Managed Medicaid Plans
Drug Formulary
By Drug Class - 2014
CoventryCares of Kentucky
CoventryCares of Pennsylvania
CoventryCares of Virginia
Vista Medicaid
The drug formulary can also be accessed at directprovider.com.
_________________________________________________________________________________________
0400
ANTIHISTAMINES &
ANTIHISTAMINE/
DECONGESTANT
COMBINATIONS
Generic combination cough
and cold products are on the
formulary.
Cephalosporins and
Related Antibiotics
First Generation
Cephalexin*
KEFLEX*
Cefadroxil*
DURICEF*
Second Generation
Antihistamines
First Generation
Brompheniramine*
DIMETANE*, DIMETANE
EXTENTABS 8, 12MG*
(OTC)
Chlorpheniramine* (OTC)
CHLOR-TRIMETON* (OTC)
Clemastine* (OTC)
TAVIST* (OTC)
Diphenhydramine* (OTC)
BENADRYL* (OTC)
Hydroxyzine HCI*
ATARAX*
Promethazine*
PHENERGAN*,
PHENADOZ*
Pseudoephedrine* (OTC)
SUDAFED* (OTC)
Brompheniramine/
Pseudoephedrine*
BROMFED-PD*,
BROMFED*
(generic only)
Second Generation
Loratidine* (OTC)
CLARITIN*,
ALAVERT*
Loratidine /Pseudoephedrine*
CLARITIN-D* (OTC)
Cetirizine* (OTC)
ZYRTEC*
0800
ANTI-INFECTIVE
AGENTS
Antifungals
Clotrimazole*
MYCELEX TROCHE*
Griseofulvin microsize*
GRIFULVIN V*, GRIS-PEG
Ketoconazole*
NIZORAL*
Nystatin*
MYCOSTATIN*
Fluconazole*
DIFLUCAN*
Terbinafine*
LAMISIL* (granules NF)
Antituberculosis
Ethambutol*
MYAMBUTOL*
Isoniazid*
ISONIAZID*
Pyrazinamide*
PYRAZINAMIDE*
Rifampin*
RIFADIN*
Antivirals
Cefaclor*
CECLOR*, CECLOR CD* (QL) Amantadine*
SYMMETREL*
Cefuroxime Axetil*
Acyclovir*
CEFTIN*
ZOVIRAX* (oral only)
Cefprozil*
CEFZIL*
Famciclovir*
FAMVIR*
Third Generation
Entecavir
Cefdinir*
BARACLUDE (QL)
OMNICEF*
Ribavirin*
Cefpodoxime*
REBETOL*, COPEGUS*
VANTIN*
(Ribapak NF, PA, SP)
Ceftriaxone Sodium*
Valacyclovir*
ROCEPHIN (QL)*
VALTREX* (QL)
Erythromycins/
Macrolides
Antiretroviral Agents
Protease Inhibitors
Erythromycin Base 250, 333,
and 500mg tabs *
ERY-TAB *
Erythromycin Ethylsuccinate*
EES* 400 tab, EES* 200,
400 suspension
Erythromycin Stearate*
ERYTHROCIN*
Erythromycin w/Sulfisoxazole*
PEDIAZOLE*
Azithromycin
ZITHROMAX (QL)
Clarithromycin*
BIAXIN*, BIAXIN XL* (QL)
Fosamprenavir
LEXIVA
Indinavir Sulfate
CRIXIVAN
Nelfinavir Mesylate
VIRACEPT
Ritonavir
NORVIR
Saquinavir
INVIRASE
Atazanavir Sulfate
REYATAZ
Lopinavir / Ritonavir
KALETRA
Darunavir
PREZISTA
Tipranavir
APTIVUS
Amprenavir
AGENERASE
Telaprevir
INCIVEK (PA)
Penicillins
Amoxicillin*
AMOXIL*, TRIMOX*
Ampicillin*
PRINCIPEN*
Penicillin VK*
PEN VEE K*, BEEPEN-VK*,
VEETIDS*
Penicillin G benzathine
BICILLIN LA
Amoxicillin/Clavulanate*
AUGMENTIN*,
AUGMENTIN ES*
AUGMENTIN XR*
Tetracyclines
Doxycycline*
VIBRAMYCIN*
Tetracycline*
ACHROMYCIN V * (tabs NF)
Minocycline*
MINOCIN*
Nucleoside Reverse
Transcriptase Inhibitors
Abacavir*
ZIAGEN*
Didanosine*
VIDEX*, VIDEX EC*
Emtricitabine
EMTRIVA
Lamivudine
EPIVIR, EPIVIR HBV
Stavudine*
ZERIT*, ZERIT XR
Zidovudine*
RETROVIR*
Tenofovir disoproxil fumarate
VIREAD
Emtricitabine/Tenofovir
disoproxil
fumarate
TRUVADA
Efavirenz/Emtricitabine/Tenofovir
disoproxil fumarate
ATRIPLA
Nucleoside Analog
Reverse Transcriptase
Inhibitor Comb.
Abacavir Sulfate/Lamivudine
EPZICOM
Emtricitabine/rilpivirine
/tenofovir disoproxil fumarate
COMPLERA
Lamivudine/Zidovudine*
COMBIVIR*
Non-Nucleoside
Reverse Transcriptase
Inhibitors
Delavirdine Mesylate
RESCRIPTOR
Efavirenz
SUSTIVA
Etravirine
INTELENCE
Nevirapine
VIRAMUNE
VIRAMUNE XR
Rilpivirine
EDURANT
Fusion or Entry
Inhibitors
Enfuvirtide
FUZEON INJECTABLE
Maraviroc
SELZENTRY
Integrase Strand
Transfer Inhibitor
Raltegravir
ISENTRESS
Antimalarials
Primaquine phosphate
PRIMAQUINE
Hydroxychloroquine*
PLAQUENIL*
Quinolones
Ciprofl oxacin*
CIPRO* (QL)
Ofl oxacin*
FLOXIN* (QL)
Levofloxacin
LEVAQUIN* (QL)
Sulfonamides
Sulfi soxazole*
GANTRISIN*
Sulfamethoxazole/Trimethoprim*
SEPTRA*, BACTRIM*,
BACTRIM
DS*, SEPTRA DS*
Sulfones
Dapsone
DAPSONE
Urinary Anti-Infectives/
Analgesics
Trimethoprim*
TRIMPEX*
Phenazopyridine*
PYRIDIUM*
Nitrofurantoin*
FURADANTIN*
Nitrofurantoin Macrocrystals*
MACROBID*,
MACRODANTIN*
Miscellaneous
Neomycin*
NEOMYCIN*
Metronidazole*
FLAGYL* (ER NF)
Acetic Acid*
ACI-JEL*
Sodium Borate, Boric Acid*
TRIMO-SAN GEL* (OTC)
Mebendazole*
VERMOX*
Clindamycin*
CLEOCIN*
Tobramycin (solution for
inhalation) (PA, QL)
TOBI
1000
ANTINEOPLASTICSCOV
ERAGE OF ONCOLOGY/
TRANSPLANT DRUGS
Alkylating Agents
Altretamine
HEXALEN
Busulfan
MYLERAN
Chlorambucil
LEUKERAN
Cyclophosphamide*
CYTOXAN*
Estramustine Phosphate
Sodium
EMCYT
Lomustine
CEENU
Melphalan
ALKERAN
Antimetabolites
Capecitabine
XELODA (PA)
Mercaptopurine
PURINETHOL
Hormones
Anastrozole*
ARIMIDEX* (PA)
Bicalutamide
CASODEX
Flutamide*
EULEXIN*
Letrozole
FEMARA (PA)
Megestrol Acetate*
MEGACE* (ES NF)
Nilutamide
NILANDRON
Tamoxifen Citrate*
TAMOXIFEN*,
NOLVADEX*,
SOLTAMOX
Testolactone
TESLAC
Toremifene Citrate
FARESTON
Miscellaneous
Bexarotene
TARGRETIN (oral) (SP)
Eroltinib
TARCEVA (PA, SP)
Etoposide*
VEPESID*
Hydroxyurea*
HYDREA*, DROXIA*
Imatinib Mesylate
GLEEVEC (PA)
Mitotane
LYSODREN
Procarbazine HCI
MATULANE
Temozolomide
TEMODAR (PA, SP)
Tretinoin*
VESANOID*
Immunosuppressives
Azathioprine*
IMURAN*
Cyclosporine*
SANDIMMUNE*, NEORAL
Mycophenolate Mofetil
CELLCEPT
Sirolimus
RAPAMUNE
Tacrolimus
PROGRAF
Immunomodulators
Thalidomide
THALOMID (PA, SP)
1200
AUTONOMIC DRUGS
Antiparkinson Agents
Apomorphine
APOKYN (PA, SP)
Bromocriptine*
PARLODEL*
Entacapone*
COMTAN
Levodopa/Carbidopa*
SINEMET*, SINEMET CR*
Pramipexole
MIRAPEX*
Ropinirole
REQUIP*
Selegiline*
ELDEPRYL*
Skeletal Muscle
Relaxants
Carisoprodol*
SOMA* (350mg only)
Carisoprodol/ASA*
SOMA Compound*
Methocarbamol*
ROBAXIN*
Baclofen*
LIORESAL*
Cyclobenzaprine*
FLEXERIL* (10mg only)
Chlorzoxazone*
PARAFON FORTE*
Dantrolene*
DANTRIUM*
Tizanidine* tablets
ZANAFLEX* (tablets only)
Cholinergic Agents
Bethanechol*
URECHOLINE*
Pyridostigmine*
MESTINON*
Donepezil
ARICEPT, ODT (AR)
Benztropine*
COGENTIN*
Chlordiazepoxide/Clidinium*
LIBRAX*
Dicyclomine*
BENTYL*
Trihexyphenidyl*
ARTANE*
Hyoscyamine*
LEVSIN*, LEVSINEX*,
ANASPAZ*,
CYSTOSPAZ*
Propantheline*
PRO-BANTHINE*
Adrenergic Agents/Beta
Agonists, Oral
Albuterol* (tablets,syrup)
PROVENTIL*, VENTOLIN*,
VOSPIRE ER* (tablets, syrup)
Metaproterenol* (10mg, 20mg
tablets)
ALUPENT*
Beta-agonists/
Bronchodiltors, Inhaled
Disulfi ram*
ANTABUSE*
Albuterol* (nebulizer soln)
ACCUNEB*
Albuterol* inhaled (QL)
VENTOLIN HFA
Metaproterenol (inhaler,
nebulized soln) (QL)
ALUPENT
Ipratropium* (inhaler, nasal
spray) (QL)
ATROVENT*, ATROVENT
HFA
Ipratropium & Albuterol*
DUONEB* (QL)
Salmeterol
SEREVENT DISKUS (QL)
Antispasmodic, Urinary
Vasoconstrictors
Flavoxate*
URISPAS*
Oxybutynin*
DITROPAN*
OXYTROL OTC
Oxybutynin ER*
DITROPAN XL*
Tolterodine*
DETROL*
Trospium*
SANCTURA*
Epinephrine
EPIPEN, EPIPEN JR,
ADRENALIN, (QL)
NMDA Receptor
Antagonist
Memantine HCl
NAMENDA (ST, AR)
Misc. Autonomic Agents
Drugs for MigraineAbortive
Acetaminophen/Dichloralphen
a-zone/Isometheptene*
MIDRIN*
Ergotamine/Caffeine*
CAFERGOT*,WIGRAINE*
Sumatriptan*
IMITREX* (QL)
Naratriptan*
AMERGE (QL)
Rizatriptan*
MAXALT*, MAXALT
MDT*(QL)
Anticholinergics
Atropine/Scopolamine/
Hyoscyamine/Phenobarbital*
DONNATAL* (capsules NF)
2000
BLOOD FORMATION &
COAGULATION
Coagulants, Anticoagulants, and
Antiplatelets
Aminocaproic Acid*
AMICAR*
Aspirin* (OTC)
ASPIRIN* (OTC)
Cilostazol*
PLETAL*
Clopidogrel
PLAVIX (300mg NF)
Dalteparin Sodium
FRAGMIN (QL)
Dipyridamole*
PERSANTINE*
Fondaparinux Sodium
ARIXTRA (QL)
Enoxaparin Sodium
LOVENOX (QL)
Pentoxifylline*
TRENTAL*
Ticlopidine*
TICLID*
Warfarin*
COUMADIN*
2400
CARDIOVASCULAR
DRUGS
Antihypertensives
Calcium Channel
Blockers
Amlodipine*
NORVASC*
Amlodipine/atorvastatin*
CADUET*
Diltiazem*
CARDIZEM*
Verapamil*
CALAN*
Verapamil*(long-acting tablet)
CALAN-SR*, VERELAN
SR* (QL)
Nifedipine*(sustained-release)
ADALAT CC*,
PROCARDIA XL*
Diltiazem*(long-acting
capsule)
CARDIZEM SR*,
CARDIZEM
CD*, CARTIA XT*,
DILACOR XR*
Felodipine*
PLENDIL*
Beta Blockers
Atenolol*
TENORMIN*
Propranolol*
INDERAL*, INDERAL LA*
Atenolol/Chlorthalidone*
TENORETIC*
Metoprolol Tartrate*
LOPRESSOR*, TOPROL
XL*
Nadolol*
CORGARD*
Pindolol*
VISKEN*
Acebutolol*
SECTRAL*
Bisoprolol Fumarate*
ZEBETA*
Alpha and Beta Blockers
Carvedilol*
COREG* (CR NF)
Labetalol*
TRANDATE*
Alpha Adrenergic
Blockers and Centrally
Acting Agents
Alfuzosin*
UROXATRAL*
Clonidine*
Please Note: This is not meant to be a list of all the drugs on the formulary. All forms of a drug may not be covered.
Drugs are listed by their Brand names for ease of use. This list was correct when printed but may have changed. Some
drugs require prior authorization or have quantity limits.
V1.2014
CATAPRES* (oral only)
Methyldopa*
ALDOMET*
Methyldopa/HCTZ*
ALDORIL*
Prazosin*
MINIPRESS*
Guanfacine*
TENEX*
Doxazosin*
CARDURA* (XL NF)
Tamsulosin*
FLOMAX*
Terazosin*
HYTRIN*
Ace Inhibitors
Captopril*
CAPOTEN*
Quinapril*
ACCUPRIL*
Quinapril/HCTZ*
ACCURETIC*
Captopril/HCTZ*
CAPOZIDE*
Enalapril*
VASOTEC*
Lisinopril*
PRINIVIL*, ZESTRIL*
Lisinopril/HCTZ*
PRINZIDE*, ZESTORETIC*
(QL)
Enalapril/HCTZ*
VASERETIC*
Moexipril*
UNIVASC*
Moexipril-HCT*
UNIRETIC*
Fosinopril*
MONOPRIL*
Fosinopril-HCT*
MONOPRIL HCTZ*
Ramipril Capsules*
ALTACE CAPS* (TABS
NF)
Benazepril*
LOTENSIN*
Benazepril-HCT*
LOTENSIN HCT*
Amlodipine / Benazepril*
LOTREL*
Trandolapril*
MAVIK*
Angiotension II Receptor
Antagonists
Candesartan Cilexetil *
ATACAND*
Candesartan Cilexetil/
hydrochlorothiazide*
ATACAND HCT*
Losartan*
COZAAR*
Losartan/hydrochlorothiazide*
HYZAAR*
Irbesartan*
AVAPRO*
Irbesartan/hydrochlorothiazide
AVALIDE*
*Generic/generic available
Not all dosage forms are available generically
(PA) Prior authorization required
(AR) Age restriction
(NF) Not on formulary
(OTC) Available over the counter with a prescription
(QL) Quantity limits apply
(SP) Must be dispensed by participating specialty pharmacy
(ST) Step Therapy
(susp = a liquid)
(tab = tablet)
Endothelin Receptor
Antagonists
Fenofibrate*
LOFIBRA*
Ambrisentan (PA,SP)
LETAIRIS
Bosentan (PA, SP)
TRACLEER
Statins
Vasodilators
Hydralazine*
APRESOLINE*
Hydralazine/HCTZ*
APRESAZIDE*
Minoxidil*
LONITEN*
Diuretics
Fluvastatin Sodium*
LESCOL*
Lovastatin*
MEVACOR*
Pravastatin*
PRAVACHOL*
Simvastatin*
ZOCOR* (80mg NF)
Atorvastatin*
LIPITOR*
Miscellaneous – Lipid
Agents
Spironolactone/HCTZ*
ALDACTAZIDE*
Chlorothiazide*
DIURIL*
Chlorthalidone*
HYGROTON*
Amiloride*
MIDAMOR*
Amiloride/HCTZ*
MODURETIC*
Hydrochlorothiazide*(HCTZ)
HYDRODIURIL*,
MICROZIDE*
Furosemide*
LASIX*
Spironolactone*
ALDACTONE*
Torsemide*
DEMADEX*
Triamterene/HCTZ*
MAXZIDE*, DYAZIDE*
Bumetanide*
BUMEX*
Indapamide*
LOZOL
Niacin (OTC)
Niacin ER*
NIASPAN
Omega-3 Fatty Acid (OTC)
USP Certified FISH OIL
only
Antiarrhythmics and
Cardiac Glycosides
Nitroglycerin Patches*
NITRO-DUR*
Sildenafil*
REVATIO (PA, SP)
Digoxin*
LANOXIN*
Quinidine Sulfate*
CIN-QUIN*
Flecainide*
TAMBOCOR*
Procainamide*
PRONESTYL*
Disopyramide*
NORPACE*, NORPACE CR*
Quinidine Gluconate*
QUINAGLUTE*
Quinidine Sulfate*
(sustainedrelease)
QUINIDEX*
Sotalol*
BETAPACE*, BETAPACE AF*
Amiodarone*
CORDARONE*
Bile Sequestrants
Cholestyramine*
QUESTRAN*, QUESTRAN
LIGHT*
Colestipol hydrochloride*
COLESTID*
Fibric Acid Derivatives
Gemfibrozil*
LOPID*
Vasodilating Agents,
Coronary
Dipyridamole*
PERSANTINE*
Isosorbide Dinitrate*(chew tab NF)
ISORDIL*
Nitroglycerin Ointment*
NITROL*, NITRO-BID*
Nitrolglycerin Oral*
NITROBID*
Nitroglycerin Spray
NITROLINGUAL
Nitroglycerin Sublingual*
NITROSTAT SL*
Isosorbide Mononitrate*
IMDUR*, ISMO*,
MONOKET*
2800
CENTRAL NERVOUS
SYSTEM AGENTS
Nonsteroidal AntiInflammatory Agents
Ibuprofen* (RX/OTC)
MOTRIN*, ADVIL*
(RX/OTC)
Acetaminophen* (OTC)
TYLENOL*
Aspirin* (OTC)
ECOTRIN*, St. JOSEPH*
(OTC)
Indomethacin* (suppository NF)
INDOCIN*, INDOCIN SR*
Piroxicam*
FELDENE*
Salsalate*
DISALCID*
Choline Magnesium
Salicylate*
TRILISATE*
Diflunisal*
DOLOBID*
Fenoprofen*
NALFON*
Naproxen* (Naprelan NF)
NAPROSYN*, NAPROSYN
EC*
Naproxen Sodium*
ANAPROX*, ANAPROX DS*
Sulindac*
CLINORIL*
Diclofenac Sodium*
VOLTAREN* (not gel),
VOLTAREN XR*
Diclofenac Potassium*
CATAFLAM*
Flurbiprofen*
ANSAID*
Oxaprozin*
DAYPRO*
Etodolac*
LODINE*, LODINE XL*
Ketorolac*
TORADOL*
Meloxicam*
MOBIC* (tabs only)
Nabumetone*
RELAFEN*
Tolmetin sodium*
TOLECTIN, DS*
Narcotic Analgesics
Codeine Sulfate*
CODEINE*
Fentanyl Transdermal
System*
DURAGESIC* (QL)
(12.5mg NF)
Hydromorphone*
DILAUDID*
Methadone*
DOLOPHINE*
Morphine Sulfate*
MSIR* (oral only),
MS Contin*
KADIAN*
Oxycodone/Acetaminophen
Tablet*
PERCOCET*, TYLOX*
Oxycodone/Aspirin*
PERCODAN*
Oxycodone*
OXYIR*
Oxymorphone*
OPANA ER*
Non-Narcotic Analgesic
Combinations
Butalbital/Acetaminophen/
Caffeine* (QL)
FIORICET*, ESGIC*
Butalbital/Aspirin/Caffeine*
FIORINAL* (QL, capsules
NF)
Codeine/Aspirin*
EMPIRIN #2,3,4*
Codeine/Acetaminophen*
TYLENOL #2,3,4*
(capsules NF)
Hydrocodone Bitartrate/
Acetaminophen*
VICODIN*, VICODIN ES*,
LORTAB*
Tramadol HCl*
ULTRAM*
Tramadol-Acetaminophen*
ULTRACET*
Opiate Antagonist
Secondary Amines
Buprenorphine/Naloxone*
SUBOXONE tablets* (PA,
QL)
Naltrexone*
REVIA*
Desipramine*
NORPRAMIN*
Nortriptyline*
PAMELOR*, AVENTYL*
Amoxapine*
ASENDIN*
Protriptyline*
VIVACTIL*
Anticonvulsants
Phenobarbital*
PHENOBARBITAL*
Carbamazepine*
TEGRETOL*, TEGRETOL
XR,
Carbamazepine, extendedrelease
EQUETRO
Phenytoin*
DILANTIN*, PHENYTEK
Ethosuximide*
ZARONTIN*
Primidone*
MYSOLINE*
Clonazepam*
KLONOPIN*, ODT*
Valproic Acid*
DEPAKENE*
Divalproex Sodium*
DEPAKOTE*, DEPAKOTE
ER*
Gapapentin*
NEURONTIN*
Zonisamide*
ZONEGRAN*
Oxcarbazepine*
TRILEPTAL*
Lamotrigine*
LAMICTAL*
Topiramate
TOPAMAX
Levetiracetam*
KEPPRA*
Levetiracetam ER*
KEPPRA XR*
Diazepam rectal gel
DIASTAT PED (QL),
DIASTAT
ACUDIAL (QL)
2816
ANTIDEPRESSANT
AGENTS
Tricyclic
Antidepressants
Amitriptyline*
ELAVIL*
Doxepin*
SINEQUAN*
Imipramine*
TOFRANIL*, TOFRANIL PM*
Clomipramine*
ANAFRANIL*
Citalopram*
CELEXA*
Escitalopram*
LEXAPRO*
Fluoxetine*
PROZAC* (weekly NF)
Fluoxetine/Olanzapine*
SYMBYAX* (AR)
Fluvoxamine*
LUVOX*
Paroxetine*
PAXIL*
Sertraline*
ZOLOFT*
Tricyclic
Antidepressants
Antipsychotics
Amitriptyline/Perphenazine*
TRIAVIL*
Miscellaneous
Antidepressants
Trazodone*
DESYREL*
Bupropion*
WELLBUTRIN*,
SR* , XL*
Venlafaxine*
EFFEXOR*, EFFEXOR XR
(ST)
Venlafaxine ER tablets (ST)
MAO-I
Phenelzine
NARDIL
Antimanic Agents
Lithium*
LITHOBID*, ESKALITH*,
ESKALITH CR* (all forms)
Tetracyclic
Antidepressants
Maprotiline*
LUDIOMIL*
Tetracyclic
Antidepressants
Mirtazapine*
REMERON*, ODT*
Please Note: This is not meant to be a list of all the drugs on the formulary. All forms of a drug may not be covered.
Drugs are listed by their Brand names for ease of use. This list was correct when printed but may have changed. Some
drugs require prior authorization or have quantity limits.
V1.2014
SSRIs
*Generic/generic available
Not all dosage forms are available generically
(PA) Prior authorization required
(AR) Age restriction
(NF) Not on formulary
(OTC) Available over the counter with a prescription
(QL) Quantity limits apply
(SP) Must be dispensed by participating specialty pharmacy
(ST) Step Therapy
(susp = a liquid)
(tab = tablet)
281608
ANTIPSYCHOTICS
Antipsychotics
Chlorpromazine*
(spansule NF)
THORAZINE*
Clozapine*
CLOZARIL*
Fluphenazine*
PROLIXIN*, PERMITIL*
Haloperidol*
HALDOL*
Loxapine*
LOXITANE*
Lurasidone
LATUDA (ST)
Olanzapine*
ZYPREXA (AR)
Olanzapine/Fluoxetine*
SYMBYAX (AR)
Perphenazine*
TRILAFON*
Quetiapine fumurate
SEROQUEL* (AR, XR NF)
Risperdone*
RISPERDAL* (oral only)
(AR)
Thioridazine*
MELLARIL*
Thiothixene*
NAVANE* (oral only)
Trifluoperazine*
STELAZINE*
Ziprasidone*
GEODON* (AR)
2820
CEREBRAL
STIMULANTS
Respiratory and Cerebral
Stimulants
Amphetamine mixture*
ADDERALL*
Amphetamine mixture
ADDERALL* XR (AR)
Dextroamphetamine*
DEXEDRINE*
Dexmethylphenidate*
FOCALIN* (XR NF)
Methylphenidate*
RITALIN*, RITALIN SR*,
METHYLIN ER*
Methylphenidate, long-acting
CONCERTA* (AR)
RITALIN LA (ST on 10mg,
AR)
METADATE CD* (AR)
Modafinil*
PROVIGIL* (PA)
2824
ANXIOLYTICS,
SEDATIVES, &
HYPNOTICS
Anxiolytics, Sedatives,
and Hypnotics
Alprazolam*
XANAX*, XANAX XR* (AR)
Chloral Hydrate*
NOCTEC*
Chlordiazepoxide* (AR, XL
and tablets NF)
LIBRIUM*
Clorazepate*(LA NF, AR)
TRANXENE*
Diazepam*
VALIUM*
Flurazepam* (AR)
DALMANE*
Hydroxyzine HCI*
ATARAX*
Hydroxyzine Pamoate
capsule*
VISTARIL*
Lorazepam*
ATIVAN*
Temazepam* (AR)
RESTORIL* (7.5 and 22.5
NF)
Oxazepam* (AR)
SERAX*
Triazolam*(AR)
HALCION*
Promethazine*
PHENERGAN*
Buspirone*
BUSPAR*
Zolpidem* (AR)
AMBIEN*
Zaleplon* (AR)
SONATA*
4000
ELECTROLYTIC,
CALORIC & WATER
Diuretics
Spironolactone/HCTZ*
ALDACTAZIDE*
Chlorothiazide*
DIURIL*
Chlorthalidone*
HYGROTON*
Amiloride*
MIDAMOR*
Amiloride/HCTZ*
MODURETIC*
Hydrochlorothiazide*(HCTZ)
HYDRODIURIL*,
MICROZIDE*
Furosemide*
LASIX*
Spironolactone*
ALDACTONE*
Triamterene/HCTZ*
MAXZIDE*,DYAZIDE*
Bumetanide*
BUMEX*
Indapamide*
LOZOL*
Antidiuretic
Desmopressin*
DDAVP*
Uricosuric Agents
Probenecid*
BENEMID*
Potassium Supplements
Tablets
Potassium Chloride 8mEq*
SLOW K*
Potassium Chloride 10mEq,
20mEq*
K-DUR*
Powders/Effervescent
Tablets
Packets* 20mEq, 25mEq,
50mEq,15mEq
K-LOR*, K-LYTE*
Codeine/Guaifenesin*
ROBITUSSIN AC*,
GUAITUSS
AC*, CHERACOL*
Codeine/Promethazine*
PHENERGAN
W/CODEINE*
Dextromethorphan/
Guaifenesin* (OTC)
ROBITUSSIN DM*,
CHLORDEX GP*,
RONDEC*
Dextromethorphan/Promethazine*
PHENERGAN DM*
Guaifenesin* (OTC)
ROBITUSSIN*
Hydrocodone/Homatropine*
HYCODAN*
Expectorant and
Expectorant
Combinations
Trifluridine*
VIROPTIC*
Hyperkalemic Agent
Sodium Polystyrene
Sulfonate*
KAYEXALATE*
Alkalinizing Agent
Potassium Citrate
UROCIT K
Ammonia Detoxicants
Lactulose*
CEPHULAC*
Urinary Acidifiers
Phosphate Replacement
K-PHOS NEUTRAL, KPHOS
Laxative
Polyethylene glycol (PEG)
solution*
MIRALAX* (OTC)
Phospate Binder
Calcium Acetate
PHOSLO*
4800
EXPECTORANT &
COUGH AGENTS
Mucolytic Agents
Acetylcysteine*
MUCOMYST*
Dornase Alfa
PULMOZYME (PA,QL)
5200
EYE, EAR, NOSE &
THROAT
Topical Anti-Infectives
Anti-Inflammatory (otic)
Carbamide Peroxide 6.5%*
(OTC)
DEBROX* (OTC)
Acetic Acid*
VOSOL*
Benzocaine/Acetic Acid*
A/B OTIC DROPS*
Aluminum Acetate/Acetic
Acid* (OTC)
DOMEBORO OTIC
SOLUTION* (OTC)
Hydrocortisone/Acetic Acid*
VOSOL HC OTIC*
Neomycin/Polymyxin B
Sulfate/
Hydrocortisone*
CORTISPORIN OTIC
SOLN.*
Fluocinolone acetonide oil
DERMOTIC OIL EAR
DROPS
Pramoxine/Choroxylenol*
PRAMOTIC DROPS*
Ofloxacin*
FLOXIN OTIC*
Anti-Infectives
(ophthalmic)
Bacitracin*
BACITRACIN*
Erythromycin*
ILOTYCIN*
Gentamicin*
GENOPTIC*,
GARAMYCIN*
Neomycin/Dexamethasone*
NEO-DECADRON*
Antitussive/
Decongestants
Benzonatate*
TESSALON PERLES*
Please Note: This is not meant to be a list of all the drugs on the formulary. All forms of a drug may not be covered.
Drugs are listed by their Brand names for ease of use. This list was correct when printed but may have changed. Some
drugs require prior authorization or have quantity limits.
V1.2014
Antivirals (ophthalmic)
Guaifenesin
MUCINEX (OTC)
Liquids
Potassium Chloride*
KAOCHLOR*
Neomycin Sulfate/Gramicidin/
Polymyxin B Sulfate*
NEOSPORIN Solution*
Polymyxin B Sulfate/Neomycin
Sulfate/Dexamethasone*
MAXITROL*
Sulfacetamide 10%*
BLEPH 10*
Neomycin/Polymyxin B
Sulfate/
Hydrocortisone/Bacitracin*
CORTISPORIN*
Neomycin/Bacitracin/Polymyxin
B Sulfate*
NEOSPORIN Ointment*
Ofloxin*
OCUFLOX* (10ml NF)
Ciprofl oxacn*
CILOXAN*
Tobramycin Sulfate*
TOBREX*
Ophthalmic AntiInflammatories
Dexamethasone*
DECADRON*
Prednisolone Acetate*
PRED MILD*, PRED
FORTE*
ECONOPRED*
Flurbiprofen*
OCUFEN*
Carbonic Anhydrase
Inhibitors
Acetazolamide*
DIAMOX* (oral only)
Brinzolamide
AZOPT (ST, QL)
Dorzolamide HCl*
TRUSOPT*
Miotics
Pilocarpine*(Ocusert NF)
ISOPTO CARPINE*
Dipivefrin HCl*
PROPINE*
Mydriatics
Artificial Tears* (OTC)
ISOPTO TEARS* (OTC)
Atropine*
ISOPTO ATROPINE*
Homatropine*
ISOPTO HOMATROPINE*
Vasoconstrictors
Naphazoline*
PRIVINE* (OTC)
Naphaxoline/Pheniramine*
(OTC)
NAPHCON-A* (OTC)
*Generic/generic available
Not all dosage forms are available generically
(PA) Prior authorization required
(AR) Age restriction
(NF) Not on formulary
(OTC) Available over the counter with a prescription
(QL) Quantity limits apply
(SP) Must be dispensed by participating specialty pharmacy
(ST) Step Therapy
(susp = a liquid)
(tab = tablet)
Betaxolol*
BETOPTIC* (suspension
NF)
Simethicone* (OTC)
MYLICON*
Lactase* (OTC)
LACTAID*
Lactobacillus Acidophilus*
(OTC)
LACTINEX*
Diphenoxylate/Atropine*
LOMOTIL*
Lactulose*
CEPHULAC*
Polyethylene glycol/electrolyte
solution*
GOLYTELY, NULYTELY*
Pancrelipase
CREON
PANCREAZE
Misc EENT
H2 Antagonists – OTC
Beta Blockers
Levobunolol*
BETAGAN*
Timolol*
TIMOPTIC*, TIMOPTIC
XE*
Carteolol HCl*
OCUPRESS*
Metipranolol*
OPTIPRANOLOL*
Beta Blockers (Beta-1
Selective)
Phenylephrine* (OTC)
NEO-SYNEPHRINE*
Sodium chloride spray* (OTC)
OCEAN SPRAY*
Benzocaine/Pectin* (OTC)
ORABASE-B*
Epinastine Hydrochloride*
ELESTAT*
Menthol/Cetylpyridium
Lozenge* (OTC)
CEPACOL*
Cromolyn*
CROLOM*
Brimonidine*
ALPHAGAN* (P is NF)
Latanoprost*
XALATAN* (QL)
Travoprost
TRAVATAN Z (ST, QL)
Ketotifen* (OTC)
ZADITOR*
Azelastine Hydrochloride*
OPTIVAR*
Nasal Steroids/AntiInflamatory
Cromolyn* (OTC)
NASALCROM*
Flunisolide*
NASALIDE* (QL)
Fluticasone*
FLONASE* (QL)
Triamcinolone*
NASACORT AQ (QL)
5600
GASTROINTESTIONAL
DRUGS
(RX are NF)
Cimetidine*
TAGAMET HB* (OTC)
Cimetidine*
TAGAMET
Ranitidine*
ZANTAC* (OTC)
Ranitidine*
ZANTAC*
Nizantadine*
AXID AR * (OTC)
Nizatidine*
AXID*
Famotidine*
PEPCID AC* (OTC)
Famotidine*
PEPCID
Proton Pump Inhibitors
All non-formulary PPIs require
PA. Formulary PPIs do not
require PA.
Lansoprazole* (QL)
PREVACID OTC* (Solutab
NF)
Lansoprazole*
PREVACID
Omeprazole Magnesium
PRILOSEC OTC (QL)
Omeprazole *
PRILOSEC *
Pantoprazole*
PROTONIX*
GI Motility
Metoclopramide*
REGLAN*
Miscellaneous
Cytoprotective Agents
Basalazide
COLAZAL*
Bismuth subsalicylate* (OTC)
PEPTO-BISMOL*
Calcium carbonate* (OTC)
TUMS*
Electrolyte Rehydrating (OTC)
PEDIALYTE*
Sucralfate*
CARAFATE*
Loperamide* (OTC)
IMODIUM A-D*
Magnesium
Hydroxide/Aluminum
Hydroxide* (OTC)
MAALOX*
Prostaglandins
Misoprostol*
CYTOTEC*
Antiemetics
Meclizine * (RX/OTC)
MECLIZINE* (RX/OTC)
Trimethobenzamide*
TIGAN*
Prochlorperazine*
COMPAZINE*
Ondansetron*
ZOFRAN* (QL)
Misc. GI Drugs
Sulfasalazine*
AZULFIDINE*,
AZULFIDINE EN*
Mesalamine
APRISO, CANASA
Ursodiol*
ACTIGALL*
Laxatives and Stool
Softeners (OTC)
Bisacodyl* (OTC)
DULCOLAX*
Docusate Calcium* (OTC)
SURFAK*
Docusate Potassium* (OTC)
DIALOSE*
Docusate Sodium* (OTC)
COLACE*
Docusate Sodium/
Casanthrol* (OTC)
PERI-COLACE*
Magnesium Citrate* (OTC)
CITRATE OF MAGNESIA*
Magnesium Hydroxide* (OTC)
MILK OF MAGNESIA*
Methylcellulose* (OTC)
CITRUCEL*
Mineral Oil* (OTC)
MINERAL OIL*
Senna* (OTC)
SENOKOT*
Senna/Docusate Sodium*
(OTC)
SENOKOT -S*
Sodium Phosphate/Sodium
Biphosphate* (OTC)
FLEET ENEMA*
6000
ARTHRITIS/GOUT
Nonsteroidal AntiInflammatory Agents
Probenecid*
BENEMID*
Allopurinol*
ZYLOPRIM*
Colchicine/Probenecid*
COLBENEMID*
Methotrexate*
METHOTREXATE*,
RHEUMATREX*
Leflunomide*
ARAVA*
6400
RESPIRATORY DRUGS
Albuterol Inhaler
VENTOLIN HFA (QL)
Ipratropium* (inhaler, nasal
spray)
ATROVENT*, ATROVENT
HFA (QL)
Cromolyn*
INTAL* (QL)
Metaproterenol Sulfate
ALUPENT (QL)
Albuterol Tablets*
VOSPIRE ER*
Terbutaline*
BRETHINE*
Ipratropium & Albuterol*
DUONEB*(QL)
Salmeterol
SEREVENT DISKUS (QL)
Albuterol/Ipratropium
COMBIVENT RESPIMAT
Tiotropium Bromide
SPIRIVA (QL)
Inhaled AntiInflammatory Agents
AEROCHAMBER (QL)
Fluticasone
FLOVENT, FLOVENT HFA
Beclometahsone
QVAR
Budesonide (Inhalation)
(Turbohaler NF)
PULMICORT RESPULES
(AR, QL)
Budesonide/formoterol
SYMBICORT (QL)
Mometasone/Formoterol
DULERA (QL))
PEAK FLOW METER (QL)
Leukotriene Antagonist
Montelukast*
SINGULAIR (PA)
Zafirlukast
ACCOLATE
Estrogens
Estrogens, Conjugated
PREMARIN TABLETS
(CREAM NF)
Estradiol*
ESTRACE TABS*,
VAGINAL
CREAM, VAGIFEM
Estropipate*
OGEN*
Estradiol Transdermal
System*
CLIMARA*
Estrogen, Esterfi ed
MENEST
Estrogens, Conjugated/
Medroxyprogesterone
PREMPRO, PREMPHASE
Estrogens AgonistAntagonist
Raloxifene
EVISTA
Anti-Estrogen
Tamoxifen*
NOLVADEX*,
TAMOXIFEN*
Growth Hormone/AntiGrowth Hormone
Octreotide
SANDOSTATIN (PA, SP)
Somatropin
OMNITROPE powder for
injection (cartidges NF)
(PA, SP)
Contraceptives
Theophylline and Other
Xathines Solids
Theophylline*
THEO-24*, THEO-VENT*,
THEOCHRON*,
T-PHYL*, SLO-BID*,
QUIBRON-T*, UNIPHYL*
Etonogestrel-Ethinyl Estradiol
Vaginal Ring
NUVARING (QL)
Medroxyprogesterone Acetate
(Contraceptive)*
DEPO-PROVERA INJ*
(QL)
Levonorgestrel
PLAN B (with written script
only)
Beta-Agonists, Oral
Albuterol (soln, syrup, tablets)*
PROVENTIL*
Metaproterenol*
METAPREL*, ALUPENT*
Terbutaline*
BRETHINE*
Bronchodilators
Sodium Chloride Soln for
Inhalation* (OTC)
SODIUM CHLORIDE *
Aclidinium
TUDORZA (QL)
Albuterol*
ACCUNEB*
Please Note: This is not meant to be a list of all the drugs on the formulary. All forms of a drug may not be covered.
Drugs are listed by their Brand names for ease of use. This list was correct when printed but may have changed. Some
drugs require prior authorization or have quantity limits.
V1.2014
6800
HORMONES &
SYNTHETIC
SUBSTITUTES
Oral Contraceptives
(Monophasic) (Quantity
Limits Apply to All)
Desogestrel/Ethinyl Estradiol*
ORTHO-CEPT*,
CYCLESSA*,
APRI*, SOLIA*,
DESOGEN*,
RECLIPSEN*
Ethynodiol/Ethinyl Estradiol*
DEMULEN*, ZOVIA*,
KELNOR*
*Generic/generic available
Not all dosage forms are available generically
(PA) Prior authorization required
(AR) Age restriction
(NF) Not on formulary
(OTC) Available over the counter with a prescription
(QL) Quantity limits apply
(SP) Must be dispensed by participating specialty pharmacy
(ST) Step Therapy
(susp = a liquid)
(tab = tablet)
Levonorgestrel/Ethinyl
Estradiol*
NORDETTE*, LEVORA*,
PORTIA*
Levonorgestrel/Ethinyl
Estradiol*
ALESSE*, AVIANE*,
LESSINA*, LUTERA*
Norethindrone/Ethinyl
Estradiol*
ORTHO-NOVUM 1/35*,
NECON 1/35*, NORTREL
1/35*, NORINYL 1/35*,
NORETHIN 1/35*
Norethindrone/Ethinyl
Estradiol*
MODICON*, NECON
0.5/35-21*, NECON 0.5/3528*, NORTREL 0.5/35*,
BREVICON
Norgestrel/Ethinyl Estradiol*
LO/OVRAL*, LOWOGESTREL*, CRYSELLE*
Norethindrone/Ethinyl
Estradiol*
LOESTRIN FE 1.5/20*,
MICROGESTIN FE 1.5/30*,
JUNEL FE 1.5/20*
Norethindrone/Ethinyl
Estradiol*
OVCON-50*, OVCON-35*,
BALZIVA*
Norethindrone/Ethinyl
Estradiol*
LOESTRIN FE 1/20*,
MICROGESTIN FE 1/20*,
JUNEL FE 1/20*
Norethindrone/Ethinyl
Estradiol*
ORTHO-NOVUM 10/11*,
NECON 10/11*
Norethindrone/Ethinyl
Estradiol*
MIRCETTE*, KARIVA*
Norethindrone/Mestranol*
ORTHO-NOVUM 1/50*,
NECON 1/50*, NORINYL
1/50*
Norgestrel/Ethinyl Estradiol*
OVRAL*, OGESTREL*
Norgestimate/Ethinyl
Estradiol*
ORTHO-CYCLEN*,
MONONESSA*,
SPRINTEC*, PREVIFEM*
Drospirenone/Ethinyl Estradiol
YASMIN*, OCELLA*
Oral Contraceptives
(Multiphasic) (Quantity
Limits Apply to All)
Desogestrel/Ethinyl Estradiol*
CYCLESSA*, CESIA*,
VELIVET*
Levonorgestrel/Ethinyl
Estradiol*
TRIPHASIL*, TRIVORA*,
ENPRESSE*
Norethindrone/Ethinyl
Estradiol*
ESTROSTEP FE*
Norethindrone/Ethinyl
Estradiol*
ORTHO-NOVUM 7/7/7*,
NECON 7/7/7*,
NORTREL 7/7/7*
Norethindrone/Ethinyl
Estradiol*
TRI-NORINYL*,
ARANELLE*,
LEENA*
Norgestimate/Ethinyl Estradiol
ORTHO-TRI-CYCLEN*,
TRI-PREVIFEM*,
TRINESSA*,
TRI-SPRINTEC*
Anti-Androgens
Glipizide*
GLUCOTROL*,
GLUCOTROL XL*
Glipizide / Metformin*
METAGLIP*
Glyburide / Metformin*
GLUCOVANCE*
Glimepiride*
AMARYL*
Metformin*
GLUCOPHAGE *,
GLUCOPHAGE XR*
Acarbose*
PRECOSE*
Pioglitazone
ACTOS (ST)
Sitagliptin
JANUVIA (ST)
Sitagliptin / Metformin
JANUMET (ST)
JANUMET XR (ST)
Finasteride*
PROSCAR*
Insulin
Progestin-Only
(oral contraceptives)
(Quantity Limits Apply to All)
Norethindrone*
ORTHO-MICRONOR*,
AMILA*, ERRIN*,
JOLIVETTE*, NOR-BE*,
NOR-Q-D*
Lilly Brand Human Insulin,
Androgens
Methyltestosterone
ANDROID
Testosterone cypionate
injection
DEPO-TESTOSTERONE*
INJ
Testosterone topical gel
TESTIM GEL (PA)
Note: Insulin cartridges and
needles are NF and need prior
authorization, except for
regular and rapid acting
insulin.
Insulin Human glargine
LANTUS (pens NF)
Drugs to Treat
Endometriosis
Lifescan glucometers are
covered on the formulary with
a written prescription (QL)
Danazol*
DANOCRINE*
VerioIQ Meter (QL, ST)
Progestin Drugs
Corticosteroids
Medroxyprogesterone*
PROVERA*
Norethindrone*
AYGESTIN*
Progesterone, Micronized
PROMETRIUM
Prednisone*
ORASONE*
Hydrocortisone*
CORTEF*
Dexamethasone*
DECADRON*
Methylprednisolone*
MEDROL*
Prednisolone*
PRELONE*, ORAPRED*,
PEDIAPRED*
Thyroid and Antithyroid
Agents
Levothyroxine* (use same
brand consistently)
LEVOXYL*,
LEVOTHROID*,
SYNTHROID*
Methimazole*
TAPAZOLE*
Propylthiouracil*
PROPYLTHIOURACIL*
Thyroid*
ARMOUR THYROID*
Antidiabetic Agents Oral Agents
Chlorpropamide*
DIABINESE*
Tolbutamide*
ORINASE*
Tolazamide*
TOLINASE*
Glyburide*
MICRONASE*, DIABETA*,
GLYNASE*
Bone Metabolism
Alendronate*
FOSAMAX*
*Ibandronate Sodium*
BONIVA*
8400
SKIN & MUCOUS
MEMBRANE
Terconazole*
TERAZOL*
Butoconazole Nitrate
GYNAZOLE-1
Anti-infectives-Topical
Antifungal-Topical
Hydrogen Peroxide 3%*
(OTC)
HYDROGEN PEROXIDE
3%* (OTC)
Neomycin/Polymyxin B/
Bacitracin* (OTC)
NEOSPORIN*
Polymyxin B/Bacitracin* (OTC)
POLYSPORIN*
Bacitracin* (OTC)
BACIGUENT*
Polymyxin B/Bacitracin*
POLYSPORIN*
Gentamicin*
GARAMYCIN*
Silver Sulfadiazine*
SILVADENE*
Metronidazole gel*
METROGEL
Mupirocin*
BACTROBAN*
Mupirocin Calcium
BACTROBAN NASAL
Clotrimazole* (OTC)
MYCELEX*, LOTRIMIN*,
FUNGOID, LOTRIMIN
(1% Soln)
Miconazole* (OTC)
MICATIN*
Butenafi ne
MENTAX
Tolnaftate* (OTC)
TINACTIN*
Nystatin*
MYCOSTATIN*
Clotrimazole/Betamethasone
Diproprionate*
LOTRISONE*
Nystatin/Triamcinolone*
MYCOLOG II*
Econazole*
SPECTAZOLE*
Ketoconazole*
NIZORAL*
Ciclopirox*
LOPROX* (cream and
suspension only) (QL)
Ciclopirox*
PENLAC* (QL)
Antiacne
Aluminum Chloride*
DRYSOL*
Erythromycin Solution*, Gel*,
Pads*
A/T/S*, ERY-DERM*, TSTAT*, ERYMAX*,
T-STAT*, EMGEL*,
ERYCETTE*
Clindamycin*
CLEOCIN T* (lotion, gel,
soln, pads), CLINDETS*
Clindamycin/Benzoyl
Peroxide*
BENZACLIN *
Erythromycin gel - Benzoyl
Peroxide*
BENZAMYCIN GEL*
Sodium Sulfacetamide &
Sulfur Lotion*
SULFACET-R*
Tretinoin*
RETIN A* (micro NF),
AVITA* (QL)
Tazarotene
TAZORAC
Isotretinoin*
ACCUTANE* (PA)
Antibiotic-Vaginal
7200
LOCAL ANESTHETICS
Lidocaine/Prilocaine*
EMLA* (cream only)
Lidocaine
LIDODERM (PA, QL)
Butoconazole* (OTC)
FEMSTAT-3*
Miconazole* (OTC)
MONISTAT*
Clotrimazole* (OTC)
GYNE-LOTRIMIN*
Ticonazole* (OTC)
VAGISTAT-1*
Metronidazole*
METROGEL Vaginal*
7600
OXYTOCICS
Methylergonovine Maleate
METHERGINE
Please Note: This is not meant to be a list of all the drugs on the formulary. All forms of a drug may not be covered.
Drugs are listed by their Brand names for ease of use. This list was correct when printed but may have changed. Some
drugs require prior authorization or have quantity limits.
V1.2014
Scabicides and
Pediculicides
Permethrin 1%* (OTC)
NIX*
Pyrethrins Spray* (OTC)
A-200 LICE CONTROL*
Pyrethrins/Piperonyl
Butoxide* (OTC)
RID*
Permethrin*
ELIMITE*
Malathion
OVIDE (QL)
(Topical)
Group VII (Lowest
Potency)
Hydrocortisone 2.5%*
HYTONE*, CORT-DOME*
Hydrocortisone 0.5,1%* (OTC)
CORTAID*
Group VI
Clotrimazole/Betamethasone
Diproprionate*
LOTRISONE*
Fluocinolone Acetonide* Soln,
Cream 0.01%
SYNALAR*
Triamcinolone Acetonide*
Cream, Oint. 0.025%
KENALOG*
Betamethasone Valerate
Lotion 0.1%*
VALISONE*
*Generic/generic available
Not all dosage forms are available generically
(PA) Prior authorization required
(AR) Age restriction
(NF) Not on formulary
(OTC) Available over the counter with a prescription
(QL) Quantity limits apply
(SP) Must be dispensed by participating specialty pharmacy
(ST) Step Therapy
(susp = a liquid)
(tab = tablet)
Desonide* Cream, Oint 0.05%
DESOWEN*
Amcinonide*
CYCLOCORT*
Alclometasone*
ACLOVATE* (QL)
Fluticasone*
CUTIVATE* (QL)
Group V
Triamcinolone Acetonide*
0.1% (cream, ointment, lotion)
KENALOG*,
ARTISTOCORT*
Betamethasone Valerate*
cream 0.1%
VALISONE*
Fluocinolone Acetonide*
cream 0.025%
SYNALAR*
Prednicarbate*
DERMATOP*
Group IV
Triamcinolone* 0.5% (cream,
ointment)
KENALOG*,
ARTISTOCORT*
Fluocinolone Acetonide*
0.025% ointment
SYNALAR*
Group III
Betamethasone Valerate* Oint
0.1%
VALISONE*
Mometasone Furoate (cream,
ointment, lotion)*
ELOCON*
Hydrocortisone Butyrate*
LOCOID LIPOCREAM*,
LOCOID* (cream, ointment,
soln)*, LOCOID (lotion)
Group II
Betamethasone Dipropionate
0.05%* (cream, ointment,
lotion)
DIPROSONE*
Fluocinonide* 0.05% (cream,
ointment, gel, soln)
LIDEX*
Desoximetasone* (cream,
ointment, gel)
TOPICORT*
Group 1 (Highest
Potency)
Difl orasone Diacetate*
PSORCON E*
Clobetasol* 0.05% (cream,
ointment, lotion, soln)
TEMOVATE*, CLOBEX*
Halobetasol Propionate*
ULTRAVATE* (QL)
Augmented Betamethasone*
DIPROLENE*,
DIPROLENE AF*
Rectal
Prenatal
Hydrocortisone*
ANUSOL-HC*
ALL generic prenatal vitamins
(RX/ OTC) are covered.
(PRENATE and NEEVO
Branded products are NF)
Keratolytic Agent
Ammonium Lactate*
AMLACTIN 12% (OTC
only)
Podofi lox*
CONDYLOX*
Amino Acid Derivatives
Levocarnitine*
CARNITOR*
Misc. Skin and Mucous
Membrane Agent
Salicylic Acid 17%/Collodion*
(OTC)
DUOFILM*
Mineral Oil/Petrolatum Oint*
(OTC)
AQUAPHOR*, EUCERIN*
Zinc Oxide Oint* (OTC)
ZINC OXIDE*
Diphenhydramine Cream 2%*
(OTC)
BENADRYL*
Vitamin A&D Oint* (OTC)
A&D OINT* (
Calamine Lotion* (OTC)
CALAMINE LOTION*
Glycerin/Benzoyl
ale/Petrolatum
Cream* (OTC)
MOISTUREL*
Urea
ZIOX
Triamcinolone 0.1%in
Orabase*
KENALOG IN ORABASE*
Fluorouracil*
EFUDEX*
Pimecrolimus
ELIDEL (AR, QL) (100gm
NF)
Imiquimod*
ALDARA* (QL)
Enzyme combination, topical
GRANULEX*
8800
VITAMINS
Vitamin B complex
Cyanocobalamin injection*
VITAMIN B-12* (QL)
Folic Acid*
FOLIC ACID*
Vitamin D
Ergocalciferol* (OTC)
CALCIFEROL* and
DRISDOL*
Calcitriol*
ROCALTROL*
Paricalcitol
ZEMPLAR (ST)
Vitamin K
Antipsoriatics and
Antipruritics
Selenium Sulfi de 2.5%*
SELSUN*
Phytonadione
MEPHYTON
Pediatric/Fluoride
Multivitamin* (OTC)
POLY-VI-SOL*
Multivitamin + Iron
(pediatric)* (OTC)
POLY-VI-SOL IRON*
Fluoride/Polyvitamins*
(drops and tablets)
POLY-VI-FL OR*
Vitamin, A, D, and C*
TRI-VI-SOL*
Vitamin, A, D, and C with Iron*
TRI-VI-SOL with IRON*
Sodium Fluoride* (drops and
tablets)
LURIDE*
Certolizumab pegol
CIMZIA (PA, SP)
Peginterferon alfa-2b
PEG-INTRON (PA, SP)
Interferon alfa-2b
INTRON A (PA, SP)
Interferon beta-1a
AVONEX (PA, SP)
Interferon gamma-1b
ACTIMMUNE (PA, SP)
Glatiramer acetate
COPAXONE (PA, SP)
Immune globulin
subcutaneous
HIZENTRA (PA, SP)
Epoetin alfa
PROCRIT (PA, SP)
Sargramostim
LEUKINE (PA, SP)
Filgrastim
NEUPOGEN (PA, ST)
Minerals
Calcium Carbonate * (OTC)
TUMS*
Calcium Carbonate w/ Vitamin
D* (OTC)
CALTRATE 600+D*
Calcium Gluconate* (OTC)
CALCIUM GLUCONATE*
(OTC)
Calcium Lactate*
CALCIUM LACTATE*
Ferrous Fumarate* (OTC)
FERROUS FUMARATE*
Ferrous Gluconate* (OTC)
FERGON*
Ferrous Sulfate* (OTC)
FEOSOL*
Sodium Biphosate/Potassium
Phosphate* (OTC)
NEUTRA-PHOS
POWDER*
MISCELLANEOUS
DRUGS
Rho (D) Immunle Globulin
Injectable
RHOGAM, WINRHO
Glucagen Injection
GLUCAGON (QL)
Silver Nitrate*
SILVER NITRATE*
Succimer
CHEMET
Dental Products
Fluoride Rinse* (OTC)
ACT*, GEL-KAM*
PREVIDENT 5000 PLUS*
Stannous Fluoride*
PERIOMED*, GEL-KAM*
Doxycycline Hyclate*
PERIOSTAT*
Chlorhexidine Gluconate*
PERIDEX*
Biologic Response
Modifiers
Etanercept
ENBREL (PA, SP)
Please Note: This is not meant to be a list of all the drugs on the formulary. All forms of a drug may not be covered.
Drugs are listed by their Brand names for ease of use. This list was correct when printed but may have changed. Some
drugs require prior authorization or have quantity limits.
V1.2014
*Generic/generic available
Not all dosage forms are available generically
(PA) Prior authorization required
(AR) Age restriction
(NF) Not on formulary
(OTC) Available over the counter with a prescription
(QL) Quantity limits apply
(SP) Must be dispensed by participating specialty pharmacy
(ST) Step Therapy
(susp = a liquid)
(tab = tablet)
OTC Formulary by Class
Over-The-Counter (OTC) drugs are listed by brand name. They are covered by a written prescription. Brand names are for reference only. Brand name OTCs will not be covered if a
generic is available. This is not a complete list.
Analgesics
Laxative Products
Advil Jr. ®, Advil®, Aleve®,
Bayer®, Bufferin®, Ecotrin®,
Excedrin Migraine®,
Excedrin®, Midol®, Motrin
Child®, Motrin® IB, St.
Joseph’s Baby Aspirin®,
Tylenol Jr. ®, Tylenol®
Citrate of Magnesia®,
Citrucel®, Colace®, Dulcolax®,
Fibercon®, Fleet® Enema,
Fleet®, Metamucil®, Milk of
Magnesia®, Mineral Oil*,
Miralax®, Peri-Colace®,
Senokot®, Senokot-S®,
Surfak®
Antacids/Anti-gas
Products
Gaviscon®, Maalox®, Mylanta®,
Mylicon®, Pepcid AC®, Pepcid
Complete®, Prilosec OTC®,
Simethicone®, Tagamet®,
Tums®, Zantac®, Prevacid
15mg OTC®
Antidiarrheal Products
Imodium®
Kaopectate®,
A-D,
Pedialyte®, Pepto-Bismol®
Antihistamines
Benadryl®, Chlor-Trimeton®,
Claritin®, Claritin-D 24®,
Tavist®, Triaminic®, Zyrtec®,
Cough and Cold
Products
Benadryl®, Coricidin®,
Mucinex®, Nasalcrom®,
Robitussin®, Robitussin® DM,
Sudafed®
Mouth and Throat
Products
Eye, Ear, and Nose
Products
Pediculicide Products
Afrin®, Alaway® Drops,
Debrox®, Isopto® Tears,
Nasalcrom®, NeoSynephrine®, Ocean Spray®,
Saline Mist®, Swim Ear®,
Tears Naturale®, Visine®,
Zaditor OTC®
Baby Orajel®, Cepacol®
A-200 Lice Control®, Nix®, PinX®, RID®
Topical Antifungal
Products
Topical Antimicrobial
Products
Bacitracin®, Neosporin®,
Polysporin®
Feosol®, Fergon®,
Fer-In-Sol®, Os-Cal®, Prenatal
Vitamins®
Topical Miscellaneous
Products
Miscellaneous Products
A+D® Cream, Abreva®,
Aquaphor®, Benadryl®,
Benzoyl Peroxide®, Calamine
Lotion®, Caldryl®, Capsaicin®,
Compound W®, Cortaid®,
Cortizone-10®, Desitin®, Dr.
Smith’s Ointment, Duofilm®,
Eucerin®, oisturel®, Zinc Oxide
Smoking Cessation
Products
Condoms (QL 12), Lactaid®,
Lactinex®, Plan B®, Oxytrol for
Women, Sodium Chloride®
Nicoderm CQ® (QL),
Nicorette gum® (QL), Commit®
(QL)
Vaginal Anti-Infectives
Gyne-Lotrimin®, Monistat®,
Mycelex®
Fungoid Tincture®, Lamisil
AT®, Lotrimin® AF, Micatin®,
Nizoral AD®, Tinactin®
Please Note: This is not meant to be a list of all the drugs on the formulary. All forms of a drug may not be covered.
Drugs are listed by their Brand names for ease of use. This list was correct when printed but may have changed. Some
drugs require prior authorization or have quantity limits.
V1.2014
Vitamin and Mineral
Products
*Generic/generic available
Not all dosage forms are available generically
(PA) Prior authorization required
(AR) Age restriction
(NF) Not on formulary
(OTC) Available over the counter with a prescription
(QL) Quantity limits apply
(SP) Must be dispensed by participating specialty pharmacy
(ST) Step Therapy
(susp = a liquid)
(tab = tablet)