PRESCRIPTION DRUG FORMULARY
This is a list of the most commonly prescribed drugs. It represents
an abbreviated version of the drug list that is at the core of your
prescription-drug benefit plan. The list is not all-inclusive and
does not guarantee coverage. In addition to using this list, you are
encouraged to ask your doctor to prescribe generic drugs
whenever appropriate.
A
acetaminophen/cod
acyclovir
adapalene
ADDERALL XR (ST,QL)
albuterol nebulizer soln
alendronate
allopurinol
ALPHAGAN P
Alprazolam
ALREX
ALTOPREV
amantadine
amitriptyline
amlodipine
amlodipine/benazepril
amlodipine/valsartan
amoxicillin
amoxicillin/pot clav
amphetamine salt cmb (QL)
ampicillin
ANALPRAM
ANORO ELLIPTA (QL)
ARCAPTA
aripoprazole
ARNUITY ELLIPTA
ASACOL
ASACOL HD
atenolol
atorvastatin
atropine sulfate
AVELOX
AZELEX
AZILECT
azithromycin
B
baclofen
balsalazide
benazepril
benzonatate
BESIVANCE
BETOPTIC S
bisoprolol fumarate/hctz
BRINTELLIX (ST, QL)
brimonidine
tartrate budesonide
buprenorphine hcl/naloxone
hcl (PA,QL)
buprenorphine hcl (PA, QL)
bupropion sr/xl
buspirone/hcl
butalbital/apap/caf (QL)
BYETTA (ST, QL)
C
calcitriol
CANASA
candesartan
candesartan/hctz
CARAC
carbamazepine xr
carbidopa/levodopa
carisoprodol
carvedilol
cefdinir
cefuroxime
celecoxib
cephalexin
CHANTIX
chlorhexidine gluconate
cholestyramine
chlorthalidone
CIALIS (PA)
ciclopirox
cilostazol
cimetidine
CIPRODEX
ciprofloxacin/hcl
citalopram/hbr (QL)
clindamycin
clindamycin phos/benzoyl peroxide
CLINDESSE
clobetasol
CLOBEX
clomiphene
clonazepam (QL)
clonidine
clopidogrel
clotrimazole-betamethasone
clozapine
COMBIPATCH
COMBIVENT
CONDYLOX
COREG CR
CRINONE
CRIXIVAN
cyanocobalamin
cyclobenzaprinc
cyclosporine
D
DALIRESP (ST)
PLEASE NOTE: Brand-name drugs may move to nonpreferred status if
a generic version becomes available during the year. Not all the drugs
listed are covered by all prescription-drug benefit programs; check your
benefit materials for the specific drugs covered and the copayments for
your prescription-drug benefit program. For specific questions about your
coverage, please call the phone number printed on your member ID card.
DAYTRANA (ST) (QL)
desmopressin acetate
desonide
dexamethasone
dextroamphetamine sulfate (QL)
diazepam (QL)
diclofenac
dicyclomine
digoxin
diltiazem cd
divalproex sodium
DIVIGEL (ST)
donepezil (QL)
doxazosin
doxycycline (QL)
DUAVEE
duloxetine/hcl
E
EFFIENT (QL)
ELIDEL
EMEND (QL)
enalapril
ENDOMETRIN
ENJUVIA (ST)
enoxaparin
EPIDUO
escitalopram
ESTRACE
estradiol
estradiol transdermal patch
eszopiclone
EURAX
EXELON (QL)
F
famcyclovir
famotidine
fenofibrate
fenofibric acid
fentanyl transdermal (QL)
finasteride
flecainide
fluconazole
flunisolide nasal spray fluoxetine
fluvoxamine maleate
folic acid
fosinopril sodium/hctz
FORADIL
FOSRENOL FRAGMIN
FREESTYLE TEST STRIPS
furosemide oral
FYCOMPA (ST, QL)
G
gabapentin
gemfibrozil
glimepiride
glipizide
glipizide xl
Glyburide
H
haloperidol
hydralazine
hydrochlorothiazide
hydrocodone/apap (QL)
hydrocortisone
hydromorphone (QL)
hydroxychloroquine
hydroxyurea
hydroxyzine
hyoscyamine sulfate
I
ibandronate
ibuprofen
imipramine
INCURESE ELLIPTA
indomethacin
INJECTAFER (PA required)
INVOKAMET (ST)
irbesartan
isosorbide mononitrate
itraconazole
J
JALYN
K
klor-con
Ketoconazole
L
labetalol
lactulose
lamotrigine
LATUDA (ST, QL)
latanoprost
leflunomide
LETAIRIS (PA)
levetiracetam
levofloxacin
levothyroxine
lisinopril
lisinopril/hctz
This document is effective through December 31, 2020. This list is subject to change.
LODOSYN
lorazepam
losartan
losartan/hctz
lovastatin
LUMIGAN
OXYTROL
P
M
meclizine
meloxicam
memantine
MEPRON
MESTINON
metaxalone
metformin
metformin ER
methadone/hcl non-inj
methocarbamol
methotrexate
methylphenidate (QL)
methylphenidate ER (QL)
methylprednisolone tabs
metoclopramide
metolazone
metoprolol
metoprolol xl
metronidazole tabs
minocycline
mirtazapine
modafinil (PA, QL)
moexipril/hctz
mometasone montelukast sodium
morphine sulfate/er (QL)
mupirocin
Mycophenolate
N
nabumetone
nadolol
naproxen
naltrexone
NASONEX
neomycin/polymyxin
niacin
nifedipine er
nitrofurantoin
nitroglycerin
NITROSTAT
nortriptyline
NOVOLIN (ALL)
NUCYNTA
NUVIGIL (PA, QL)
Nystatin
O
oflaxacin
olanzapine
omega-3
ondansetron
ONGLYZA
oxybutynin er
oxcarbazepine
oxycodone (QL)
oxycodone/apap (QL)
pantoprazole
paroxetine
PATANOL (ST)
PEGASYS (PA)
penicillin vk
PERFOROMIST
perphenazine
phenytoin sodium xl
pilocarpine
pioglitazone
pioglitazone/metformin
pioglitazone/glimepiride phenazopyridine
phentermine
polyethylene glycol
polymyxin b sulfate- trimethoprim
potassium chloride
pramipexole xr
PRAMOSONE
pravastatin
prednisolone
prednisone oral
PRISTIQ
PROAIR
progesterone
promethazine tabs
promethazine/codeine
propranolol
PYLERA
Q
quetiapine fumarate
quinapril
temazepam (QL)
terazosin
terbinafine
terbutaline sulfate
testosterone theophylline
timolol maleate tizanidine
tobramycin sulfate
TOBRADEX
topiramate
TRACLEER (PA)
tramadol
TRANSDERM-SCOP
trandolapril
TRAVATAN Z
travoprost trazadone
triamcinolone acetonide
triamterene/hctz
trimethoprim/sulfa
U
Ursodiol
V
VAGIFEM
valacyclovir/hcl valsartan
valsartan/hctz
venlafaxine
venlafaxine ER (QL)
verapamil sr
VICTOZA (ST, QL)
VIGAMOX
VIMPAT (ST,QL)
VIOKACE
W
warfarin
R
X
rabeprazole
ramipril
RANEXA
REYATAZ
risperidone (QL)
rizatriptan benzoate (QL)
ropinirole
ropinitole
rosuvastin
XOPENEX HFA
S
Z
zaleplon
ZETIA (ST)
ziprasidone (QL)
zolpidem
zolpidem er (QL)
zolmitriptan (QL)
zolmitriptan odt (QL)
zonisamide
SENSIPAR
SEREVENT DISKUS
sertraline
sildenafil citrate (PA, QL)
SILENOR
simvastatin
spironolactone
sulfamethoxazole- trimethoprim
sumatriptan oral (QL)
T
TACROLIMUS
tamoxifen
tamsulosin
telmisartan
This document is effective through December 31, 2020. This list is subject to change.