State Employees’ Prescription Drug Plan Preferred Drug List€¦ · State Employees’ Prescription Drug Plan Preferred Drug List is a guide that includes medications that may be

State Employees’ Prescription Drug Plan Preferred Drug ListPlease bring this guide with you on your next doctor visit.

Express Scripts manages your prescription benefit for the State Employees’ Prescription Drug Plan.

Medco is now a part of the Express Scripts family of pharmacies.

PMS 301C BLACK

July 2013

MG44000A - STATE OF FLORIDA PDL _v1_MG44000A - STATE OF FLORID

NOTES


State Employees’ Prescription Drug Plan Preferred Drug List is a guide that includes medications that may be covered under your prescription drug plan. This list was reviewed by an independentgroup of practicing doctors and pharmacists, and it contains medications made by most pharmaceutical manufacturers. Itincludes medications for many covered conditions.

SAVING MONEY ON PRESCRIPTIONSYour plan may prefer some medications over others. These arecalled preferred drugs.

You may pay:• Lowest copayment/coinsurance for generic drugs• Higher copayment/coinsurance for preferred

brand-name drugs• Highest copayment/coinsurance for nonpreferred

brand-name drugs

Your doctor may be able to help you save money by prescribinggeneric and preferred brand-name drugs if appropriate. So be sureto bring this guide with you on every visit to your doctor. Somecommonly prescribed nonpreferred drugs are also listed in this reference guide.

Please note: This guide does not contain a complete list ofpreferred and nonpreferred drugs. It only lists the mostcommonly prescribed drugs. Visit Express-Scripts.com/sofrxplanwhere you can price medications and search for lowest-costdrugs. Members should register at Express-Scripts.com to checkthe price and coverage of medications under your plan. Simplyselect “Price a medication” from the left hand menu and searchfor your medication to see pricing. Click “View coverage notes”on the pricing results page to see any coverage details. If you are a first-time visitor to Express-Scripts.com®, please take amoment to register. (Be sure to have your member ID numberand a recent prescription number handy.) Not all medicationslisted here are covered by every prescription drug plan.

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FINDING MEDICATIONS WITH LOWERCOPAYMENTS/COINSURANCEThis guide lists medications two ways to help you find somegeneric, preferred, and nonpreferred brand-name drugs.

SECTION I - ALPHABETICALLY BY DRUG CATEGORY (SUCH AS RESPIRATORY)Within each category, medications are listed in alphabetical order, with generic, preferred brand-name, and nonpreferredbrand-name drugs sorted separately:

G Means a preferred generic medicationP Means a preferred brand-name medicationNP Means a nonpreferred brand-name medication

SECTION II - ALPHABETICALLY BY BRAND NAMEAfter each nonpreferred brand-name drug, you will find possible generic and preferred brand-name alternatives.

SAFETY CONSIDERATION SYMBOLSHere is a quick guide for you and your doctor, which explains our safety symbols. These symbols appear next to certain medications.

Means weigh risk of birth defects or other adverse outcomes.

Means do not use in pregnancy.

The information in this guide was in effect at the time of printing and maybe subject to change.


Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.

= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.

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SECTION I: THERAPEUTIC DRUG CATEGORIES

Oral PenicillinsG amoxicillin trihydrateG amoxicillin trihydrate/

potassium clavulanateG ampicillin trihydrateG dicloxacillin sodiumG penicillin v

potassiumP Augmentin Chewable

Tablet 250 - 62.5mgP Augmentin

Suspension 125 - 31.25mg/5

NP AmoxilNP Augmentin Chewable

Tablet 200 - 28.5mg,400 - 57mg

NP Augmentin ESNP Augmentin

Suspension 200 - 28.5mg/5, 250 - 62.5mg/5,400 - 57mg/5

NP Augmentin TabletNP Augmentin XRNP Moxatag

Oral TetracyclinesG doxycycline hyclateG doxycycline

monohydrateG minocycline HClG tetracycline HCl

P OraceaNP AdoxaNP Adoxa PakNP DoryxNP DynacinNP MinocinNP MonodoxNP PeriostatNP SolodynNP Vibramycin

Oral CephalosporinsG cefaclorG cefadroxil hydrateG cefdinirG cefpodoxime proxetilG cefprozilG cefuroxime axetilG cephalexin

monohydrateNP Ceclor CDNP CedaxNP CeftinNP DuricefNP KeflexNP OmnicefNP SpectracefNP Suprax

ANTI-INFECTIVES (Antibiotics/Antifungals)




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Oral ErythromycinsG azithromycinG clarithromycinG clarithromycin ERG erythromycin baseG erythromycin

ethylsuccinateG erythromycin

ethylsuccinate/sulfisoxazole acetyl

G erythromycin stearateP DificidNP BiaxinNP Biaxin XLNP EryPedNP PCENP ZithromaxNP Zmax

Oral QuinolonesG ciprofloxacin HClG levofloxacinG ofloxacinP AveloxP Cipro SuspensionNP Cipro TabletNP Cipro XRNP FactiveNP FloxinNP LevaquinNP NoroxinNP Proquin XR

Oral SulfasG erythromycin

ethylsuccinate/sulfisoxazole acetyl

G sulfadiazine

G sulfamethoxazole/trimethoprim

G sulfisoxazoleNP Bactrim DSNP Septra DS

Oral Urinary TractAgentsG methenamine

hippurateG methenamine

mandelateG nitrofurantoinG nitrofurantoin

macrocrystalG phenazopyridine HClG trimethoprimNP FuradantinNP HiprexNP MacrobidNP MacrodantinNP MonurolNP Primsol

Oral AntifungalAgentsG clotrimazoleG fluconazoleG flucytosineG griseofulvin G griseofulvin

ultramicrosizeG itraconazoleG ketoconazoleG nystatinG terbinafine HClG voriconazole


Hypnotic AgentsG chloral hydrateG estazolamG flurazepam HClG temazepamG triazolamG zaleplonG zolpidem tartrateP LunestaP RozeremP SilenorNP AmbienNP Ambien CRNP DoralNP EdluarNP HalcionNP IntermezzoNP Restoril NP SonataNP Zolpimist

TricyclicAntidepressantsG amitriptyline HClG amoxapineG clomipramine HClG desipramine HClG doxepin HClG imipramine HClG imipramine

pamoate G nortriptyline HClG protriptyline HClG trimipramine maleateNP AnafranilNP NorpraminNP PamelorNP SurmontilNP TofranilNP Tofranil-PMNP Vivactil



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P Lamisil Oral GranulesP NoxafilP Sporanox Oral

SolutionNP AncobonNP DiflucanNP Grifulvin VNP Gris-PegNP Lamisil TabletNP MycostatinNP Mycelex Troche NP Nizoral

NP OravigNP Sporanox CapsuleNP Vfend

PSYCHOTHERAPEUTICS (Anxiety/Depression)




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MiscellaneousAntidepressantsG bupropion HCl G maprotiline HClG mirtazapineG trazodone HClG venlafaxine HClP CymbaltaP PristiqNP DesyrelNP EffexorNP Effexor XRNP Oleptro ERNP RemeronNP WellbutrinNP Wellbutrin SRNP Wellbutrin XL

AntipsychoticsG chlorpromazine HClG clozapineG fluphenazine HClG haloperidolG haloperidol lactate

concentrate, oralG loxapine succinateG olanzapineG perphenazineG quetiapine fumarateG risperidoneG thiothixeneG trifluoperazine HClG ziprasidone HCl

P AbilifyP ClozarilP LatudaP MobanP OrapP Risperdal ConstaP Seroquel XRNP FanaptNP GeodonNP InvegaNP RisperdalNP SaphrisNP SeroquelNP SymbyaxNP ZyprexaNP Zyprexa Zydis

AnxiolyticsG alprazolamG alprazolam XRG buspirone HClG chlordiazepoxide

HClG clorazepate

dipotassiumG diazepamG lorazepamG oxazepamNP AtivanNP BusparNP NiravamNP Tranxene T-TabNP ValiumNP XanaxNP Xanax XR




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MAOIAntidepressantsG phenelzine sulfateG tranylcypromine

sulfateNP EmsamNP NardilNP Parnate

SSRI AntidepressantsG citalopram HBrG escitalopram oxalateG fluoxetine HClG fluvoxamine maleateG paroxetine HClG sertraline HClP ViibrydNP CelexaNP LexaproNP Luvox CRNP PaxilNP Paxil CRNP PexevaNP ProzacNP Prozac WeeklyNP SarafemNP Zoloft

MiscellaneousPsychotherapeuticAgentsG amphetamine

aspartate/amphetamine sulfate/dextroamphetamine

G dextroamphetaminesulfate

G lithium carbonate

G lithium citrateG methamphetamine

HClG methylphenidate HClG modafinilP DaytranaP IntunivP Quillivant XRP StratteraP Vyvanse P XyremNP AdderallNP Adderall XRNP ConcertaNP DesoxynNP DexedrineNP FocalinNP Focalin XRNP KapvayNP LiquaddNP LithobidNP Metadate CDNP Methylin Oral

SolutionNP Methylin Chewable

TabletNP NuvigilNP ProvigilNP RitalinNP Ritalin LANP Ritalin SR




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Beta BlockersG acebutolol HClG atenololG betaxolol HClG bisoprolol fumarateG carvedilolG labetalol HClG metoprolol succinateG metoprolol tartrateG nadololG pindololG propranolol HClG timolol maleateP BystolicP Coreg CRNP CoregNP CorgardNP InderalNP Inderal LANP Innopran XLNP KerloneNP LevatolNP LopressorNP SectralNP TenorminNP Toprol XLNP TrandateNP Zebeta

Calcium BlockersG diltiazem HClG nimodipineG verapamil HClP Cardizem LA 120mgNP Calan SRNP CardizemNP Cardizem CD

NP Cardizem LA 180mg,240mg, 300mg,360mg, 420mg

NP Cardizem SRNP Covera-HSNP Dilacor XRNP Isoptin S.R.NP NimotopNP TiazacNP VerelanNP Verelan PM

DihydropyridinesG amlodipine besylateG felodipineG isradipineG nifedipineG nisoldipineNP Adalat CCNP Cardene SRNP DynaCirc CRNP NorvascNP Procardia XLNP Sular

Nitroglycerin PatchesG nitroglycerin patchP Nitro-Dur PatchNP Minitran Patch

AdrenergicAntagonists & RelatedDrugsG clonidine HClG doxazosin mesylateG guanfacine HClG methyldopa

CARDIOVASCULAR(Blood Pressure/Heart/Cholesterol)




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G prazosin HClG reserpineG terazosin HClNP CarduraNP Cardura XLNP CatapresNP Catapres-TTSNP HytrinNP MinipressNP Nexiclon XRNP Tenex

Angiotensin IIBlockers & ReninInhibitorsG candesartan/

hydrochlorothiazideG eprosartan

mesylateG irbesartanG irbesartan/

hydrochlorothiazideG losartan potassiumG losartan/

hydrochlorothiazideG valsartan/

hydrochlorothiazideP AmturnideP AtacandP BenicarP Benicar HCTP DiovanP MicardisP Micardis HCTP TekamloP TekturnaP Tekturna HCTP ValturnaNP Atacand HCTNP AvalideNP Avapro

NP CozaarNP Diovan HCTNP EdarbiNP EdarbyclorNP HyzaarNP TevetenNP Teveten HCT

AntilipidemicsG atorvastatin calciumG cholestyramine/

aspartameG cholestyramine/

sucroseG colestipol HClG fenofibrate,

micronizedG fenofibrate,

nanocrystallizedG fluvastatin sodiumG gemfibrozilG lovastatinG pravastatinG simvastatinP AltoprevP CrestorP FenoglideP JuxtapidP LipofenP LovazaP NiaspanP SimcorP TriglideP TrilipixP VascepaP VytorinP WelcholP ZetiaNP AdvicorNP AntaraNP Caduet




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NP ColestidNP FibricorNP LescolNP Lescol XLNP LipitorNP LivaloNP LofibraNP LopidNP MevacorNP PravacholNP QuestranNP Questran LightNP TricorNP Zocor

ACE InhibitorsG benazepril HClG captoprilG enalapril maleateG fosinopril sodiumG lisinoprilG moexiprilG perindopril erbumineG quinaprilG ramiprilG trandolaprilNP AccuprilNP AceonNP AltaceNP LotensinNP MavikNP PrinivilNP UnivascNP VasotecNP Zestril

CombinationAntihypertensivesG amlodipine

besylate/benazeprilG atenolol/

chlorthalidoneG benazepril HCl/

hydrochlorothiazideG bisoprolol fumarate/

hydrochlorothiazideG captopril/

hydrochlorothiazideG enalapril maleate/

hydrochlorothiazideG fosinopril/

hydrochlorothiazideG hydralazine HCl/

hydrochlorothiazideG lisinopril/

hydrochlorothiazideG methyldopa/

hydrochlorothiazideG metoprolol/

hydrochlorothiazideG moexipril/

hydrochlorothiazideG propranolol HCl/

hydrochlorothiazideG quinapril/

hydrochlorothiazideG trandolapril/

verapamilP AzorP ExforgeP Exforge HCTP TarkaP TribenzorP TwynstaNP AccureticNP Clorpres




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Insulin TherapyP ApidraP Apidra SolostarP HumalogP Humalog Mix 50/50P Humalog Mix 75/25P HumulinP LantusP Lantus SoloStarP LevemirP NovoLogP NovoLog Mix 70/30NP Novolin

Non-InsulinHypoglycemic AgentsG acarboseG glimepirideG glipizideG glipizide/

metformin HClG glyburideG glyburide/

metformin HClG glyburide, micronizedG metformin HClG nateglinideG pioglitizone HCl

G pioglitizone HCl/glimepiride

G pioglitizone HCl/metformin HCl

G tolazamideG tolbutamideP Actoplus Met XRP BydureonP ByettaP JanumetP Janumet XRP JanuviaP JentaduetoP JuvisyncP Kombiglyze XRP OnglyzaP PrandimetP PrandinP RiometP SymlinP TradjentaP VictozaNP Actoplus MetNP ActosNP AmarylNP AvandametNP AvandarylNP Avandia

ENDOCRINE (Diabetes/Hormones/Contraceptives)

NP CorzideNP DutoprolNP Lopressor HCTNP Lotensin HCTNP LotrelNP Prinzide

NP TenoreticNP UnireticNP VasereticNP ZestoreticNP Ziac




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NP CyclosetNP DiaBetaNP DuetactNP FortametNP GlucophageNP Glucophage XRNP GlucotrolNP Glucotrol XLNP GlucovanceNP GlumetzaNP GlynaseNP GlysetNP MetaglipNP PrecoseNP Starlix

Blood Glucose TestStripsG alcohol antiseptic

padsP Accu-Chek Active Test

StripsP Accu-Chek Aviva Plus

Test StripsP Accu-Chek Aviva Test

StripsP Accu-Chek Comfort

Curve Test StripsP Accu-Chek Compact

Test StripsP Accu-Chek Smartview

Test StripsP Fast Take Test StripsP One Touch Test StripsP One Touch Ultra Test

Strips P One Touch Verio Test

Strips P Surestep Pro Test

StripsP Surestep Test Strips

Contraceptive AgentsG desogestrel-ethinyl

estradiolG desogestrel-ethinyl

estradiol/ethinylestradiol

G ethinyl estradiol/drospirenone

G ethynodiol d-ethinylestradiol

G levonorgestrelG levonorgestrel-

ethinyl estradiolG levonorgestrel-

ethinyl estradiol/ethinyl estradiol

G norethindroneG norethindrone a-e

estradiolG norethindrone a-e

estradiol/ferrousfumarate

G norethindrone-ethinyl estradiol

G norethindrone-ethinyl estradiol/ferrous fumarate

G norethindrone-mestranol

G norgestimate-ethinyl estradiol

G norgestrel-ethinylestradiol

P BeyazP EllaP Loestrin 24 FeP Lo Loestrin FeP NataziaP NuvaRingP Safyral




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P YazNP AlesseNP BreviconNP CyclessaNP DemulenNP DesogenNP Estrostep FeNP Femcon FeNP LevliteNP LoestrinNP Loestrin FeNP Lo/OvralNP LoSeasoniqueNP LybrelNP MircetteNP ModiconNP NordetteNP NorinylNP Ortho-CeptNP Ortho-CyclenNP Ortho EvraNP Ortho MicronorNP Ortho Tri-CyclenNP Ortho Tri-Cyclen LoNP OvconNP OvralNP Plan B One-StepNP SeasonaleNP SeasoniqueNP Tri-NorinylNP Yasmin

Estrogens/EstrogenCombinationsG estradiolG estradiol/

norethindroneacetate

G estropipate

G methyl-testosterone/estrogens, esterified

G norethindrone/ethinyl estradiol

P CenestinP ClimaraP CombipatchP DivigelP EnjuviaP Estrace Vaginal

CreamP EstradermP EstringP EvamistP Premarin Tablet P PremphaseP PremproP VagifemP VivelleP Vivelle-DotNP ActivellaNP AloraNP AngeliqNP Climara ProNP ElestrinNP Estrace TabletNP EstrasorbNP EstrogelNP FemhrtNP FemringNP FemtraceNP MenestNP MenostarNP OgenNP Ortho-PrefestNP PrefestNP Premarin Vaginal

Cream




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NSAIDsG diclofenac sodium/

misoprostolG etodolacG flurbiprofenG ibuprofenG indomethacinG ketoprofenG meclofenamate

sodiumG meloxicamG nabumetoneG naproxenG naproxen sodiumG oxaprozinG piroxicamG sulindacG tolmetin sodium

P FlectorP VimovoP Voltaren GelNP Anaprox DSNP AnsaidNP ArthrotecNP CambiaNP CataflamNP ClinorilNP DayproNP diclofenac

potassiumNP diclofenac sodiumNP DuexisNP EC-NaprosynNP FeldeneNP IndocinNP LodineNP Mobic

NSAIDS (Pain Relievers)

Ulcer DrugsG cimetidine HCl liquidG cimetidine tabletG famotidineG lansoprazoleG misoprostolG nizatidineG omeprazoleG omeprazole/sodium

bicarbonateG pantoprazole sodiumG ranitidine HCl

P Nexium NP AciphexNP AxidNP CytotecNP DexilantNP PepcidNP PrevacidNP Prilosec RxNP ProtonixNP TagametNP Zantac RxNP Zegerid Rx

G I (Ulcer)




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NP MotrinNP NalfonNP NaprelanNP NaprosynNP PennsaidNP RelafenNP Sprix

NP ToradolNP Voltaren TabletsNP Voltaren-XR

NSAID COX-2InhibitorsP Celebrex

G flavoxateG oxybutynin chloride G tolterodine tartrateG trospium chlorideP Detrol LAP EnablexP GelniqueP Myrbetriq

P OxytrolP Sanctura XRP ToviazP VesicareNP DetrolNP Ditropan XLNP Sanctura

DRUGS TO TREAT OVERACTIVE BLADDER

Beta Agonists OralG albuterol sulfateG metaproterenol

sulfateG terbutaline sulfateNP AlupentNP Proventil

Beta Agonist InhalersG albuterolG albuterol sulfateG levalbuterol HClG metaproterenol

sulfate

P ForadilP PerforomistP Proair HFAP Serevent DiskusP Ventolin HFANP AccunebNP Arcapta NeohalerNP BrovanaNP Maxair AutohalerNP Proventil HFANP XopenexNP Xopenex HFA

Inhaled SteroidsG budesonide

RESPIRATORY (Allergy/Asthma)




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P AlvescoP AsmanexP Pulmicort FlexhalerP Pulmicort 1mg/2mL

RespulesP QVARNP AerobidNP Aerobid-MNP AzmacortNP Flovent DiskusNP Flovent HFANP Pulmicort 0.25mg/2mLNP Pulmicort 0.5mg/2mL

Nasal CorticosteroidsG flunisolideG fluticasone propionateG triamcinolone

acetonide P NasonexP QnaslP Rhinocort AquaP VeramystNP Beconase AQNP FlonaseNP Nasacort AQNP Omnaris

MiscellaneousPulmonary AgentsG acetylcysteineG cromolyn sodium

ampul for nebulization

G ipratropium/albuterolsulfate

G ipratropium bromidesolution

G montelukast sodiumG sildenafil citrateG zafirlukastP AdcircaP Advair DiskusP Advair HFAP Atrovent HFAP BerinertP CinryzeP CombiventP Combivent RespimatP DalirespP DuleraP FirazyrP Intal InhalerP KalydecoP LetairisP PulmozymeP SpirivaP SymbicortP TracleerP Tudorza PressairP TyvasoP VentavisP XolairNP AccolateNP DuonebNP KalbitorNP RevatioNP SingulairNP ZyfloNP Zyflo CR




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G alendronate sodiumG calcitonin, salmon,

syntheticG ibandronate sodiumP Actonel P AtelviaP EvistaP ForteoNP Actonel with CalciumNP Boniva

NP FosamaxNP Fosamax Plus DNP Miacalcin Nasal SprayNP Prolia

OSTEOPOROSIS/PAGET’S DISEASE

Anticonvulsants/Anti-SeizureG carbamazepineG clonazepamG diazepamG divalproex sodiumG ethosuximideG felbamateG gabapentinG lamotrigineG levetiracetamG oxcarbazepineG phenobarbitalG phenytoinG phenytoin sodium

extendedG primidoneG tiagabineG topiramateG valproic acid

G zonisamideP Banzel P CelontinP DiastatP Dilantin 30mgP GabitrilP Lamictal ODTP LyricaP OnfiP PeganoneP Tegretol XR 100mgP PotigaP SabrilP VimpatNP CarbatrolNP DepakoteNP Depakote ERNP Depakote SprinkleNP Dilantin 100mg

CapsuleNP Dilantin

NEUROLOGICALS




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NP EquetroNP Felbatol NP GraliseNP KeppraNP Keppra XRNP KlonopinNP LamictalNP Lamictal XRNP MysolineNP NeurontinNP PhenytekNP TegretolNP Tegretol XR 200mg,

400mgNP TopamaxNP TrileptalNP ZarontinNP Zonegran

Migraine/HeadacheTherapyG acetaminophen/

butalbitalG acetaminophen/

caffeine/butalbital G aspirin/caffeine/

butalbitalG dihydroergotamine

mesylateG ergotamine/caffeineG isometheptene

mucate/acetaminophen/dichloralphenazone

G naratriptan HClG rizatriptan benzoateG sumatriptan succinateP ErgomarP Relpax

P TreximetP ZomigP Zomig ZMTNP AlsumaNP AmergeNP AxertNP Cafergot tabletNP FrovaNP ImitrexNP MaxaltNP Maxalt MLTNP MidrinNP MigranalNP PhrenilinNP Phrenilin ForteNP Sumavel

Drugs to treatAlzheimers DiseaseG donepezil HClG galantamine HBrG rivastigmine tartrateP Aricept 23mgP Exelon PatchP Exelon SolutionP NamendaNP Aricept 5mg, 10mgNP Aricept ODTNP CognexNP Exelon CapsulesNP RazadyneNP Razadyne ER


Nonpreferred Possible Preferred ProductsProduct

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SECTION II: NONPREFERRED DRUGS AND THEIR POSSIBLE PREFERRED

ALTERNATIVES

Accolate® zafirlukast (various)Accuneb® albuterol sulfate (generic)Accupril® quinapril (generic)Accuretic® quinapril/hydrochlorothiazide (generic)Aceon® perindopril erbumine (generic)Aciphex® omeprazole (generic), Nexium® (AstraZeneca)Activella® estradiol/norethindrone acetate (generic)Actonel® alendronate sodium (generic), ibandronate sodium

with Calcium (generic)Actoplus Met® pioglitazone/metformin (generic)Actos® pioglitazone HCl (generic)Adalat CC® nifedipine ER (generic), amlodipine besylate (generic),

nisoldipine (generic)Adderall® amphetamine salt combo (generic)Adderall XR® dextroamphetamine-amphetamine ER (generic)Adoxa® doxycycline monohydrate (generic)Adoxa Pak® doxycycline monohydrate (generic)Advicor® atorvastatin calcium (generic), lovastatin (generic),

pravastatin (generic), simvastatin (generic), Crestor®

(AstraZeneca), Niaspan® (Abbott), VytorinTM

(Merck/Schering)Aerobid® Asmanex® (Schering), Pulmicort Flexhaler®

(AstraZeneca), QVAR® (Ivax)Aerobid-M® Asmanex® (Schering), Pulmicort Flexhaler®

(AstraZeneca), QVAR® (Ivax)Alesse® Aviane® (Barr-branded generic*), Lessina® (Barr-

branded generic*), Lutera® (Watson-branded generic*),Lybrel® (Wyeth)

Alora® estradiol patch (generic), Climara® (Berlex), Estraderm®

(Novartis), Vivelle® (Novartis)Alsuma® sumatriptan succinate (generic)Altace® ramipril (generic)Amaryl® glimepiride (generic)Ambien® zolpidem tartrate (generic)Ambien CR® zolpidem tartrate ER (generic)

*Branded generics have the same co-payment as regular generics.



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Amerge® naratriptan HCl (generic)Amoxil® amoxicillin trihydrate (generic)Anafranil® clomipramine HCl (generic)Anaprox DS® naproxen sodium (generic)Ancobon® flucytosine (generic)Angeliq® estradiol/norethindrone acetate (generic),

Premphase® (Wyeth), Prempro® (Wyeth)Ansaid® flurbiprofen (generic)Antara® fenofibrate (generic)Arcapta Neohaler® Foradil® (Schering), Serevent Diskus® (GlaxoSmithKline)

Aricept® 5mg,10mg donepezil HCl (generic)Aricept ODT® donepezil HCl (generic)Arthrotec® ibuprofen (generic), naproxen (generic), Celebrex®

(Pfizer)Atacand HCT® candesartan/hydrochlorothiazide (generic)Ativan® lorazepam (generic)Augmentin® amoxicillin trihydrate/potassium clavulanate (generic)chewable tablet200-28.5mg,400-57mg

Augmentin® amoxicillin trihydrate/potassium clavulanate (generic)suspension200-28.5mg/5, 250-62.5mg/5,400-57mg/5

Augmentin® amoxicillin trihydrate/potassium clavulanate (generic)tablet

Augmentin ES® amoxicillin trihydrate/potassium clavulanate (generic)Augmentin XR® amoxicillin trihydrate/potassium clavulanate (generic)Avalide® irbesartan/hydrochlorothiazide (generic)Avandamet® metformin HCl (generic), pioglitazone (generic)Avandaryl® glimepiride (generic), pioglitazone (generic)Avandia® pioglitazone (generic)Avapro® irbesartan (generic)Axert® naratriptan HCl (generic), rizatriptan (generic),

sumatriptan succinate (generic), Relpax® (Pfizer), Zomig®

(AstraZeneca)Axid® nizatidine (generic)Bactrim DS® sulfamethoxazole/trimethoprim (generic)



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Beconase AQ® flunisolide (generic), fluticasone propionate (generic),triamcinolone acetonide (generic), Nasonex®

(Schering), Rhinocort Aqua® (AstraZeneca), Veramyst®

(GlaxoSmithKline)Biaxin® clarithromycin (generic)Biaxin XL® clarithromycin ER (generic)Boniva® ibandronate sodium (generic)Brevicon® Necon® (Watson-branded generic*), Nortrel®

(Barr-branded generic*)Brovana® Foradil® (Schering), Perforomist® (Dey Labs), Proair HFA®

(Teva), Serevent Diskus® (GlaxoSmithKline)Buspar® buspirone HCl (generic)Butisol Sodium® chloral hydrate (generic), temazepam (generic),

triazolam (generic)Caduet® amlodipine besylate (generic), atorvastatin calcium

(generic)Calan SR® verapamil HCl tablet, sustained action (generic)Cambia® etodolac (generic), ibuprofen (generic), naproxen

(generic)Carbatrol® carbamazepine (generic)Cardene SR® amlodipine besylate (generic), nifedipine ER (generic)Cardizem® diltiazem HCl (generic)Cardizem CD® diltiazem HCl capsule, sustained release 24 hr

(generic)Cardizem LA® diltiazem ER (generic)180mg, 240mg,300mg, 360mg, 420mg

Cardizem SR® diltiazem HCl capsule, sustained release 12 hr (generic)

Cardura® doxazosin mesylate (generic)Cataflam® etodolac (generic), ibuprofen (generic), naproxen

(generic)Catapres® clonidine HCl tablet (generic)Catapres-TTS® clonidine HCl patch (generic)Ceclor CD® cefaclor (generic), cefdinir (generic),

cefuroxime axetil (generic)Cedax® cefaclor (generic), cefdinir (generic),

cefuroxime axetil (generic)Ceftin® cefuroxime axetil (generic)Celexa® citalopram (generic)



22

Cipro Tablet® ciprofloxacin HCl tablet (generic)Climara Pro® Combipatch® (Novartis)Clinoril® sulindac (generic)Clorpres® chlorthalidone (generic), clonidine HCl (generic)Colestid® cholestyramine (generic), Welchol® (Sankyo)Coreg® carvedilol (generic)Corgard® nadolol (generic)Corzide® bisoprolol fumarate/hydrochlorothiazide (generic),

metoprolol/hydrochlorothiazide (generic), propranololHCl/hydrochlorothiazide (generic)

Covera-HS® verapamil HCl capsule, 24 hr sustained release (generic)Cozaar® losartan potassium (generic)Cyclessa® Caziant® (Watson-branded generic*), Cesia® (Prasco

Labs-branded generic*), Velivet® (Barr-branded generic*)Cycloset® metformin HCl (generic), Byetta® (Amylin Pharma),

Janumet® (Merck), Januvia® (Merck), Onglyza®

(Bristol-Myers Squibb)Cytotec® misoprostol (generic)Daypro® oxaprozin (generic)Demulen® Zovia® (Watson-branded generic*)Depakote® divalproex sodium (generic)Depakote ER® divalproex sodium ER (generic)Depakote® Sprinkle divalproex sodium (generic)Desogen® Apri® (Barr-branded generic*),

Solia® (Prasco Labs-branded generic*)Desoxyn® methamphetamine HCl (generic)Desyrel® trazodone HCl (generic)Detrol® tolterodine tartrate (generic)Dexedrine® dextroamphetamine sulfate (generic)Dexilant® omeprazole (generic), Nexium® (AstraZeneca)DiaBeta® glyburide (generic)Diclofenac etodolac (generic), ibuprofen (generic), naproxen

Potassium (generic)Diclofenac etodolac (generic), ibuprofen (generic), naproxen

Sodium (generic)Diflucan® fluconazole (generic)Dilacor XR® diltiazem XR (generic)Dilantin® phenytoin sodium capsule (generic)

100mg CapsuleDilantin® phenytoin (generic)





23

Diovan HCT® valsartan/hydrochlorothiazide (generic)Ditropan XL® oxybutynin chloride ER (generic)Doral® temazepam (generic), triazolam (generic), zaleplon

(generic), zolpidem tartrate (generic)Doryx® doxycycline hyclate (generic)Duetact® pioglitazone/glimepiride (generic)Duexis® famotidine (generic), ibuprofen (generic), naproxen

(generic), omeprazole (generic)Duoneb® ipratropium/albuterol sulfate (generic)Duricef® cefadroxil hydrate (generic)Dutoprol® hydrochlorothiazide (generic), metoprolol succinate

(generic)Dynacin® minocycline HCl (generic)DynaCirc CR® amlodipine besylate (generic), nifedipine ER (generic),

nisoldipine (generic)EC-Naprosyn® naproxen (generic)Edarbi® losartan potassium (generic), Atacand® (AstraZeneca),

Benicar® (Daiichi Sankyo), Diovan® (Novartis), Micardis®

(BIPI)Edarbyclor® candesartan/hydrochlorothiazide (generic),

irbesartan/hydrochlorothiazide (generic),losartan/hydrochlorothiazide (generic),valsartan/hydrochlorothiazide (generic), Benicar HCT®

(Daiichi Sankyo), Micardis HCT® (Boehringer Ingelheim)Edluar® zolpidem tartrate (generic)Effexor® venlafaxine HCl (generic)Effexor XR® venlafaxine HCl (generic)Elestrin® estradiol patch (generic), Climara® (Berlex), Divigel®

(Upsher Smith), Estraderm® (Novartis), Vivelle®

(Novogyne)Emsam® phenelzine sulfate (generic), tranylcypromine sulfate

(generic)Equetro® carbamazepine (generic), divalproex sodium (generic),

lithium carbonate (generic)EryPed erythromycin ethylsuccinate (generic)Suspension®

400mg/5mlEstrace® Tablet estradiol (generic)Estrasorb® estradiol patch (generic), Divigel® (Upsher Smith)Estrogel® estradiol patch (generic), Climara® (Berlex), Divigel®

(Upsher Smith), Estraderm® (Novartis), Vivelle®

(Novartis)



24

Estrostep Fe® Apri® (Barr-branded generic*), Kariva® (Barr-brandedgeneric*), Microgestin Fe® (Watson-branded generic*)

Exelon® Capsules rivastigmine tartrate (generic)Factive® ciprofloxacin (generic), levofloxacin (generic)Fanapt® clozapine (generic), olanzapine (generic), quetiapine

fumarate (generic), risperidone (generic), ziprasidoneHCl (generic), Seroquel XR® (AstraZeneca)

Felbatol® felbamate (generic)Feldene® piroxicam (generic)Femhrt® Jinteli® (Teva-branded generic*)Femcon Fe® Zeosa® (Teva-branded generic*)Femring® Estrace Vaginal Cream® (Warner Chilcott), Estring®

(Pfizer)Femtrace® estradiol (generic)Fibricor® fenofibrate (generic), Triglide® (Sciele), Trilipix® (Abbott)Flonase® fluticasone propionate (generic)Flovent Diskus® Alvesco® (Sunovion), Asmanex® (Schering), Pulmicort

Flexhaler® (AstraZeneca), QVAR® (Ivax)Flovent HFA® Alvesco® (Sunovion), Asmanex® (Schering), Pulmicort

Flexhaler® (AstraZeneca), QVAR® (Ivax)Floxin® ofloxacin (generic)Focalin® dexmethylphenidate HCl (generic)Focalin XR® dextroamphetamine-amphetamine ER (generic),

methylphenidate CD (generic), methylphenidate ER(generic), Daytrana® (Shire US Inc.), Methylin ER®

(Mallinckrodt Pharmaceuticals)Fortamet® metformin HCl ER (generic), metformin HCl tablet

(generic)Fosamax® alendronate sodium (generic), Actonel® (Warner

Chilcott), Atelvia® (Warner Chilcott), Fosamax Plus D® alendronate sodium (generic), ibandronate sodium

(generic)Frova® naratriptan HCl (generic), rizatriptan (generic),

sumatriptan succinate (generic), Relpax® (Pfizer), Zomig® (AstraZeneca), Zomig ZMT® (AstraZeneca)

Furadantin® nitrofurantoin (generic)Geodon® ziprasidone HCl (generic)Glucophage® metformin HCl (generic)Glucophage XR® metformin HCl ER (generic), metformin HCl tablet

(generic)Glucotrol® glipizide (generic)





25

Glucotrol XL® glipizide ER (generic)Glucovance® glyburide/metformin HCl (generic)Glynase® glyburide, micronized (generic)Glyset® acarbose (generic)Gralise® gabapentin (generic)Grifulvin V® griseofulvin ultramicrosize (generic), itraconazole

(generic), ketoconazole (generic), terbinafine HCl(generic)

Gris-Peg® griseofulvin ultramicrosize (generic), itraconazole(generic), ketoconazole (generic), terbinafine HCl(generic)

Guanabenz clonidine HCl (generic), methyldopa (generic)Acetate®

Halcion® triazolam (generic)Hiprex® methenamine hippurate (generic)Hytrin® terazosin (generic)Hyzaar® losartan/hydrochlorothiazide (generic)Imitrex® sumatriptan succinate (generic)Inderal® propranolol HCl (generic)Inderal LA® propranolol capsule, sustained action (generic)Indocin® indomethacin (generic)Innopran XL® propranolol capsule, sustained action (generic)Intermezzo® zaleplon (generic)Invega® olanzapine (generic), quetiapine fumarate (generic),

risperidone (generic), ziprasidone HCl (generic),Seroquel XR® (AstraZeneca)

Isoptin S.R.® verapamil HCl tablet, sustained action (generic)Kalbitor® Berinert® (CSL Behring)Kapvay® clonidine HCl (generic), Intuniv® (Shire US Inc.)Keflex® cephalexin monohydrate (generic)Keppra® levetiracetam (generic)Keppra XR® levetiracetam (generic)Kerlone® betaxolol HCl (generic)Klonopin® clonazepam (generic)Lamictal® lamotrigine (generic)Lamictal XR® lamotrigine XR (generic)Lamisil® tablet terbinafine HCl (generic)

Lescol® fluvastatin sodium (generic)



26

Lescol XL® atorvastatin calcium (generic), lovastatin (generic),simvastatin (generic), Altoprev® (Andrx), Crestor®

(AstraZeneca), VytorinTM (Merck/Schering)Levaquin® levofloxacin (generic)Levatol® acebutolol HCl (generic), atenolol (generic),

metoprolol tartrate (generic)Levlite® Aviane® (Barr-branded generic*), Lessina®

(Barr-branded generic*), Lybrel® (Wyeth) Lexapro® escitalopram oxalate (generic)Lipitor® atorvastatin calcium (generic)Liquadd® dextroamphetamine sulfate (generic)Lithobid® lithium carbonate tablet, sustained action (generic)Livalo® atorvastatin calcium (generic), lovastatin (generic),

pravastatin (generic), simvastatin (generic), Crestor®

(AstraZeneca)Lodine® etodolac (generic)Loestrin® Junel® (Barr-branded generic*), Microgestin®

(Watson-branded generic*)Loestrin Fe® Junel Fe® (Barr-branded generic*), Microgestin Fe®

(Watson-branded generic*)Lofibra® fenofibrate (generic), Triglide® (First Horizon), Trilipix®

(Abbott)Lo/Ovral® Low-Ogestrel® (Watson-branded generic*)Lopid® gemfibrozil (generic)Lopressor® metoprolol tartrate (generic)Lopressor HCT® metoprolol/hydrochlorothiazide (generic)LoSeasonique® Amethia Lo® (Watson-branded generic*), Camrese Lo®

(Teva-branded generic*)Lotensin® benazepril HCl (generic)Lotensin HCT® benazepril HCl/hydrochlorothiazide (generic)Lotrel® amlodipine besylate/benazepril (generic)Luvox CR® fluvoxamine maleate (generic)Lybrel® Amethyst® (Watson-branded generic*)Macrobid® nitrofurantoin macrocrystal (generic)Macrodantin® nitrofurantoin (generic)Mavik® trandolapril HCl (generic)Maxair Autohaler® Proair HFA® (Teva), Ventolin HFA® (GlaxoSmithKline)Maxalt® rizatriptan (generic)Maxalt MLT® rizatriptan (generic)





27

Menest® estradiol (generic), estropipate (generic), Cenestin®

(Duramed/Barr), Enjuvia® (Duramed/Barr),Premarin® (Wyeth)

Menostar Patch® Climara Patch® (Berlex), Vivelle Patch® (Novartis)Metadate CD® methylphenidate CDMetaglip® glipizide/metformin (generic)Methylin® methylphenidate HCl (generic)

Oral SolutionMethylin® methylphenidate HCl (generic)

Chewable TabletMevacor® lovastatin (generic)Miacalcin® calcitonin-salmon (generic)Midrin® isometheptene/apap/dichloralphenazone (generic)Migranal® naratriptan HCl (generic), rizatriptan (generic),

sumatriptan nasal spray (generic), Relpax® (Pfizer),Zomig® Nasal Spray (AstraZeneca)

Minipress® prazosin HCl (generic)Minitran® nitroglycerin patch (generic), Nitro-Dur® (Schering)Minocin® minocycline HCl (generic)Mircette® Kariva® (Barr-branded generic*)Mobic® meloxicam (generic)Modicon® Necon® (Watson-branded generic*), Nortrel®

(Barr-branded generic*)Monistat 3 Vaginal miconazole 3 vaginal suppository (generic)

Suppository®

Monodox® doxycycline monohydrate (generic)Monurol® ciprofloxacin HCl (generic), sulfamethoxazole/

trimethoprim (generic), trimethoprim (generic)Motrin® ibuprofen (generic)Moxatag® amoxicillin (generic)Mysoline® primidone (generic)Nalfon® etodolac (generic), ibuprofen (generic), indomethacin

(generic), meclofenamate sodium (generic), naproxen (generic), sulindac (generic)

Naprelan® naproxen sodium (generic)Naprosyn® naproxen (generic)Nardil® phenelzine sulfate (generic)Nasacort AQ® triamcinolone acetonide (generic)Nembutal chloral hydrate (generic), temazepam (generic),

Sodium® triazolam (generic)Neurontin® gabapentin (generic)



28

Nexiclon XR® clonidine HCl (generic)Nimotop® nimodipine (generic)Niravam® alprazolam (generic)Nizoral® ketoconazole (generic)Nordette® Levora® (Watson-branded generic*), Portia®

(Barr-branded generic*)Norinyl® Necon® (Watson-branded generic*), Nortrel®

(Barr-branded generic*)Norpramin® desipramine HCl (generic)Noroxin® ciprofloxacin HCl (generic), levofloxacin (generic),

Avelox® (Merck)Norvasc® amlodipine besylate (generic)Novolin® Humulin® (Eli Lilly)Nuvigil® modafinil (generic)Ogen® estropipate (generic)Oleptro ER® trazodone HCl (generic)Omnaris® flunisolide (generic), fluticasone propionate (generic),

triamcinolone acetonide (generic), Nasonex®

(Schering), Rhinocort Aqua® (AstraZeneca), Veramyst®

(GlaxoSmithKline)Omnicef® cefdinir (generic)Oravig® clotrimazole (generic), fluconazole (generic), nystatin

suspension (generic)Ortho-Cept® Apri®(Barr-branded generic*), Solia®

(Prasco Labs-branded generic*)Ortho-Cyclen® MonoNessa® (Watson-branded generic*), Previfem®

(Teva-branded generic*), Sprintec® (Barr-branded generic*)

Ortho Evra® MonoNessa® (Watson-branded generic*), TriNessa®

(Watson-branded generic*)Ortho Micronor® norethindrone acetate (generic)Ortho-Novum® Necon® (Watson-branded generic*), Nortrel®

1/35, 7/7/7 (Barr-branded generic*)Ortho-Prefest® estradiol/norethindrone acetate (generic),

Premphase® (Wyeth), Prempro® (Wyeth)Ortho Tri-Cyclen® TriNessa® (Watson-branded generic*), Tri-Previfem®

(Teva-branded generic*), Tri-Sprintec® (Barr-brandedgeneric*)

Ortho Tri-Cyclen TriNessa® (Watson-branded generic*), Tri-Previfem®

Lo® (Teva-branded generic*), Tri-Sprintec® (Barr-brandedgeneric*)

Ovcon® Necon® (Watson-branded generic*)





29

Ovral® Ogestrel® (Watson-branded generic*)Pamelor® nortriptyline HCl (generic)Parnate® tranylcypromine sulfate (generic)Paxil® paroxetine HCl (generic)Paxil CR® paroxetine HCl sustained release tab (generic)PCE® erythromycin (generic)Pennsaid® etodolac (generic), ibuprofen (generic), naproxen

(generic)Pepcid® famotidine (generic)Periostat® doxycycline hyclate (generic)Pexeva® paroxetine HCl (generic)Phenytek® phenytoin sodium (generic)Phrenilin® acetaminophen/butalbital (generic)Plan B One-Step® Next Choice One Dose® (Watson-branded generic*)Ponstel® etodolac (generic), ibuprofen (generic), indomethacin


Pravachol® pravastatin (generic)Precose® acarbose (generic)Prefest® estradiol/norethindrone acetate (generic),

Premphase® (Wyeth), Prempro® (Wyeth)Premarin® Estrace® Vaginal Cream (Warner Chilcott)Vaginal Cream

Prevacid® lansoprazole (generic), omeprazole (generic), Nexium®

(AstraZeneca)Prilosec Rx® omeprazole (generic), Nexium® (AstraZeneca)Primsol® trimethoprim (generic)Prinivil® lisinopril (generic)Prinzide® lisinopril/hydrochlorothiazide (generic)Procardia XL® nifedipine ER (generic)Prolia® alendronate sodium (generic), ibandronate sodium

(generic), Evista® (Eli Lilly), Forteo® (Eli Lilly)Proquin XR® ciprofloxacin HCl (generic)Protonix® Nexium® Suspension (AstraZeneca)

SuspensionProtonix® Tablet pantoprazole sodium (generic), omeprazole (generic),

Nexium® (AstraZeneca)Proventil HFA® Proair HFA® (Teva), Ventolin HFA® (GlaxoSmithKline)Provigil® modafinil (generic)Prozac® fluoxetine HCl (generic)



30

Prozac Weekly® fluoxetine HCl (generic)Pulmicort® budesonide (generic)0.25mg/2mL,0.5mg/2mL

Questran® cholestyramine (generic), prevalite (generic)Questran Light® cholestyramine/aspartame (generic), prevalite (generic)Razadyne® galantamine (generic)Razadyne ER® galantamine ER (generic)Relafen® nabumetone (generic)Remeron® mirtazapine soltabs (generic), mirtazapine tabs

(generic)Restoril® temazepam (generic)Revatio® sildenafil citrate (generic)Risperdal® risperidone (generic)Ritalin® methylphenidate HCl (generic)Ritalin LA® methylphenidate ER (generic), dextroamphetamine

sulfate (generic), dextroamphetamine-amphetamineER (generic), methylphenidate CD (generic), Daytrana®

(Shire US Inc.)Ritalin SR® methylphenidate ER (generic)Sanctura® trospium chloride (generic)Saphris® clozapine (generic), olanzapine (generic), quetiapine

fumarate (generic), risperidone (generic), ziprasidoneHCl (generic), Seroquel XR® (AstraZeneca)

Sarafem® fluoxetine HCl (generic)Seasonale® Amethyst® (Watson-branded generic*), Jolessa®

(Barr-branded generic*), Quasense® (Watson-brandedgeneric*),

Seasonique® Amethia® (Watson-branded generic*), Camrese®

(Teva-branded generic*)Seconal Sodium® chloral hydrate (generic), temazepam (generic),

triazolam (generic)Sectral® acebutolol HCl (generic)Septra DS® sulfamethoxazole/trimethoprim (generic)Seroquel® quetiapine fumarate (generic)Singulair® montelukast sodium (generic)Solodyn® minocycline HCl (generic), doxycycline monohydrate

(generic)Sonata® zaleplon (generic)Spectracef® cefaclor (generic), cefdinir (generic), cefuroxime axetil

(generic)





31

Sporanox® itraconazole (generic)Capsule

Sprix® etodolac (generic), ibuprofen (generic), naproxen(generic)

Starlix® nateglinide (generic)Sular® nisoldipine (generic), amlodipine besylate (generic),

isradipine (generic), nifedipine ER (generic)Suprax® cefdinir (generic), cefuroxime axetil (generic)Surmontil® trimipramine maleate (generic)Symbyax® fluoxetine HCl (generic), olanzapine (generic),

quetiapine fumarate (generic), risperidone (generic),Seroquel XR® (AstraZeneca)

Tagamet® cimetidine (generic)Tegretol® carbamazepine (generic)Tegretol XR® carbamazepine XR (generic)

200mg, 400mgTenex® guanfacine HCl (generic)Tenoretic® atenolol/chlorthalidone (generic)Tenormin® atenolol (generic)Teveten® eprosartan mesylate (generic), losartan potassium

(generic), Atacand® (AstraZeneca), Benicar® (DaiichiSankyo), Diovan® (Novartis), Micardis® (BIPI)

Teveten HCT® candesartan/hydrochlorothiazide (generic),losartan/hydrochlorothiazide (generic),valsartan/hydrochlorothiazide (generic), Benicar HCT®

(Daiichi Sankyo), Micardis HCT® (BIPI)Thioridazine HCl® chlorpromazine HCl (generic), haloperidol (generic),

quetiapine fumarate (generic), risperidone (generic)Tiazac® diltiazem HCl capsule, sustained release 24 hr (generic)Tofranil® imipramine HCl (generic)Tofranil-PM® imipramine pamoate (generic)Topamax® topiramate (generic)Toprol XL® metoprolol succinate (generic)Toradol® etodolac (generic), ibuprofen (generic), indomethacin


Trandate® labetalol HCl (generic)Tranxene T-Tab® clorazepate dipotassium (generic)Tricor® fenofibrate (generic)Trileptal® oxcarbazepine (generic)



32

Tri-Norinyl® Necon® (Watson-branded generic*), Nortrel®

(Barr-branded generic*)Uniretic® moexipril/hydrochlorothiazide (generic)Univasc® moexipril HCl (generic)Valium® diazepam (generic)Vaseretic® enalapril maleate/hydrochlorothiazide (generic)Vasotec® enalapril maleate (generic)Verelan® verapamil ER (generic)Verelan PM® verapamil ER PM (generic)Vfend® voriconazole (generic)Vibramycin® Syrup Vibramycin® Suspension (Pfizer)Vivactil® protriptyline HCl (generic)Voltaren® Tablets etodolac (generic), ibuprofen (generic), naproxen

(generic)Voltaren-XR® etodolac (generic), ibuprofen (generic), naproxen

(generic)Wellbutrin® bupropion HCl (generic)Wellbutrin SR® bupropion HCl tablet, sustained release (generic)Wellbutrin XL® bupropion HCl tablet, extended release (generic)Wytensin® clonidine HCl (generic), methyldopa (generic)Xanax® alprazolam (generic)Xanax XR® alprazolam XR (generic)Xopenex® levalbuterol HCl (generic)

1.25mg/0.5Xopenex HFA® Proair HFA® (Teva), Ventolin HFA® (GlaxoSmithKline)Yasmin® Ocella® (Barr-branded generic*)Zantac Rx® ranitidine HCl (generic)Zarontin® ethosuximide (generic)Zebeta® bisoprolol fumarate (generic)Zegerid Rx® omeprazole/sodium bicarbonate (generic), omeprazole

(generic), Nexium® (AstraZeneca)Zestoretic® lisinopril/hydrochlorothiazide (generic)Zestril® lisinopril (generic)Ziac® bisoprolol fumarate/hydrochlorothiazide (generic)Zithromax® azithromycin (generic)Zmax® azithromycin (generic)Zocor® simvastatin (generic)Zoloft® sertraline HCl (generic)Zolpimist® zolpidem tartrate (generic)




33

Zonegran® carbamazepine (generic), clonazepam (generic) ethosuximide (generic,) phenobarbital (generic), phenytoin sodium (generic), Lyrica® (Pfizer)

Zyflo® montelukast sodium (generic)Zyflo CR® montelukast sodium (generic)Zyprexa® olanzapine (generic)Zyprexa Zydis® olanzapine ODT (generic)




This guide does not contain a complete list of preferred and nonpreferred drugs. It only lists the most commonly prescribed drugs. Visit Express-Scripts.com/sofrxplan where you can price medications and search for lowest-cost drugs.Members should register at Express-Scripts.com to check the price and coverage of medicationsunder your plan. Simply select “Price a medication” from the left hand menu and search for your medication to see pricing. Click“View coverage notes” on the pricing results pageto see any coverage details. If you are a first-timevisitor to Express-Scripts.com®, please take amoment to register. (Be sure to have your memberID number and a recent prescription numberhandy.) Or call Member Services toll-free at 1-877-531-4793.

© 2013 Express Scripts Holding Company.All rights reserved.MG44000A

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Documents

State Employees’ Prescription Drug Plan Preferred Drug List€¦ · State Employees’ Prescription Drug Plan Preferred Drug List is a guide that includes medications that may be