29
RECOMMENDED DRUG LIST ALPHABETICAL TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 * A/T/S SOLUTION (SWABS, PADS & PLEDGETS EXCLUDED) 2 ABILIFY TABLETS / SOLUTION 2 ACCOLATE TABLETS 2 ACCU-CHEK ACTIVE TEST STRIPS (QL) 2 ACCU-CHEK ADVANTAGE TEST STRIPS (QL) 2 ACCU-CHEK AVIVA TEST STRIPS (QL) 2 ACCU-CHEK COMFORT CURVE TEST STRIPS (QL) 2 ACCU-CHEK COMPACT TEST STRIPS/ DRUM (QL) 1 * ACCUPRIL TABLETS 1 * ACCURETIC TABLETS Benazepril / HCTZ (LOTENSIN HCT), Lisinopril / HCTZ (ZESTORETIC) 1 * ACCUTANE CAPSULES (QL) 1 * Acebutolol Capsules 3 ACEON TABLETS Benazepril (LOTENSIN), Lisinopril (ZESTRIL), Quinapril (ACCUPRIL), Enalapril (VASOTEC), Captopril (CAPOTEN), Fosinopril (MONOPRIL), Moexipril (UNIVASC) 1 * Acetaminophen / Codeine Tablets 1 * Acetaminophen 2.5 / Hydrocodone 1.67 Elixir 1 * Acetaminophen 325 / Hydrocodone 5 Tablets Acetaminophen 500 / Hydrocodone 5 Tablets 1 * Acetaminophen 500 / Hydrocodone 5 Tablets 1 * Acetaminophen 7.5/ Hydrocodone 650 Tablets 1 * Acetazolamide Tablets 1 * Acetic Acid 2% / Hydrocortisone 1% Otic Solution 1 * Acetic Acid 2% Otic Solution 1 * Acetic Acid Otic Aluminum Acetate Solution 1 * Acetylcysteine 1 * ACHROMYCIN V CAPSULES 2 ACIPHEX (QL) 1 * ACLOVATE CREAM / OINTMENT 1 * ACTICIN CREAM (QL) 1 * ACTIGALL CAPSULES 3 * ACTIQ LOZENGES (PA) Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Fentanyl patches (DURAGESIC), PERCOCET 5/325, PERCODAN 5/325 3 ACTIVELLA CLIMARA PRO, PREMPRO, PREMPHASE, Medroxyprogesterone (PROVERA) plus Estradiol tablets (ESTRACE), Estradiol patches (CLIMARA), ESTRADERM, VIVELLE, VIVELLE-DOT or Estropipate (OGEN, ORTHO-EST) 2 ACTONEL TABLETS 5 MG, 35 MG, 75 MG (QL) 2 ACTONEL with CALCIUM TABLETS (QL) 2 ACTOPLUS MET TABLETS 2 ACTOS TABLETS 2 ACULAR LS OPHTHALMIC SOLUTION 2 ACULAR OPHTHALMIC SOLUTION 1 * Acyclovir Oral Tablets / Capsules / Suspension 1 * ADALAT CC TABLETS 1 * ADALAT TABLETS 1 * ADDERALL TABLETS 3 ADDERALL XR CAPSULES (QL) Amphetamine mixture IR (ADDERALL), Dextroamphetamine/SR (DEXEDRINE, Methylphenidate/SR (RITALIN/SR, METADATE ER), CONCERTA 2 ADVAIR DISKUS (QL) 2 ADVAIR HFA (QL) 1 * ADVANCED NATALCARE TABLET 1 * ADVANCED-RF NATALCARE TAB 2 ADVICOR TABLETS (QL) Lovastatin (MEVACOR) and Niacin 3 AEROBID INHALER, AEROBID-M INHALER Triamcinolone (AZMACORT), Mometasone (ASMANEX), Budesonide (PULMICORT), Fluticasone (FLOVENT), Beclomethasone (QVAR) , Fluticasone AND Salmeterol (ADVAIR) 2 AEROCHAMBER 2 AGENERASE CAPSULES 3 AGGRENOX CAPSULES Aspirin + Dipyridamole (PERSANTINE), Clopidogrel (PLAVIX), Ticlopidine (TICLID), Cilostazol (PLETAL) 3 * AGRYLIN CAPSULES 1 * AK-PENTOLATE OPHTHALMIC SOLUTION 1 * AK-TOB OPHTHALMIC SOLUTION 3 ALAMAST OPHTHALMIC DROPS Cromolyn sodium (CROLOM), Ketotifen (ZADITOR: OTC AVAILABLE: NOT COVERED) 3 ALBENZA TABLETS 1 * Albuterol ER Tablets CAPS Indicate Brand Name *Generic Available Brand Name For Reference Only If Generic Available 1 of 29 2/1/08 PA=Prior Authorization Req'd QL=Quantity Limits Apply X=Exclusion-Check Plan Docs

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

  • Upload
    others

  • View
    8

  • Download
    0

Embed Size (px)

Citation preview

Page 1: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * A/T/S SOLUTION (SWABS, PADS & PLEDGETS EXCLUDED)2 ABILIFY TABLETS / SOLUTION 2 ACCOLATE TABLETS2 ACCU-CHEK ACTIVE TEST STRIPS (QL)2 ACCU-CHEK ADVANTAGE TEST STRIPS (QL)2 ACCU-CHEK AVIVA TEST STRIPS (QL)2 ACCU-CHEK COMFORT CURVE TEST STRIPS (QL)2 ACCU-CHEK COMPACT TEST STRIPS/ DRUM (QL)1 * ACCUPRIL TABLETS 1 * ACCURETIC TABLETS Benazepril / HCTZ (LOTENSIN HCT), Lisinopril / HCTZ (ZESTORETIC)1 * ACCUTANE CAPSULES (QL)1 * Acebutolol Capsules

3ACEON TABLETS

Benazepril (LOTENSIN), Lisinopril (ZESTRIL), Quinapril (ACCUPRIL), Enalapril (VASOTEC), Captopril (CAPOTEN), Fosinopril (MONOPRIL), Moexipril (UNIVASC)

1 * Acetaminophen / Codeine Tablets1 * Acetaminophen 2.5 / Hydrocodone 1.67 Elixir1 * Acetaminophen 325 / Hydrocodone 5 Tablets Acetaminophen 500 / Hydrocodone 5 Tablets1 * Acetaminophen 500 / Hydrocodone 5 Tablets1 * Acetaminophen 7.5/ Hydrocodone 650 Tablets1 * Acetazolamide Tablets1 * Acetic Acid 2% / Hydrocortisone 1% Otic Solution1 * Acetic Acid 2% Otic Solution1 * Acetic Acid Otic Aluminum Acetate Solution1 * Acetylcysteine1 * ACHROMYCIN V CAPSULES2 ACIPHEX (QL)1 * ACLOVATE CREAM / OINTMENT1 * ACTICIN CREAM (QL)1 * ACTIGALL CAPSULES

3 * ACTIQ LOZENGES (PA)

Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Fentanyl patches (DURAGESIC), PERCOCET 5/325, PERCODAN 5/325

3 ACTIVELLA

CLIMARA PRO, PREMPRO, PREMPHASE, Medroxyprogesterone (PROVERA) plus Estradiol tablets (ESTRACE), Estradiol patches (CLIMARA), ESTRADERM, VIVELLE, VIVELLE-DOT or Estropipate (OGEN, ORTHO-EST)

2 ACTONEL TABLETS 5 MG, 35 MG, 75 MG (QL)2 ACTONEL with CALCIUM TABLETS (QL)2 ACTOPLUS MET TABLETS2 ACTOS TABLETS 2 ACULAR LS OPHTHALMIC SOLUTION2 ACULAR OPHTHALMIC SOLUTION1 * Acyclovir Oral Tablets / Capsules / Suspension 1 * ADALAT CC TABLETS1 * ADALAT TABLETS1 * ADDERALL TABLETS

3 ADDERALL XR CAPSULES (QL)

Amphetamine mixture IR (ADDERALL), Dextroamphetamine/SR (DEXEDRINE, Methylphenidate/SR (RITALIN/SR, METADATE ER), CONCERTA

2 ADVAIR DISKUS (QL)2 ADVAIR HFA (QL)1 * ADVANCED NATALCARE TABLET1 * ADVANCED-RF NATALCARE TAB2 ADVICOR TABLETS (QL) Lovastatin (MEVACOR) and Niacin

3 AEROBID INHALER, AEROBID-M INHALER

Triamcinolone (AZMACORT), Mometasone (ASMANEX), Budesonide (PULMICORT), Fluticasone (FLOVENT), Beclomethasone (QVAR) , Fluticasone AND Salmeterol (ADVAIR)

2 AEROCHAMBER2 AGENERASE CAPSULES

3 AGGRENOX CAPSULESAspirin + Dipyridamole (PERSANTINE), Clopidogrel (PLAVIX), Ticlopidine (TICLID), Cilostazol (PLETAL)

3 * AGRYLIN CAPSULES1 * AK-PENTOLATE OPHTHALMIC SOLUTION1 * AK-TOB OPHTHALMIC SOLUTION

3 ALAMAST OPHTHALMIC DROPSCromolyn sodium (CROLOM), Ketotifen (ZADITOR: OTC AVAILABLE: NOT COVERED)

3 ALBENZA TABLETS1 * Albuterol ER Tablets

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 1 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 2: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * Albuterol Inhaler (QL)1 * Albuterol Tablets1 * Alclometasone Dipropionate Cream / Ointment1 * ALDACTAZIDE TABLETS1 * ALDACTONE TABLETS3 ALDARA CONDYLOX GEL1 * ALDOMET TABLETS1 * ALDORIL TABLETS

* Alendronate Tablets1 * ALESSE3 ALINIA SUSPENSION / TABLETS 2 ALKERAN TABLETS3 * ALLEGRA Loratadine (CLARITIN: AVAILABLE OTC - NOT COVERED)3 * ALLEGRA-D CLARITIN-D (AVAILABLE OTC - NOT COVERED)1 * Allopurinol Tablets3 ALOCRIL OPHTHALMIC SOLUTION Cromolyn (CROLOM), ALOMIDE, PATANOL2 ALOMIDE OPHTHALMIC SOLUTION3 ALORA PATCHES ESTRADERM, Estradiol Patches (CLIMARA), VIVELLE, VIVELLE-DOT1 * ALPHAGAN OPHTHALMIC SOLUTION2 ALPHAGAN P OPHTHALMIC SOLUTION1 * Alprazolam Tablets

3 ALREX OPHTHALMIC SUSPENSIONDexamethasone (DEXASOL), Fluorometholone (FML), Prednisolone (ECONOPRED, PRED FORTE)

3 ALTABAX OINTMENT Mupirocin (BACTROBAN)1 * ALTACE CAPSULES

not covered ALTACE TABLETS USE ALTACE CAPSULES

3 ALTOPREV TABLETS Lovastatin (MEVACOR), Pravastatin (PRAVACHOL), Simvastatin (ZOCOR)1 * Aluminum Chloride Hexahydrate2 ALUPENT INHALER 1 * ALUPENT TABLETS1 * Amantadine Capsules1 * AMARYL TABLETS

3 AMBIEN CR TABLETS (QL)Flurazepam (DALMANE),Temazepam (RESTORIL), Triazolam (HALCION), Zolpidem (AMBIEN)

1 * AMBIEN TABLETS (QL)2 AMERGE TABLETS (QL)1 * Amiloride1 * Amiloride / Hydrochlorothiazide Tablets1 * Aminophylline Tablets (QL)1 * Amiodarone Tablets3 AMITIZA CAPSULES Lactulose (CEPHULAC), Polethylene Glycol 3350 (MIRALAX)3 * Amitriptyline / Perphenazine Tablets Amitriptyline Tablets and Perphenazine Tablets1 * Amitriptyline Tablets1 * Amlodipine Tablets (QL)1 * AMNESTEEM CAPSULES (QL)2 Amoxapine Tablets1 * Amoxicillin Capsules/Suspension/Chewable Tablets1 * Amoxicillin Clavulanate Potassium Tablets / Suspension1 * AMOXIL

3 Amphetamine Salt Combo SR

Methylphenidate Long Acting (RITALIN SR, METADATE ER), CONCERTA), Dextroamphetamine SR (DEXEDRINE), Amphetamine Mixture (ADDERALL)

1 * Ampicillin Capsules / Suspension1 * Amylase / Lipase / Protease1 * Amylase / Lipase / Protease / Pancreatin1 * ANAFRANIL CAPSULES3 * Anagrelide Capsules1 * ANAPROX DS TABLETS1 * ANAPROX TABLETS1 * ANASPAZ TABLETS3 ANDRODERM PATCHES ANDROGEL3 ANDROGEL

3 ANGELIQ TABLETS

CLIMARA PRO, PREMPRO, PREMPHASE, Medroxyprogesterone (PROVERA) AND Estradiol tablets (ESTRACE), Estradiol patches (CLIMARA), ESTRADERM, VIVELLE, VIVELLE-DOT, or Estropipate (OGEN, ORTHO-EST)

2 ANTABUSE TABLETS

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 2 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 3: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * ANUSOL-HC SUPP

3 ANZEMET (QL)

Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN),prochlorperazine (COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN)

1 * APAP / Dichloralphenazone / Isometheptene Capsules3 APIDRA Insulin1 * APRESOLINE TABLETS2 APTIVUS CAPSULES1 * ARALEN TABLETS1 * Aranelle Tablets3 * ARAVA TABLETS Azathioprine, hydroxychloroquine , methotrexate, sulfasalazine2 ARICEPT 2 ARIMIDEX TABLETS1 * ARISTOCORT CREAM / OINTMENT1 * ARMOUR THYROID2 AROMASIN TABLETS1 * ARTANE TABLETS

3 ARTHROTEC TABLETS

Diclofenac (VOLTAREN/XR), Etodolac IR (LODINE), Ibuprofen (MOTRIN), Indomethacin (INDOCIN/SR), Meloxicam (MOBIC), Naproxen (NAPROSYN) Piroxicam (FELDENE), Sulindac (CLINORIL)

2 ASACOL TABLETS (QL)2 ASMANEX TWISTHALER (QL)1 * Aspirin, Delayed Release Tablets, EC1 * Aspirin, Sustained Release Tablets2 ASTELIN NASAL SPRAY3 ATACAND Benazepril (LOTENSIN), Lisinopril (ZESTRIL), BENICAR, DIOVAN

3 ATACAND HCT Benazepril/HCTZ (LOTENSIN HCT), Lisinopril /HCTZ (ZESTORETIC), BENICAR HCT , DIOVAN HCT ,

1 * ATARAX TABLETS1 * Atenolol / Chlorthalidone Tablets1 * Atenolol Tablets1 * ATIVAN TABLETS2 ATRIPLA TABLETS (QL)1 * Atropine Sulfate Ophthalmic Solution & Ointment2 ATROVENT HFA INHALER2 ATROVENT NASAL SPRAY1 * Augmented Betamethasone Dipropionate Cream1 * AUGMENTIN CAPSULES / SUSPENSION2 AUGMENTIN XR CAPSULES / SUSPENSION1 * AURALGAN Otic Solution1 * AUROTO Otic Solution

3 AVALIDE TABLETS (QL)Benazepril/HCTZ (LOTENSIN HCT), Lisinopril / HCTZ (ZESTORETIC), BENICAR HCT, DIOVAN HCT

2 AVANDAMET TABLETS 2 AVANDARYL TABLETS 2 AVANDIA TABLETS 3 AVAPRO (QL) Benazepril (LOTENSIN), Lisinopril (ZESTRIL), BENICAR, DIOVAN2 AVELOX TABLETS (QL)1 * AVENTYL CAPSULES2 AVINZA CAPSULES3 AVODART CAPSULES Finasteride (PROSCAR), Doxazosin (CARDURA), Terazosin (HYTRIN)3 AXERT TABLETS (QL) AMERGE, IMITREX

3 AXID TABLETSCimetidine (TAGAMET), Ranitidine (ZANTAC), PEPCID AC (AVAILABLE OTC - NOT COVERED)

1 * Azathioprine Tablets

3 AZELEX CREAM

Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R)

2 AZILECT TABLETS1 * Azithromycin Tablets1 * Azithromycin Tablets (QL)2 AZMACORT (QL)2 AZOPT OPHTHALMIC SOLUTION1 * AZULFIDINE TABLETS (ENTERIC COATED NOT COVERED)1 * Baclofen Tablets1 * BACTRIM DS TABLETS1 * BACTRIM TABLETS1 * BACTROBAN OINTMENT

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 3 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 4: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * Balsalazide Capsules (QL)2 BARACLUDE TABLETS (PA)2 B-D BRAND DISPOSABLE INSULIN NEEDLES & SYRINGES3 BECONASE AQ (QL) NASONEX, Fluticasone (FLONASE), NASACORT AQ, VERAMYST1 * BEEPEN-VK TABLETS / SUSPENSION1 * Belladonna / Phenobarbital Tablets/ Elixir1 * Benazepril / Amlodipine Tablets1 * Benazepril / HCTZ Tablets1 * Benazepril Capsules1 * BENEMID TABLETS2 BENICAR HCT TABLETS (QL)2 BENICAR TABLETS (QL)1 * BENTYL CAPSULES

3 BENZACLIN GEL

Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R)

1 * BENZAMYCIN1 * Benzocaine / Antipyrine Otic Solution1 * Benzonatate Capsules1 * Benztropine Mesylate Tablets1 * BETAGAN OPHTHALMIC SOLUTION1 * Betamethasone Dipropionate Cream / Ointment1 * BETAPACE AF TABLETS1 * BETAPACE TABLETS1 * Betaxolol Opthmalic Solution1 * Bethanechol Tablets2 BETIMOL OPHTHALMIC SOLUTION2 BETOPTIC-S OPHTHALMIC SOLUTION1 * BIAXIN SUSPENSION1 * BIAXIN TABLETS (QL)1 * BIAXIN XL TABLETS (QL)3 BIDIL TABLETS Hydralazine (APRESOLINE) + Isosorbide (ISORDIL)2 BILTRICIDE TABLETS1 * Bisoprolol / Hydrochlorothiazide Tablets1 * Bisoprolol Tablets1 * BLEPH 10 OPHTHALMIC OINT./ SOLUTION2 BLEPHAMIDE OPHTHALMIC OINTMENT1 * BLOCADREN TABLETS

3 BONIVA TABLETS (QL)Alebdrenoate (FOSAMAX), FOSAMAX-D, ACTONEL, ACTONEL W CALCIUM

2 BRETHAIRE INHALER1 * BRETHINE TABLETS1 * Brimonidine Ophthalmic Solution1 * Bromcriptine Capsules / Tablets1 * BROMFED CAPSULES1 * BROMFED PD CAPSULES1 * BROMFED TABLETS1 * Brompheniramine 12 mg / Pseudoephedrine 120 mg3 BROVANA SOLUTION FOR INHALATION SEREVENT

X Budeprion Sustained Release tablets - BENEFIT EXCLUSION**Some Plans May Cover Smoking Cessation Products For A Limited DurationRefer to Plan Documents for Coverage.

1 * Bumetanide Tablets1 * BUMEX TABLETS1 * Bupropion Sustained Release Tablets1 * Bupropion Tablets1 * BUSPAR TABLETS1 * Buspirone Tablets1 * Butalbital 50 / Acetaminophen 325 / Caffeine 40 Tablets1 * Butalbital 50 / Aspirin 325 / Caffeine 40 Tablets / Capsules1 * Butalbital 50 / Aspirin 650 Tablets

3 * Butorphanol Nasal Spray (PA) (QL)

FIORICET, FIORINAL , ISOYLL, Acetaminophen and codeine (TYLENOL/CODEINE), Hydrocodone 5mg and Acetaminophen 500 mg (VICODIN, LORTAB), Tramadol (ULTRAM)

3 * Cabergoline Tablets (QL)3 CADUET TABLETS (PA)1 * CAFERGOT TABLETS / SUPPOSITORIES1 * CALAN SR TABLETS

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 4 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 5: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * CALAN TABLETS1 * Calcitonin (Salmon) Nasal Soln1 * Calcitriol Capsules3 CAMPRAL TABLETS Naltrexone (REVIA) , ANTABUSE2 CANASA SUPPOSITORIES1 * CAPOTEN TABLETS 1 * CAPOZIDE TABLETS1 * Captopril / HCTZ Tablets1 * Captopril Capsules1 * CARAC CREAM1 * CARAFATE TABLETS1 * Carbachol Ophthalmic Solution1 * Carbamazepine Tablets1 * Carbidopa / Levodopa CR Tablets1 * Carbidopa / Levodopa Tablets1 * Carbinoxamine 4 / Pseudoephedrine 60 / DM 15 Syrup1 * CARBOPTIC OPHTHALMIC SOLUTION

3 * CARDENE CAPSULESNifedipine SR (ADALAT CC), Felodipine (PLENDIL), SULAR, Verapamil SA Tabs (CALAN SR), Amlodipine (NORVASC)

3 CARDENE SR CAPSULESNifedipine SR (ADALAT CC), Felodipine (PLENDIL), SULAR, Verapamil SA Tabs (CALAN SR), Amlodipine (NORVASC)

1 * CARDIZEM CD CAPSULES1 * CARDIZEM SR CAPSULES1 * CARDIZEM TABLETS1 * CARDURA TABLETS1 * Carisoprodol Tablets2 CASODEX TABLETS

3 * CATAFLAM TABLETS

Ibuprofen (MOTRIN), Meloxicam (MOBIC), Indomethacin/SR (INDOCIN/SR), Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin (DAYPRO), Sulindac (CLINORIL), Diclofenac (VOLTAREN), Piroxicam (FELDENE)

1 * CATAPRES -TABLETS ONLY3 CATAPRES-TTS PATCHES Clonidine Tablets (CATAPRES)1 * CECLOR CAPSULES / SUSPENSION2 CEENU CAPSULES1 * Cefaclor Capsules / Suspension1 * Cefadroxil Capsules1 * Cefpodoxime Proextil Tablets1 * CEFTIN CAPSULES / SUSPENSION1 * Cefuroxime Capsules1 * CEFZIL CAPSULES / SUSPENSION

3 CELEBREX (QL)

Ibuprofen (MOTRIN), Meloxicam (MOBIC), Indomethacin/SR (INDOCIN/SR), Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin (DAYPRO), Sulindac (CLINORIL), Diclofenac (VOLTAREN), Piroxicam (FELDENE)

1 * CELEXA TABLETS (QL)2 CELLCEPT 2 CELONTIN CAPSULES

3 CENESTIN TABLETSPREMARIN, Estropipate (OGEN, ORTHO-EST), Esterified Estrogens (MENEST, ESTRATAB), Estradiol (ESTRACE)

1 * Centany Ointment1 * Cephalexin Capsules / Suspension1 * CEPHULAC SOLUTION2 CERVICAL CAP

3 CESAMET CAPSULES (PA) (QL)

Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN),prochlorperazine (COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN)

1 * Cesia Tablets

X CHANTIX TABLETS - BENEFIT EXCLUSION**Some Plans May Cover Smoking Cessation Products For A Limited DurationRefer to Plan Documents for Coverage.

1 * Chloral Hydrate Capsules1 * Chlordiazepoxide Capsules1 * Chlorhexidine Gluconate (Covered Only If Dental Rider purchased)1 * Chloroquine 500 mg Only Tablets1 * Chlorpheniramine 2/ Phenylephrine 10/ Methscopolamine 1.25-Syrup 1 * Chlorpheniramine 4 / Pseudoephedrine 60 Capsules1 * Chlorpheniramine 4.5 / Phenylephrine 5 Suspension

1 * Chlorpheniramine 8/ Phenylephrine 20/ Methscopolamine 2.5 Capsules

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 5 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 6: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * Chlorpromazine Tablets1 * Chlorthalidone Tablets

3 * Chlorzoxasone TabletsMethocarbamol (ROBAXIN), Carisoprodol (SOMA), Cyclobenzaprine (FLEXERIL)

1 * Cholestyramine - Bulk Powder Only 1 * Choline Magnesium Salicylate TabletsX CIALIS TABLETS (NOT COVERED BY ALL PLANS) (PA) (QL)1 * Cilostazol Tablets1 * CILOXAN OPHTHALMIC SOLUTION1 * Cimetidine 400 mg, 800 mg Tablets3 CIPRO HC OTIC SOLUTION Cortisporin Otic, TOBRADEX, ZYLET SUSPENSION1 * CIPRO TABLETS1 * CIPRO XR 1000 mg TABLETS (QL) Ciprofloxacin (CIPRO)1 * CIPRO XR 500 mg TABLETS (QL) Ciprofloxacin (CIPRO)2 CIPRODEX OTIC SUSPENSION (QL)1 * Ciprofloxacin Ophthalmic Solution1 * Ciprofloxacin Tablets1 * Citalopram Tablets (QL)1 * CITRACAL PRENATAL RX TABLET3 CLARINEX TABLETS CLARITIN (AVAILABLE OTC - NOT COVERED)1 * Clarithromycin Tablets1 * Clemastine Tablets

3 * CLENIA CREAM

Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), (RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R)

1 * CLEOCIN CAPSULES1 * CLEOCIN T SOLUTION (SWABS & PADS EXCLUDED)1 * CLEOCIN VAGINAL CREAM1 * Clidinium / Chlordiazepoxide Capsules1 * CLIMARA PATCHES2 CLIMARA PRO PATCHES1 * Clindamycin Capsules1 * Clindamycin Solution 1% (Swabs & Pads Excluded)1 * CLINORIL TABLETS1 * Clobetasol Propionate Cream / Ointment/ Gel / Solution / Emollient

3 CLOBEX LOTIONBetamethasone Dip. Augmented (DIPROLENE), clobetasol (TEMOVATE), Desoxymethasone (TOPICORT LP

1 * CLOMID TABLETS (QL)1 * Clomiphene Tablets (QL)1 * Clomipramine Capsules1 * Clonazepam Tablets1 * Clonidine (Tablets only)1 * Clorazepate Capsules1 * Clotrimazole / Betamethasone Cream / Lotion (QL)1 * Clotrimazole Troches1 * Clozapine Tablets1 * CLOZARIL TABLETS1 * Codeine 10 / Guaifenesin 100 / Pseudoephedrine 30 Solution1 * Codeine / Aspirin Tablets1 * Codeine 10 / Brompheniramine 2 / Phenylephrine 12.5 Syrup1 * Codeine 10 / Chlorpheniramine 2 / Pseudoephedrine 30 Liq1 * Codeine 10/ Bromodiphenhydramine 12.5 Syrup1 * CODEINE TABLETS1 * Codeine Tablets1 * COGENTIN TABLETS3 COGNEX CAPSULES 1 * COLAZAL CAPSULES (QL)1 * COL-BENEMID TABLETS1 * COLCHICINE TABLETS1 * Colchicine Tablets3 COLESTID GRANULES1 * COLESTID TABLETS Cholestyramine Powder (QUESTRAN, QUETRAN LIGHT)1 * Colestipol Tablets1 * COLYTE 3 COMBIGAN OPHTHALMIC SOLUTION USE ALPHAGAN AND TIMOLOL OPHTHALMIC SOLUTION

3 COMBIPATCHPREMPRO, PREMPHASE, PREMARIN and Medroxyprogesterone (PROVERA)

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 6 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 7: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS3 COMBIVENT INHALER PROVENTIL HFA and ipratropium (ATROVENT)2 COMBIVIR TABLETS3 COMBUNOX TABLETS (QL)1 * COMPAZINE TABLETS / SUPPOSITORIES3 COMTAN TABLETS2 CONCERTA (QL)2 CONDYLOX – GEL2 COPEGUS TABLETS (PA)1 * CORDARONE TABLETS

3 CORDRAN CREAM / OINTMENT / TAPE /LOTION

Betamethasone Dip. (DIPROSONE), Betamethasone Val. (VALISONE), Fluocinolone (SYNALAR), ELOCON, Triamcinolone (KENALOG, ARISTOCORT)

3 COREG CR TABLETS (QL)1 * COREG TABLETS (QL)1 * CORGARD TABLETS1 * CORTEF TABLETS1 * CORTENEMA2 CORTIFOAM1 * Cortisone Tablets1 * CORTISPORIN OPHTHALMIC SOLUTION & OINTMENT1 * CORTISPORIN OTIC SOLUTION / SUSPENSION3 COSOPT OPHTHALMIC SOLUTION AZOPT plus Timolol (TIMOPTIC)1 * COUMADIN TABLETS3 COVERA -HS TABLETS Verapamil SA Tabs (CALAN SR)3 COZAAR TABLETS Benazepril (LOTENSIN), Lisinopril (ZESTRIL), BENICAR , DIOVAN2 CREON CAPSULES3 CRESTOR (QL) Simvastatin (ZOCOR), VYTORIN2 CRINONE 8% VAGINAL CREAM 2 CRIXIVAN CAPSULES1 * CROLOM OPHTHALMIC SOLUTION1 * Cromolyn Sodium Inhaled/Nasal/Nebulizer1 * Cromolyn Sodium Ophthalmic Solution2 CUPRIMINE

3 * CUTIVATE CREAM /OINTMENT/ LOTION

Betamethasone Dip. (DIPROSONE), Betamethasone Val. (VALISONE), Fluocinolone (SYNALAR), Fluocinonide (LIDEX), Triamcinolone (KENALOG, ARISTOCORT)

1 * CYCLESSA TABLETS1 * Cyclobenzaprine 10 mgTablets3 * Cyclobenzaprine 5 mg Tablets Cyclobenzaprine 10 mg Tablets1 * Cyclopentolate Ophthalmic Solution1 * Cyclosporine 1 * Cyclosporine Microemulsion2 CYMBALTA CAPSULES (QL)1 * Cyproheptadine 4 mg Tablets Only2 Cyproheptadine Syrup2 CYTOMEL1 * CYTOTEC TABLETS1 * CYTOVENE CAPSULES2 CYTOXAN TABLETS1 * DALMANE CAPSULES 1 * Danazol Capsules1 * DANOCRINE CAPSULES1 * DANTRIUM CAPSULES2 DAPSONE TABLETS3 DARAPRIM TABLETS1 * DARVOCET-N 100 Tablets1 * DARVON CAPSULES1 * DAYPRO TABLETS3 DAYTRANA PATCHES1 * DDAVP1 * DECADRON OPHTHALMIC SOLUTION & OINTMENT1 * DECADRON TABLETS1 * DECLOMYCIN TABLETS1 * DECONAMINE SR CAPSULES1 * DELTA CORTEF TABLETS1 * DELTASONE TABLETS3 * DEMADEX TABLETS Furosemide (LASIX), Bumetanide (BUMEX)

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 7 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 8: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * Demeclocycline Tablets1 * DEMEROL TABLETS1 * DEMULEN

3 DENAVIR CREAM (QL)ABREVA ((AVAILABLE OTC - NOT COVERED), Acyclovir (ZOVIRAX (oral)), VALTREX

1 * DEPAKENE CAPSULES2 DEPAKOTE ER TABLETS2 DEPAKOTE TABLETS2 DEPEN1 * Desipramine Tablets1 * Desmopressin Tablets / Spray1 * Desonide Cream / Ointment / Lotion1 * DESOWEN CREAM / OINTMENT / LOTION1 * Desoximetasone 0.05% CREAM

3 DESOXYN TABLETS Methylphenidate SR/ER (Ritalin SR, Metadate ER), Dextroamphetamine SR (DEXEDRINE), Amphetamine Mixture (ADDERALL), CONCERTA

1 * DESYREL TABLETS2 DETROL LA CAPSULES Oxybutinin Immediate Release Tabs.2 DETROL TABLETS Oxybutinin Immediate Release Tabs.1 * Dexamethasone / Neomycin / Polymyxin Ophth. Soln & Oint1 * Dexamethasone Ophthalmic Solution & Ointment1 * Dexamethasone Tablets1 * Dexchlorpheniramine Tablets1 * DEXEDRINE SPANSULES1 * DEXEDRINE TABLETS 1 * Dextroamphetamine CR Capsules1 * Dextroamphetamine Tablets1 * DIABETA TABLETS2 DIAMOX SEQUELS1 * DIAMOX TABLETS1 * Diazepam Tablets2 DIBENZYLINE1 * Diclofenac Sodium Tablets1 * Dicloxacillin Capsules / Suspension1 * Dicyclomine Capsules3 * DIDRONEL TABLETS ACTONEL, FOSAMAX2 DIFFERIN GEL /CR /SOL /PADS1 * Diflorasone Diacetate Cream / Oinment1 * Diflorasone Diacetate, Emollient Cream1 * DIFLUCAN 150 MG TAB ONLY (QL)1 * DIFLUCAN TABLET (PA)1 * DIGITEK TABLETS1 * Digoxin Tablets1 * DILACOR XR CAPSULES1 * DILANTIN CAPSULES/ TABLETS1 * DILAUDID TABLETS1 * Diltiazem Extended Release Capsules1 * Diltiazem Immediate Release Tablets1 * Diltiazem SR Capsules1 * DIMETANE-DC EXPECTORANT2 DIOVAN HCT TABLETS (QL)2 DIOVAN TABLETS (QL)3 DIPENTUM CAPSULES ASACOL TABLETS1 * Diphenoxylate / Atropine Tablets1 * Dipivefrin Ophthalmic Solution1 * DIPROLENE AF CREAM 1 * DIPROSONE CREAM / OINTMENT1 * Dipyridamole Tablets1 * DISALCID TABLETS1 * Disopyramide Capsules1 * Disopyramide Controlled Release Capsules1 * Disulfiram Tablets1 * DITROPAN TABLETS 3 * DITROPAN XL TABLETS Oxybutinin Immediate Release Tabs., DETROL, DETROL LA3 * DOLOBID TABLETS Salsalate (SALFLEX), Magnesium Trisalicylate (TRILISATE),1 * DOLOPHINE TABLETS (QL)

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 8 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 9: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * DOMEBORO OTIC SOLUTION1 * DONNATAL TABLETS / ELIXIR1 * DOPAR3 DORAL TABLETS Lorazepam (ATIVAN), Temazepam (RESTORIL),Flurazepam (DALMANE)3 DORYX TABLETS3 * DOSTINEX TABLETS (QL)2 DOVONEX CREAM / OINTMENT (QL)1 * Doxazosin Mesylate Tablets1 * Doxepin Capsules3 * Doxycycline Hyclate 20mg Capsules / Tablets1 * Doxycycline Hyclate 50mg, 100mg Capsules / Tablets1 * DRISDOL CAPSULES1 * DRYSOL2 DUAC GEL (QL)2 DUETACT TABLETS (QL)3 DUONEB INHALATION SOLUTION Ipratropium (ATROVENT) plus Albuterol (PROVENTIL) inhalation solution1 * DURAGESIC PATCHES (QL)1 * DURICEF1 * DYAZIDE CAPSULES3 DYNACIN - NOT COVERED - USE MINOCYCLINE Minocycline (MINOCIN)

3 DYNACIRC CR TABLETSAmlodipine (NORVASC), Nifedipine SR (ADALAT CC, PROCARDIA XL), Felodipine (PLENDIL)

2 EASPIRIN TABLETS 975 MG (QL)1 * Econazole Cream1 * ECONOPRED OPHTHALMIC SOLUTION1 * ECONOPRED PLUS OPHTHALMIC SOLUTION3 EDECRIN TABLETS Furosemide (LASIX), Bumetanide (BUMEX), Metolazone (ZAROXOLYN)1 * EES SUSPENSION2 EFFEXOR CAPSULES XR (QL)1 * EFFEXOR TABLETS1 * EFUDEX CREAM / SOLUTION1 * ELAVIL TABLETS1 * ELDEPRYL CAPSULES3 ELESTAT OPHTHALMIC SOLUTION Cromolyn (CROLOM),ALOMIDE, PATANOL, PATADAY

3 ELIDEL CREAM

PROTOPIC , Betamethasone dipropionate, Augmented betamethasone dipropionate (DIPROLENE), Betamethasone valerate 0.1% (BETA-VAL), Clobetasol proprionate (TEMOVATE), Desoximetasone (TOPICORT), Diflorasone cream & ointment (APEXICON, APEXICON E, PSORCON E), Fluocinolone 0.025% (SYNALAR), Fluocinonide (LIDEX, LIDEX E), Halobetasol propionate (ULTRAVATE), Mometasone (ELOCON), Triamcinolone 0.1% (ARISTOCORT, KENALOG)

1 * ELIMITE CREAM (QL)1 * ELIXOPHYLLINE LIQ.3 ELMIRON CAPSULES1 * ELOCON CREAM / OINTMENT2 EMCYT CAPSULES

3 EMEND CAPSULES (QL)

Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN),prochlorperazine (COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN)

1 * EMGEL 3 * EMLA CREAM1 * EMPIRIN TABLETS #2, #3, #4

3 EMSAM PATCHES

Amitriptyline (ELAVIL),Bupropion/SR (WELLBUTRIN/SR),Citalopram (CELEXA), Desipramine (NORPRAMIN), Doxepin (SINEQUAN), Fluoxetine (PROZAC), Imipramine (TOFRANIL), Mirtazapine/soltab (REMERON/ SOLTAB), Nortriptyline (AVENTYL, PAMELOR), Paroxetine (PAXIL), Sertraline (ZOLOFT), Trazodone (DESYREL), Venlafaxine IR (EFFEXOR

2 EMTRIVA CAPSULES 200MG (QL)1 * E-MYCIN TABLETS3 ENABLEX TABLETS Oxybutinin Immediate Release Tabs., DETROL, DETROL LA1 * Enalapril Tablets1 * ENTEX PSE 120/400 TABLETS3 ENTOCORT EC CAPSULES1 * Epinephrine HCl Ophthalmic Solution3 EPIVIR HBV TABLETS2 EPIVIR TABLETS2 EPZICOM TABLETS2 ERGOMAR TABLETS

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 9 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 10: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * Ergonovine Maleate Tablets1 * Ergotamine / Caffeine Tablets / Suppositories1 * Ergotamine Tartrate Tablets1 * Ergotamine/ Belladonna/ Phenobarbital Tablets / Elixir2 ERGOTRATE TABLETS3 ERTACZO CREAM Nystatin, Econazole (SPECTAZOLE), LAMISIL AT (OTC-NOT COVERED)1 * ERYCETTE SOLN (SWABS & PADS EXCLUDED)1 * ERYDERM SOLN (SWABS & PADS EXCLUDED)1 * ERYGEL2 ERYPED TABLETS2 ERY-TAB1 * ERYTHROCIN TABLETS1 * Erythromycin / Benzoyl Peroxide Cream1 * Erythromycin / Sulfisoxazole Suspension1 * Erythromycin 1.5 % Soln (Swabs & Pads EXCLUDED)1 * Erythromycin 2 % Gel1 * Erythromycin 2.0 % Soln (Swabs & Pads EXCLUDED)1 * Erythromycin Base Ophthalmic Solution & Ointment1 * Erythromycin Base Tablets1 * Erythromycin Ethylsuccinate Suspension1 * Erythromycin Stearate TABLETS1 * ESGIC TABLETS1 * ESKALITH CAPSULES

3 * Estazolam TabletsZolpidem (AMBIEN), Lorazepam (ATIVAN), Temazepam (RESTORIL),Flurazepam (DALMANE)

1 * ESTRACE TABLETS2 ESTRACE VAGINAL CREAM2 ESTRADERM PATCHES1 * Estradiol Tablets (QL)3 ESTRASORB TOPICAL EMULSION ESTRADERM, Estradiol Patches (CLIMARA), VIVELLE, VIVELLE-DOT2 ESTRATAB TABLETS ESTRADERM, Estradiol Patches (CLIMARA), VIVELLE, VIVELLE-DOT1 * ESTRATEST HS TABLETS1 * ESTRATEST TABLETS

3 ESTRINGEstradiol patches (CLIMARA), ESTRADERM, VIVELLE, VIVELLE-DOT, ESTRACE VAGINAL CR, PREMARIN VAGINAL CR

3 ESTROGEL (QL)

PREMARIN, Estropipate (OGEN, ORTHO-EST), Esterified Estrogens (MENEST, ESTRATAB), Estradiol Tablets (ESTRACE), Estradiol patches (CLIMARA), VIVELLE, VIVELLE-DOT, ESTRADERM, ESTRACE VAGINAL CR, PREMARIN VAGINAL CR

1 * Estropipate Tablets3 * ESTROSTEP TABLETS1 * Ethambutol Tablets1 * Ethionamide Tablets1 * Ethosuximide Capsules1 * Etodolac ER Tablets1 * Etodolac Tablets/Capsules1 * EULEXIN CAPSULES2 EURAX CREAM / LOTION2 EVISTA TABLETS (QL)

3 EXELDERMNystatin (MYCOSTATIN), LAMISIL AT CREAM (OTC AVAILABLE - NOT COVERED), Econazole (SPECTAZOLE), Ketoconazole Tablets (NIZORAL)

2 EXELON CAPSULES2 EXFORGE TABLETS(EST) Amlodipine (NORVASC) plus DIOVAN3 EXJADE TABLETS2 EXTENDRYL SR CAPSULES1 * EXTENDRYL SYRUP3 EXUBERA INHALATION POWDER3 FACTIVE TABLETS (QL)1 * Famotidine Tablets3 * FAMVIR TABLETS Acyclovir (ZOVIRAX), VALTREX2 FANSIDAR TABLETS2 FARESTON TABLETS2 FELBATOL TABLETS1 * FELDENE CAPSULES2 FEMARA TABLETS

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 10 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 11: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS

3 FEMHRT TABLETS

CLIMARA PRO, PREMPRO, PREMPHASE, Medroxyprogesterone (PROVERA) PLUS Estradiol Tablets (ESTRACE), Estradiol patches (CLIMARA), VIVELLE, VIVELLE-DOT, ESTRADERM, or Estropipate (OGEN, ORTHO-EST)

3 FEMRING (3 Month Supply)Estradiol Patches (CLIMARA), ESTRADERM, VIVELLE, VIVELLE-DOT, ESTRACE VAGINAL CR, PREMARIN VAGINAL CR

1 * Fenofibrate Micronized Tablets 67mg, 134 mg, 160 mg, 200 mg1 * Fenofibrate Tablets 160 mg1 * Fenoprofen Capsules

3 * Fentanyl Lozenges (PA)

Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, PERCOCET 5/325, PERCODAN 5/325

3 FENTORA BUCCAL (PA) (QL)

Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Fentanyl patches (DURAGESIC), PERCOCET 5/325, PERCODAN 5/325

3 * Fexofenadine Tablets Loratadine (CLARITIN: AVAILABLE OTC - NOT COVERED)2 FINACEA GEL1 * Finasteride Tablets 1 * FIORICET TABLETS1 * FIORITAL TABLETS / CAPSULES1 * FIORPAP TABLETS1 * FLAGYL TABLETS 250 mg or 500 mg Only2 FLAREX OPHTHALMIC SOLUTION1 * Flavoxate Tablets1 * Flecainide Tablets3 FLECTOR PATCHES (QL)1 * FLEXERIL 10 MG TABLETS3 * FLEXERIL 5 MG TABLETS

2 FLOMAX CAPSULES Terazosin (HYTRIN), Doxazosin (CARDURA), Finasteridie (PROSCAR) (PA)

1 * FLONASE NASAL SPRAY (QL)1 * FLORINEF TABLETS1 * FLORONE CREAM 2 FLOVENT HFA (QL)2 FLOXIN OTIC SOLUTION1 * Fluconazole 150 mg Tab – Females Only (QL)1 * Fluconazole Tablets (QL)1 * Fludrocortisone Tablets1 * Fluocinolone Acetonide 0.01% Cream / Ointment / Solution1 * Fluocinolone Acetonide 0.025% Cream / Ointment1 * Fluocinolone Acetonide 0.2% HP Cream1 * Fluocinonide Cream/ Ointment1 * Fluoride / Polyvitamins (Without Iron; Drops & Tabs) 1 * Fluoride / Vitamins A,D,C (Without Iron; Drops & Tabs)1 * Fluorometholone Ophthalmic Suspension1 * Fluorometholone Ophthalmic Suspension & Ointment1 * FLUOR-OP OPHTHALMIC SOLUTION2 FLUOROPLEX CREAM / SOLUTION1 * Fluoxetine Capsules Only - 10mg, 20mg Only

3 * Fluoxetine Tablets

Fluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL), Venlafaxine (EFFEXOR), EFFEXOR XR, Bupropion (WELLBUTRIN, WELLBUTRIN SR), LEXAPRO

1 * Fluoxymesterone Tablets1 * Fluphenazine Tablets1 * Flurazepam Capsules (QL)1 * Flutamide Capsules1 * Fluticasone Nasal Spray1 * Fluticasone Nasal Spray (QL)

3 * Fluvoxamine Tablets

Fluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL), Venlafaxine (EFFEXOR), EFFEXOR XR, Bupropion (WELLBUTRIN, WELLBUTRIN SR), LEXAPRO

2 FML FORTE OPHTHALMIC SOLUTION1 * FML OPHTHALMIC SOLUTION & OINTMENT

3 FOCALIN TABLETS (QL)Methylphenidate/SR (Ritalin/SR), Dextroamphetamine (DEXEDRINE), Amphetamine Mixture (ADDERALL), CONCERTA

3 FOCALIN XR CAPSULES Methylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE), Amphetamine Mixture (ADDERALL), CONCERTA

1 * Folic Acid 1 mg Tablets2 FORADIL AEROLIZER (QL)

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 11 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 12: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS3 FORTAMET TABLETS Metformin Tablets SR (GLUCOPHAGE XR)1 * FORTICAL NASAL SPRAY1 * FOSAMAX TABLETS (QL)2 FOSAMAX-D TABLETS (QL)1 * Fosinopril Capsules3 FOSRENOL2 FREESTYLE TEST LITE STRIPS (QL)2 FREESTYLE TEST STRIPS (QL)3 FROVA (QL) AMERGE, IMITREX1 * FULVICIN P/G TABLETS2 FULVICIN U/F TABLETS1 * Furosemide Tablets1 * gabapentin Tablets / Capsules1 * GABARONE TABLETS

3 GABITRIL TABLETS

Methsuximide (CELONTIN) , Valproic Acid/ER (DEPAKOTE ER), Felbamate (FELBATOL), Carbamazepine SR (TEGRETOL SR), Topiramate (TOPAMAX), Oxcarbazepine (TRILEPTAL)

1 * Ganciclovir Capsules1 * GARAMYCIN CREAM / OINTMENT1 * GARAMYCIN OPHTHALMIC OINT./ SOLUTION1 * Gemfibrozil Tablets1 * GENOPTIC OPHTHALMIC OINT./ SOLUTION1 * GENTACIDIN OPHTHALMIC SOLUTION1 * Gentamicin Ophthalmic Solution & Ointment1 * Gentamicin Sulfate Cream / Ointment3 GEOCILLIN TABLETS2 GEODON CAPSULES2 GLEEVEC TABLETS (PA)1 * Glimepiride Tablets1 * Glipizide Long Acting1 * Glipizide Tablets1 * GLUCOPHAGE TABLETS1 * GLUCOPHAGE XR TABLETS1 * GLUCOTROL TABLETS1 * GLUCOTROL XL TABLETS1 * GLUCOVANCE TABLETS1 * Glyburide Micronized Tablets1 * Glyburide Tablets1 * GLYNASE TABLETS3 GLYSET TABLETS PRECOSE2 Griseofulvin Ultramicrosize Tablets2 GRIS-PEG TABLETS1 * Guaifenesin 10 / Codeine Phosphate 100 Liq NR Expectorant1 * Guaifenesin 100 / Codeine 10 / Pseudoephedrine 301 * Guaifenesin 100 / Codeine 10 Expectorant1 * Guaifenesin 600 / Pseudoephedrine 120 Tablets1 * Guanabenz Tablets1 * Guanfacine Tablets2 GUANIDINE TABLETS1 * HALCION TABLETS (QL)

3 HALOG CREAM / OINTMENT

Augmented Betamethasone Dip. (DIPROLENE AF), Betamethasone Val. (VALISONE), Fluocinonide (LIDEX/E), Diflorasone cream (MAXIFLOR, PSORCON E)

1 * Haloperidol Tablets2 HALOTESTIN TABLETS1 * HCTZ TABLETS/ CAPSULES3 HECTOROL CAPSULES2 HEPSERA (PA)2 HEXALEN CAPSULES3 HIPREX TABLETS Methenamine Mandelate Tablets1 * HISTUSSIN HC SYRUP2 HIVID TABLETS1 * Homatropine Ophthalmic Solution2 HUMALOG INSULIN (QL)2 HUMALOG INSULIN PENS (QL)2 HUMALOG MIX 50/50 INSULIN (QL)2 HUMALOG MIX 50/50 INSULIN PENS (QL)

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 12 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 13: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS2 HUMALOG MIX 75/25 INSULIN (QL)2 HUMALOG MIX 75/25 INSULIN PENS (QL)1 * HUMATIN CAPSULES2 HUMULIN INSULIN (QL)2 HUMULIN INSULIN PENS (QL)1 * HYCODAN SYRUP1 * HYCOTUSS EXPECTORANT1 * Hydralazine Tablets1 * HYDREA TABLETS1 * Hydrochlorothiazide (HCTZ) 12.5mg Capsules1 * Hydrochlorothiazide (HCTZ) Tablets 25mg, 50mg1 * Hydrocodone 2.5 / Phenylephrine 5 / Chlorpheniramine 2 Syrup1 * Hydrocodone 2.5 / Guaifenesin 100 /Pseudoephedrine 30 Soln1 * Hydrocodone 5 / Guaifenesin 100 Expectorant1 * Hydrocodone 5 / Homatropine 1.5 Syrup 1 * Hydrocortisone (Rectal Cream)1 * Hydrocortisone 2.5% Cream / Ointment 1 * Hydrocortisone / Neomycin / Polymyxin Ophth. Susp & Oint1 * Hydrocortisone / Neomycin / Polymyxin Otic Solution/ Susp.1 * Hydrocortisone 2.5% Lotion1 * Hydrocortisone Retention Enema1 * Hydrocortisone Suppositories1 * Hydrocortisone Tablets

3 * Hydrocortisone Valerate Cream/ ointmentBetamethasone Dip. Augmented (DIPROLENE), clobetasol (TEMOVATE), Desoxymethasone (TOPICORT LP

1 * HYDROCORTONE TABLETS1 * HYDRODIURIL TABLETS1 * Hydromorphone Tablets1 * Hydroxychloroquine Tablets1 * Hydroxyurea Tablets1 * Hydroxyzine Pamoate Capsules1 * Hydroxyzine HCl Tablets1 * HYGROTON TABLETS1 * Hyoscyamine Sulfate CR Tablets1 * Hyoscyamine Sulfate Tablets1 * HYTONE CREAM / OINTMENT1 * HYTRIN TABLETS / CAPSULES3 HYZAAR BENICAR HCT (PA), DIOVAN HCT (PA)1 * IBU TABLETS1 * Ibuprofen Tablets1 * ILOTYCIN OPHTHALMIC OINTMENT1 * IMDUR TABLETS1 * Imipramine Tablets2 IMITREX TABLETS (QL)1 * IMURAN TABLETS1 * INATAL ULTRA TABLET1 * Indapamide Tablets1 * INDERAL LA CAPSULES1 * INDERAL TABLETS1 * INDERIDE TABLETS1 * INDOCIN CAPSULES1 * INDOCIN SR CAPSULES1 * Indomethacin Capsules1 * Indomethacin, Sustained Release Capsules1 * INFLAMASE FORTE OPHTHALMIC SOLUTION & OINTMENT3 * INNOPRAN XL CAPSULES Propranolol ER (INDERAL LA CAPSULES)2 INSPIREASE3 INSPRA TABLETS Spironolactone (ALDACTONE)1 * INTAL INHALER

3 INVEGA EXTENDED RELEASE TABLETS ABILIFY, chlorpromazine (THORAZINE), GEODON, RISPERDAL, SEROQUEL, ZYPREXA

2 INVIRASE CAPSULES1 * Iodinated Glycerol / Dextromethorphan Syrup1 * IOPHEN-DM SYRUP1 * Ipratropium Inhaler2 IRESSA TABLETS (PA)

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 13 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 14: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS2 ISENTRESS TABLETS1 * Isoniazid Tablets1 * ISOPTIN SR TABLETS1 * ISOPTIN TABLETS1 * ISOPTO ATROPINE OPHTHALMIC SOLUTION2 ISOPTO CARBACHOL OPHTHALMIC SOLUTION1 * ISOPTO CARPINE OPHTHALMIC SOLUTION2 ISOPTO CETAPRED OPHTHALMIC SOLUTION1 * ISOPTO-HOMATROPINE OPHTHALMIC SOLUTION2 ISOPTO-HYOSCINE OPHTHALMIC SOLUTION1 * ISORDIL TABLETS1 * Isosorbide Dinitrate Tablets1 * Isosorbide Mononitrate Tablets1 * Isotretinoin Caps (QL)1 * Itraconazole Capsules (PA)2 JANUMET TABLETS (QL)2 JANUVIA TABLETS (QL)3 * Jolessa tablets (3 Months Supply)2 KADIAN CAPSULES (QL)2 KALETRA CAPSULES1 * KAON-CL1 * KAYEXALATE1 * K-DUR TABLETS1 * KEFLEX CAPSULES / SUSPENSION1 * KENALOG CREAM / OINTMENT1 * KENALOG IN ORABASE2 KEPPRA TABLETS3 KERALAC CREAM / LOTION3 KERLONE TABLETS Atenolol (TENORMIN), Metoprolol/SR (LOPRESSOR, TOPROL XL)

3 KETEK TABLETS (PA)Amoxicillin/clavulanate (AUGMENTIN), Azithromycin (ZITHROMAX), Doxycycline (VIBRAMYCIN), Clarithromycin/SR (BIAXIN/XL)

1 * Ketoconazole 2% Cream (QL)3 * Ketoconazole Shampoo1 * Ketoconazole Tablets 1 * Ketoprofen Capsules1 * Ketorolac Ophthalmic Solution1 * Ketorolac Oral Tablets (QL)2 KETOSTIX (QL)

3 * KLARON LOTION

Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R)

1 * KLONOPIN TABLETS1 * KLOR-CON1 * KLOR-CON PACKETS.1 * K-LYTE (DS)PACKETS2 K-PHOS TABLETS3 KRISTALOSE CRYSTALS Lactulose Solution (CHRONULAC), (Polethylene Glycol 3350 (MIRALAX)1 * KRONOFED-A, JR. CAPSULES1 * K-TABS

3 KYTRIL TABLETS (QL)

Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN),prochlorperazine (COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN)

1 * Labetalol Tablets1 * Lactulose Solution1 * LAMICTAL TABLETS1 * LAMISIL TABLETS (PA)1 * Lamotrigine Tablets3 LANOXICAPS CAPSULES Digoxin (LANOXIN)1 * LANOXIN TABLETS2 LANTUS CARTRIDGES (PA) (QL) LANTUS VIALS2 LANTUS VIALS (QL)1 * LARIAM TABLETS (QL)1 * LARODOPA TABLETS1 * LASIX TABLETS1 * Leena Tablets3 * Leflunomide Tablets3 LESCOL CAPSULES (QL) Lovastatin (MEVACOR), Pravastatin (PRAVACHOL), Simvastatin (ZOCOR)

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 14 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 15: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS3 LESCOL XL TABLETS (QL) Lovastatin (MEVACOR), Pravastatin (PRAVACHOL), Simvastatin (ZOCOR)2 LETAIRIS TABLETS 1 * Leucovorin Tablets2 LEUKERAN TABLETS3 LEVAQUIN TABLETS (QL) Ciprofloxacin (CIPRO), AVELOX2 LEVEMIR INSULIN (QL)1 * LEVLEN TABLETS1 * LEVLITE TABLETS1 * Levobunolol Ophthalmic Solution1 * Levodopa Tablets1 * LEVOTHROID TABLETS1 * Levothyroxine Tablets1 * LEVOXYL TABLETS1 * LEVSIN TABLETS1 * LEVSINEX TABLETS2 LEXAPRO TABLETS (QL)2 LEXIVA TABLETS1 * LIBRAX CAPSULES1 * LIBRIUM CAPSULES1 * LIDEX CREAM / OINTMENT1 * LIDEX E CREAM 1 * Lidocaine, Viscous Solution3 LIDODERM PATCHES1 * LIORESAL TABLETS

3 LIPITOR (QL) Lovastatin (MEVACOR), Pravastatin (PRAVACHOL), Simvastatin (ZOCOR), VYTORIN

1 * LIQUID PRED SOLUTION1 * Lisinopril / HCTZ Tablets1 * Lisinopril Tablets1 * Lithium Carbonate Tablets / Capsules2 LITHOBID TABLETS3 LIVOSTIN OPHTHALMIC SOLUTION ALOMIDE, Cromolyn (CROLOM), PATADAY, PATANOL1 * LO/OVRAL TABLETS

3 *LOCOID CREAM / OINTMENT

Betamethasone dipropionate lotion, Betamethasone valerate 0.1% cream (BETA-VAL), Fluocinolone 0.025% (SYNALAR), Mometasone (ELOCON), Triamcinolone 0.1% (ARISTOCORT, KENALOG)

1 * LODINE TABLETS / CAPSULES1 * LODINE XL TABLETS 3 LOESTRIN 24 TABLETS1 * LOESTRIN FE TABLETS1 * LOESTRIN TABLETS1 * LOMOTIL TABLETS1 * LONITEN TABLETS1 * LOPID TABLETS1 * LOPRESSOR TABLETS3 * LOPROX CREAM /SUSPENSION Nystatin, Econazole (SPECTAZOLE), LAMISIL AT (OTC)3 LOPROX CREAM GEL Nystatin, Econazole (SPECTAZOLE), LAMISIL AT (OTC)

3 LORABID CAPSULES / SUSPENSIONOMNICEF, Cefprozil (CEFZIL), Cefuroxime (CEFTIN), Cefuroxime (CEFTIN), Cefadroxil (DURICEF)

1 * Lorazepam Tablets1 * LORCET PLUS 7.5/650 TABLETS1 * LORTAB 5/500 TABLETS1 * LORTAB ELIXIR

2 LOTEMAX OPHTHALMIC SUSPENSION (QL)Dexamethasone (DEXASOL), Fluorometholone (FML), Prednisolone(ECONOPRED, PRED FORTE)

1 * LOTENSIN HCT TABLETS1 * LOTENSIN TABLETS

1 * LOTREL TABLETS (QL)

Amlodipine (NORVASC) PLUS Benazepril (LOTENSIN), Lisinopril (ZESTRIL), Captopril (CAPOTEN), Enalapril (VASOTEC), Fosinopril (MONOPRIL), Quinapril (ACCUPRIL), or Moexipril (UNIVASC

1 * LOTRISONE CREAM / LOTION(QL)3 LOTRONEX TABLETS (PA)1 * Lovastatin Tablets (QL)3 LOVAZA TABLETS1 * Loxapine Capsules1 * LOXITANE CAPSULES1 * LOZOL TABLETS

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 15 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 16: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS2 LUMIGAN OPHTHALMIC SOLUTION (QL)

3 LUNESTA TABLETS (EST) (QL)Flurazepam (DALMANE), Temazepam (RESTORIL), Triazolam (HALCION), Zolpidem (AMBIEN)

1 * LURIDE TABLETS2 LYBREL TABLETS3 LYRICA TABLETS (QL) Gabapentin (NEURONTIN)2 LYSODREN TABLETS1 * MACROBID CAPSULES1 * MACRODANTIN CAPSULES3 MALARONE TABLETS FANSIDAR1 * MANDELAMINE TABLETS1 * Maprotiline Tablets

3 MARINOL CAPSULES

Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN),prochlorperazine (COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN)

2 MATULANE CAPSULES

3 MAVIK TABLETS

Benazepril (LOTENSIN), Lisinopril (ZESTRIL), Captopril (CAPOTEN), Enalapril (VASOTEC), Fosinopril (MONOPRIL), Quinapril (ACCUPRIL), Moexipril (UNIVASC)

2 MAXAIR AUTOHALER (QL)3 MAXALT TABLETS (QL) AMERGE, IMITREX3 MAXALT-MLT TABLETS (QL) AMERGE, IMITREX1 * MAXIFLOR CREAM / OINTMENT1 * MAXITROL OPHTHALMIC SOLUTION & OINTMENT1 * MAXIVATE CREAM / OINTMENT1 * MAXZIDE TABLETS2 MEBARAL TABLETS1 * Mebendazole Tablets (QL)1 * MEDROL TABLETS1 * Medroxyprogesterone Tablets1 * Mefloquine Tablets (QL)1 * MEGACE TABLETS AND SUSPENSION1 * Megestrol Tablets1 * Meloxicam Tablets (QL)2 MENEST TABLETS3 MENOSTAR PATCH1 * Meperidine Tablets 2 MEPHYTON TABLETS

3 * Meprobamate TabletsLorazepam (ATIVAN), Diazepam (VALIUM), Alprazolam (XANAX), Oxazepam(SERAX)

2 MEPRON SUSPENSION1 * Mercaptopurine Tablets

X MERIDIA CAPSULES - BENEFIT EXCLUSION**Some Plans May Cover for Morbid Obesity Only - Refer to Plan Documentsfor Coverage.

1 * Mesalamine Enema1 * MESTINON TABLETS2 MESTINON TIMESPAN TABLETS / SYRUP

3 METADATE CD TABLETS Methylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE), Amphetamine Mixture (ADDERALL), CONCERTA

1 * METAGLIP TABLETS1 * Metaproterenol Oral Tablets1 * Metformin Tablets1 * Metformin / Glipizide Tablets1 * Metformin / Glyburide Tablets1 * Metformin SR Tablets1 * Methadone Tablets (QL)1 * Methazolamide Tablets1 * Methenamine Mandelate Tablets2 METHERGINE TABLETS (QL)1 * Methimazole2 METHITEST TABLETS1 * Methocarbamol Tablets1 * Methotrexate Tablets1 * Methyldopa / Hydrochlorothiazide Tablets1 * Methyldopa Tablets1 * Methylphenidate SR Tablets (PA)1 * Methylphenidate Tablets (PA)1 * Methylprednisolone Tablets

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 16 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 17: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * Methyltestosterone Tablets3 * Metipranolol Ophth. Soln.1 * Metoclopramide Tablets1 * Metolazone Tablets1 * Metoprolol ER Tablets1 * Metoprolol Tablets1 * METROCREAM TOPICAL CREAM2 METROGEL GEL TOPICAL1 * METROGEL VAGINAL GEL1 * Metronidazole Tablets 250 mg and 500 mg Only1 * Metronidazole Topical Cream1 * Mexiletine Capsules1 * MEXITIL CAPSULES1 * MIACALCIN NASAL SPRAY 3 MICARDIS HCT TABLETS BENICAR HCT , DIOVAN HCT3 MICARDIS TABLETS BENICAR, DIOVAN1 * Microgestin Fe Tablets1 * MICRO-K CAPSULES1 * MICRONASE TABLETS1 * MICRONOR TABLETS1 * MICROZIDE CAPSULES1 * MIDRIN CAPSULES3 MIGRANAL NASAL SPRAY (QL) IMITREX NASAL SPRAY1 * MIGRATINE CAPSULES1 * MINIPRES CAPSULES

1 *MINOCIN 50 MG, 100 MG (IMMEDIATE RELEASE ONLY-PELLETS NOT COVERED)

1 *Minocycline 50 mg,100 mg (IMMEDIATE RELEASE ONLY-PELLETS NOT COVERED)

1 * Minoxidil Tablets2 MINTEZOL TABLETS1 * MIRALAX POWDER (QL)2 MIRAPEX TABLETS1 * MIRCETTE TABLETS1 * Mirtazapine Soluble Tabs1 * Mirtazapine Tablets1 * Misoprostol Tablets3 MOBAN TABLETS1 * MOBIC TABLETS (QL)1 * MODICON TABLETS1 * MODURETIC TABLETS1 * MONONESSA TABLETS1 * MONOPRIL / HCT TABLETS1 * MONOPRIL TABLETS 1 * Morphine Solution1 * Morphine SR Tablets1 * Morphine Suppositories1 * MOTRIN TABLETS1 * MS CONTIN TABLETS (QL)1 * MSIR TABLETS1 * MUCOMYST1 * Mupirocin Ointment1 * MYAMBUTOL TABLETS1 * MYCELEX TROCHES2 MYCIFRADIN ORAL SOLUTION2 MYCOBUTIN CAPSULES1 * MYCOLOG II CREAM / OINTMENT1 * MYCOSTATIN CREAM / OINTMENT1 * MYCOSTATIN TABLETS1 * MYCOTRIACET CREAM / OINTMENT1 * MYDFRIN OPHTHALMIC SOLUTION3 MYFORTIC CAPSULES (PA)2 MYLERAN TABLETS1 * MYSOLINE TABLETS1 * Nabumetone Tablets (QL)1 * Nadolol Tablets

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 17 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 18: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS3 NAFTIN CREAM1 * Naltrexone Tablets 3 NAMENDA TABLETS ARICEPT , EXELON 1 * NAPROSYN TABLETS1 * Naproxen Sodium Tablets1 * Naproxen Sodium, DS Tablets1 * Naproxen Tablets (Enteric Coated Not Covered)2 NARDIL TABLETS2 NASACORT AQ (QL)3 NASAREL SPRAY2 NASONEX SPRAY (QL)2 NATACYN OPHTHALMIC SUSPENSION1 * NATAFORT TABLET1 * NATALCARE PLUS TABLETS1 * NATALCARE RX TABLETS1 * NATALCARE TABLETS1 * NATALCARE THREE TABLET1 * NATATAB CFE TABLET1 * NATATAB FA TABLET1 * NAVANE CAPSULES2 NEBUPENT SOLUTION3 * Nefazodone Tablets 1 * Neomycin / Bacitracin / Polymyxin Ophthalmic Solution & Oint.1 * Neomycin / Polymyxin / Prednisone Ophth. Soln.1 * Neomycin Tablets1 * NEORAL CAPSULES 1 * NEOSPORIN OPHTHALMIC OINTMENT1 * NEOSPORIN OPHTHALMIC SOLUTION1 * NEPTAZANE TABLETS3 NEUPRO PATCHES (QL)1 * NEURONTIN CAPSULES / TABLETS3 NEVANAC OPHTHALMIC SOLUTION2 NEXAVAR TABLETS (PA)3 NEXIUM CAPSULES (PA) (QL) ACIPHEX, Omeprazole 10 MG, 20MG2 NIASPAN TABLETS

3 * Nicardipine Capsules Nifedipine SR (ADALAT CC), Felodipine (PLENDIL), SULAR, Amlodipine (NORVASC)

X NICOTROL NASAL SPRAY - BENEFIT EXCLUSION**Some Plans May Cover Smoking Cessation Products For A Limited DurationRefer to Plan Documents for Coverage.

1 * Nifedipine Immediate Release Tablets1 * Nifedipine, Sustained Release Tablets2 NILANDRON TABLETS1 * NILSTAT TABLETS2 NIMOTOP CAPSULES1 * NITRO-BID CAPSULES1 * Nitrofurantoin Macrocrystals1 * Nitroglycerin Ointment1 * Nitroglycerin Oral Capsules1 * Nitroglycerin Patches (QL)1 * Nitroglycerin Sublingual Tablets2 NITROLINGUAL SPRAY1 * NITROSTAT SL TABLETS1 * NIZORAL CREAM (QL)1 * NIZORAL TABLETS1 * NOLVADEX TABLETS1 * NORCO TABLETS Acetaminophen 500 / Hydrocodone 5 Tablets1 * Norethindrone Tablets1 * NORFLEX TABLETS1 * NORGESIC FORTE TABLETS1 * NORGESIC TABLETS1 * NORMODYNE TABLETS3 NOROXIN TABLETS Ciprofloxacin (CIPRO), AVELOX1 * NORPACE CAPSULES1 * NORPACE CR CAPSULES1 * NORPRAMIN TABLETS1 * Nortriptyline Tablets

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 18 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 19: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * NORVASC TABLETS (QL)2 NORVIR CAPSULES1 * NOVAHISTINE DH EXPECTORANT1 * NOVAHISTINE EXPECTORANT3 NOVOLIN (VIALS OR CARTRIDGES ONLY) HUMULIN 3 NOVOLOG (VIALS OR CARTRIDGES ONLY) HUMALOG 3 NOVOLOG MIX (VIALS OR CARTRIDGES ONLY)3 NOXAFIL SUSPENSION (PA) Itraconazole (SPORANOX), VFEND, Fluconazole (DIFLUCAN)1 * NULYTELY SOLUTION2 NUVARING1 * Nystatin Cream / Ointment1 * Nystatin Oral Suspension1 * Nystatin Tablets1 * OCUFEN OPHTHALMIC SOLUTION1 * OCUFLOX OPHTHALMIC SOLUTION1 * Odansetron Tablets (QL)1 * Odansetron Orally Disintegrating Tablets (QL)1 * Ofloxacin Ophthalmic Solution3 * Ofloxacin Tablets Ciprofloxacin (CIPRO), AVELOX1 * OGEN TABLETS1 * Ogestrel Tablets

3 OMACOR CAPSULES (QL) (Name changed to LOVAZA)Fenofibrate (TRICOR, LOFIBRA), TRIGLIDE, ANTARA, Gemfibrozil (LOPID),NIASPAN

1 * Omeprazole 10 MG, 20MG (QL)1 * OMNICEF CAPSULES / SUSPENSION1 * OMNIPEN CAPSULES / SUSPENSION1 * OMS CONCENTRATE1 * Ondansetron Orally Disintegrating Tablets1 * Ondansetron Tablets

3 ONE TOUCH TEST STRIPS (QL)FREESTYLE FREEDOM, FREESTYLE LITE, ACCU-CHEK COMPACT PLUS, ACCU-CHEK AVIVA, PRECISION XTRA

2 OPANA ER TABLETS (QL)3 OPANA TABLETS3 OPTIVAR OPHTHALMIC SOLUTION ALOMIDE, PATANAOL, PATADAY, ZADITOR (AVAILABLE OTC)2 ORABASE HCA3 ORACEA CAPSULES Doxycycline (VIBRAMYCIN)1 * Oral Colon Lavage Solution

3 ORAMORPH TABLETS

Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, Meperidine(DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Fentanyl patches (DURAGESIC), PERCOCET 5/325, PERCODAN 5/325

1 * ORASONE TABLETS1 * Orphenadrine / Aspirin / Caffeine Tablets1 * Orphenadrine Citrate Tablets2 ORTHO DIAPHRAGM2 ORTHO EVRA PATCH1 * ORTHO MICRONOR1 * ORTHO TRI-CYCLEN2 ORTHO TRI-CYCLEN LO1 * ORTHO-CEPT1 * ORTHO-CYCLEN1 * ORTHO-EST TABLETS1 * ORTHO-NOVUM 1 * ORTHO-NOVUM 10/111 * ORTHO-NOVUM 7/7/7 1 * ORUDIS CAPSULES

3 OVCON

ORTHO-NOVUM 1/35, MODICON, (ORTHO-CEPT, MICROGESTIN (LOESTRIN), ORTHO-CYCLEN, ORTHO TRI-CYCLEN- suggest to take these out), Brevicon, Necon, Nortrel, Ogestrel, Demulen 1/50, Zovia 1/50

3 OVIDE LOTION EURAX, Permethrin (ELIMITE, ACTICIN)1 * OVRAL2 OVRETTE1 * OXANDRIN TABLETS (PA)1 * Oxandrolone Tablets (PA)1 * Oxaprozin Tablets1 * Oxazepam Capsules

3 OXISTAT CREAMNystatin, Econazole (SPECTAZOLE), LAMISIL AT (AVAILABLE OTC - NOT COVERED), LOTRIMIN (AVAILABLE OTC-NOT COVERED)

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 19 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 20: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS2 OXSORALEN ULTRA TABLETS ONLY1 * Oxybutynin Immediate Release Tablets1 * Oxycodone 4.5/ Aspirin 325 Tablets1 * Oxycodone 5 / Acetaminophen 325 Tablets1 * Oxycodone 5/ Acetaminophen 500 Capsules

3 Oxycodone SR Tablets (QL)

Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Fentanyl patches (DURAGESIC), PERCOCET 5/325, PERCODAN 5/325

3 * OXYCONTIN (QL)

Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Fentanyl patches (DURAGESIC), PERCOCET 5/325, PERCODAN 5/325

3 OXYTROL PATCHES Oxybutynin Immediate Release Tablets, DETROL, DETROL LA1 * PAMELOR CAPSULES2 PANCREASE (MT)3 PANRETIN GEL 1 * PARLODEL TABLETS / CAPSULES1 * PARNATE TABLETS1 * Paromomycin Capsules1 * Paroxetine HCl Tablets2 PATADAY OPHTHALMIC SOLUTION (QL)2 PATANOL OPHTHALMIC SOLUTION2 PAXIL CR TABLETS (QL)1 * PAXIL TABLETS2 PEAK FLOW METER1 * PEDIAZOLE SUSPENSION1 * PEDIAZOLE SUSPENSION1 * Penicillin VK Tablets / Suspension3 * PENLAC NAIL LACQUER (PA) (NOT COVERED IN ALL PLANS) Terbinafine (LAMISIL) (PA), Itraconazole (SPORANOX) (PA)3 PENTASA CAPSULES Sulfasalazine (AZULFIDINE), ASACOL3 Pentazocine / Acetaminophen Tablets1 * PENTOLAIR OPHTHALMIC SOLUTION1 * Pentoxifylline Tablets1 * PEPCID TABLETS3 PERCOCET TABLETS (All Strengths Except 5/325)1 * PERCOCET 5/325 TABLETS1 * PERCODAN FULL STRENGTH TABLETS1 * PERIACTIN 2mg/5ml SYRUP1 * PERIACTIN 4 MG TABLETS1 * PERIDEX (Covered Only With Dental Rider)1 * Permethrin Cream / Lotion (QL)1 * Perphenazine Tablets1 * PERSANTINE TABLETS1 * Phenazopyridine Tablets1 * PHENERGAN / DM SYRUP1 * PHENERGAN SYRUP1 * PHENERGAN TABLETS1 * PHENERGAN VC CODEINE1 * PHENERGAN/ CODEINE1 * Phenobarbital Tablets

X * Phentermine Capsules/Tablets - BENEFIT EXCLUSION**Some Plans May Cover for Morbid Obesity Only - Refer to Plan Documentsfor Coverage.

1 * Phenylephrine 2.5% Ophthalmic Solution1 * PHENYTEK CAPSULES1 * Phenytoin Capsules2 PHOSLO TABLETS / CAPSULES2 PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION1 * PILOCAR OPHTHALMIC SOLUTION1 * Pilocarpine HCL Ophthalmic Solution2 PILOPINE HS1 * PIMA SOLUTION1 * Pindolol Tablets1 * Piroxicam Capsules2 PLAN B (AGE LIMIT)1 * PLAQUENIL TABLETS2 PLAVIX TABLETS (QL)1 * PLENDIL TABLETS1 * PLETAL TABLETS

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 20 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 21: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS

3 PLEXION CREAM

Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R)

1 * POLARAMINE TABLETS1 * POLY-CITRA SYRUP1 * Polyethylene Glycol 33501 * POLY-HISTINE ELIXIR1 * Polymixin B Sulfate / Trimethoprim Ophthalmic Solution1 * POLYTRIM OPHTHALMIC SOLUTION1 * POLY-VI-FLOR TABLETS / DROPS

3 PONSTEL CAPSULES

Ibuprofen (MOTRIN), Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin (DAYPRO), Sulindac (CLINORIL), Diclofenac (VOLTAREN), Piroxicam (FELDENE)

1 * Potassium Chloride 8 mEq, 10 mEq, 20 mEq1 * Potassium Chloride Effervescent Tablets1 * Potassium Chloride Liquid1 * Potassium Chloride Packets.1 * Potassium Citrate CR Tablets1 * Potassium Iodide Solution2 PRANDIN TABLETS1 * PRAVACHOL TABLETS (QL)1 * Pravastatin Tablets (QL)1 * Prazosin Capsules1 * PRECARE CONCEIVE TABLET1 * PRECARE PRENATAL CAPLET1 * PRECARE PRENATAL TABLETS2 PRECISION Q.I.D. TEST STRIPS (QL)2 PRECISION XTRA TEST STRIPS (QL)2 PRECOSE TABLETS1 * PRED FORTE OPHTHALMIC SUSPENSION1 * PRED MILD OPHTHALMIC SUSPENSION1 * Prednisolone Acetate Ophthalmic Suspension1 * Prednisolone Phosphate Ophthalmic Solution1 * Prednisolone Tablets1 * Prednisone Tablets

3 PREFEST TABLETS

CLIMARA PRO, PREMPRO, PREMPHASE, Medroxyprogesterone (PROVERA) PLUS Estradiol tablets (ESTRACE), Estradiol patches (CLIMARA), VIVELLE, VIVELLE-DOT, or Estropipate (OGEN, ORTHO-EST)

1 * PRELONE SYRUP2 PREMARIN TABLETS2 PREMARIN VAGINAL CREAM2 PREMPHASE TABLETS2 PREMPRO LOW TABLETS2 PREMPRO TABLETS1 * PRENATAL MR 90 FE TABLET SA1 * Prenatal Multivitamins / Folic Acid (Rx Strength)1 * Prenatal Vitamins With Folic Acid 1 mg1 * PRENATE ADVANCE TABLETS3 * PRENATE ELITE TABLETS1 * PRENATE GT TABLETS1 * PRENATE ULTRA

Not Covere

d PREVACID CAPSULES

ACIPHEX, Omeprazole (PRILOSEC)10 MG, 20MG

3 PREVACID NAPRAPAC (PA) (QL) ACIPHEX PLUS Naproxen3 PREVACID SOLUTABS (PA) (QL) ACIPHEX, Omeprazole (PRILOSEC)10 MG, 20MG3 PREVPAC (PA) (QL)2 PREZISTA TABLETS (QL)1 * PRILOSEC 10 MG, 20 MG CAPSULES ACIPHEX, Omeprazole (PRILOSEC)10 MG, 20MG

Not Covered PRILOSEC 40MG CAPSULES (PA) (QL) ACIPHEX, Omeprazole (PRILOSEC) 20mg x 2 Capsules

2 PRIMAQUINE TABLETS1 * Primidone Tablets1 * PRINCIPEN CAPSULES / SUSPENSION

Not Covered PROAIR HFA PROVENTIL HFA

1 * Probenecid / Colchicine Tablets

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 21 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 22: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * Probenecid Tablets1 * Procainamide Tablets / Capsules2 PROCANBID TABLETS3 PROCHIEVE VAGINAL CREAM1 * Prochlorperazine Tablets / Supositories1 * PROCTO-CREAM2 PROCTOFOAM HC2 PROCTOFOAM NS2 PROGRAF1 * PROLIXIN TABLETS1 * Promethazine Syrup1 * Promethazine Tablets1 * Promethazine/ Codeine Syrup1 * Promethazine/ Phenylephrine/ Codeine Syrup1 * Promethazine/ PhenylephrineSyrup3 PROMETRIUM CAPSULES (QL) Medroxyprogesterone (PROVERA)1 * PRONESTYL TABLETS / CAPSULES1 * Propafenone Tablets1 * PROPINE OPHTHALMIC SOLUTION1 * Propoxyphene HCl 65 Capsules1 * Propoxyphene Napsylate / APAP Tablets1 * Propranolol / Hydrochlorothiazide Tablets1 * Propranolol Tablets1 * Propylthiouracil (PTU)1 * PROSCAR TABLETS (QL)

3 PROSOM TABLETSTemazepam (RESTORIL), Flurazepam (DALMANE), Oxazepam (SERAX), Triazolam (HALCION), Zolpidem (AMBIEN)

2 PROSTIGMIN TABLETS3 PROTONIX (QL) ACIPHEX, Omeprazole 10 MG, 20MG2 PROTOPIC OINTMENT 2 PROVENTIL HFA AEROSOL (QL)1 * PROVENTIL INHALER (QL)1 * PROVENTIL TABS1 * PROVERA TABLETS

3 PROVIGIL (QL) (PA)

Methylphenidate (RITALIN, RITALIN SR), Dextroamphetamine (DEXEDRINEDEXEDRINE SPANSULE), Amphetamine mixture (ADDERALL)

1 * PROZAC CAPSULES ONLY - 10 MG & 20 MG ONLY3 * PROZAC TABLETS Fluoxetine Capsules (PROZAC)

3 PROZAC WEEKLY CAPSULESFluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL), EFFEXOR XR, Bupropion (WELLBUTRIN, WELLBUTRIN SR)

1 * PSORCON CREAM / OINTMENT1 * PSORCON E CREAM2 PULMICORT FLEXHALER (QL)2 PULMICORT RESPULES (QL)2 PULMOZYME (QL)1 * PURINETHOL TABLETS2 PYRAZINAMIDE TABLETS1 * PYRIDIUM TABLETS1 * Pyridostigmine Tablets1 * QUESTRAN BULK - POWDER ONLY1 * QUESTRAN LIGHT - POWDER ONLY1 * QUINAGLUTE TABLETS1 * Quinapril Tablets1 * QUINIDEX TABLETS1 * Quinidine Gluconate Tablets1 * Quinidine Sulfate Sustained Release Tablets1 * Quinidine Sulfate Tablets3 QUININE CAPSULES (QL)3 QUIXIN OPHTHALMIC SOLUTION Ciprofloxacin (CILOXAN), OCUFLOX2 QVAR (QL)1 * Ramipril Capsules3 RANEXA TABLETS (QL) Isordil, Lopressor (Metoprolol), Amlodipine (Norvasc)1 * Ranitidine 300 mg Tablets Only1 * Ranitidine 75mg/5ml Syrup3 RAPAMUNE (PA)3 RAZADYNE ER CAPSULES ARICEPT , EXELON

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 22 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 23: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS3 RAZADYNE TABLETS ARICEPT , EXELON 1 * REBETOL CAPSULES (PA)1 * REGLAN TABLETS3 REGRANEX GEL 2 REGULAR ILETIN1 * RELAFEN TABLETS (QL)3 RELENZA (PA) Amantadine (SYMMETREL), TAMIFLU (PA)3 RELPAX (QL) AMERGE, IMITREX1 * REMERON SOLTABS1 * REMERON TABLETS3 RENAGEL TABLETS Calcium Carbonate (OTC AVAILABLE: NOT COVERED) , PHOSLO 3 RENVELA TABLETS Calcium Carbonate (OTC AVAILABLE: NOT COVERED) , PHOSLO 2 REQUIP TABLETS2 RESCRIPTOR TABLETS2 RESERPINE TABLETS3 RESTASIS OPHTHALMIC EMULSION REFRESH, VISINE TEARS (OTC NOT COVERED)1 * RESTORIL CAPSULES (QL)1 * RETIN A CREAM / GEL2 RETIN A MICRO1 * RETROVIR CAPSULES / TABLETS3 REVATIO TABLETS (PA) REMODULIN (PA), TRACLEER, VENTAVIS (PA)1 * REVIA TABLETS3 REVLIMID (PA)2 REYATAZ CAPSULES (QL)1 * RHEUMATREX TABLETS3 RHINOCORT AQUA (QL) NASONEX, Fluticasone Nasal (FLONASE), NASACORT AQ, VERAMYST1 * Ribavirin Tablets / Capsules (PA)2 RIDAURA1 * RIFADIN CAPSULES1 * Rifampin Capsules3 RILUTEK TABLETS2 RISPERDAL TABLETS

3 RITALIN LA CAPSULESMethylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE), Amphetamine Mixture (ADDERALL), CONCERTA

1 * RITALIN SR TABLETS 1 * RITALIN TABLETS 1 * ROBAXIN TABLETS3 * ROBINUL TABLETS Dicyclomine (BENTYL), LIBRAX1 * ROBITUSSIN AC EXPECTORANT1 * ROBITUSSIN DAC EXPECTORANT1 * ROCALTROL CAPSULES1 * RONDEC DM SYRUP

3 * ROSAC CREAM

Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur(SULFACET-R)

3 * ROSULA GEL

Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur(SULFACET-R)

1 * ROWASA ENEMA1 * ROXICET 5 / 325 TABLETS1 * ROXICODONE

3 ROZEREM TABLETS (EST) (PA) (QL)Flurazepam (DALMANE), Temazepam (RESTORIL), Triazolam (HALCION), Zolpidem (AMBIEN)

1 * RYNATAN PEDIATRIC SUSPENSION2 RYTHMOL SR CAPSULES1 * RYTHMOL TABLETS1 * SALAGEN TABLETS1 * Salsalate Tablets3 SANCTURA TABLETS Oxybutynin Immediate Release Tablets, DETROL, DETROL LA1 * SANDIMMUNE CAPSULES 1 * Scopolamine HBr Ophthalmic Solution

3 * SEASONALE TABLETS (3 month supply)ORTHO-NOVUM, MODICON, ORTHO-CEPT, MICROGESTIN (LOESTRIN), ORTHO-CYCLEN, ORTHO TRI-CYCLEN

3 * SEASONIQUE TABLETS (3 month supply)ORTHO-NOVUM, MODICON, ORTHO-CEPT, MICROGESTIN (LOESTRIN), ORTHO-CYCLEN, ORTHO TRI-CYCLEN

1 * SEBIZON Lotion3 SEBUTEX (PA) Methadone1 * SECTRAL CAPSULES

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 23 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 24: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * Selegiline Tablets1 * Selenium Sulfide 2.5% Lotion1 * SELSUN LOTION2 SELZENTRY TABLETS (QL)3 SENSIPAR TABLETS Calcium Carbonate (OTC AVAILABLE: NOT COVERED) , PHOSLO1 * SEPTRA DS TABLETS1 * SEPTRA TABLETS1 * SERAX CAPSULES2 SEREVENT DISKUS (QL)1 * SEROPHENE TABLETS (QL)2 SEROQUEL TABLETS (QL)2 SEROQUEL XR TABLETS (QL)1 * Sertraline Tablets1 * SILVADENE CREAM1 * Silver Sulfadiazine cream1 * Simvastatin Tablets1 * SINEMET CR TABLETS1 * SINEMET TABLETS1 * SINEQUAN CAPSULES2 SINGULAIR TABLETS 10 MG 2 SINGULAIR TABLETS 4 MG and 5 MG

3 SKELAXIN TABLETSMethocarbamol (ROBAXIN), Carisoprodol (SOMA), Cyclobenzaprine (FLEXERIL 10mg)

1 * SLO-BID CAPSULES1 * SLOW K1 * Sodium Fluoride Tablets and Drops1 * Sodium Polysterene Sulfonate Powder1 * Sodium Polysterene Sulfonate Solution3 SOLARAZE GEL EFUDEX (Fluoruracil) 2 * Solia Tablets1 * SOMA TABLETS

3 SONATA CAPSULES (EST) (QL)Flurazepam (DALMANE), Temazepam (RESTORIL), Triazolam (HALCION), Zolpidem (AMBIEN)

3 SORIATANE CAPSULES1 * Sotalol Tablets1 * SOTRET CAPSULES (QL)1 * SPECTAZOLE CREAM3 SPECTRACEF TABLETS OMNICEF, CEFZIL, CEFTIN, CECLOR, DURICEF, KEFLEX, CEDAX2 SPIRIVA INHALER (QL)1 * Spironolactone / HCTZ Tablets1 * Spironolactone Tablets1 * SPORANOX CAPSULES (PA)1 * Sprintec Tablets2 SPRYCEL TABLETS (PA) GLEEVEC1 * SPS SOLUTION1 * SSD CREAM1 * SSKI SOLUTION

3 * STADOL NASAL SPRAY (PA) (QL)

FIORICET, FIORINAL , ISOYLL, Acetaminophen and codeine (TYLENOL/CODEINE), Hydrocodone 5mg and Acetaminophen 500 mg (VICODIN, LORTAB)

2 STALEVO TABLETS Carbidopa /Levodopa (SINEMET, SINEMET CR)3 STARLIX TABLETS PRANDIN

3 STRATTERA (QL)Methylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE), Amphetamine Mixture (ADDERALL), CONCERTA

3 STRIANT BUCCAL TABLETS 1 * STRONGSTART TABLETS3 SUBOXONE TABLETS (PA) Methadone1 * Sucralfate Tablets2 SULAR TABLETS2 * SULFACET R LOTION (QL)1 * Sulfacetamide / Prednisolone Acetate Susp. & Oint.1 * Sulfacetamide / Prednisolone Ophthalmic Ointment2 Sulfacetamide / Sulfur Lotion (QL)1 * Sulfacetamide Ophthalmic Solution1 * Sulfamethoxazole / Trimethoprim (SMZ / TMP) Tablets1 * Sulfamethoxazole / Trimethoprim DS (SMZ / TMP DS) Tablets1 * Sulfasalazine Tablets (Enteric Coated Tablets Not Covered)

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 24 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 25: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * Sulindac Tablets1 * SUMYCIN CAPSULES

3 SURMONTIL CAPSULES

Amitriptyline (ELAVIL), Doxepin (SINEQUAN), Nortriptyline (PAMELOR), Imipramine (TOFRANIL), Paroxetine (PAXIL), Citalopram (CELEXA), Fluoxetine (PROZAC), Sertraline (ZOLOFT

2 SUSTIVA CAPSULES / TABLETS2 SUTENT CAPSULES (PA) GLEEVEC (PA), NEXAVAR (PA)3 SYMBICORT INHALATION3 SYMBYAX CAPSULES ZYPREXA PLUS fluoxetine Capsules1 * SYNALAR CREAM / OINTMENT / SOLUTION2 SYNAREL NASAL SOLUTION3 SYNERA PATCHES1 * SYNTHROID TABLETS1 * TAGAMET 400 MG, 800 MG TABLETS

3 * TALWIN NX TABLETSPropoxyphene (DARVON), Propoxyphene Compound (DARVON COMPOUND), Hydrocodone and Acetaminophen (VICODIN, LORTAB

1 * TAMBOCOR TABLETS3 TAMIFLU (PA) Amantadine (SYMMETREL)1 * Tamoxifen Citrate Tablets1 * TAPAZOLE2 TARCEVA TABLETS (PA)2 TARGRETIN CAPSULES

3 TARKA TABLETS

Verapamil SR (CALAN SR) PLUS Benazepril (LOTENSIN), Captopril (CAPOTEN), Lisinopril (ZESTRIL), Enalapril (VASOTEC), Fosinopril (MONOPRIL), Quinapril (ACCUPRIL),or Moexipril (UNIVASC)

3 TASIGNA CAPSULES3 TASMAR TABLETS1 * TAVIST TABLETS2 TAZORAC CREAM / GEL (QL)1 * TEBAMIDE SUPPOSITORIES1 * TEGRETOL TABLETS2 TEGRETOL XR TABLETS2 TEKTURNA TABLETS (EST)2 TEKTURNA HCT TABLETS (EST)1 * Temazepam Capsules (QL)2 TEMODAR CAPSULES (QL)1 * TEMOVATE CREAM / OINTMENT/ GEL/ SOLUTION/ EMOLLIENT1 * TENEX TABLETS1 * TENORETIC TABLETS1 * TENORMIN TABLETS

3 * TERAZOL VAGINAL CREAM / TABLETS

MONISTAT (AVAILABLE OTC - NOT COVERED), GYNE LOTRIMIN (AVAILABLE OTC - NOT COVERED), VAGISTAT (AVAILABLE OTC - NOT COVERED), Fluconazole (DIFLUCAN 150mg) (one tablet

1 * Terazosin Capsules / Tablets1 * Terbinafine Tablets (PA)1 * Terbutaline Sulfate Tablets2 TESLAC TABLETS1 * TESSALON PERLES3 TESTIM GEL 1 * Tetracycline Capsules3 TEVETEN HCT CAPSULES (QL) BENICAR HCT , DIOVAN HCT, 3 TEVETEN TABLETS (QL) BENICAR, DIOVAN3 THALOMID CAPSULES (PA)3 THEO-24 CAPSULES. Theophylline SR (THEO-DUR)1 * THEODUR TABLETS1 * Theophylline Liquid1 * Theophylline, 80mg/15cc (Alcohol Free)1 * Theophylline, Immediate Release Tablets1 * Theophylline, Sustained Release Capsules2 THIOGUANINE TABLETS2 Thioridazine Tablets2 Thiothixene Capsules1 * THORAZINE TABLETS1 * Thyroid, Dessicated

3 THYROLAR TABLETSLevothyroxine (SYNTHROID, LEVOXYL, LEVOTHROID), CYTOMEL, Thyroid

1 * TIAZAC CAPSULES1 * TICLID TABLETS

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 25 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 26: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * Ticlopidine Tablets1 * TIGAN CAPSULES2 TIKOSYN CAPSULES2 TILADE AEROSOL1 * Timolol Maleate Ophthalmic Soln.1 * Timolol Tablets1 * Timolol XE Gel1 * TIMOPTIC OPHTHALMIC SOLUTION2 TIMOPTIC XE GEL3 TINDAMAX TABLETS Metronidazole (FLAGYL)

3 * Tizanidine TabletsMethocarbamol (ROBAXIN), Carisoprodol (SOMA), Cyclobenzaprine (FLEXERIL)

3 TOBI NEBULIZER SOLUTION 2 TOBRADEX OPHTHALMIC SUSPENSION (QL)1 * Tobramycin Ophthalmic Solution & Ointment1 * TOBREX OPHTHALMIC OINT./ SOLUTION

3 TOFRANIL PM CAPSULESAmitriptyline (ELAVIL), Desipramine (NORPRAMIN), Imipramine, Nortriptyline (PAMELOR)

1 * TOFRANIL TABLETS1 * Tolazamide Tablets1 * TOLBUTAMIDE TABLETS1 * TOLECTIN DS CAPSULES1 * TOLECTIN TABLETS1 * TOLINASE TABLETS1 * Tolmetin DS Capsules2 TOPAMAX TABLETS1 * TOPICORT LP CREAM 1 * TOPROL XL TABLETS 1 * TORADOL (QL) TABLETS3 Torsemide Tablets Furosemide (LASIX), Bumetanide (BUMEX)1 * TOTACILLIN CAPSULES / SUSPENSION2 TRACLEER TABLETS 1 * Tramadol Tablets1 * TRANDATE TABLETS1 * TRANXENE CAPSULES1 * Tranylcypromine2 TRAVATAN OPHTHALMIC SOLUTION (QL)2 TRAVATAN Z OPHTHALMIC SOLUTION (QL)1 * Trazodone Tablets2 TRECATOR TABLETS1 * TRENTAL TABLETS1 * Tretinoin Cream / Gel1 * Triamcinolone / Nystatin Cream / Ointment1 * Triamcinolone 0.1% in Orabase1 * Triamcinolone Acetonide Cream / Ointment / Lotion1 * Triamterene / HCTZ Capsules1 * Triamterene / HCTZ Tablets1 * Triazolam Tablets (QL)2 TRICOR TABLETS 48 MG and 145 MG2 Trifluoperazine Tablets1 * Trifluridine Ophthalmic Solution1 * Trihexyphenidyl Tablets1 * TRILEPTAL TABLETS1 * TRI-LEVLEN TABLETS1 * TRILISATE TABLETS1 * Trimethobenzamide Capsules1 * Trimethoprim Tablets1 * TRIMOX 1 * TRIMPEX TABLETS1 * TRI-NORINYL TABLETS3 * TRIPHASIL Tablets1 * Tri-Previfem Tablets1 * Tri-Sprintec Tablets1 * TRI-VI-FLOR TABLETS / DROPS2 TRIZIVIR TABLETS3 TRUSOPT OPHTHALMIC SOLUTION AZOPT

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 26 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 27: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS2 TRUVADA TABLETS1 * TUSSEND SYRUP2 TUSSIONEX SUSPENSION1 * TUSSI-ORGANIDIN NR SYRUP2 TYKERB TABLETS (PA)1 * TYLENOL CODEINE TABLETS #2, #3, #41 * TYLOX 5 / 500 CAPSULES3 TYZEKA TABLETS (PA)1 * ULTRA NATALCARE TABLET3 * ULTRACET TABLETS Tramadol (ULTRAM) PLUS Acetaminophen (TYLENOL) 1 * ULTRAM TABLETS2 ULTRASE MT CAPSULES1 * ULTRAVATE CREAM / OINTMENT1 * UNIPHYL TABLETS1 * UNIRETIC TABLETS1 * UNIVASC TABLETS 1 * Urecholine Tablets2 URISED TABLETS1 * URISPAS TABLETS1 * UROCIT-K TABLETS3 UROXATRAL TABLETS (QL) Doxazosin (CARDURA), Terazosin (HYTRIN), Finasteride (PROSCAR) 1 * URSO CAPSULES1 * Ursodiol 250 mg Capsules1 * Ursodiol 300 mg Capsules

3 VAGIFEM VAGINAL TABLETSEstradiol patches (CLIMARA), ESTRADERM, VIVELLE, VIVELLE-DOT, ESTRACE VAGINAL CR, PREMARIN VAGINAL CR

2 VALCYTE TABLETS (QL)1 * VALIUM TABLETS1 * Valproic Acid Capsules2 VALTREX TABLETS (QL)3 VANCOCIN (PA) (QL)3 VANCOMYCIN (PA) (QL)1 VANDAZOLE VAGINAL GEL1 * VANTIN SUSPENSION1 * VANTIN TABLETS1 * VASERETIC TABLETS1 * VASOTEC TABLETS1 * VEETIDS TABLETS / SUSPENSION1 * Velivet Tablets1 * Venlafaxine Tablets (Immediate Release)1 * VEPESID CAPSULES2 VERAMYST NASAL SUSPENSION1 * Verapamil SA Tablets1 * Verapamil Tablets3 VEREGEN OINT (QL)

1 * VERELAN CAPSULESVerapamil SA Tabs (CALAN SR), Felodipine (PLENDIL), Nifedipine SA (ADALAT CC)

3 VERELAN PM CAPSULESVerapamil SA Tabs (CALAN SR, ISOPTIN SR), Felodipine (PLENDIL), Nifedipine SA (ADALAT CC)

1 * VERMOX TABLETS (QL)2 VESANOID CAPSULES3 VESICARE TABLETS Oxybutynin Immediate Release Tablets, DETROL, DETROL LA

3 VEXOL OPHTHALMIC SUSPENSIONDexamethasone (DEXASOL), Fluorometholone 0.1%/FML FORTE 0.25%, Prednisolone (PRED MILD)

2 V-FEND TABLETS (PA)X V-FEND TABLETS (PA)1 * VIBRAMYCIN CAPSULES1 * VIBRA-TABS1 * VICODIN 5 / 500 TABLETS1 * VICODIN ES 7.5 / 750 TABLETS1 * VICODIN HP TABLETS

3 * VICOPROFEN TABLETSHydrocodone and Acetaminophen (VICODIN, LORTAB) plus Ibuprofen (MOTRIN)

1 * VIDAYLIN/F TABLETS / DROPS1 * VIDEX EC CAPSULES1 * VIDEX TABLETS2 VIGAMOX OPHTHALMIC SOLUTION Ciprofloxacin (CILOXAN), OCUFLOX

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 27 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 28: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * VINATE GT TABLET2 VIOKASE POWDER2 VIRACEPT TABLETS2 VIRAMUNE TABLETS2 VIREAD TABLETS (QL)1 * VIROPTIC OPHTHALMIC SOLUTION1 * VISCOUS XYLOCAINE1 * VISKEN TABLETS1 * VISTARIL CAPSULES

3 VIVACTIL TABLETSAmitriptyline (ELAVIL), Desipramine (NORPRAMIN), Imipramine (TOFRANIL), Nortriptyline (PAMELOR)

2 VIVELLE PATCHES2 VIVELLE-DOT PATCHES3 VOLTAREN GEL1 * VOLTAREN IMMEDIATE RELEASE TABLETS2 VOLTAREN OPHTHALMIC SOLUTION3 * VOLTAREN XR TABLETS1 * VOSOL HC OTIC SOLUTION1 * VOSOL OTIC SOLUTION1 * VOSPIRE ER TABLETS Terbutaline (BRETHINE TABLETS)2 VYTORIN TABLETS2 VYVANSE CAPSULES (QL)1 * Warfarin Sodium Tablets

3 WELCHOL TABLETSCholestyramine Powder (QUESTRAN, QUESTRAN LIGHT) - BULK POWDER ONLY

1 * WELLBUTRIN SR TABLETS1 * WELLBUTRIN TABLETS1 * WELLBUTRIN XL TABLETS (QL)1 * WELLCOVORIN TABLETS

3 * WESTCORT CREAM / OINTMENTBetamethasone Dip. Augmented (DIPROLENE), clobetasol (TEMOVATE), Desoxymethasone (TOPICORT LP

1 * WIGRAINE CAPSULES1 * WYMOX CAPSULES1 * WYTENSIN TABLETS3 XALATAN OPHTHALMIC SOLUTION (QL) LUMIGAN, TRAVATAN, TRAVATAN Z1 * XANAX TABLETS

3 XANAX XR TABLETSAlprazolam (XANAX), Lorazepam (ATIVAN), Oxazepam (SERAX), Diazepam(VALIUM)

2 XELODA TABLETS

X XENICAL CAPSULES - BENEFIT EXCLUSION**Some Plans May Cover for Morbid Obesity Only - Refer to Plan Documentsfor Coverage.

3 XIBROM OPHTHALMIC SOLUTION ACULAR, DICLOFENAC (VOLTAREN)3 XIFAXAN TABLETS (QL) Ciprofloxacin (CIPRO)2 XOPENEX HFA AEROSOL (QL)3 XOPENEX NEBULIZER SOLUTION Albuterol (PROVENTIL), XOPENEX HFA3 XYREM ORAL SOLUTION (PA) (QL) Methylphenidate/SR/ER (RITALIN, RITALIN SR, METADATE ER)3 XYZAL TABLETS CLARITIN (AVAILABLE OTC - NOT COVERED)2 YASMIN TABLETS2 YAZ TABLETS2 YODOXIN TABLETS

3 ZANAFLEX TABLETSMethocarbamol (ROBAXIN), Carisoprodol (SOMA), Cyclobenzaprine (FLEXERIL)

1 * ZANTAC 300 MG TABLETS ONLY1 * ZARONTIN CAPSULES1 * ZAROXOLYN TABLETS3 ZAVESCA CAPSULES (PA)1 * ZEBETA TABLETS3 ZEMPLAR CAPSULES2 ZERIT CAPSULES1 * ZESTORETIC TABLETS1 * ZESTRIL TABLETS

3 ZETIA TABLETS Lovastatin (MEVACOR), VYTORIN, Pravastatin (PRAVACHOL), Simvastatin(ZOCOR), ADVICOR

1 * ZIAC TABLETS2 ZIAGEN TABLETS1 * ZITHROMAX TABLETS (QL)2 ZMAX ORAL SUSPENSION1 * ZOCOR TABLETS (QL)

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 28 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs

Page 29: TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS 1 … · recommended drug list alphabetical tier generic drug name suggested alternative drugs 1 * a/t/s solution (swabs, pads &

RECOMMENDED DRUG LIST ALPHABETICAL

TIER GENERIC DRUG NAME SUGGESTED ALTERNATIVE DRUGS1 * ZOFRAN ODT TABLETS (QL)1 * ZOFRAN TABLETS (QL)1 * ZOLOFT TABLETS1 * ZOLPIDEM CAPSULES (QL)3 ZOMIG TABLETS / NASAL SPRAY (QL) AMERGE, IMITREX3 ZOMIG ZMT TABLETS (QL) AMERGE, IMITREX3 * ZONALON CREAM OTC BENADRYL CREAM-NOT COVERED, Hydroxyzine (VISTARIL)1 * ZONEGRAN CAPSULES1 * ZONISAMIDE CAPSULES

CAPS Indicate Brand Name*Generic AvailableBrand Name For Reference Only If Generic Available 29 of 29

2/1/08PA=Prior Authorization Req'd

QL=Quantity Limits ApplyX=Exclusion-Check Plan Docs