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1 To search this list, click on the drug or therapeutic class below and scroll through the list. ANESTHETICS ANTIINFECTIVES ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS CARDIOVASCULAR MEDICATIONS AUTONOMIC & CNS MEDICATIONS DERMATOLOGICAL MEDICATIONS EAR-NOSE-THROAT MEDICATIONS ENDOCRINE MEDICATIONS Or, click this task pane.* Search GASTROINTESTINAL MEDICATIONS MUSCULOSKELETAL MEDICATIONS NUTRITION, BLOOD MODIFIERS, ELECTROLYTES OBSTETRICAL & GYNECOLOGICAL MEDICATIONS OPHTHALMIC MEDICATIONS RESPIRATORY MEDICATIONS UROLOGICAL MEDICATIONS DIAGNOSTIC & MISCELLANEOUS MEDICATIONS button and enter the name of the drug in the pop-up If you don t find your drug in the list below, please check the Freedom Drug List Alternatives document. This document will help you and your doctor identify alternative drugs that can be used and are included in the Freedom Drug List. The alternatives list is available through this link: Need Assistance? If you speak a foreign language, translation and interpretation services are available to assist you. You may obtain interpreter services for verbal communications with us by calling (860) or Si usted habla un idioma extranjero, la traducción y la interpretación servicios están disponibles para ayudarle. Usted puede obtener servicios de intérprete para las comunicaciones verbales con nosotros llamando al (860) o ANESTHETICS Topical Anesthetics lidocaine gel (Anamantle HC) lidocaine patch (Lidoderm) lidocaine viscous lidocaine/prilocaine (Emla) tetracaine CETACAINE QUTENZA (PA/QL/LD) Page 1 of 35 * Please note: If the Search button does not work in the browser you are using, use the search feature within your web browser.

2 ANTIINFECTIVES Oral Antibacterial amoxicillin (Amoxil) amoxicillin/clavulanate (Augmentin/Augmentin XR/Augmentin ES Susp) ampicillin (Principen) atovaquone (Mepron) (PA) azithromycin (Zithromax) cefaclor (Ceclor/Ceclor CD) cefadroxil (Duricef) cefdinir (Omnicef) cefpodoxime (Vantin) cefprozil tabs and susp (Cefzil) cefuroxime (Ceftin) cephalexin (Keflex) cephradine (Velosef) ciprofloxacin (Cipro) ciprofloxacin ER (Cipro XR) clarithromycin/er (Biaxin/XL) clindamycin (Cleocin) dicloxacillin (Dycill) doxycycline (Vibramycin) erythromycin (Ery-Tab) erythromycin/sulfisoxazole (Pediazole) levofloxacin (Levaquin) minocycline (Dynacin) moxifloxacin (Avelox) nitrofurantoin (Macrodantin) ofloxacin (Floxin) penicillin VK (Beepen VK) sulfamethoxazole/trimethoprim (Bactrim) sulfisoxazole (Gantrisin) tetracycline (Sumycin) trimethoprim (Trimpex) vancomycin Use Tier 1 antiinfective agent! i.e. azithromycin (Zithromax) for a lower copayment VANCOCIN CEDAX COARTEM (PA) DIFICID (PA) FACTIVE KETEK MOXATAG NOROXIN SUPRAX ZMAX ZYVOX (QL) Oral Antifungal clotrimazole troche (Mycelex Troche) fluconazole (Diflucan) griseofulvin (Gris-PEG) itraconazole (Sporanox) (PA) (QL) ketoconazole (Nizoral) nystatin (Mycostatin) terbinafine (Lamisil) voriconazole (VFend) (QL) CRESEMBA (QL) LAMISIL GRANULES NOXAFIL ONMEL (PA) ORAVIG (ST/QL) Page 2 of 35

3 ANTIINFECTIVES Oral Antiviral Antiretrovirals for HIV didanosine (Videx EC) EMTRIVA INTELENCE ISENTRESS lamivudine (Epivir) nevirapine (Viramune) stavudine (Zerit) SUSTIVA VIREAD TIVICAY VITEKTA ZIAGEN zidovudine 300mg and 50mg/5ml syrup (Retrovir) Oral Antiviral Protease Inhibitors AGENERASE APTIVUS CRIXIVAN INVIRASE KALETRA NORVIR REYATAZ VIRACEPT Oral Antiviral Combinations ATRIPLA COMBIVIR COMPLERA EPZICOM EVOTAZ PREZCOBIX PREZISTA STRIBILD TRIUMEQ TRIZIVIR TRUVADA CCR5 Antagonist SELZENTRY Other Antiviral P= Preferred acyclovir (Zovirax Capsules) amantadine (Symmetrel) famciclovir (Famvir) valacyclovir (Valtrex) CYTOVENE RELENZA (QL) TAMIFLU (QL) BARACLUDE HEPSERA SITAVIG (PA) VALCYTE (QL) DAKLINZA (PA/SP)* EPIVIR HBV FUZEON (PA) HARVONI (PA/ST/SP)* OLYSIO (PA/ST/SP)* ribavirin (Rebetol) (PA/SP) SOVALDI (PA/ST/SP)* TECHNIVIE (PA/SP)* TYBOST VIEKIRA PAK (PA/SP)* P Page 3 of 35

4 ANTIINFECTIVES Other Anti-infective atovaquone/proguanil (Malarone) (PA) chloroquine (Aralen) (PA) ethambutol (Myambutol) hydroxychloroquine (Plaquenil) isoniazid mebendazole (Vermox) mefloquine (Lariam) (PA) metronidazole (Flagyl) neomycin paromomycin (Humatin) pyrazinamide quinine (Qualaquin) (PA) rifampin (Rifadin) DAPSONE DARAPRIM MYCOBUTIN PRIMAQUINE ALINIA (QL) COARTEM (PA) FANSIDAR IMPAVIDO (PA) NEBUPENT SKLICE STROMECTOL TINDAMAX (QL) XIFAXAN CAYSTON (PA/LD) SIRTURO (LD) Topical Antibacterial gentamicin (Garamycin) mupirocin (Bactroban) silver sulfadiazine (Silvadene) ALTABAX Topical Antifungal ciclopirox 0.77% topical (Loprox) ciclopirox 8% (Penlac, CNL8 Nail Kit (PA) ) clotrimazole/betamethasone (Lotrisone) econazole (Spectazole) ketoconazole (Nizoral) naftifine (Naftin) nystatin (Mycostatin) nystatin/triamcinolone (Mycolog) Terbinafine (Lamisil) ERTACZO EXELDERM EXTINA OXISTAT VUSION (PA) Topical Antiviral DENAVIR ZOVIRAX Page 4 of 35

5 ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS Alkylating Agents/ Antimetabolites mercaptopurine (Purinethol) methotrexate CEENU LEUKERAN MYLERAN THIOGUANINE PURIXAN (LD) cyclophosphamide (Cytoxan) melphalan (Alkeran) VALCHLOR (PA/QL) Androgens, Estrogens, Progestins and Related anastrozole (Arimidex) bicalutamide (Casodex) exemestane (Aromasin) flutamide (Eulexin) letrozole (Femara) megestrol (Megace) tamoxifen (Nolvadex) HALOTESTIN (PA) MEGACE ES Immunosuppressant prednisone (Deltasone) azathioprine (Imuran) cyclosporine (Neoral, Sandimmune) mycophenolate mofetil (Cellcept) MYFORTIC sirolimus (Rapamune) tacrolimus (Prograf) Allergenic Extracts GRASTEK (PA) ORALAIR (PA/SP) RAGWITEK (PA) Page 5 of 35

6 ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS Miscellaneous Antineoplastic *Dispensing limited to a 30-day supply anagrelide (Agrylin) hydroxyurea (Hydrea) leucovorin temozolomide (Temodar) (PA/SP)* TARGRETIN (SP) AFINITOR (PA/SP)* BOSULIF (PA/SP/QL)* CAPRELSA (PA/LD)* COMETRIQ (PA/QL/LD)* ERIVEDGE (PA/SP/QL)* GAZYVA (PA/SP)* GILOTRIF (PA/SP/QL)* GLEEVEC (PA/SP)* HYCAMTIN (PA/SP)* IBRANCE (PA/SP)* IMBRUVICA (PA/QL/LD)* INLYTA (PA/SP/QL)* ICLUSIG (PA/QL/LD)* ISTODAX (PA/SP)* JAKAFI (PA/SP/QL)* LENVIMA (PA/SP/)* LYNPARZA (PA/SP)* MEKINIST (PA/SP)* NEXAVAR (PA/SP)* OFORTA (PA/SP)* POMALYST (PA/SP)* REVLIMID (PA/SP)* SPRYCEL (PA/SP)* STIVARGA (PA/QL/SP)* SUTENT (PA/QL/SP)* SYLATRON (PA/SP)* SYNRIBO (PA/QL/LD)* TAFINLAR (PA/SP)* TARCEVA (PA/QL/SP)* TASIGNA (PA/SP)* THALOMID (PA/QL/SP)* TORISEL (PA/SP)* TYKERB (PA/QL/SP)* VOTRIENT (PA/SP)* XALKORI (PA/SP)* XTANDI (PA/SP)* ZELBORAF (PA/SP/QL)* ZOLINZA (PA/SP)* ZORTRESS (PA/SP)* ZYDELIG (PA/LD)* ZYKADIA (PA/SP)* ZYTIGA (PA/SP/QL)* Page 6 of 35

7 CARDIOVASCULAR MEDICATIONS Antiarrhythmics Calcium Antagonists Diuretics digitek digoxin (Lanoxin) amlodipine (Norvasc) diltiazem (Cardizem) diltiazem er/sr/xr (Cardizem CD/Cartia XT/ Diltiazem CD) felodipine/er (Plendil) nicardipine (Cardene) nifedipine (Procardia) nifedipine er/xl (Procardia XL) nimodipine (Nimotop) (PA) nisoldipine (Sular) verapamil (Calan) verapamil sr (Calan SR) amiloride (Midamore) amiloride/hctz (Moduretic) clorthalidone (Hygroton) bumetanide (Bumex) eplerenone (Inspra) furosemide (Lasix) hydrochlorothiazide metolazone (Zaroxolyn) indapamide (Lozol) spironolactone (Aldactone) spironolactone/hctz (Aldactazide) torsemide (Demadex) triamterene/hctz (Dyazide) Consider Best Buy options first! CARDENE SR DYNACIRC CR EDECRIN Beta-Adrenergic Antagonist acebutolol (Sectral) atenolol (Tenormin) bisoprolol (Zebeta) metoprolol (Lopressor) metoprolol succinate (Toprol XL) nadolol (Corgard) pindolol (Visken) propranolol/propranolol ER (Inderal/LA) sotalol (Betapace) DUTOPROL INNOPRAN XL Alpha-Beta Antagonists carvedilol (Coreg) labetalol (Trandate) COREG CR Use generic carvedilol Page 7 of 35

8 CARDIOVASCULAR MEDICATIONS Other Antihypertensive clonidine (Catapres/TTS) doxazosin (Cardura) guanfacine (tenex) methyldopa (Aldomet) hydralazine (Apresoline) prazosin (Minipres) terazosin (Hytrin) TEKAMLO (ST) TEKTURNA (ST) VALTURNA (ST) Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Antagonists candesartan (Atacand) captopril (Capoten) benazepril (Lotensin) enalapril (Vasotec) eprosartan (Teveten) irbesartan (Avapro) fosinopril (Monopril) lisinopril (Prinvil, Zestril) losartan (Cozaar) moexipril (Univasc) quinapril (Accupril) ramipril (Altace) telmisartan (Micardis) trandolapril (Mavik) valsartan (Diovan) Antihypertensive Combinations amlodipine/benazepril (Lotrel) atenolol/chlorthalidone (Tenoretic) benazepril/hctz (Lotensin HCT) bisoprolol/hctz (Ziac) candesartan/hctz (Atacand HCT) captopril/hctz (Capozide) enalapril/hctz (Vaseretic) fosinopril/hctz (Monopril HCT) hydralazine/hctz (Apresazide) irbesartan/hctz (Avalide) lisinopril/hctz (Zestoretic) losartan HCTZ (Hyzaar) methyldopa/hctz (Aldoril) metoprolol/hctz (Lopressor HCT) moexipril/hctz (Uniretic) propranolol/hctz (Inderide) quinapril/hctz (Accuretic) telmisartan/amlodipine (Twynsta) telmisartan/hctz (Micardis HCT) trandolapril/verapamil (Tarka) valsartan/hctz (Diovan HCT) AMTURNIDE (ST) ENTRESTO (PA) Page 8 of 35

9 CARDIOVASCULAR MEDICATIONS Vasodilating dipyridamole (Persantine) isosorbide dinitrate (Isordil) isosorbide mononitrate (Ismo) nitroglycerin (Nitrobid, Nitro-Dur) papaverine (Pavabid) NITROLINGUAL SPRAY RANEXA CORLANOR (PA/QL) Antidysrhythmic amiodarone (Cordarone) disopyramide/cr (Norpace/CR) flecainide (Tambocor) mexiletine (Mexitil) procainamide/sr (Procan/SR) propafenone/er (Rythmol/SR) sotalol (Betapace) MULTAQ RYTHMOL SR TIKOSYN Antilipidemic HMG-CoA Reductase Inhibitors/ Combinations atorvastatin (Lipitor) atorvastatin/amlodipine (Caduet) lovastatin (Mevacor) pravastatin (Pravachol) simvastatin (Zocor) Antilipidemic Other cholestyramine (Questran) colestipol (Colestid) fenofibrate 54mg, 160mg or 200mg fenofibrate micronized (Lofibra) (ST) gemfibrozil (Lopid) omega-3 acid ethyl esters (Lovaza) (PA) fenofibrate 48mg, 145 mg (Tricor) fenofibric acid (Trilipix) niacin ER (Niaspan) WELCHOL (ST) ZETIA (QL) VASCEPA (PA) JUXTAPID (PA/QL/LD)* KYNAMRO (PA/SP)* PRALUENT (PA/SP)* Other Cardiovascular *Dispensing limited to a 30-day supply P = Preferred midodrine (Proamatine) pentoxifylline (Trental) ADCIRCA (PA/SP)* ADEMPAS (PA/SP)* LETAIRIS (PA/QL/SP)* P NORTHERA (PA/SP)* OPSUMIT (PA/SP)* ORENITRAM (PA/SP)* REMODULIN (PA/SP)* sildenafil (Revatio) (PA/QL/SP)* TRACLEER (ST/QL/SP)* TYVASO (PA/SP/QL)* VENTAVIS (PA/SP)* Page 9 of 35

10 AUTONOMIC & CNS MEDICATIONS Non-narcotic Analgesics tramadol (Ultram) tramadol/acetaminophen (Ultracet) tramadol ER (Ultram ER) PRIALT (PA) Class II Narcotics Short Acting codeine fentanyl lozenge (Actiq) (PA/QL) hydromorphone (Dilaudid) levorphanol meperidine (Demerol) methadone morphine sulfate oxycodone (Roxicodone) oxycodone/acetaminophen (Percocet/Tylox) oxycodone/aspirin (Percodan) oxycodone/ibuprofen (Combunox) (QL) oxymorphone (Opana) NUCYNTA OXECTA Class II Narcotics Long Acting Oxycontin Excluded Please consider Best Buy Options fentanyl patch (Duragesic) morphine sulfate ER tablets (MS Contin) morphine ER beads (Avinza) morphine ER capsules (Kadian) oxymorphone ER (Opana ER Rx must state Original Formulation on prescription) NUCYNTA ER EXALGO (ST/QL) Class III Narcotics Class IV Narcotics acetaminophen/codeine (Tylenol #2/#3/#4) aspirin/codeine (Empirin #2/#3/#4) buprenorphine (Subutex) buprenorphine/naloxone (Suboxone tabs) (PA) hydrocodone/apap (Vicodin/Lortab) hydrocodone/aspirin (Lortab ASA) hydrocodone/ibuprofen (Vicoprofen) pentazocine/apap (Talwin) pentazocine/naloxone (Talwin NX) BUTRANS (QL) SUBOXONE FILM Page 10 of 35

11 AUTONOMIC & CNS MEDICATIONS to Treat and Prevent Headaches acetaminophen/butalbital (Phrenilin) acetaminophen/caff/butalbital (Fioricet) almotriptan (Axert) (QL) aspirin/caffeine/butalbital (Fiorinal) butorphanol (Stadol) (QL) ergotamine/caffeine (Cafergot) isometh/dicloral/acetaminophen (Midrin) naratriptan (Amerge) (QL) rizatriptan (Maxalt/Maxalt MLT) (QL) sumatriptan (Imitrex) (QL) zolmitriptan (Zomig/Zomig ZMT) (QL) MIGRANAL (QL) ZOMIG NASAL SPRAY (QL) Anxiolytics alprazolam (Xanax ) alprazolam ER (Xanax XR) buspirone (Buspar) chlordiazepoxide (Librium) clonazepam (Klonopin) clonazepam wafer (Klonopin Wafers) diazepam (Valium) lorazepam (Ativan) meprobamate (Equanil) oxazepam (Serax) ALPRAZOLAM- INTENSOL NIRAVAM ONFI Sedative Hypnotic Antimania chloral hydrate estazolam (Prosom) eszopiclone (Lunesta) flurazepam (Dalmane) hydroxyzine (Atarax/Vistaril) temazepam (Restoril) triazolam (Halcion) zalepon (Sonata) zolpidem (Ambien) zolpidem CR (Ambien CR) lithium carbonate (Eskalith/Lithobid) Use generic Ambien- Tier 1! ROZEREM (QL) SILENOR (PA) Page 11 of 35

12 AUTONOMIC & CNS MEDICATIONS Anticonvulsant carbamazepine (Tegretol) Carbamazepine Ext Rel (Tegretol XR) clonazepam (Klonopin) divalproex sodium (Depakote/ER) ethosuximide (Zarontin) felbamate (Felbatol) gabapentin (Neurontin) lamotrigine/xr (Lamictal/XR) (PA) levetiracetam (Keppra) levetiracetam ER (Keppra XR) oxcarbazepine (Trileptal) phenobarbital phenytoin (Dilantin) primidone (Mysoline) tiagabine (Gabitril) topiramate (Topamax) valproic acid (Depakene) zonisamide capsules (Zonegran) CELONTIN DIASTAT PHENYTEK APTIOM EQUETRO FYCOMPA HORIZANT (ST/QL) LAMICTAL ODT (PA) LYRICA (PA) STAVZOR (PA) VIMPAT SABRIL (SP) Antidepressant amitriptyline (Elavil) amitriptyline/perphenazine (Triavil) amoxapine (Ascendin) clomipramine (Anafranil) desipramine (Norpramin) doxepin (Sinequan) imipramine (Tofranil) imipramine pamoate (Tofranil PM) (PA) nortriptyline (Pamelor) protriptyline (Vivactil) Antidepressant SSRIs citalopram (Celexa) escitalopram (Lexapro) fluoxetine (Prozac) fluoxetine PMDD (Sarafem) (ST) fluvoxamine (Luvox) fluvoxamine (Luvox CR) (ST) paroxetine/cr (Paxil/CR) sertraline (Zoloft) BRISDELLE Page 12 of 35

13 AUTONOMIC & CNS MEDICATIONS Antidepressant Other bupropion bupropion SR/XL (Wellbutrin SR/XL) duloxetine (Cymbalta/Irenka) maprotiline (Ludiomil) mirtazapine (Remeron/Soltab) nefazodone (Serzone) trazodone (Desyrel) venlafaxine Extended Release Caps (Effexor XR) PRISTIQ (PA/QL) Venlafaxine Extended Release Tabs Antidepressant MAO Inhibitors phenelzine (Nardil) tranylcypromine (Parnate) EMSAM Antivertigo and Antiemetic ST = Prior use of ondansetron is required dronabinol (Marinol) meclizine (Antivert) granisetron (Kytril) (ST/QL) ondansetron (Zofran) prochlorperazine (Compazine) promethazine (Phenergan) trimethobenzamide (Tigan) Use ondansetron first- Tier 1! AKYNZEO (QL) ANZEMET (ST/QL) CESAMET (PA) DICLEGIS (QL) EMEND (QL) SANCUSO (ST/QL) ZUPLENZ (PA/QL) Antiparkinson *Dispensing limited to a 30-day supply amantadine (Symmetrel) benztropine (Cogentin) bromocriptine (Parlodel) carbidopa/levodopa (Sinemet) entacapone (Comtan) pramipexole (Mirapex) ropinirole/er (Requip/XL) (QL) selegiline (Eldepryl) trihexyphenidyl (Artane) AZILECT MIRAPEX MIRAPEX ER NEUPRO RYTARY STALEVO TASMAR ZELAPAR APOKYN (PA/SP/QL)* Misc. Neurologic XENAZINE (PA/SP) Conventional (Typical) Antipsychotic chlorpromazine (Thorazine) fluphenazine (Prolixin) haloperidol (Haldol) loxapine (Loxitane) perphenazine (Trilafon) thioridazine (Mellaril) thiothixene (Navane) trifluoperazine (Stelazine) ADASUVE (PA) Page 13 of 35

14 AUTONOMIC & CNS MEDICATIONS Novel (Atypical) Antipsychotic aripiprazole (Abilify) (ST/QL on Tablets) clozapine (Clozaril) olanzapine (Zyprexa) (QL) quetiapine (Seroquel) (QL) risperidone (Risperdal) ziprasidone (Geodon) (QL) SEROQUEL XR (QL) ABILIFY MAINTENNA (PA) CLOZAPINE ODT FANAPT (ST/QL) INVEGA (ST/QL) INVEGA SUSTENNA (ST) LATUDA (ST/QL) REXULTI (PA) RISPERDAL CONSTA (ST/QL) SAPHRIS (ST/QL) VERSACLOZ (PA) Antipsychotic/ Depression olanzapine/fluoxetine (Symbyax) CNS Stimulants/ ADHD amphetamine salts/er (Adderall/XR) clonidine ER (Kapvay ER) dextroamphetamine (Dexadrine) dexmethylphenidate/xr (Focalin/XR) methamphetamine (Desoxyn) methylphenidate CD (Metadate CD) methylphenidate/er (Ritalin/SR) methylphenidate ER (Concerta) modafinil (Provigil) (PA/QL) pemoline (Cylert) APTENSIO XR DAYTRANA INTUNIV NUVIGIL (PA/QL) QUILLIVANT XR RITALIN LA STRATTERA VYVANSE Other CNS/ Autonomic bupropion (Zyban) disulfiram (Antabuse) naltrexone (Revia) Pyridostigmine (Mestinon) CAMPRAL CHANTIX GUANIDINE NUEDEXTA (PA) EVZIO (PA/QL) HETLIOZ (PA/SP) VIVITROL (PA/SP) XYREM (PA/SP) Alzheimer s donepezil (Aricept) galantamine (Razadyne/ER) (PA for age <50) rivastigmine (Exelon) (PA for age <50) EXELON PATCH (ST) ARICEPT 23 (PA) ARICEPT ODT (PA for age<50) NAMENDA/XR (PA for age<50) NAMZARIC (PA for age <50) Page 14 of 35

15 AUTONOMIC & CNS MEDICATIONS to Treat Multiple Sclerosis limited to a 30- day supply P=Preferred AMPYRA (PASP/QL) AUBAGIO (PA/SP/QL) AVONEX (PA/QL/SP) P BETASERON P (PA/QL/SP) EXTAVIA (PA/ST/SP) (*Pls use Betaseron) GILENYA (PA/QL/SP) P Glatopa (Copaxone) P (PA/QL/SP) P *PLEGRIDY (PA/SP) REBIF (PA/ST/SP/QL) TECFIDERA (PA/SP) P TYSABRI (PA/ST/SP) Rx benefit Page 15 of 35

16 DERMATOLOGICAL MEDICATIONS Topical Corticosteroid Very High Potency augmented betamethasone (Diprolene AF) clobetasol (Temovate) clobetasol foam (Olux) (ST/QL) diflorasone acetate halobetasol (Ultravate) CLOBEX (ST) (Use clobetasol first) OLUX E (ST) Topical Corticosteroid High Potency amcinonide (Cyclocort) betamethasone dipropionate (Diprolene) betamethasone valerate (Valisone) desoximetasone (Topicort) diflorasone (Florone) fluocinolone (Synalar) fluocinonide (Lidex) HALOG/HALOG E VANOS (ST) Topical Corticosteroid Medium Potency betamethasone foam (Luxiq) flurandrenolide (Cordran lotion) fluticasone (Cutivate) hydrocortisone butyrate (Locoid) hydrocortisone valerate (Westcort) mometasone (Elocon) prednicarbate (Dermatop E) triamcinolone (Kenalog) CLODERM CORDRAN Tape (QL) PANDEL Topical Corticosteroid Low Potency alclometasone dipropionate (Aclovate) desonide (DesOwen) hydrocortisone (Hytone) Note: 0.5% and 1% available without a prescription-otc VERDESO (ST) (Use desonide first) Oral Antipruritic Agents cyproheptadine (Periactin) hydroxyzine (Atarax/Vistaril) to treat Psoriasis and Eczema *Dispensing limited to a 30-day supply calcipotriene (Dovonex) (QL) methotrexate selenium sulfide (Selsun) ATOPICLAIR DOVONEX (ST) FABIOR SORIATANE TACLONEX (QL) TAZORAC VECTICAL (QL) COSENTYX (PA/SP)* ENBREL (PA/SP)* HUMIRA (PA/SP)* OTEZLA (PA/ST/SP)* REMICADE (PA/MB/SP)* SORILUX (ST) Page 16 of 35

17 DERMATOLOGICAL MEDICATIONS Oral Dermatological AMNESTEEM CLARAVIS doxycycline doxycycline monohydrate (Adoxa) (PA) doxycycline hyclate (Doryx) (PA) doxycycline rosacea (Oracea) (PA) minocycline Minocycline ER (Solodyn) (PA) MYORISAN OXSORALEN-ULTRA ABSORICA (PA) ACTICLATE (ST) XIMINO (PA) Topical Acne and Rosacea adapalene (Differin 0.1% cream or gel) benzoyl peroxide/clindamycin (Benzaclin/Duac) clindamycin (Cleocin) erythromycin (Emgel) erythromycin/benzamycin (Benzamycin) metronidazole (Metrogel 0.75%) tretinoin (Retin-A) EPIDUO NORITATE RETIN-A MICRO ACANYA ACZONE AZELEX BENZEPRO CLINAC BPO CLINDAGEL DIFFERIN LOTION, 0.3% GEL FINACEA METROGEL/METROL OTION ONEXTON (PA) PLEXION ROSAC ZIANA Topical Dermatological aluminum chloride Hydroquinone (Lustra/AF) imiquimod (Aldara) (QL) lindane (Qwell) permethrin (Acticin) podofilox topical solution (Condylox) urea (Carmol, Keralac) CONDYLOX GEL EURAX CARAC DERMA-CAS DERMA-SMOOTHE/FS (QL) ELIDEL (QL) EVOCLIN NATROBA OXSORALEN PICATO (QL) PROTOPIC (QL) REGRANEX (PA) SANTYL SILVER NITRATE SOLARAZE XERAC AC ZYCLARA (QL) Page 17 of 35

18 EAR-NOSE-THROAT MEDICATIONS Affecting the Ear acetic acid acetic acid/hydrocortisone (VoSol HC Otic) antipyrine/benzocaine (Auralgan Otic) neomycin/polymix/hc otic (Cortisporin Otic) ofloxacin otic CIPRO HC CIPRODEX COLY-MYCIN Affecting the Nose Affecting the Mouth azelastine (Astelin) azelastine 0.15% (Astepro) budesonide AQ (Rhinocort AQ) flunisolide (Nasalide) fluticasone (Flonase) triamcinolone nasal (Nasacort AQ) triamcinolone (Kenalog in Orabase) NASACORT OTC EVOXAC Page 18 of 35

19 ENDOCRINE MEDICATIONS Insulin Misc. Diabetic HUMALOG HUMULIN LANTUS SOLOSTAR LANTUS VIALS LEVEMIR TOUJEO BYDUREON (ST/QL) BYETTA (ST/QL) VICTOZA (ST/QL) SYMLIN (ST/QL) Oral Diabetic Thiazolidinediones (Glitazones) pioglitazone (Actos) (QL) Oral Diabetic DPP4 s Oral Diabetic DPP4 Combination products NESINA (ST) TRADJENTA (ST) JENTADUETO (PA) KAZANO (PA) OSENI (PA) Oral Diabetic Metformin metformin/xr (Glucophage/XR) Oral Diabetic Combination products glipizide/metformin (Metaglip) glyburide/metformin (Glucovance) pioglitazone/glimepiride (Duetact) (QL/ST) pioglitazone-metformin (ActoPlus Met) (ST/QL) repaglinide/metformin (Prandimet) ActoplusMet XR (ST/QL) Oral Diabetic Sulfonylureas chlorpropamide (Diabenese) glimepiride (Amaryl) glipizide/er (Glucotrol/XL) glyburide (Diabeta/Micronase) tolazamide (Tolinase) tolbutamide (Orinase) Oral Diabetic Other acarbose (Precose) nateglinide (Starlix) repaglinide (Prandin) INVOKAMET (ST) INVOKANA (ST) WELCHOL (ST) CYCLOSET GLYSET Glucocorticoid and Mineralcorticoid dexamethasone (Decadron) fludrocortisone acetate (Florinef) hydrocortisone (Hydrocortone) methylprednisolone (Medrol) prednisolone (Orapred/Prelone) prednisone (Deltasone) triamcinolone (Aristocort) RAYOS ACTHAR GEL (PA/SP) ESBRIET (PA/SP) OFEV (PA/SP) Page 19 of 35

20 ENDOCRINE MEDICATIONS Osteoporosis alendronate (Fosamax) calcitonin-salmon (Miacalcin) etidronate disodium tabs (Didronel) ibandronate (Boniva tablets) raloxifene (Evista) BONIVA INJECTION (ST/SP) FORTEO PROLIA (PA/QL/SP) zoledronic acid (Reclast) Thyroid and Antithyroid levothyroxine (Synthroid/Levoxyl) liothyronine (Cytomel) methimazole (Tapazole) propylthiouracil (PTU) thyroid (Armour Thyroid) SYNTHROID NATPARA (PA) Androgen Androgel Excluded Please consider Testim danazol (Danocrine) fluoxymesterone (PA/QL) methyltestosterone (Methitest) (PA/QL) TESTIM (PA/QL) TESTONE CIK Other Endocrine cabergoline tablets (Dostinex) (QL) ALDURAZYME (PA/SP) ARCALYST (PA/SP) CERDELGA (PA /SP) CHOLBAM (LD) DDAVP Nasal ELEYSO (PA/SP) FABRAZYME (PA/SP)* ILARIS (PA/QL/SP)* KALYDECO (PA/QL/SP)* KORLYM (PA/LD) KUVAN (PA/SP) MYOZYME (PA/SP) NAGLAZYME (PA/SP) ORKAMBI (PA/SP)* SAMSCA (PA/SP) SIGNIFOR (PA/SP) SUCRAID (PA/SP) VIMIZIM (PA/SP)* VPRIV (PA/SP) ZAVESCA (PA/SP) Page 20 of 35

21 generics, and the name listed first below in lower case is the generic name. The branded names in ( ) are provided for reference only. Check your benefit materials to determine cost-share if the brand is filled. Antidiarrheal diphenoxylate/atropine (Lomotil) loperamide (Immodium) paregoric GASTROINTESTINAL MEDICATIONS FULYZAQ Irritable Bowel alosetron (Lotronex) (QL) (PA for Males) AMITIZA (QL) LINZESS (QL) Antispasmodics/ Affecting GI Motility H2 Antagonists Note: All of the H2 drugs below are also available without a prescription (OTC) Proton Pump Inhibitors Nexium Excluded Please consider Best Buy Options dicyclomine (Bentyl) hyoscyamine (Levsin) metoclopramide (Reglan) cimetidine (Tagamet) famotidine (Pepcid) nizatidine (Axid) ranitidine (Zantac) lansoprazole (Prevacid) omeprazole (Prilosec) pantoprazole (Protonix) Prevacid/lansoprazole OTC Prilosec/omeprazole OTC rabeprazole (Aciphex) Zegerid OTC Metoclopramide (Metozolv ODT) (PA) Helicobacter Pylori PYLERA HELIDAC PREVPAC Other Antiulcer misoprostol (Cytotec) sucralfate (Carafate) Laxatives and Cathartics electrolyte solution (Golytely/Nulytely) MOVANTIK MOVIPREP PREPOPIK RELISTOR (PA) Other GI (Crohn s Disease, Ulcerative Colitis) Asacol, Delzicol, Lialda and Pentasa Excluded Please consider Best Buy Options balsalazide (Colazal) budesonide (Entocort EC) glycopyrrolate (Robinul) lipram pangestyme sulfasalazine (Azulfidine/EN) ursodiol (Actigall/Urso) APRISO CANASA CREON PANCREASE MT PANCRELIPASE ZENPEP GASTROCROM (PA) ULTRASE/ULTRASE MT UCERIS VIOKASE CUVPOSA (PA/SP) ENBREL (PA/QL/SP)* ENTYVIO (PA/ST/MB)* GATTEX (PA/SP) HUMIRA (PA/QL/SP)* REMICADE (PA/MB/SP)* SANDOSTATIN/LAR (PA/QL/SP) SOMATULINE DEPOT (SP) Page 21 of 35

22 generics, and the name listed first below in lower case is the generic name. The branded names in ( ) are provided for reference only. Check your benefit materials to determine cost-share if the brand is filled. GASTROINTESTINAL MEDICATIONS Blood Modifiers *Dispensing limited to a 30-day supply Growth Hormones and Related *Dispensing limited to a 30-day supply ARANESP (QL)* EPOGEN (QL)* EXJADE (PA/SP)* FERRIPROX (LD) GRANIX (QL/SP)* JADENU (PA)* NEULASTA (QL)* NEUPOGEN (QL)* PROCRIT (QL)* VIDAZA (PA/SP) EGRIFTA (PA/LD) INCRELEX (PA)* OMNITROPE (PA/SP)* P ZORBTIVE (PA)* P = Preferred Interferons *Dispensing limited to a 30-day supply P = Preferred *ACTIMMUNE (PA/SP) *INTRON-A (PA/SP) *PEGASYS (PA/QL/SP) P *PEG-INTRON (PA/QL/SP) *ROFERON-A (PA/SP) Interleukins PROLEUKIN (PA/SP) Page 22 of 35

23 MUSCULOSKELETAL MEDICATIONS Salicylates and Related Non-Steroidal Antiinflammatory Agents (NSAIDS) choline mag trisalicylate (Trilisate) diflunisal (Dolobid) salsalate (Disalcid) celecoxib (Celebrex) diclofenac/er (Voltaren/XR) etodolac/xl (Lodine/XL) ibuprofen (Motrin) suspension available OTC indomethacin/sr (Indocin/SR) ketoprofen (Orudis) ketorolac (Toradol) (QL) meclofenamate (Meclomen) meloxicam (Mobic) mefenamic acid (Ponstel) nabumetone (Relafen) naproxen/cr (Anaprox/Naprosyn/EC) naproxen DR oxaprozin (Daypro) piroxican (Feldene) sulindac (Clinoril) Try a Tier 1 choice first, like naproxyn or ibuprofen ARTHROTEC (PA) NAPRELAN SPRIX NS (ST/QL/LD) VOLTAREN GEL Other for Arthritis *Dispensing limited to a 30-day supply hydroxychloroquine (Plaquenil) leflunamide (Arava) methotrexate CUPRIMINE RIDAURA ENBREL (PA/QL/SP)* HUMIRA (PA/QL/SP)* Hyaluronic Acids EUFLEXXA (PA/QL/SP) SYNVISC (PA/QL/SP) SYNVISC ONE (PA/QL/SP) to Treat and Prevent Gout allopurinol (Zyloprim) probenacid (Benemid) probenacid & colchicine (Co-Benemid) COLCRYS colchicine MITIGARE ULORIC KRYSTEXXA (PA/SP) Page 23 of 35

24 MUSCULOSKELETAL MEDICATIONS Skeletal Muscle Relaxants baclofen (Lioresal) (QL) carisoprodol (Soma) (250mg PA) carisoprodol/aspirin (Soma Compound) chlorzoxazone (Parafon Forte) chlorzoxazone/acetaminophen (Flexaphen) cyclobenzaprine (Flexeril) cyclobenzaprine ER (Amrix/Fexmid) (PA/QL) dantrolene (Dantrium) diazepam (Valium) metaxalone (Skelaxin) methocarbamol (Robaxin) methocarbamol/aspirin (Robaxisal) orphenadrine (Norflex) tizanide tablets (Zanaflex tabs) Page 24 of 35

25 NUTRITION, BLOOD MODIFIERS, ELECTROLYTES Therapeutic Vitamins and Minerals calcium acetate (Phoslo) calcitriol (Rocaltrol) cyanocobalamin (Vitamin B12) folbic (Foltx) ergocalciferol (Vitamin D) folic acid (Folate) sodium fluoride (Luride) CALCIFEROL HECTOROL NASCOBAL ZEMPLAR Potassium Supplements potassium bicarbonate/chloride (K-lyte) potassium chloride (K-Dur) potassium gluconate (Kaon) Potassium Removing Resins sodium polystyrene sulfonate (Kayexalate) Calcimimetic Agent SENSIPAR Oral Anticoagulants and Vitamin K Warfarin (Coumadin) ELIQUIS (QL) MEPHYTON XARELTO PRADAXA (QL) SAVAYSA Injectible Anticoagulants *Dispensing limited to a 30-day supply fondaparinux (Arixtra)* Enoxaparin (Lovenox) * FRAGMIN* INNOHEP (QL)* IPRIVASK (QL) Antiplatelet aspirin/dipyridamole (Aggrenox) cilostazol (Pletal) clopidogrel (Plavix) dipyridamole (Persantine) ticlopidine (Ticlid) BRILINTA EFFIENT ZONTIVITY (PA) Platelet Stimulators NPLATE (PA) PROMACTA (PA/SP) Page 25 of 35

26 Blood Detoxicants lactulose (Cephulac) RENAGEL (QL) RENVELA FOSRENOL VELPHORO (PA) Hemophilia Blood Factor Products (zero copay applies) *30 day max fill HYATE-C (PA/SP)* MONARC-M (PA/SP)* ADVATE (PA/SP)* ALPHANATE (PA/SP)* ALPROLIX (PA/SP)* BENEFIX (PA/SP)* ELOCTATE (PA/SP)* HUMATE-P (PA/SP)* HYATE-C (PA/SP)* IXINITY (PA/SP)* KOGENATE (PA/SP)* MONARC-M (PA/SP)* MONOCLATE-P (PA/SP)* NOVOSEVEN (PA/SP)* RECOMBINATE (PA/SP)* XYNTHA (PA/SP)* Page 26 of 35

27 OBSTETRICAL & GYNECOLOGICAL MEDICATIONS Prenatal Vitamins Specialized OB/GYN OB/GYN Topical Antiinfectives Infertility P = Preferred Complete Natal DHA Complete-RF Prenatal PR Natal 400 Prenaplus Prenatal Plus Iron Tablets Prenatal 19 Prenatal AD Prenatabs Rx Select OB Ultra Natalcare Vinate GT Vinate M Vinate Ultra Vinate II Vitafol OB Vol-Tab Rx Vol-Plus methylergonovine (Methergine) terbutaline (Brethine) clindamycin vaginal cream (Cleocin) triple sulfa vaginal MetroGel vaginal clomiphene citrate (Clomid) Branded Prenatal Vitamins SYNAREL (PA) LYSTEDA leuprolide (Lupron) LUPRON DEPOT NUVESSA BRAVELLE (PA/SP) P CETROTIDE (PA/SP) chorionic gonadotropin FOLLISTIM (PA/SP) P GANIRELIX (PA/SP) GONAL-F (PA/SP) LUVERIS (PA/SP) MENOPUR (PA/SP) OVIDREL Novarel REPRONEX (PA/SP) Oral Estrogen estradiol (Estrace) estropipate (Ogen, Ortho-Est) ESTRATEST/HS PREMARIN CENESTIN DUAVEE ENJUVIA MENEST OSPHENA Topical Estrogen estradiol transdermal patch (Climara/Vivelle DOT/Estraderm) ESTRACE VAGINAL CREAM ESTRING EVAMIST PREMARIN VAGINAL CREAM VAGIFEM DIVIGEL (QL) ELESTRIN ESTROGEL ESTRASORB MENOSTAR Page 27 of 35

28 OBSTETRICAL & GYNECOLOGICAL MEDICATIONS Estrogen/Progestin Combinations COMBIPATCH PREMPHASE PREMPRO ACTIVELLA CLIMARA PRO FEMHRT PREFEST Progestin medroxyprogesterone (Provera) CRINONE DEPO-PROVERA ENDOMETRIN (PA) PROMETRIUM MAKENA Contraceptives Tier 1 options and those marked # are now Zero Cost where applicable per Health Care Reform Legislation altavera (Nordette) alyacen (Norinyl) apri (Desogen) aranelle (Tri-Norinyl) aviane (Alesse) azurette (Mircette) balziva (Ovcon) briellyn (Ovcon) camila (Nor-QD) caziant (Cyclessa) cesia (Cyclessa) cryselle (Lo/Ovral) cyclafem (Ortho-Novum) emoquette (Desogen) enpresse (Tri-Levlen) gildesse FE (Lo-estrin FE) gianvi (Yaz) errin (Ortho Micronor) heather (Nor QD) jolessa (Seasonale) jolivette (Ortho Micronor) junel/fe (Loestrin/Fe) kariva (Mircette) kelnor (Demulen) leena (Tri-Norinyl) lessina (Alesse) levonorgestrel-ethinyl estradiol (Lo- Seasonique) levora (Nordette) loryna (Yaz) low-ogestrel (Lo-Ovral) lutera (Alesse) microgestin/fe (Loestrin/FE) mononessa (Ortho-Cyclen) necon (Ortho-Novum) nikki (Yaz) nora be (Nor-QD) norethindrone (Nor-QD) norethinedrone-ethinyl estradiol (Ovcon) nortrel (Modicon) Ask your doctor to try a Tier 1 choice first! # syeda (Yasmin) # vestura (Yaz) #ORTHO DIAPHRAGM #PARAGARD IUD (LD) #MIRENA (PA/SP) (Medical Benefit) #SKYLA (PA/SP) (Medical Benefit) Page 28 of 35

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