapine tablet
clorazepate tablet
codeine/APAP tablet
colchicine tablet
colestipol HCL granules, tablet
cortisone acetate tablet
cromolyn ophthalmic solution
cromolyn neb sodium solution
cryselle tablet*
cyanocobalamin injection
Non-Preferred/NonFormulary Brand Name
Soma®
Soma® Compound
Generic
cyclobenzaprine tablet
cyclophosphamide tablet
cyclosporine capsule, solution
cyclosporine, modified capsule,
solution
D
danazol capsule
dantrolene capsule
desipramine tablet
desmopressin tablet, nasal
spray, nasal solution
desonide/petrolatum cream
desoximetasone gel, ointment,
cream
dexamethasone sod phos
ophthalmic suspension
dexamethasone tablet, elixir
dextroamphetamine tablet
dextroamphetamine SR
capsule
diazepam tablet, solution
diclofenac sod ophthalmic
solution
diclofenac tablet
dicloxacillin capsule
dicyclomine capsule, tablet
didanosine capsule
diflorasone diacetate ointment,
cream
diflunisal tablet
digoxin tablet, elixir
diltiazem SR capsule
diltiazem SR capsule
diltiazem SR capsule
diltiazem tablet
diphenoxylate/atropine tablet
dipivefrin ophthalmic solution
dipyridamole tablet
Coreg®
Ceclor®
Duricef®
Omnicef®
Cefzil®
Ceftin®
Keflex®
Velosef®
Librium®
Peridex®
Aralen®
Diuril®
Thorazine®
Diabinese®
Hygroton®
Questran®
Trilisate®
Loprox®
Penlac®
Pletal®
Tagamet®
Cipro®
Celexa
Bicitra®
Biaxin®
Tavist®
Cleocin®
Cleocin®
disopyramide & ER capsule
doxazosin tablet
doxepin capsule
doxycycline capsule, tablet
doxycycline hyclate tablet
dyphylline tablet
E
enalapril tablet
enalapril/HCTZ tablet
ergotamine/caffeine tablet,
suppository
erythromycin base EC tablet
erythromycin base ophthalmic
ointment
erythromycin base/benzoyl
peroxide gel
erythromycin ethylsuc tablet,
suspension
Temovate®
Clomid®*
Anafranil®
Klonopin®
Catapres®
Clozaril®
Tranxene®
Tylenol® #3
Colestid®
Cortone®
Crolom
Intal®
Lo/Ovral®**
*May not be a covered benefit under some plans.
**This brand is preferred/formulary.
13
Non-Preferred/NonFormulary Brand
Flexeril®
Cytoxan®
Sandimmune®**
Neoral®
Danocrine®
Dantrium®
Norpramin®
DDAVP®**
Desonide®
Topicort®
Decadron®
Dexedrine®
Dexedrine Spansule®
Valium®
Voltaren®
Dynapen®
Bentyl®
Videx EC®
Psorcon®
Dolobid®
Lanoxin**
Cardizem® CD
Cardizem® SR
Dilacor® XR
Cardizem®
Lomotil®
Propine®
Persantine®
Norpace®, Norpace CR®**
Cardura®
Sinequan®
Vibramycin®
Periostat®
Lufyllin®
Vasotec®
Vaseretic®
Cafergot®
Emycin®
Benzamycin®
EES®
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Generic
erythromycin/sulfisoxazole
suspension
estazolam tablet
estradiol tablet
estradiol transdermal patch
estropipate tablet
ethambutol tablet
ethosuximide syrup
etodolac capsule
etoposide capsule
F
famciclovir tablet
famotidine tablet
felodipine tablet
fenofibrate microsphere
capsule, tablet
fenoprofen tablet, capsule
fentanyl citrate lollipop
fentanyl patch
fexofenadine tablet
finasteride tablet
flecainide tablet
fluconazole tablet, oral
suspension
fludrocortisone tablet
flunisolide nasal spray
fluticasone propionate nasal
spray
fluocinolone acetonide cream,
ointment
fluocinonide cream, ointment,
solution, gel
fluoride drops
fluorometholone ophthalmic
suspension
fluorouracil cream, solution
fluoxetine capsule
fluphenazine tablet,
concentrate, elixir
flurazepam capsule
flurbiprofen ophthalmic
solution
flurbiprofen tablet
flutamide capsule
fluvoxamine tablet
folic acid tablet
fosinopril tablet
fosinopril/HCTZ tablet
furosemide tablet
G
gabapentin capsule, tablet
ganciclovir capsule
gemfibrozil capsule
gentamicin cream, ointment
gentamicin ophthalmic
solution
glimepiride tablet
Non-Preferred/NonFormulary Brand Name
Generic
glipizide tablet
glipizide ER tablet
glipizide-metformin tablet
glyburide tablet
glyburide, micronized tablet
griseofulvin microsize oral
suspension
griseofulvin microsize tablet
griseofulvin ultramicrosize
tablet
guanfacine tablet
H
haloperidol tablet, solution
heparin sodium injection
homatropine ophthalmic
solution
hydralazine tablet
hydralazine/HCTZ tablet
hydrochlorothiazide tablet
hydrocodone/APAP tablet
hydrocodone/homatropine
tablet, syrup
hydrocodone/ibuprofen tablet
hydrocort/polymyx/neomycin otic
hydrocortisone cream,
ointment, lotion
hydrocortisone butyrate
cream, ointment, solution
hydromorphone tablet
hydroxychloroquine tablet
hydroxyurea capsule
hydroxyzine HCL tablet
hydroxyzine pamoate capsule
hyoscyamine capsule
I
ibuprofen tablet
imipramine tablet
indapamide tablet
indomethacin capsule
ipratropium bromide solution
ipratropium nasal spray
ipratropium/albuterol
inhalation solution
isoniazid tablet
isosorbide dinitrate & ER
tablet
isosorbide mononitrate & ER
tablet
isotretinoin (amnesteem,
claravis, sotret) capsule
itraconazole capsule*
K
ketoconazole shampoo, tablet
Pediazole®
Prosom®
Estrace
Ogen
Myambutol®
Zarontin**
Lodine®
Toposar®, Vepesid®
Famvir®
Pepcid®
Plendil
Nalfon®
Actiq®
Duragesic®
Allegra®
Proscar
Tambocor®
Diflucan
Florinef®
Nasalide®
Flonase
®
Synalar
®
Lidex®
Fluor-Op®
Efudex®
Prozac®
Prolixin®
Dalmane®
Ocufen®
Ansaid®
Eulexin®
Luvox®
Folvite®
Monopril®
Monopril HCT®
Lasix®
Neurontin
Cytovene®
Lopid®
Garamycin®
®
Genoptic®
Amaryl®
*May not be a covered benefit under some plans.
**This brand is preferred/formulary.
14
Non-Preferred/NonFormulary Brand Name
Glucotrol®
Glucotrol® XL
Metaglip™
Diabeta®
Glynase®
Grifulvin® V
Fulvicin® U/F
Fulvicin® P/G
Tenex®
Haldol®
Isopto® Homatropine**
Apresoline®
Apresazide®
Oretic®
Vicodin®
Hycodan®
Vicoprofen®
Cortisporin® Otic
Ala-cort®
Locoid®
Dilaudid®
Plaquenil®
Hydrea®
Atarax®
Vistaril
Cystospaz-M®
Motrin®
Tofranil®
Lozol®
Indocin®
Atrovent®
Atrovent®
Duoneb®
Isordil® & Dilatrate® SR
Ismo® & Imdur®
Accutane®
Sporanox®
Nizoral®
ketoprofen capsule
Orudis®
ketoprofen ER capsule
ketotifen fumarate ophthalmic
solution
Oruvail® SR
Zaditor®
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Generic
L
labetalol tablet
lactulose syrup
lamotrigine tablet
leflunomide tablet
leucovorin tablet
leuprolide non-depot injection
levobunolol ophthalmic
solution
levothyroxine sodium tablet
lidocaine viscous solution
lindane lotion, shampoo
lisinopril tablet
lisinopril/HCTZ tablet
lithium carbonate capsule
lithium citrate syrup
loperamide capsule, liquid
lorazepam tablet
lovastatin tablet
loxapine succinate capsule
M
maprotiline tablet
mebendazole chewtabs
meclizine tablet
meclofenamate capsule
medroxyprogesterone acetate
tablet
megestrol tablet, syrup
meloxicam tablet
menest tablet
meperidine tablet, syrup
mesalamine enema
metaproterenol tablet, syrup,
inhalation solution
metformin ER tablet
metformin tablet
methadone tablet, solution,
concentrate
methazolamide tablet
methenamine hippurate tablet
methenamine mandelate tablet
methimazole tablet
methocarbamol tablet
methocarbamol/ASA tablet
methotrexate tablet
methyclothiazide tablet
methyldopa tablet
methylphenidate ER tablet
methylphenidate tablet
methylprednisolone tablet
metoclopramide tablet, syrup
metolazone tablet
metoprolol tablet
metoprolol succinate tablet
metronidazole tablet
Non-Preferred/NonFormulary Brand Name
Generic
metronidazole vaginal gel
mexiletine capsule
midodrine tablet
minocycline capsule
minoxidil tablet
mirtazapine tablet
misoprostil tablet
moexipril HCL tablet
moexipril/HCTZ tablet
mometasone cream, lotion,
ointment
morphine SR tablet
mupirocin ointment
N
nabumetone tablet
nadolol tablet
naphazoline ophthalmic
solution
naproxen tablet
nefazodone tablet
neo/polymyx/dexamethasone
ophthalmic suspension,
ointment
nicardipine capsule
nifedipine capsule
nifedipine SA tablet
nimodipine capsule
nitrofurantoin capsule
nitroglycerin capsule
nitroglycerin patch
nora-BE tablet*
nortriptyline capsule
Trandate®
Enulose®
Lamictal®**
Arava®
Wellcovorin®
Betagan®
Xylocaine®
Kwell®
Zestril®, Prinivil®
Zestoretic®
Eskalith®
Imodium®
Ativan®
Mevacor®
Loxitane®
Ludiomil®
Vermox®
Antivert®
Meclomen®
Megace®
Mobic®
Demerol®
Rowasa®
nystatin suspension, tablet
O
octreotide injection
ofloxacin tablet
omeprazole capsule
ondansetron
ondansetron HCL
oxaprozin tablet
oxazepam capsule
oxcarbazepine tablet
oxybutynin tablet
oxybutynin chloride ER tablet
oxycodone capsule
oxycodone SR tablet
oxycodone/APAP tablet
oxycodone/ASA tablet
P
pantoprazole sodium tablet
paroxetine tablet
penicillin V potassium tablet,
suspension
pentoxifylline tablet
permethrin 5% cream
Alupent®
Glucophage® XR
Glucophage®
Dolophine®
Neptazane®
Hiprex
Mandelamine®
Tapazole®
Robaxin®
Robaxisal®
Rheumatrex®
Enduron®
Aldomet®
Ritalin® SR
Ritalin®
Medrol®
Reglan®
Zaroxolyn®
Lopressor®
Toprol XL®
Flagyl®
*May not be a covered benefit under some plans.
**This brand is preferred/formulary.
15
Non-Preferred/NonFormulary Brand Name
MetroGel-Vaginal®
Mexitil®
Proamatine®
Minocin®
Loniten®
Remeron®
Cytotec®
Univasc®
Uniretic®
Elocon®
MS Contin®
Bactroban®
Relafen®
Corgard®
Vasocon®
Naprosyn®
Serzone®
Cardene®
Procardia®
Adalat® CC
Nimotop®
Macrodantin®, Macrobid®
NitroTime®
Minitran®, Nitro-Dur®
Nor-Q-D®*,**
Pamelor®
Mycostatin®
Sandostatin®
Floxin®
Prilosec®
Zofran ODT®
Zofran®
Daypro®
Serax®
Trileptal®
Ditropan®
Ditropan® XL
OxyIR®
OxyContin®
Percocet®
Percodan®
Protonix®
Paxil®
Veetids®
Trental®
Elimite®
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Generic
perphenazine tablet
phenazopyridine tablet
phenobarbital tablet, elixir
phenylephrine ophthalmic
solution
phenytoin sodium capsule
pilocarpine ophthalmic solution
pilocarpine tablet
pindolol tablet
piroxicam capsule
polyethylene glycol/electrolyte
solution
potassium chloride tablet
potassium citrate tablet
pravastatin
prazosin capsule
prednisolone 15mg/5ml syrup
prednisolone acetate ophthalmic
suspension
prednisolone sod phosphate
ophthalmic solution
prednisolone sod phosphate
oral solution
prednisone tablet, solution
previfem tablet
primaquine phosphate tablet
primidone tablet
probenecid tablet
procainamide capsule
procainamide SA tablet
prochlorperazine tablet
promethazine tablet,
suppository
propafenone tablet
propoxyphene/APAP tablet
propranolol tablet
propranolol/HCTZ tablet
propylthiouracil tablet
protriptyline tablet
pyrazinamide tablet
Q
quinapril tablet
quinapril/ HCTZ tablet
quinidine gluconate tablet
quinidine sulfate tablet
R
ramipril capsule
ranitidine tablet, syrup
ribavirin capsule
ribavirin tablet
rifampin capsule
rifampin/isoniazid capsule
rimantadine tablet
S
salsalate tablet
Non-Preferred/NonFormulary Brand Name
Trilafon®
Pyridium®
Generic
selegiline tablet, capsule
sertraline tablet
silver sulfadiazine cream
simvastatin tablet
sotalol tablet
spironolactone tablet
spironolactone/HCTZ tablet
sucralfate tablet
sulfacetamide ophthalmic
solution
sulfacetamide sodium/sulfur
emulsion, medicated pad
sulfadiazine tablet
sulfamethoxazole/trimethoprim
tablet, suspension
sulfasalazine tablet
sulfisoxazole tablet, suspension
sulindac tablet
T
tamoxifen tablet
temazepam capsule
terazosin capsule
terbinafine HCL tablet*
tetracycline capsule
theophylline tablet, capsule,
elixir
thioridazine tablet, solution
thiothixene capsule
thyroid dessicated tablet
ticlopidine tablet
tilia FE tablet
Dilantin®**
Adsorbocarpine®
Salagen®
Visken®
Feldene®
K-Dur®**
Urocit-K®
Pravachol®
Minipress®
Prelone®
Pred Forte®
Inflamase Forte®
Orapred®
Deltasone®
Mysoline®**
Pronestyl®
Pronestyl SR®
Compazine®
Phenergan®
timolol maleate ophthalmic
solution
timolol maleate tablet
tizanidine tablet
tobramycin ophthalmic
solution
tolazamide tablet
tolbutamide tablet
tolmetin tablet
tramadol tablet
tramadol/APAP tablet
trandolapril tablet
tranylcypromine sulfate tablet
trazodone tablet
tretinoin capsule
tretinoin cream, gel, lotion*
triamcinolone acetonide
cream, ointment
triamcinolone tablet
triamterene/HCTZ tablet
triazolam tablet
trifluoperazine tablet
Rythmol®
Darvocet N®-100
Inderal®
Inderide®
Vivactil®
Accupril®
Accuretic®
Quinaglute®
Quinidex®
Altace®
Zantac®
Rebetol®
Copegus®
Rifadin®
Rifamate®
Flumadine®
Disalcid®
*May not be a covered benefit under some plans.
**This brand is preferred/formulary.
16
Non-Preferred/NonFormulary Brand Name
Eldepryl®
Zoloft®
Silvadene®
Zocor®
Betapace®
Aldactone®
Aldactazide®
Carafate®
Bleph®-10
Plexion®
Microsulfon®
Bactrim®, Septra®
Azulfidine® EN-tabs®
Gantrisin®
Clinoril®
Nolvadex®**
Restoril®
Hytrin®
Lamisil®
Achromycin®
Mellaril®
Navane®
Ticlid®
Estrostep® FE
Betimol®**
Blocadren®
Zanaflex®
Tobrex®
Tolinase®
Orinase®
Tolectin®
Ultram®
Ultracet®
Mavik®
Parnate®
Desyrel®
Vesanoid®
Retin A®*
Aristocort®
Aristocort®
Maxzide®
Halcion®
Stelazine®
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Generic
trifluridine ophthalmic
solution
trihexyphenidyl tablet
tri-legest FE tablet
trimethobenzamide capsule,
suppository
trimethoprim tablet
U
unithroid tablet
urea cream, gel, lotion
ursodiol capsule
V
valproic acid capsule, syrup
valproate sodium syrup
venlafaxine HCL tablet
verapamil tablet
verapamil SR
W
warfarin tablet
Z
zidovudine capsule, tablet,
syrup
zolpidem tartrate tablet
zonisamide capsule
**This brand is preferred/formulary.
Non-Preferred/NonFormulary Brand Name
Viroptic®
Artane®
Estrostep® FE
Tigan®
Proloprim®
Keralac®
Actigall®
Depakene®
Depakene®
Effexor®
Calan®
Calan SR®
Coumadin®**
Retrovir®
Ambien®
Zonegran®
17
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
A to Z Listing: Preferred/Formulary Brands
Effective February 1, 2008
This list can be used to assist you and your doctor in choosing a preferred/formulary brand.
Additional Information:
-
-
-
-
Preferred/formulary medications are limited to the dosage form and strength listed; if no strength is listed,
all strengths for the listed dosage form are preferred/formulary.
Sustained action/release (SA/SR), extended release (ER/XR), long-acting (LA), and enteric coated (EC) medications
are only preferred/formulary if listed.
Occasionally, preferred/formulary medications may be contract exclusions and, therefore, are not covered.
Some medications may require prior authorization or have quantity limits.
Please note that the PML/formulary list may change. To view the most current list, visit our Web site at www.regencerx.com.
For more detailed prescription benefit information, please refer to your benefits booklet.
A
Accolate® tablet
Aclovate® cream, ointment
Actonel® tablet
Actonel® with Calcium tablet
Actos® tablet
Acular® ophthalmic solution
Acular LS™ ophthalmic solution
Acular® PF ophthalmic droperette
Adderall XR™ capsule
Agenerase® capsule, solution
Albenza® tablet
Alesse® tablet*
Alinia® tablet, suspension
Alkeran® tablet
Alocril® ophthalmic solution
Alphagan® P ophthalmic solution
Alrex®ophthalmic suspension
Analpram HC® rectal cream, rectal lotion
Ancobon® capsule
Anemagen® capsule
Antabuse® tablet
Anzemet® tablet
Apokyn® injection
Aranesp® injection
Aricept® tablet
Aricept ODT® tablet
Arimidex® tablet
Armour® Thyroid tablet
Aromasin® tablet
Asacol® tablet, oral solution
Ascensia® test strips*
Atripla™ tablet
Atrovent® oral inhaler
Atrovent HFA® oral inhaler
Augmentin ES-600® suspension
Avandia® tablet
Avelox® tablet
Avonex® injection
Azelex® cream
Azmacort® oral inhaler
Azopt®ophthalmic suspension
B
Bactroban Nasal® ointment
Bactroban® cream
Baraclude® tablet, oral solution
Beclovent® oral inhaler
Benicar® tablet
Benicar HCT® tablet
Benzac W® gel
Betimol® ophthalmic solution
Betoptic S® ophthalmic suspension
Biltricide® tablet
Blephamide® S.O.P. ophthalmic ointment
Bromhist® oral solution
Buphenyl®oral powder, tablet
C
Canasa® rectal suppository
Capex® shampoo
Carac®cream
Carbatrol® capsule
Carboxine-PSE® liquid
Carnitor® tablet, liquid
Casodex® tablet
Catapres-TTS® patch
Ceenu® capsule
Cellcept capsule, tablet, suspension
Celontin® tablet, capsule
Cenestin® tablet
Centany® ointment
Cerumenex® otic solution
- Please check if these are covered by your prescription benefit.
Ascensia Contour® test strips*
- Please check if these are covered by your prescription benefit.
Ascensia Breeze® 2 test strips*
- Please check if these are covered by your prescription benefit.
Asmanex® twisthaler
Astelin® nasal spray
*May not be a covered benefit under some plans.
18
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Chemet® capsule
Ciloxan® ophthalmic solution, ophthalmic ointment
Ciprodex® otic suspension
Cipro HC® otic suspension
Cloderm® cream
Cognex® capsule
Colestid® packets
Colyte® powder for reconstitution
Combivent® oral inhaler
Combivir® tablet
Compro® rectal suppository
Comtan® tablet
Condylox® gel, solution
Copaxone® injection
Cordarone® tablet
Cordran® lotion, tape, ointment, cream
Cortifoam® rectal foam
Cosopt® ophthalmic solution
Coumadin® tablet
Creon® capsule
Crestor® tablet
Crixivan® capsule
Cuprimine® capsule
Cutivate® cream, lotion, ointment
Cyclogyl® ophthalmic solution
Cystadane® oral powder
Cytomel® tablet
D
Dapsone® tablet
Daraprim® tablet
DDAVP® nasal solution, nasal spray
Demulen® tablet*
Depakote Sprinkle® capsule
Depakote® ER tablet
Depakote® tablet
Depen® tablet
Derma-Smoothe/FS® oil
Desogen® tablet*
Detrol® LA capsule
Dexamethasone Intensol® oral solution
Diabetic supplies: lancets, needles, syringes*
Epifoam® topical foam
Epipen® injection
Epipen® Jr injection
Epitol® tablet
Epivir® tablet, solution
Epivir HBV® tablet, solution
Epogen® injection
Epzicom® tablet
Ergomar® tablet
Esclim® patch
Eskalith® capsule, tablet
Eskalith CR® tablet
Estraderm® patch
Eurax® cream, lotion
Evista® tablet
Evoxac® capsule
Exelon® capsule, solution
F
Fansidar® tablet
Fareston® tablet
Felbatol® tablet, oral suspension
Femara® tablet
FemHRT® tablet
Flovent® Diskus® oral inhaler
Flovent HFA® oral inhaler
Fluoroplex® cream, solution
FML® S.O.P. ointment
Foradil® oral inhaler
Fortovase® capsule
Fosamax® tablet, oral solution
Fosamax Plus D™ tablet
Fragmin® injection
Furadantin® oral suspension
Furoxone® tablet, oral suspension
Fuzeon® injection
G
Gabitril® tablet
Galzin® capsule
Gleevec® tablet, capsule
GlucaGen® injection
Glucagon® injection
Golytely® powder for reconstitution, packets
Gynazole-1® vaginal cream
H
Helidac® combo pak
Hepsera® tablet
Hexalen® capsule
Hivid® tablet
Humalog® insulins
Humatin® capsule
Humulin® insulins
I
Imitrex® tablet, nasal spray, injection
Increlex™ injection
Inderal® LA capsule
Innohep® injection
Innopran XL™ capsule
Intal® oral inhaler
Intron® A injection
- Please check if these are covered by your prescription benefit.
Dialyvite® tablet
Diamox Sequels® capsule
Diaphragms*
Diastat® rectal gel
Diastat® AcuDial™ rectal gel
Didronel® tablet
Differin® cream, gel, solution, swab
Dilantin® capsule, chews, suspension
Dipentum® capsule
Dovonex® cream, ointment, solution
Droxia® capsule
E
Effexor XR® capsule
Elmiron® capsule
Emcyt® capsule
Emtriva® capsule
Enbrel® injection
*May not be a covered benefit under some plans.
19
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Invirase® capsule, tablet
Isopto® Atropine ophthalmic solution
Isopto® Homatropine ophthalmic solution
K
Kadian® capsule
Kaletra®capsule, solution
Kaon-CL-10® tablet
K-Dur® tablet
Kemadrin® tablet
Keppra® tablet, solution.
K-Lyte® DS tablet
Kristalose® packet
Kutrase® capsule
Ku-Zyme® capsule
Ku-Zyme® HP capsule
Kytril® solution, tablet
L
Lamictal® tablet
Lamprene® capsule
Lanoxicaps® capsule
Lanoxin® tablet, elixir
Lantus® insulin
Lantus® SoloSTAR® insulin
Lariam® tablet
Leukeran® tablet
Leukine® injection
Levothroid® tablet
Levoxyl® tablet
Lexiva® tablet
Lithobid® tablet
Loestrin® tablet*
Loestrin® FE tablet*
Loestrin® 24 FE tablet*
LoOvral® tablet*
Loprox® shampoo
Lorazepam Intensol® oral concentrate
Lotemax® ophthalmic suspension
Lovenox® injection
Lumigan® ophthalmic solution
Luxiq® topical foam
Lysodren® tablet
M
Matulane® capsule
Maxalt® tablet
Maxalt MLT® tablet
Mebaral® tablet
Mephyton® tablet
Mepron® oral suspension
Mesnex® tablet
Mestinon® tablet, syrup
Metadate® CD capsule
Methergine® tablet
Methitest® tablet
MetroCream®
MetroGel®
MetroLotion®
Miacalcin® injection, nasal spray
Micardis® tablet
Micardis HCT® tablet
*May not be a covered benefit under some plans.
▼
Obtain from a designated Specialty Pharmacy.
Micro-K® capsule
Micronor® tablet*
Migranal® nasal spray
Mintezol® oral suspension, chews
Mirapex® tablet
Moban® oral concentrate, tablet
Modicon® tablet*
Mycelex® troche
Mycobutin® capsule
Myfortic® ER tablet
Myleran® tablet
Mysoline® tablet, oral suspension
N
Nardil® tablet
Nasacort® AQ nasal spray
Nasonex® nasal spray
Nebupent® aerosol powder for inhalation
Nestabs FA® tablet
Neupogen® injection
Niaspan® tablet
Nilandron® tablet
Nolvadex® tablet
Novofine® needles*
- Please check if these are covered by your prescription benefit.
Nordette® tablet*
Norinyl® tablet*
Noritate® cream
Norpace® CR capsule
Nor-QD® tablet*
Norvir® capsule, solution
Novolin® insulins
Novolog® insulins
Nulytely® powder for reconstitution
Nutropin® injection*▼
Nutropin AQ® injection*▼
Nutropin Depot® injection*▼
O
Ocuflox® ophthalmic solution
Orap® tablet
Ortho Cept® tablet*
Ortho Cyclen® tablet*
Ortho Evra® patch*
Ortho Novum® tablet*
Ortho Prefest® tablet
Ortho Tri-Cyclen® tablet*
Ortho Tri-Cyclen® Lo tablet*
Ovide® lotion
Ovral® tablet*
Ovrette® tablet*
P
Pancrease® capsule
Pancrease® MT capsule
Pancrecarb MS® capsule
Patanol® ophthalmic solution
Peak Flow Meters
Pediapred® solution
Pegasys® injection
Peg-Intron® injection
Peg-Intron® Redipen injection
20
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Pentasa® capsule
PerioGard® oral liquid
Phenytek® capsule
Phisohex® liquid
Phoslo® capsule, tablet
Phrenilin w/Caffeine & Codeine® capsule
Pilopine HS® ophthalmic gel
Plan B® tablet*
Plavix® tablet
Prandin® tablet
Precose® tablet
Pred Mild® ophthalmic suspension
Prednisone Intensol® oral concentrate
Premarin® tablet
Premarin® vaginal cream
Premphase® tablet
Prempro® tablet
Prevacid® capsule, suspension, tablet
Prevpac®
Prezista™ tablet
Prilosec OTC™ tablet - Available at generic copay.
Primaquine® tablet
Procanbid® tablet
Procrit® injection
ProctoFoam®-HC rectal foam
Proglycem® capsule, oral suspension
Prograf® capsule
ProAir® HFA oral inhaler
Proventil HFA® oral inhaler
Pulmicort® oral inhaler
Pulmicort® respules
Pulmozyme® inhalation solution
Purinethol® tablet
Q
QVAR® oral inhaler
R
Radiogardase® capsule
Rapamune® tablet, solution
Rebetol® oral solution
Rebetron® injection
Rebif® injection
Relacon-HC® syrup
Relpax® tablet
Remicade® - Covered only under the medical benefit.
Razadyne™ tablet, solution
Requip® tablet
Rescon JR® capsule
Rescriptor® tablet
Retin-A Micro® gel*
Revatio™ tablet
Reyataz® capsule
Rhinocort Aqua® nasal spray
Ridaura® capsule
Rilutek® tablet
Risperdal® tablet, solution
S
Saizen® injection*▼
Sandimmune® capsule, solution
Sensipar® tablet
*May not be a covered benefit under some plans.
▼
Obtain from a designated Specialty Pharmacy.
Serevent Diskus® oral inhaler
Seromycin® capsule
Serophene® tablet*
Seroquel® tablet
Singulair® tablet, chews, granules
Soriatane® capsule
Soriatane® CK kit
Spacer Device
Spiriva® oral inhaler
Sporanox® solution*
Stalevo® tablet
Stimate® nasal spray
Stromectol® tablet
Sular® tablet
Sustiva® capsule, tablet
Synthroid® tablet
Syprine® capsule
T
Tamiflu® capsule, suspension for reconstitution
Tarceva® tablet
Tazorac® cream, gel
Tegretol® XR tablet
Temodar® capsule
Terazol® vaginal cream
Teslac® tablet
Testred® capsule
Thioguanine® tablet
Thyrolar® tablet
Tikosyn® capsule
Tilade® oral inhaler
Timoptic-XE® ophthalmic sol-gel
Tobi® oral inhalation solution
TobraDex® ophthalmic suspension, ointment
Topamax® tablet, sprinkle
Topicort LP® cream
Tracleer® tablet
Travatan® ophthalmic solution
Travatan Z® ophthalmic solution
Tri-Levlen® tablet*
Tri-Norinyl® tablet*
Triphasil® tablet*
Trizivir® tablet
Trusopt® ophthalmic solution
U
Ultrase® capsule
Ultrase® MT capsule
Ultravate® cream, ointment
Uniphyl® tablet
Uroxatral® tablet
URSO® tablet
V
Vagifem® vaginal tablet
Valtrex® tablet
Vfend® tablet, oral suspension
Videx® chew tablets, solution, packets
Viokase® tablet, powder for oral solution
Viracept® tablet, powder for oral solution
Viramune® tablet, oral suspension
Viread® tablet
21
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Visicol® tablet
Vivelle® patch
Vivelle-DOT® patch
Vytorin® tablet
W
Westhroid® tablet
Winstrol® tablet
X
Xeloda® tablet
Y
Yodoxin® tablet
Z
Zarontin® capsule, syrup
Zerit® capsule, oral solution
Ziagen® tablet, oral solution
Zomig® tablet, nasal spray
Zomig-ZMT™ tablet
Zyprexa® tablet
Zyprexa® Zydis® tablet
Zyvox® tablet, oral suspension
22
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Non-Preferred/Non-Formulary Brands:
Generic and Preferred Brand Alternatives
Effective February 1, 2008
This list can be used to assist you and your doctor in choosing a generic or preferred/formulary alternative.
• • • • Generic medications are listed in lower case bold. Example: fluconazole.
Non-preferred/non-formulary brands are listed in parenthesis only as a reference for generically available medications.
This is a partial list. New or rarely used medications may not be listed. Other, less-expensive options may be available over the counter (OTC) without a prescription.
OTC products generally are not a covered prescription benefit.
Additional Information:
-
-
-
-
Preferred/formulary medications are limited to the dosage form and strength listed; if no strength is listed,
all strengths for the listed dosage form are preferred/formulary.
Sustained action/release (SA/SR), extended release (ER/XR), long-acting (LA), and enteric coated (EC) medications
are only preferred/formulary if listed.
Occasionally, preferred/formulary medications may be contract exclusions and, therefore, are not covered.
Some medications may require prior authorization or have quantity limits.
Please note that the PML/formulary list may change. To view the most current list, visit our Web site at www.regencerx.com.
For more detailed prescription benefit information, please refer to your benefits booklet.
Non-Preferred/
Non-Formulary
Brand Name
A
clozapine (Clozaril®), haloperidol
(Haldol®), Risperdal®, Zyprexa®, Seroquel®
Ascensia Breeze® 2 test strips*, Ascensia
Contour® test strips*
benazepril (Lotensin®), enalapril
(Vasotec®), fosinopril (Monopril®),
lisinopril (Zestril®, Prinivil®), moexipril
(Univasc®), quinapril (Accupril®),
trandolapril (Mavik®)
cimetidine (Tagamet®), famotidine
(Pepcid®), omeprazole (Prilosec®),
pantoprazole (Protonix®), ranitidine
(Zantac®), Prevacid®, Prilosec OTC™
estradiol (Estrace®) +
medroxyprogesterone (Provera®),
estradiol (Estrace®) + norethindrone
(Aygestin®), FemHRT®, Prempro®,
Premphase®
Abilify®
Accu-Chek®
Aceon
®
Aciphex
®
Activella®
Advair® HFA
®
(Asmanex®/Azmacort®/Flovent® Diskus®/
Flovent® HFA/Pulmicort®/QVAR®) +
Serevent®Diskus®/Foradil®
*May not be a covered benefit under some plans.
Advicor
Aerobid® / M
Asmanex®, Azmacort®, Flovent® Diskus®,
Flovent® HFA, Pulmicort®, QVAR®
Aggrenox
cilostazol (Pletal®), dipyridamole
(Persantine®) + aspirin (OTC), ticlopidine
(Ticlid®), Plavix®
®
Alamast
Acular®, Alocril®, cromolyn ophthalmic
(Crolom®), ketotifen fumarate
ophthalmic solution (Zaditor®), Patanol®
Aldara®
podofilox (Condylox®)
Allegra-D®
OTC loratadine*, OTC Claritin-D®*,
OTC Alavert-D™*, fexodenadine
(Allegra®) + decongestant*
Alomide®
cromolyn ophthalmic (Crolom®),
ketotifen fumarate ophthalmic solution
(Zaditor®), Alocril®, Patanol®
Altace®
benazepril (Lotensin®), captopril
(Capoten®), enalapril (Vasotec®),
fosinopril (Monopril®), lisinopril
(Zestril®, Prinivil®), moexipril (Univasc®),
quinapril (Accupril®), trandolapril
(Mavik®)
®
(Asmanex®/Azmacort®/Flovent® Diskus®/
Flovent®HFA/Pulmicort®/QVAR®) +
Serevent®Diskus®/Foradil®
23
Generic and Preferred Brand
Alternatives
simvastatin (Zocor®), pravastatin
(Pravachol®), lovastatin (Mevacor®),
Crestor®, Vytorin® + Niaspan®
®
doxycycline (Vibramycin®)
Adoxa®
Advair Diskus
Non-Preferred/
Non-Formulary
Brand Name
Generic and Preferred Brand
Alternatives
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Generic and Preferred Brand
Alternatives
Ambien CR™
flurazepam (Dalmane®), temazepam
(Restoril®), triazolam (Halcion®),
zolpidem tartrate (Ambien®)
Amerge®
Imitrex®, Maxalt®, Zomig®, Relpax®
Amitiza®
lactulose, polyethylene glycol/electrolyte
solution
Androderm®
testosterone cypionate (DepoTestosterone®), testosterone enanthate
(Delatestryl®)
Axert®
Androgel®
testosterone cypionate (DepoTestosterone®), testosterone enanthate
(Delatestryl®)
B
Angeliq®
FemHrt®, Premphase®, Prempro®
Apidra®
Humalog®, Novolog®
Aptivus
Invirase®, Agenerase®, Reyataz®, Lexiva®,
Crixivan®, Viracept®, Norvir®
®
Arthrotec®
Atacand®
Atacand HCT®
Augmentin XR®
amoxicillin/clavulanate (Augmentin®)
Avalide®
benazepril/HCTZ (Lotensin HCT®),
Benicar HCT™, captopril/HCTZ
(Capozide®), enalapril/HCTZ
(Vasoretic®), fosinopril/HCTZ (Monopril
HCT®), lisinopril/HCTZ (Zestoretic®,
Prinzide®), Micardis HCT®, moexipril/
HCTZ (Uniretic®), quinapril/HCTZ
(Accuretic®)
Avapro®
Avodart
®
Azilect®
Bacitracin®
ophthalmic
Beconase AQ®
BenzaClin®
diclofenac (Voltaren®), etodolac
(Lodine®), naproxen (Naprosyn®),
salsalate (Disalcid®), choline magnesium
trisalicylate (Trilisate® ), meloxicam
(Mobic®)
benazapril (Lotensin®), Benicar™,
captopril (Capoten ®), enalapril
(Vasotec®), fosinopril (Monopril®),
lisinopril (Zestril®, Prinivil®), Micardis®,
moexipril (Univasc ®), quinapril
(Accupril®), trandolapril (Mavik®)
lisinopril/HCTZ (Zestoretic®), captopril/
HCTZ (Capozide®), enalapril/HCTZ
(Vaseretic®), fosinopril/HCTZ (Monopril
HCT®), Benicar HCT™, Micardis HCT®
Avandamet®
Avinza®
Betaseron®
B-D® test strips
Biaxin XL®
Boniva®
Brevoxyl®
C
terazosin (Hytrin®), doxazosin (Cardura®),
finasteride (Proscar®), prazosin
(Minipress®), Uroxatral®
Imitrex®, Maxalt®, Zomig®, Relpax®
bromocriptine (Parlodel®), pergolide
(Permax®), selegiline (Eldepryl®),
Comtan®, Mirapex®, Requip®
neomycin/polymyxin/bacitracin,
neomycin/polymyxin/gramacidin
(Neosporin®)
flunisolide (Nasalide®), fluticasone
propionate (Flonase®), Nasacort AQ®,
Nasonex, Rhinocort Aqua®
erythromycin base/benzoyl peroxide
(Benzamycin®)
Avonex®, Copaxone®, Rebif®
Ascensia® test strips*
clarithromycin, erythromycin (E-mycin®,
EES®), doxycycline (Vibramycin®),
azithromycin (Zithromax®)
Fosamax®, Actonel®
benzoyl peroxide (Desquam®, Benzac®)
Caduet®
Celebrex®
diclofenac (Voltaren® XR), etodolac
(Lodine® XL), naproxen (Naprosyn®),
salsalate (Disalcid®), choline magnesium
trisalicylate (Trilisate®)
Clarinex®
Climara®
24
fentanyl transdermal (Duragesic®),
hydromorphone (Dilaudid®), morphine
SR (MS Contin®), morphine sulfate,
oxycodone SR (Oxycontin®), oxycodone,
codeine sulfate, Kadian®
diltiazem SR (Cardizem SR®),
verapamil SR (Calan SR®), nifedipine
SA (Adalat CC®), felodipine (Plendil®)
+ simvastatin (Zocor®), pravastatin
(Pravachol®), lovastatin (Mevacor®),
Crestor®, Vytorin®
Cipro XR®
glyburide (Diabeta®), glipizide
(Glucotrol®), metformin (Glucophage®)
benazapril (Lotensin®), Benicar™,
captopril (Capoten ®), enalapril
(Vasotec®), fosinopril (Monopril®),
lisinopril (Zestril®, Prinivil®), Micardis®,
moexipril (Univasc ®), quinapril
(Accupril®), trandolapril (Mavik®)
Generic and Preferred Brand
Alternatives
ciprofloxacin (Cipro®)
OTC loratadine*, OTC Claritin®*, OTC
Alavert™*
estradiol, estropipate, Esclim®,
Estraderm®, Vivelle®, Vivelle DOT®
Climara Pro®
FemHRT®, Prempro®, Premphase®
Clobex®
clobetasol propionate (Temovate®),
betamethasone dipropionate (Diprolene®)
Colazal®
sulfasalazine (Azulfidine Entabs®),
Asacol®, Dipentum®, Pentasa®
Combipatch®
FemHRT®, Prempro®, Premphase®
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Generic and Preferred Brand
Alternatives
Exforge®
F
methylphenidate ER (Ritalin SR®),
Metadate CD®, Adderall XR®
prednisone (Deltasone®), dexamethasone
(Decadron®), methylprednisolone
(Medrol®)
Benicar™, Micardis®
velivet, cesia
bupropion SR (Wellbutrin SR®),
citalopram (Celexa®), fluoxetine
(Prozac®), paroxetine (Paxil®), sertraline
(Zoloft®)
Concerta®
Cortef
®
Cozaar®
Cyclessa®
Cymbalta®
D
Denavir®
Femring®
Finacea®
Generic and Preferred Brand
Alternatives
amlodipine (Norvasc®) + Micardis®/Benicar®
estradiol (Estrace®), Premarin® vaginal
cream
Azelex®
fluorometholone (Fluor-Op®),
prednisolone sodium acetate (Pred
Forte®), Alrex®, FML S.O.P. ®
Flarex
®
Flomax
®
terazosin (Hytrin®), prazosin
(Minipress®), doxazosin (Cardura®),
Uroxatral®
methylphenidate ER (Ritalin SR®),
Metadate CD®
acyclovir capsule (Zovirax®)
betamethasone valerate (Betaval®),
betamethasone dipropionate
(Diprolene®), flunisolone acetonide
(Synalar®), triamcinolone acetonide
(Aristocort®)
Detrol LA®, oxybutynin (Ditropan®),
oxybutynin chloride ER (Ditropan® XL)
Fortamet®
metformin (Glucophage®)
®
Freestyle test strips Ascensia® test strips*
Frova®
Imitrex®, Maxalt®, Zomig®, Relpax®
G
Diovan®
Benicar™, Micardis®
Genotropin®*▼
Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼
Diovan HCT®
Benicar HCT™, Micardis HCT®
Doryx®
doxycycline hyclate (Vibramycin®)
erythromycin/benzoyl peroxide
(Benzamycin®)
Geodon®
Risperdal®, Zyprexa®, Seroquel
Glyset®
glyburide (Diabeta®), glipizide
(Glucotrol®), metformin (Glucophage®)
Dermatop®
Detrol®
Duac
®
Duetact®
glimepiride (Amaryl®) + Avandia®/Actos®
DynaCirc CR®
diltiazem SR (Cardizem SR®) ,
verapamil SR (Calan SR®), nifedipine SA
(Adalat CC®), felodipine (Plendil®)
Focalin®
H
E
triamcinolone (Aristocort®),
betamethasone dipropionate
(Diprolene®), fluocinolone (Synalar®)
Elidel
®
Entocort EC
Anzemet®, Kytril®, metoclopramide
(Reglan®), ondansetron HCL (Zofran®,
Zofran ODT®), prochlorperazine
(Compazine®)
oxybutynin (Ditropan®), oxybutynin
chloride ER (Ditropan XL®), Detrol LA®
prednisone, methylprednisolone
Estrace®
vaginal cream
estradiol, Premarin® vaginal cream,
Vagifem®
Emend®
Enablex®
®
Estratest® / H.S.
Estring®
Exelderm®
Half-Lytely®
polyethylene glycol/electrolyte solution
Hectorol®
calcitriol (Rocaltrol®)
Humatrope®*▼
Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼
Humira®
methotrexate (Rheumatrex®), leflunomide
(Arava®), Enbrel®
Hyzaar®
I
Innopran XL®
Ivega™
J
Januvia®
K
estradiol (Estrace®), estropipate (Ogen®),
Premarin®, Cenestin®
estradiol, Premarin® vaginal cream,
Vagifem®
clotrimazole (Lotrimin®), econazole
(Spectazole®), ketoconazole (Nizoral®),
nystatin (Mycostatin®), terbinafine
(Lamisil®)
*May not be a covered benefit under some plans.
▼
Obtain from a designated Specialty Pharmacy.
folic acid + Vitamin B12 + Vitamin B6
Foltx®
propranolol (Inderal®), atenolol
(Tenormin®), Inderal LA®
Risperdal®, Seroquel®, Zyprexa®,
Zyprexa® Zydis®
glipizide (Glucotrol®), glyburide (Micronase®),
metformin (Glucophage®), insulin
Ketek®
amoxicillin/clavulanate (Augmentin®),
clarithromycin (Biaxin®), doxycycline
(Vibramycin®), azithromycin
(Zithromax®)
Kineret®
methotrexate (Rheumatrex®), leflunomide
(Arava®), Enbrel®
Klaron
benzoyl peroxide (Desquam®), Azelex®,
erythromycin/benzoyl peroxide
(Benzamycin®)
®
25
Benicar HCT™, Micardis HCT®
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Non-Preferred/
Non-Formulary
Brand Name
L
Lescol®
Lescol XL®
Levaquin®
Levemir®
Levlen®
Non-Preferred/
Non-Formulary
Brand Name
Generic and Preferred Brand
Alternatives
O
simvastatin (Zocor®), pravastatin
(Pravachol®), lovastatin (Mevacor®),
Crestor®, Vytorin®
simvastatin (Zocor®), pravastatin
(Pravachol®), lovastatin (Mevacor®),
Crestor®, Vytorin®
ofloxacin (Floxin®), ciprofloxacin
(Cipro®), Avelox®
Lantus®, Humulin N®, Novolin N®,
Humalog 75/25®, Novolog 70/30®
aviane*, lessina*, levora*, portia*
Lidoderm
®
Lipitor®
amitriptyline (Elavil®), nortriptyline
(Pamelor®), gabapentin (Neurontin®)
simvastatin (Zocor®), pravastatin
(Pravachol®), lovastatin (Mevacor®),
Crestor®, Vytorin®
cromolyn ophthalmic (Crolom ),
ketotifen fumarate ophthalmic solution
(Zaditor®), Alocril®, Patanol®
Lovaza®
fenofibrate, gemfibrozil (Lopid®), lofibra,
lovastatin (Mevacor®), pravastatin
(Pravachol®), simvastatin (Zocor®)
Lunesta®
flurazepam (Dalmane®), temazepam
(Restoril®), triazolam (Halcion®),
zolpidem tartrate (Ambien®)
M
Malarone®
Maxair®
Mircette®
N
Namenda®
Natelle®
Nexium®
Norditropin®*▼
Norditropin
Nordiflex®*▼
NuvaRing®
Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼
One-Touch® test
strips
Ascensia Breeze® 2 test strips*, Ascensia
Contour® test strips*
Opana®
codeine sulfate, hydromorphone
(Dilaudid®), morphine sulfate,
oxycodone
Opana® ER
codeine sulfate, fentanyl transdermal
(Duragesic®), hydromorphone
(Dilaudid®), Kadian®, morphine SR (MS
Contin®), morphine sulfate, oxycodone,
oxycodone SR (Oxycontin®),
Ovcon®
generic oral contraceptives *
Oxytrol®
Detrol LA®, oxybutynin (Ditropan®),
oxybutynin chloride ER (Ditropan® XL)
Oxistat
miconazole (Monistat®), clotrimazole
(Lotrimin®), ketoconazole (Nizoral®),
nystatin (Mycostatin®)
®
P
Paxil CR
citalopram (Celexa®), fluoxetine
(Prozac®), paroxetine (Paxil®), sertraline
(Zoloft®)
hydroxychloroquine (Plaquenil®),
mefloquine (Lariam®), chloroquine
(Aralen®)
Ponstel®
diclofenac (Voltaren®), etodolac
(Lodine®), naproxen (Naprosyn®),
salsalate (Disalcid®), choline magnesium
trisalicylate (trilisate®)
ProAir® HFA, Proventil HFA®
Kariva*
Precare Prenatal®
generic prenatal vitamins
Precision QID
Precision Xtra®
teststrips
Ascensia® test strips*
®
®
Aricept®, Exelon®, Razadyne™
flunisolide (Nasalide ), Rhinocort Aqua ,
fluticasone propionate (Flonase®),
Nasacort AQ®, Nasonex
generic prenatal vitamins with
folic acid
cimetidine (Tagamet®), famotidine
(Pepcid®), omeprazole (Prilosec®),
pantoprazole (Protonix®), ranitidine
(Zantac®), Prevacid®, Prilosec OTC™
®
Nasarel®
Omnitrope*▼
One-Touch® Ultra® Ascensia Breeze® 2 test strips*, Ascensia
test strips
Contour® test strips*
®
Livostin®
Olux®
generic prenatal vitamins with
folic acid
clobetasol (Temovate®)
O-Cal FA
citalopram (Celexa®), fluoxetine
(Prozac®), paroxetine (Paxil®), sertraline
(Zoloft®)
Lexapro®
Generic and Preferred Brand
Alternatives
®
Prenate Elite®
generic prenatal vitamins
with folic acid
Prevident 5000 Plus sodium fluoride gel
Prilosec®
Primacare prenatal®
Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼
Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼
generic oral contraceptives*
*May not be a covered benefit under some plans.
▼
Obtain from a designated Specialty Pharmacy.
Ascensia® test strips*
26
cimetidine (Tagamet®), famotidine
(Pepcid®), omeprazole (Prilosec®),
pantoprazole (Protonix®), ranitidine
(Zantac®), Prevacid®, Prilosec OTC™
generic prenatal vitamins
with folic acid
Prometrium®
medroxyprogesterone (Provera®)
Protonix®
omeprazole (Prilosec®), pantoprazole
(Protonix®), Prilosec OTC™
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
Non-Preferred/
Non-Formulary
Brand Name
Protopic®
Provigil®
Prozac Weekly®
Pylera®
R
Renagel®
Ritalin LA®
Rosac®
Rozerem™
S
Sanctura®
Sarafem®
Seasonale®
Serostim*▼
Skelaxin®
Sonata®
Spectracef®
triamcinolone (Aristocort®),
betamethasone dipropionate
(Diprolene®), fluocinolone (Synalar®)
methylphenidate ER (Ritalin SR®),
dextroamphetamine (Dexedrine®),
amphetamine/dextroamphetamine
(Adderall®)
fluoxetine (Prozac®)
Helidac®, PrevPac®
methylphenidate ER, Metadate CD®,
Adderall XR®
Tequin®
Teveten®
Tev-Tropin*▼
Tiazac®
Trans-Derm Scop®
Triaz®
Tricor®
Veramyst®
Vesicare®
Vigamox®
W
Welchol®
Wellbutrin XL®
X
Xalatan®
Xanax XR®
fluoxetine (Prozac®)
levora,* portia,* Nordette®*
Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼
carisoprodol (Soma®), cyclobenzaprine
(Flexeril®), methocarbamol (Robaxin®)
flurazepam (Dalmane®), temazepam
(Restoril®), triazolam (Halcion®),
zolpidem tartrate (Ambien®)
cefuroxime (Ceftin®), cefaclor (Ceclor®)
Strattera®
Tarka®
V
Valcyte®
Vantin®
Ventolin HFA®
Detrol LA®, oxybutynin (Ditropan®),
oxybutynin chloride ER (Ditropan® XL)
glyburide (Diabeta®), glipizide
(Glucotrol®), metformin (Glucophage®)
Symbyax®
T
Tyzeka®
PhosLo®
methylphenidate ER, Metadate CD®
sulfacetamide sodium/sulfur (Plexion®),
benzoyl peroxide
flurazepam (Dalmane®), temazepam
(Restoril®), triazolam (Halcion®),
zolpidem tartrate (Ambien®)
Starlix®
Symbicort®
Non-Preferred/
Non-Formulary
Brand Name
Tri-Levlen®
Truvada®
Tussionex®
Pennkinetic
Suspension
Generic and Preferred Brand
Alternatives
Xibrom®
Xifaxan®
Xopenex®
Xopenex HFA®
Xyzal®
Y
Yasmin®
Z
Zegerid®
(Asmanex®/Azmacort®/Flovent® Diskus®/
Flovent® HFA/Pulmicort®/Qvar®) +
Foradil®/Sereven®Diskus®
fluoxetine (Prozac)® + Zyprexa®
Zetia®
Ziana™
trandolapril (Mavik®)+ verapamil
(Calan®)
ofloxacin (Floxin®), ciprofloxacin
(Cipro®), Avelox®
Benicar™ , Micardis®
Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼
Zorbtive®*▼
Zovirax® ointment
Zylet®
diltiazem SR (Dilacor XR®)
meclizine (Antivert®)
benzoyl peroxide (Desquam®)
gemfibrozil (Lopid®), fenofibrate
(LoFibra)
*May not be a covered benefit under some plans.
▼
Obtain from a designated Specialty Pharmacy.
Zyrtec®
Zyrtec-D®
27
Generic and Preferred Brand
Alternatives
trivora*, enpresse*, Triphasil®*
Emtriva® + Viread®
hydrocodone bitartrate/homatropine
(Hycodan®), hydrocodone bitartrate/
guaifenesin (Hycotuss®)
Baraclude™, Epivir® HBV, Hepsera®,
Intron A®, Pegasys®
ganciclovir (Cytovene®)
cefuroxime (Ceftin®), cefaclor (Ceclor®)
ProAir® HFA,Proventil HFA®
flunisolide (Nasarel®, Nasalide®),
fluticasone (Flonase®), Nasacort AQ®,
Nasonex®, Rhinocort® Aqua®
oxybutynin (Ditropan®), oxybutynin
chloride ER (Ditropan® XL), Detrol LA®
ciprofloxacin (Ciloxan®), ofloxacin (Ocuflox®)
cholestyramine (Questran®),
colestipol HCL (Colestid®)
bupropion SR (Wellbutrin SR®)
Travatan®, Travatan Z®, Lumigan®
alprazolam (Xanax®)
flurbiprofen (Ocufen®), Acular®,
Acular LS™, Acular® PF
azithromycin (Zithromax®), ciprofloxacin
(Cipro®), ofloxacin (Floxin®)
albuterol
ProAir HFA®, Proventil HFA®
fexofenadine (Allegra®), OTC Alavert™*,
OTC Claritin®*, OTC loratadine*
generic oral contraceptives*
cimetidine (Tagamet®), famotidine
(Pepcid®), omeprazole (Prilosec®),
pantoprazole (Protonix®), ranitidine
(Zantac®), Prevacid®, Prilosec OTC™
simvastatin (Zocor®), pravastatin (Pravachol®),
lovastatin (Mevacor®), Crestor®, Vytorin®
clindamycin (Cleocin®), erythromycin
base/ethanol (Erygel®), sulfacetamide
sodium (Klaron®), erythromycin
base/benzoyl peroxide (Benzamycin®),
tretinoin (Retin A®), Differin®, Tazorac®
Nutropin®*▼, Nutropin AQ®*▼, Saizen®*▼
acyclovir (Zovirax) tablets, capsules or
suspension, Valtrex® tablet
TobraDex® ophthalmic suspension, ointment
OTC loratadine*, OTC Claritin®*, OTC
Alavert™*, fexofenadine(Allegra®)
OTC loratadine* + decongestant*
OTC Claritin-D®*, OTC Alavert-D™*,
fexodenadine (Allegra®) + decongestant
Effective February 1, 2008
©2008. RegenceRx. All Rights Reserved.
P.O. Box 1271, Portland, OR 97207-1271
www.regencerx.com
00260-or
2-08
Effective February
1, /2008
©2008. RegenceRx. All Rights Reserved.