BLOOD CANCER DRUGS-OTHER (ANTINEOPLASTICS) BLOOD MODIFIERS CANCER DRUGS-OTHER (ANTINEOPLASTICS) anagrelide (P) NEUPOGEN SYLATRON (P) pentoxifylline (M) (P) PROCRIT CANCER DRUGS -ORAL BLOOD THINNERS (ANTICOAGULANTS) (ANTINEOPLASTICS)
COUMADIN (M) CANCER DRUGS -ORAL (ANTINEOPLASTICS) enoxaparin (M) anastrozole fondaparinux (P) AFINITOR FRAGMIN (M) bicalutamide PRADAXA (P) (M) BOSULIF warfarin (P) CAPRELSA (M) STROKE PREVENTION exemestane ERIVEDGE (P) (M) GLEEVEC (P) clopidogrel (P) ticlopidine (M) HYCAMTIN INLYTA (P) (M) CANCER DRUGS-OTHER letrozole NEXAVAR (P) (ANTINEOPLASTICS) (P) REVLIMID (P) CANCER DRUGS-OTHER SPRYCEL (ANTINEOPLASTICS)
JAKAFI (P)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
CANCER DRUGS -ORAL CENTRAL NERVOUS SYSTEM (ANTINEOPLASTICS) ANTI-PARKINSON DRUGS CANCER DRUGS -ORAL (M) (ANTINEOPLASTICS) pramipexole ropinirole (M) STIVARGA (P) selegiline (M) SUTENT (P) TARCEVA (P) ATTENTION DEFICIT DISORDER (ADD), TASIGNA (P) NARCOLEPSY (P) TEMODAR (M) (P) amphetamine/dextroamphetamine THALOMID (M) (P) dexmethylphenidate TYKERB (M) (P) dextroamphetamine VOTRIENT (M) (P) methamphetamine XALKORI (M) (P) methylphenidate sr XELODA (M) XTANDI (P) methylphenidate ZELBORAF (P) (P) SEIZURE MEDICATIONS (ANTICONVULSANTS) ZOLINZA (P) ZYTIGA carbamazepine extended release (M) carbamazepine (M) CENTRAL NERVOUS SYSTEM clonazepam (M) diazepam (M) ALZHEIMER'S DRUGS divalproex (M) (M) (M) divalproex sodium ARICEPT-23 (M) (M) ethosuximide donepezil (M) NAMENDA (M) gabapentin lamotrigine (M) (M) ANTI-PARKINSON DRUGS levetiracetam phenytoin (M) amantadine (M) primidone (M) APOKYN topiramate (M) bromocriptine (M) valproic acid (M) levodopa/carbidopa (M) zonisamide (M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
CENTRAL NERVOUS SYSTEM DIABETES & HIGH BLOOD SUGAR
SLEEP AIDS ANTIDIABETIC DRUGS
temazepam LEVEMIR (M) zaleplon metformin xr (M) zolpidem metformin (M) nateglinide (M) CHEST PAIN & HEART DISEASE NOVO INSULIN (M) NOVOLOG (M) CHEST PAIN & HEART DISEASE ONGLYZA (M) (M) (M) piogliazone/metformin isosorbide dinitrate pioglitazone (M) isosorbide mononitrate (M) (M) (M) PRANDIN nitroglycerin sl VICTOZA (M) transdermal nitroglycerin (M) BLOOD SUGAR TEST STRIPS DIABETES & HIGH BLOOD SUGAR ACCU-CHEK meter test strips (Q,M) ANTIDIABETIC DRUGS ONE TOUCH meter test strips (Q,M)
(M) acarbose DISEASES BYETTA (M) (M) glimepiride ARTHRITIS (RHEUMATOID) glipizide extended release (M) glipizide (M) ENBREL (P) glyburide and metformin (M) HUMIRA (P) glyburide (M) leflunomide (M) JANUMET XR (M) methotrexate (M) JANUMET (M) JANUVIA (M) BONE DISEASE KOMBIGLYZE (M) alendronate (M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
DISEASES ENT (EAR/NOSE/THROAT)
BONE DISEASE ALLERGIES & COLDS (NASAL)
calcitonin salmon nasal spray (M) fluticasone propionate (M) etidronate (M) triamcinolone (M) EVISTA (M) ibandronate (M) ALLERGIES (ORAL)
(M) GOUT desloratadine levocetirizine (M) allopurinol (M) COLCRYS (M) MISCELLANEOUS
HEPATITIS lidocaine viscous
INTRON A (M) EYE PEGASYS (P) ribavirin ANTI-INFLAMMATORY DROPS
MULTIPLE SCLEROSIS DRUGS prednisolone acetate
COPAXONE (P,M) COMBINATION EYE INFECTION DROPS REBIF (P,M) dexamethasone/neomycin/polymyxin THYROID DISEASE dexamethasone/tobramycin
levothyroxine (M) EYE INFECTION DROPS liothyronine (M) methimazole (M) ciprofloxacin propylthiouracil (M) ENT (EAR/NOSE/THROAT)
ALLERGIES & COLDS (NASAL) azelastine
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
EYE EYE
EYE INFECTION DROPS MISCELLANEOUS DRUGS
ofloxacin ketorolac tromethamine 0.5% polymyxin b/bacitracin RESTASIS (M) polymyxin b/trimethoprim polymyxin/neomycin/gramicidin sol. HEART RHYTHM DISORDERS sodium sulfacetamide tobramycin drops HEART RHYTHM DISORDERS
trifluridine (M) VIGAMOX acebutolol amiodarone (M) (M) GLAUCOMA DRUGS digoxin disopyramide controlled release (M) acetazolamide (M) disopyramide (M) ALPHAGAN P 0.1% (M) propafenone (M) AZOPT (M) sotalol (M) brimonidine 0.15% (M) COMBIGAN (M) HIGH BLOOD PRESSURE & HEART (M) dorzolamide/timolol DISEASE dorzolamide (M) (M) latanoprost ACE INHIBITORS levobunolol (M) LUMIGAN (M) benazepril (M) methazolamide (M) enalapril (M) pilocarpine (M) lisinopril (M) timolol (M) moexipril (M) quinapril (M) MISCELLANEOUS DRUGS trandolapril (M)
atropine ALPHA BETA BLOCKERS flurbiprofen ketoralac tromethamine, 0.4 % carvedilol (M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
HIGH BLOOD PRESSURE & HEART HIGH BLOOD PRESSURE & HEART DISEASE DISEASE
ALPHA BETA BLOCKERS CALCIUM CHANNEL BLOCKERS
doxazosin (M) nisoldipine (M) labetalol (M) verapamil extended release (M) prazosin (M) verapamil (M) ANGIOTENSIN II BLOCKERS COMBINATION DRUGS
DIOVAN (M) amlodipine/benazepril (M) EDARBI (M) atenolol/chlorthalidone (M) irbesartan (M) benazepril/hctz (M) losartan (M) bisoprolol/hctz (M) EDARBYCLOR (M) BETA BLOCKERS irbesartan/hctz (M) (M) (M) lisinopril/hctz acebutolol (M) (M) losartan/hctz atenolol (M) (M) moexipril/hct BYSTOLIC valsartan/hctz (M) metoprolol xl (M) (M) metoprolol SYMPATHOLYTICS nadolol (M) propranolol extended rel. (M) clonidine (M) propranolol (M) guanfacine (M)
CALCIUM CHANNEL BLOCKERS WATER PILLS OR DIURETICS
amlodipine (M) furosemide (M) diltiazem extended release (M) hydrochlorothiazide (M) diltiazem (M) metolazone (M) nifedipine extended release (M) spironolactone (M) nifedipine sustained release (M) torsemide (M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
HIGH BLOOD PRESSURE & HEART HIV & AIDS DISEASE COMBINATION DRUGS WATER PILLS OR DIURETICS KALETRA (M) (M) triamterene/hctz (M) lamivudine/zidovudine STRIBILD (M) TRIZIVIR (M) HIGH CHOLESTEROL DRUGS (M) (ANTILIPEMICS) TRUVADA NON-NUCLEOSIDE REVERSE TRANSCRIPTASE HIGH CHOLESTEROL DRUGS INHIBITORS (ANTILIPEMICS) (M) (M) EDURANT atorvastatin (M) (M) INTELENCE cholestyramine (M) (M) nevirapine colestipol (M) (M) RESCRIPTOR fluvastatin (M) (M) SUSTIVA gemfibrozil lovastatin (M) (M) NUCLEOSIDE REVERSE TRANSCRIPTASE pravastatin INHIBITORS simvastatin (M) abacavir (M) HIV & AIDS didanosine (M) EMTRIVA (M) MISCELLANEOUS FUZEON (M) HIVID (M) (M) ATRIPLA lamivudine (M) (M) ISENTRESS stavudine (M) (M) SELZENTRY VIDEX Powder (M) VIREAD (M) COMBINATION DRUGS zidovudine capsules (M) zidovudine tablets and syrup (M) COMPLERA (M) (M) EPZICOM PROTEASE INHIBITORS
APTIVUS (M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
HIV & AIDS HORMONES
PROTEASE INHIBITORS MISCELLANEOUS
CRIXIVAN (M) desmopressin acetate tablets (M) FORTOVASE, INVIRASE (M) LEXIVA (M) STEROID REPLACEMENT MEDICATION NORVIR (M) PREZISTA (M) hydrocortisone REYATAZ (M) VIRACEPT (M) IMMUNE SYSTEM HORMONES ANTI-REJECTION (IMMUNOSUPPRESSANTS) azathioprine (M) GROWTH cyclosporine (M) (M) (P) mercaptopurine NORDITROPIN (M) SEROSTIM (P) mycophenolate RAPAMUNE (M) (M) HORMONE REPLACEMENT DRUGS tacrolimus
ethinyl estradiol/norethindrone (M) INFECTIONS
MALE BACTERIAL (CEPHALOSPORINS)
ANDRODERM (M) cefuroxime AXIRON (M) cephalexin capsules oxandrolone BACTERIAL (COMBINATION ANTIBIOTICS) MISCELLANEOUS trimethoprim/sulfamethoxazole desmopressin acetate nasal spray (M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
INFECTIONS INFECTIONS BACTERIAL (FLUROQUINOLONES) FUNGAL (ANTIFUNGAL DRUGS)
ciprofloxacin er itraconazole ciprofloxacin ketoconazole levofloxacin terbinafine
BACTERIAL (MACROLIDES) MISCELLANEOUS ANTI-INFECTIVE DRUGS
azithromycin suspension (Q) atovaquone/proguanil azithromycin tablets (Q) chloroquine phosphate clarithromycin extended release hydroxychloroquine clarithromycin ZYVOX erythromycin ethylsuccinate TUBERCULOSIS (ANTITUBERCULOSIS DRUG) BACTERIAL (MISCELLANEOUS (M) ANTIBIOTICS) ethambutol isoniazid/rifampin (M) clindamycin metronidazole URINARY TRACT
BACTERIAL (PENICILLINS) nitrofurantoin (macrocrystals) nitrofurantoin exten. rel. amoxicillin/clavulanate amoxicillin/pot.clavulanate VIRAL (ANTIVIRAL DRUGS)
BACTERIAL (TETRACYCLINES) acyclovir famciclovir doxycycline monohydrate valacyclovir doxycycline VALCYTE minocycline MENTAL HEALTH FUNGAL (ANTIFUNGAL DRUGS) ANTIDEPRESSANTS fluconazole bupropion xl 150mg (M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
MENTAL HEALTH MENTAL HEALTH
ANTIDEPRESSANTS MANIC-DEPRESSION OR BIPOLAR DRUGS
bupropion (M) lithium carbonate ext. rel. (M) citalopram (M) clomipramine (M) MISCELLANEOUS DRUGS desipramine (M) escitilopram (M) MISCELLANEOUS DRUGS fluoxetine (M) (M) Novofine needles (M) imipramine (M) mirtapazine orally disintegrating (M) Novotwist needles mirtazapine (M) nortriptyline (M) MUSCLE RELAXERS paroxetine controlled release (M) paroxetine (M) MUSCLE RELAXERS phenelzine (M) protriptyline (M) carisoprodol sertraline (M) cyclobenzaprine tranylcypromine (M) metaxalone venlafaxine (M) methocarbamol tizanidine ANTIPSYCHOTIC DRUGS NARCOLEPSY olanzapine (M) quetiapine fumurate (M) NARCOLEPSY risperidone (M) (P) thiothixene (M) modafinil ziprasidone (M) OB-GYN ANXIETY BIRTH CONTROL PILLS (MONOPHASIC alprazolam CONTRACEPTIVES) diazepam 0.03mg ethinyl estradiol/ 0.15mg levonorgestrel (Q,M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
OB-GYN OB-GYN
BIRTH CONTROL PILLS (MONOPHASIC BREAST CANCER (ANTI-ESTROGENS) CONTRACEPTIVES) tamoxifen (M) 30 mcg ethinyl estradiol/0.15 mg levonorgestrel (M) FEMALE HORMONES (ESTROGENS) (M) drospirenone/ethinyl estradiol (M) (M) estradiol patch drospirenone/ethinylestradiol (M) (M) estradiol ethinyl estradiol/desogestrel (M) (M) estropipate ethinyl estradiol/norethindrone (M) (M) PREMARIN VAGINAL CREAM ethinyl estradiol/norgestimate (M) ethinylestradiol 30 mcg/desogestrel 0.15 PREMARIN mg (M) (M) FEMALE HORMONES (PROGESTINS) low-ogestrel (M) mestranol/norethindrone (M) (M) medroxyprogesterone acetate necon micronized progesterone (M) zovia (M) FEMALE HORMONES (REPLACEMENT BIRTH CONTROL PILLS (PROGESTIN ONLY) COMBINATIONS) (Q) medroxyprogesterone injection (M) (M) FEMHRT norethindrone 0.35 mg PREMPHASE (M) PREMPRO (M) BIRTH CONTROL PILLS (TRIPHASIC CONTRACEPTIVES) FERTILITY (M) desogestrel/ethinylestradiol (P) (M) BRAVELLE desogestril/ethinyl estradiol (P) (M) chorionic gonadotropin ethinyl estradiol+norethindrone clomiphene ethinyl estradiol/norethindrone acetate (M) CETROTIDE (P) ethinyl estradiol/norethindrone (M) ganirelix acetate (P) norgestinate-ethinyl estradiol (M) ORTHO TRI-CYCLEN LO (M)
BREAST CANCER (ANTI-ESTROGENS)
FARESTON (M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
OB-GYN PAIN MANAGEMENT (ANALGESICS)
FERTILITY PAIN MANAGEMENT (ANALGESICS)
GONAL-F (P) fentanyl lozenge (P) MENOPUR (P) fentanyl transdermal progesterone in oil (P) hydromorphone REPRONEX (P) ibuprofen/hydrocodone (M) ibuprofen (M) UTERINE CONTRACTIONS & BLEEDING indomethacin (M) ketorolac methylergonovine meloxicam (M) meperidine YEAST OR BACTERIAL INFECTIONS (P) morphine sulfate clindamycin morphine sulfate morphine, sustained release metronidazole vaginal gel (M) terconazole nabumetone naproxen (M) (Q) PAIN MANAGEMENT (ANALGESICS) naratriptan oxaprozin (M) PAIN MANAGEMENT (ANALGESICS) oxycodone/apap oxycodone/aspirin (M) acetaminophen/codeine piroxicam (M) apap/dichloral-phenazone/isometheptene (M) sulindac (Q) butalbital/caffeine/aspirin sumatriptan (M) butorphanol (Q) tramadol diclofenac sodium xr (M) diclofenac sodium (M) RESPIRATORY PROBLEMS diclofenac/misoprostol (M) dihydroergotamine mesylate (M) ASTHMA & COPD (MISCELLANEOUS ergotamine/caffeine (M) INHALERS) ADVAIR (M) COMBIVENT (M) DULERA (M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
RESPIRATORY PROBLEMS SKIN ASTHMA & COPD (MISCELLANEOUS ACNE INHALERS) benzoyl peroxide/erythromycin ipratropium bromide (M) clindamycin phos/benzyl peroxide SPIRIVA (M) clindamycin/tretinoin (P) SYMBICORT (M) clindamycin tretinoin cream and gel (P) ASTHMA (BRONCHODILATORS) ANTI-INFLAMMATORY OR CORTICOSTEROIDS levabuterol (M) PROAIR HFA (M) alclometasone cream & oint. SEREVENT (M) aug. betamethasone diprop. cream VENTOLIN HFA (M) aug. betamethasone diprop. oint. betamethasone diprop. ASTHMA (STEROID INHALERS) clobetasol propionate
(M) desonide ASMANEX halobetasol propionate budesonide (M) (M) hydrocortisone valerate FLOVENT HFA mometasone furoate PULMICORT FLEXHALER (M) DISEASES-ECZEMA & PSORIASIS MISCELLANEOUS DRUGS calcipotriene cream EPIPEN JR. (Q) (M) PROTOPIC montelukast TAZORAC (P) zafirlukast (M) GENITAL WARTS SKIN imiquimod ACNE podofilox sol'n
(P) adapalene LICE AND SCABIES TREATMENT
permethrin cream
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
SKIN STOMACH & DIGESTIVE DISORDERS
MISCELLANEOUS ACID & STOMACH ULCERS
ciclopirox famotidine 40 mg (M) fluorouracil lansoprazole (M) misoprostol (M) TOPICAL ANTIBIOTICS nizatidine (M) omeprazole 10mg & 40mg (P,M) clindamycin topical pantoprazole (M) metronidazole topical gel ranitidine 300 mg (M) mupirocin ointment sucralfate silver sulfadiazine ANTI-DIARRHEAL DRUGS TOPICAL ANTIFUNGAL DRUGS diphenoxylate/atropine ciclopirox olamine clotrimazole/betamethasone ANTI-NAUSEA nystatin ZOVIRAX CREAM AND OINTMENT dronabinol EMEND STEROIDS (ORAL ANTI- granisetron INFLAMMATORY DRUGS) ondansetron BOWEL & COLON DISEASE STEROIDS (ORAL ANTI-INFLAMMATORY DRUGS) ASACOL HD (M) ASACOL (M) methylprednisolone (M) budesonide (micronized) prednisolone sodium hydrocortisone/pramoxine hydrocortisone STOMACH & DIGESTIVE DISORDERS LIALDA (M) mesalamine rectal susp (M) ACID & STOMACH ULCERS
cimetidine (M)
KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
STOMACH & DIGESTIVE DISORDERS SUPPLEMENTS
IRRITABLE BOWEL SYNDROME VITAMIN D
dicyclomine calcitriol capsules (M) calcitriol suspension (M) MALABSORPTION DISEASE HECTOROL (M)
(M) pancrelipase UROLOGY
MISCELLANEOUS BLADDER CONTROL (ANTISPASMODICS)
peg/electrolyte soln. (M) (M) DETROL LA sulfasalazine (M) (M) hyoscyamine ursodiol oxybutynin sr (M) oxybutynin (M) SEVERE HEARTBURN & REFLUX tolterodine (M) metoclopramide (M) BLADDER CONTROL (CHOLINERGIC AGENTS)
SUBSTANCE ABUSE bethanechol chloride (M)
DRUG ADDICTION IMPOTENCE (ERECTILE DYSFUNCTION) (P) buprenorphine tab VIAGRA (Q) naltrexone (P) SUBOXONE PROSTATE DISEASE (BENIGN PROSTATIC HYPERTROPHY) QUIT SMOKING AIDS AVODART (M) bupropion sr doxazosin (M) finasteride (M) KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
UROLOGY
PROSTATE DISEASE (BENIGN PROSTATIC HYPERTROPHY)
JALYN (M) tamsulosin (M) terazosin (M)
URINARY TRACT PAIN (ANESTHETICS)
phenazopyridine
KEY: Preferred Brand-Name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication
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