Attachment A OP-140117
ddI (Didanosine) Medications Exempted from Depakene (Valproic Acid) $4.00 per Medication Co-pay Depakote (Divalproex) Depoestradiol Desyrel (Trazodone) (Brand Name) Diabeta (Glyburide) 3TC (Lamivudine) Diamox (Acetazolamide) Actos (Pioglitazone) Diflucan (Fluconazole) AirDuo (Fluticasone/Salmeterol) Dilantin (Phenytoin) Aldactone (Spironolactone) Emtriva (Emtricitabine) Aldomet (Methyldopa) Enulose (Lactulose) Alphagan (Brimonidine) Epivir (Lamivudine) Alvesco (Ciclesonide) Epzicom (Abacavir Sulfate/Lamivudine) Aminophylline (Aminophylline) Eskalith (Lithium Carbonate) Apresoline (Hydralazine) Estrace (Estradiol) Aptivus (Tipranavir) Flomax (Tamsulosin) Atarax (Hydroxyzine) Flovent (Fluticasone Inhaler) Ativan (Lorazepam) Geodon (Ziprasidone) Atripla (Emtricitabine/Viread/Sustiva) Glucophage (Metformin) Atrovent (Ipratropium) Glucotrol (Glipizide) AZT (Zidovudine) Haldol (Haloperidol) Azulfidine (Sulfasalazine) Heparin (Heparin) Benadryl (Diphenhydramine) Hydrodiuril (Hydrochlorothiazide) Betoptic (Betaxolol) Imdur (Isosorbide Mononitrate) Brethine (Terbutaline) Imuran (Azathioprine) Calan (Verapamil) Inderal (Propranolol) Cardizem (Diltiazem) INH (Isoniazid) Catapres (Clonidine) Insulin Celexa (Citalopram) Iopidine (Aprclonidine) Cogentin (Benztropine) Isentress (Raltegravir) Colestid (Colestipol) Isopto-Carpine (Pilocarpine) Combivent (Ipratropium/Albuterol) Inhaler Isopto-Homatropine (Homatropine) Coreg (Carvedilol) Kaletra (Lopinavir/Ritonavir) Coumadin (Warfarin) Kayexalate (Sodium Polystyrene Sulfate) Cozaar (Losartan) Keppra (Levetiracetam) Crixivan (Indinavir) Klonopin (Clonazepam) D4T (Stavudine) Lamictal (Lamotrigine) ddC (Zalcitabine) Page 1 of 5
Attachment A OP-140117
Lanoxin (Digoxin) Pyrazinamide Lasix (Furosemide) Quinidine Sulfate Levothroid (Levothyroxine) Quinaglute (Quinidine) Lexiva (Fosamprenavir) Remeron (Mirtazapine) Lipitor (Atorvastatin) Renvela (Sevelamer Carbonate) Loniten (Minoxidil) Rescriptor (Delavirdine) Lopid (Gemfibrozil) Retrovir (Zidovudine) Lopressor (Metoprolol) Reyataz (Atazanavir) Lotensin (Benazepril) Ribasphere (Ribavirin) Lozol (Indapamide) Rifadin (Rifampin) Maxzide (Triamterene/HCTZ) Risperdal (Risperidone) Methotrexate Selzentry (Maraviroc) Myambutol (Ethambutol) Sinemet (Carbidopa/Levodopa) Mycobutin (Rifabutin) Sinequan (Doxepin) Mysoline (Primidone) Stelazine (Trifluoperazine) Navane (Thiothixene) Sustiva (Efavirenz) Neoral (Cyclosporine) Synthroid (Levothyroxine) Nitro ointment (Nitroglycerin) Tegretol (Carbamazepine) Nitro-Dur (Nitroglycerin) Tenex (Guanfacine) Nitro-SL (Nitroglycerin) Theodur (Theophylline) Nolvadex (Tamoxifen) Timoptic (Timolol) Norvasc (Amlodipine) Tofranil (Imipramine) Norvir (Ritonavir) Toprol XL (Metoprolol) Pentasa (Mesalamine) Trizivir (Abacavir/Lamivudine/Zidovudine) Phenobarbital Trusopt (Dorzolamide) Plaquenil (Hydroxychloroquine) Truvada (Tenofovir/Emtricitabine) Plavix (Clopidogrel) Valium (Diazepam) Pletal (Cilostazol) Vasodilan (Isoxsuprine) Pravachol (Pravastatin) Videx (Didanosine) Premarin (Estrogen) Viracept (Nelfinavir) Prezista (Darunavir) Viramune (Nevirapine) Prinivil (Lisinopril) Viread (Tenofovir) Procainamide Vistaril (Hydroxyzine) Prolixin (Fluphenazine) Xalatan (Latanoprost) Proscar (Finasteride) Xopenex (Levalbuterol tartrate) Provera (Medroxyprogesterone) Zaroxolyn (Metolazone) Prozac (Fluoxetine) Zerit (Stavudine)
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Attachment A OP-140117
Ziagen (Abacavir) Zocor (Simvastatin) Zoloft (Sertraline) Zyloprim (Allopurinol) Zyprexa (Olanzapine) All Formulary Mental Health Medications
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Attachment A OP-140117
Diphenhydramine (Benadryl) Medications Exempted from Diltiazem (Cardizem) $4.00 per Medication Co-pay Divalproex (Depakote) Dorzolamide (Trusopt) Doxepin (Sinequan) (Generic Name) Efavirenz (Sustiva) Abacavir (Ziagen) Emtricitabine (Emtriva) Abacavir Sulfate/Lamivudine (Epzicom) Emtricitabine/Viread/Sustiva (Atripla) Abacavir/Lamivudine/Zidovudine (Trizivir) Estradiol (Estrace) Acetazolamide (Diamox) Estrogen (Premarin) Allopurinol (Zyloprim) Ethambutol (Myambutol) Aminophylline (Aminophylline) Finasteride (Proscar) Amlodipine (Norvasc) Fluconazole (Diflucan) Apraclonidine (Iopidine) Fluoxetine (Prozac) Atazanavir (Reyataz) Fluphenazine (Prolixin) Atorvastatin (Lipitor) Fluticasone/salmeterol (AirDuo) Azathioprine (Imuran) Fosamprenavir (Lexiva) Benazepril (Lotensin) Furosemide (Lasix) Betaxolol (Betoptic) Gemfibrozil (Lopid) Benztropine (Cogentin) Glipizide (Glucotrol) Brimonidine (Alphagan) Glyburide (Diabeta) Carbamazepine (Tegretol) Guanfacine (Tenex) Carbidopa/Levodopa (Sinemet) Haloperidol (Haldol) Carvedilol (Coreg) Heparin (Heparin) Ciclesonide (Alvesco) Homatropine (Isopto-Homatropine) Cilostazol (Pletal) Hydralazine (Apresoline) Citalopram (Celexa) Hydrochlorothiazide (Hydrodiuril) Clonazepam (Klonopin) Hydroxychloroquine (Plaquenil) Clonidine (Catapres) Hydroxyzine (Vistaril, Atarax) Clopidogrel (Plavix) Imipramine (Tofranil) Colestipol (Colestid) Indapamide (Lozol) Cyclosporine (Neoral) Indinavir (Crixivan) Darunavir (Prezista) Insulin Delavirdine (Rescriptor) Ipratropium (Atrovent) Depoestradiol Ipratropium/Albuterol (Combivent) Diazepam (Valium) Isoniazid (INH) Didanosine (Videx, ddI) Isosorbide Mononitrate (Imdur) Digoxin (Lanoxin) Page 4 of 5
Attachment A OP-140117
Isoxsuprine (Vasodilan) Quinidine Sulfate Lactulose (Enulose) Raltegravir (Isentress) Lamivudine (Epivir, 3TC) Ribavirin (Ribasphere) Lamotrigine (Lamictal) Rifabutin (Mycobutin) Latanoprost (Xalatan) Rifampin (Rifadin) Levalbuterol tartrate (Xopenex) Risperidone (Risperdal) Levetiracetam (Keppra) Ritonavir (Norvir) Levothyroxine (Synthroid, Levothroid) Sertraline (Zoloft) Lisinopril (Prinivil) Sevelamer Carbonate (Renvela) Lithium Carbonate (Eskalith) Simvastatin (Zocor) Lopinavir/Ritonavir (Kaletra) Sodium Polystyrene Sulfate (Kayexalate) Lorazepam (Ativan) Spironolactone (Aldactone) Losartan (Cozaar) Stavudine (Zerit, D4T) Maraviroc (Selzentry) Sulfasalazine (Azulfidine) Medroxyprogesterone (Provera) Tamoxifen (Nolvadex) Mesalamine (Pentasa) Tamsulosin (Flomax) Metformin (Glucophage) Tenofovir (Viread) Methotrexate Tenofovir/Emtricitabine (Truvada) Methyldopa (Aldomet) Terbutaline (Brethine) Metolazone (Zaroxolyn) Theophylline (Theodur) Metoprolol (Lopressor, Toprol XL) Thiothixene (Navane) Minoxidil (Loniten) Timolol Ophth (Timoptic) Mirtazapine (Remeron) Tipranavir (Aptivus) Nelfinavir (Viracept) Trazodone (Desyrel) Nevirapine (Viramune) Trifluoperazine (Stelazine) Nitroglycerin (Nitro-Dur, Nitro-SL, Nitro Triamterene/HCTZ (Maxzide) Ointment) Valproic Acid (Depakene) Olanzapine (Zyprexa) Verapamil (Calan) Phenobarbital Warfarin (Coumadin) Phenytoin (Dilantin) Zidovudine (Retrovir, AZT) Pilocarpine (Isopto-Carpine) Ziprasidone (Geodon) Pioglitazone (Actos) All Formulary Mental Health Medications Pravastatin (Pravachol) Primidone (Mysoline) (R 10/20) Procainamide Propranolol (Inderal) PyrazinamideQuinidine (Quinaglute)
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