Your 2020 90 Day Supply Drug List Brand and/or generic may be excluded from coverage. Lower-cost options are available and covered. Brand may be excluded from coverage. Lower-cost options are available and covered. Medications subject to change without notice. This is not a complete list of medications, and not all medications listed may be covered under your plan. Review your benefit plan documents to see what medications are covered under your plan. Where differences are noted between this list and your benefit plan documents, the benefit plan documents will govern. Please refer tomyuhc.com ® for information on specific drugs included in this program or call the member phone number listed on your health plan ID card.
Brand Drug Name Generic Drug Name
ADHD INTUNIV guanfacine hcl (adhd) ANTI-INFECTIVES, MISC PLAQUENIL hydroxychloroquine sulfate ASTHMA / COPD ACCOLATE zafirlukast ADVAIR DISKUS, ADVAIR HFA, AIRDUO fluticasone-salmeterol AEROSPAN flunisolide hfa ALVESCO ciclesonide ANORO ELLIPTA umeclidinium-vilanterol ARCAPTA NEOHALER indacaterol maleate ARNUITY ELLIPTA fluticasone furoate (inhalation) ASMANEX TWISTHALER, ASMANEX HFA mometasone furoate (inhalation) ATROVENT HFA ipratropium bromide hfa BEVESPI AEROSPHERE glycopyrrolate-formoterol fumarate BREO ELLIPTA fluticasone furoate-vilanterol
90 Day Supply Drug List Effective 04-01-20 1 Brand Drug Name Generic Drug Name
BROVANA arformoterol tartrate COMBIVENT RESPIMAT ipratropium-albuterol DALIRESP roflumilast DUAKLIR aclidinium-formoterol DULERA mometasone furoate-formoterol fumarate dihydrate ELIXOPHYLLIN, THEO-24, THEOCHRON theophylline FLOVENT DISKUS, ARMONAIR RESPICLICK fluticasone propionate (inhalation) FLOVENT HFA fluticasone propionate hfa INCRUSE ELLIPTA umeclidinium bromide IPRATROPIUM BROMIDE ipratropium bromide PERFOROMIST formoterol fumarate PULMICORT FLEXHALER, PULMICORT budesonide (inhalation) QVAR beclomethasone dipropionate QVAR REDIHALER beclomethasone dipropionate hfa SEEBRI NEOHALER, LONHALA MAGNAIR glycopyrrolate (inhalation) SEREVENT DISKUS salmeterol xinafoate SINGULAIR montelukast sodium SPIRIVA HANDIHALER, SPIRIVA RESPIMAT tiotropium bromide monohydrate STRIVERDI RESPIMAT olodaterol hcl SYMBICORT budesonide-formoterol fumarate dihydrate TRELEGY ELLIPTA fluticasone-umeclidinium-vilanterol TUDORZA PRESSAIR aclidinium bromide UTIBRON NEOHALER indacaterol maleate-glycopyrrolate ZYFLO, ZYFLO CR zileuton BLOOD CLOT PREVENTION / STROKE PREVENTION AGGRENOX aspirin-dipyridamole BEVYXXA betrixaban maleate BRILINTA ticagrelor DIPYRIDAMOLE dipyridamole EFFIENT prasugrel hcl ELIQUIS apixaban PLAVIX clopidogrel bisulfate
90 Day Supply Drug List Effective 04-01-20 2 Brand Drug Name Generic Drug Name
PLETAL cilostazol PRADAXA dabigatran etexilate mesylate SAVAYSA edoxaban tosylate XARELTO rivaroxaban ZONTIVITY vorapaxar sulfate BLOOD DISORDERS TRENTAL TAB 400MG pentoxifylline BLOOD GLUCOSE MONITORING GLUCOSE BLOOD TEST STRIP glucose blood test strip CARDIOVASCULAR ACCUPRIL quinapril hcl ACCURETIC quinapril-hydrochlorothiazide ACEBUTOLOL HCL acebutolol hcl ACEON perindopril erbumine ADALAT CC, PROCARDIA, PROCARDIA XL, NIFEDIAC CC, AFEDITAB CR, nifedipine NIFEDICAL XL ALDACTAZIDE spironolactone & hydrochlorothiazide ALTACE ramipril AMILORIDE HCL amiloride hcl AMILORIDE/HYDROCHLOROTHIAZIDE amiloride & hydrochlorothiazide ATACAND candesartan cilexetil ATACAND HCT candesartan cilexetil-hydrochlorothiazide AVALIDE irbesartan-hydrochlorothiazide AVAPRO irbesartan AZOR amlodipine besylate-olmesartan medoxomil BENICAR olmesartan medoxomil BENICAR HCT olmesartan medoxomil-hydrochlorothiazide BETAPACE AF sotalol hcl (afib/afl) BETAPACE, SORINE sotalol hcl BETAXOLOL HCL betaxolol hcl BIDIL isosorbide dinitrate-hydralazine hcl
90 Day Supply Drug List Effective 04-01-20 3 Brand Drug Name Generic Drug Name
BUMEX bumetanide BYSTOLIC nebivolol hcl BYVALSON nebivolol-valsartan CADUET amlodipine besylate-atorvastatin calcium CALAN, CALAN SR, ISOPTIN SR, verapamil hcl VERELAN PM, VERELAN CAPTOPRIL captopril CAPTOPRIL/HYDROCHLOROTHIAZIDE captopril & hydrochlorothiazide CARDIZEM diltiazem hcl CARDIZEM LA, CARDIZEM CD, diltiazem hcl coated beads DILTIAZEM CD, MATZIM LA, CARTIA XT CARDURA doxazosin mesylate CAROSPIR, ALDACTONE spironolactone CATAPRES, CATAPRES TTS clonidine hcl CHLORTHALIDONE chlorthalidone CLORPRES clonidine & chlorthalidone COREG carvedilol COREG CR carvedilol phosphate CORGARD nadolol CORLANOR ivabradine hcl CORZIDE nadolol & bendroflumethiazide COZAAR losartan potassium DEMADEX torsemide DIOVAN valsartan DIOVAN HCT valsartan-hydrochlorothiazide DIURIL chlorothiazide DYAZIDE, MAXZIDE triamterene & hydrochlorothiazide DYRENIUM triamterene EDARBI azilsartan medoxomil EDARBYCLOR azilsartan medoxomil-chlorthalidone EDECRIN ethacrynic acid ENTRESTO sacubitril-valsartan EPANED, VASOTEC enalapril maleate
90 Day Supply Drug List Effective 04-01-20 4 Brand Drug Name Generic Drug Name
EPROSARTAN MESYLATE eprosartan mesylate EXFORGE amlodipine besylate-valsartan EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide FELODIPINE ER felodipine FLECAINIDE ACETATE flecainide acetate FOSINOPRIL SODIUM fosinopril sodium FOSINOPRIL SODIUM/ fosinopril sodium & hydrochlorothiazide HYDROCHLOROTHIAZIDE GUANFACINE HCL guanfacine hcl HEMANGEOL, INDERAL LA propranolol hcl HYDRALAZINE HCL hydralazine hcl HYZAAR losartan potassium & hydrochlorothiazide INDAPAMIDE indapamide INNOPRAN XL, INDERAL XL propranolol hcl sustained-release beads INSPRA eplerenone ISORDIL TITRADOSE, DILATRATE SR isosorbide dinitrate ISOSORBIDE MONONITRATE, ISOSORBIDE isosorbide mononitrate MONONITRATE ER ISRADIPINE isradipine KAPSPARGO SPRINKLE, TOPROL XL, metoprolol succinate FIRST METOPROLOL KATERZIA amlodipine benzoate LABETALOL HCL labetalol hcl LANOXIN, DIGITEK, DIGOX digoxin LASIX furosemide LOPRESSOR metoprolol tartrate LOPRESSOR HCT, DUTOPROL metoprolol & hydrochlorothiazide LOTENSIN benazepril hcl LOTENSIN HCT benazepril & hydrochlorothiazide LOTREL amlodipine besylate-benazepril hcl MAVIK trandolapril METHYCLOTHIAZIDE methyclothiazide METHYLDOPA methyldopa METHYLDOPA/HYDROCHLOROTHIAZIDE methyldopa & hydrochlorothiazide
90 Day Supply Drug List Effective 04-01-20 5 Brand Drug Name Generic Drug Name
METOLAZONE metolazone MEXILETINE HCL mexiletine hcl MICARDIS telmisartan MICARDIS HCT telmisartan-hydrochlorothiazide MICROZIDE, EZIDE hydrochlorothiazide MINIPRESS prazosin hcl MINOXIDIL minoxidil MOEXIPRIL HCL moexipril hcl MOEXIPRIL/HYDROCHLOROTHIAZIDE moexipril-hydrochlorothiazide MULTAQ dronedarone hcl NICARDIPINE HCL nicardipine hcl NIMODIPINE nimodipine NITRO-DUR, NITRO-BID, NITRO-TIME, nitroglycerin MINITRAN NORPACE CR, NORPACE disopyramide phosphate NORVASC amlodipine besylate PACERONE amiodarone hcl PINDOLOL pindolol PRESTALIA perindopril arginine-amlodipine besylate PROPRANOLOL/HYDROCHLOROTHIAZIDE propranolol & hydrochlorothiazide QBRELIS, PRINIVIL, ZESTRIL lisinopril QUINIDINE GLUCONATE quinidine gluconate QUINIDINE SULFATE quinidine sulfate RANEXA ranolazine RYTHMOL SR propafenone hcl SULAR nisoldipine TARKA trandolapril-verapamil hcl TEKTURNA aliskiren fumarate TEKTURNA HCT aliskiren-hydrochlorothiazide TENORETIC atenolol & chlorthalidone TENORMIN atenolol TERAZOSIN HCL terazosin hcl TIAZAC, TAZTIA XT diltiazem hcl extended release beads
90 Day Supply Drug List Effective 04-01-20 6 Brand Drug Name Generic Drug Name
TIKOSYN dofetilide TIMOLOL MALEATE timolol maleate olmesartan medoxomil-amlodipine- TRIBENZOR hydrochlorothiazide TWYNSTA telmisartan-amlodipine VASERETIC enalapril maleate & hydrochlorothiazide ZEBETA bisoprolol fumarate ZESTORETIC lisinopril & hydrochlorothiazide ZIAC bisoprolol & hydrochlorothiazide CHOLESTEROL LOWERING AGENTS ALTOPREV, MEVACOR lovastatin COLESTID colestipol hcl CRESTOR, EZALLOR SRPINKLE rosuvastatin calcium FIBRICOR fenofibric acid FLOLIPID, ZOCOR simvastatin LESCOL XL, LESCOL fluvastatin sodium LIPITOR atorvastatin calcium LIVALO pitavastatin calcium LOFIBRA fenofibrate micronized LOPID gemfibrozil LOVAZA, TRIKLO omega-3-acid ethyl esters NEXLETOL bempedoic acid NIASPAN, NIACOR niacin (antihyperlipidemic) PRAVACHOL pravastatin sodium QUESTRAN cholestyramine QUESTRAN LIGHT, PREVALITE cholestyramine light TRICOR, FENOGLIDE, LIPOFEN, TRIGLIDE fenofibrate TRILIPIX choline fenofibrate VASCEPA icosapent ethyl VYTORIN ezetimibe-simvastatin WELCHOL colesevelam hcl ZETIA ezetimibe ZYPITAMAG pitavastatin magnesium
90 Day Supply Drug List Effective 04-01-20 7 Brand Drug Name Generic Drug Name
CONTRACEPTION AMETHYST levonorgestrel-ethinyl estradiol (continuous) BALCOLTRA levonorgestrel-ethinyl estradiol-ferrous bisglycinate CRYSELLE-28, ELINEST, LOW-OGESTREL, norgestrel & ethinyl estradiol OGESTREL CYCLESSA, VELIVET, CAZIANT, CESIA desogestrel-ethinyl estradiol (triphasic) DESOGEN, RECLIPSEN, APRI, EMOQUETTE, ISIBLOOM, JULEBER, desogestrel & ethinyl estradiol CYRED, SOLIA, ENSKYCE ENPRESSE-28, MYZILRA, LEVONEST, levonorgestrel-eth estradiol (triphasic) TRIVORA-28 ESTROSTEP FE, TRI-LEGEST FE, TILIA FE norethindrone acetate-ethinyl estradiol-fe FALESSA levonorgestrel-ethinyl estradiol & folic acid FEMCON FE, GENERESS FE, LAYOLIS FE, ZENCHENT FE, WYMZYA FE, norethindrone & ethinyl estradiol-fe KAITLIB FE KELNOR, ZOVIA ethynodiol diacet & eth estrad LESSINA, PORTIA-28, AVIANE, ORSYTHIA, VIENVA, ALTAVERA, FALMINA, AUBRA, CHATEAL, AUBRA EQ, CHATEAL EQ, levonorgestrel & eth estradiol DELYLA, LUTERA, LEVORA 0.15/30- 28, SRONYX, MARLISSA, KURVELO, LARISSIA, LILLOW norethindrone acetate-ethinyl estradiol-fe fum LO LOESTRIN FE (biphasic) LOESTRIN 1.5/30-21, LOESTRIN 1/20-21, JUNEL 1/20, JUNEL 1.5/30, LARIN 1.5/30, LARIN 1/20, norethindrone acet & eth estra MICROGESTIN 1/20, MICROGESTIN 1.5/30 MIRCETTE, KARIVA, KIMIDESS, PIMTREA, desogestrel-ethinyl estradiol (biphasic) AZURETTE, VIORELE, BEKYREE NATAZIA estradiol valerate-dienogest NECON 1/50-28 norethindrone & mestranol NECON 10/11-28 norethindrone-eth estradiol (biphasic) NUVARING etonogestrel-ethinyl estradiol
90 Day Supply Drug List Effective 04-01-20 8 Brand Drug Name Generic Drug Name ORTHO MICRONOR, DEBLITANE, SHAROBEL, LYZA, TULANA, NORLYROC ,ERRIN, CAMILA, NORA- norethindrone BE, JOLIVETTE, HEATHER, INCASSIA, JENCYCLA, NORLYDA ORTHO TRI-CYCLEN, ORTHO TRI-CYCLEN LO, TRI-LO-SPRINTEC, TRI-SPRINTEC, TRI-PREVIFEM, TRI-ESTARYLLA, TRI-LO- norgestimate-ethinyl estradiol (triphasic) ESTARYLLA, TRI-LINYAH, TRINESSA, TRI-VYLIBRA, TRINESSA LO, TRI-LO- MARZIA, TRI FEMYNOR, TRI-MILI ORTHO-CYCLEN, SPRINTEC 28, PREVIFEM, ESTARYLLA, MONO- norgestimate-ethinyl estradiol LINYAH, VYLIBRA, MONONESSA, MILI, FEMYNOR ORTHO-NOVUM 7/7/7, TRI-NORINYL 28, NORTREL 7/7/7, ARANELLE, CYCLAFEM 7/7/7, DASETTA 7/7/7, norethindrone-eth estradiol (triphasic) LEENA, NECON 7/7/7, ALYACEN 7/7/7, PIRMELLA 7/7/7 OVCON-35, ORTHO-NOVUM 1/35, BREVICON-28, NORINYL 1+35, ZENCHENT, NORTREL 0.5/35 (28), NORTREL 1/35, BALZIVA, GILDAGIA, norethindrone & eth estradiol CYCLAFEM 1/35, PHILITH, DASETTA 1/35, WERA, NECON 1/35, NECON 0.5/35-28, ALYACEN 1/35, VYFEMLA, PIRMELLA 1/35, BRIELLYN SAFYRAL, BEYAZ, RAJANI, TYDEMY drospirenone-ethinyl estradiol-levomefolate calcium SEASONIQUE, LOSEASONIQUE, QUARTETTE, CAMRESE, RIVELSA, CAMRESE LO, LEVONORGESTREL/ ETHINYL ESTRADIOL, LEVONORGESTREL AND ETHINYL levonorgestrel-ethinyl estradiol (91-day) ESTRADIOL, JOLESSA, INTROVALE, SETLAKIN, AMETHIA LO, AMETHIA, QUASENSE, ASHLYNA, DAYSEE, FAYOSIM
90 Day Supply Drug List Effective 04-01-20 9 Brand Drug Name Generic Drug Name TAYTULLA, MINASTRIN 24 FE, LOESTRIN FE 1/20, LOESTRIN FE 1.5/30, JUNEL FE 24, JUNEL FE 1/20, JUNEL FE 1.5/30, LARIN FE 1.5/30, LARIN FE 1/20, LARIN 24 FE, TARINA FE 1/20, MICROGESTIN FE, MICROGESTIN FE norethin acet & estrad-fe 1.5/30, MICROGESTIN 24 FE, GILDESS FE 1/20, GILDESS FE 1.5/30, LOMEDIA 24 FE, BLISOVI 24 FE, BLISOVI FE 1/20, BLISOVI FE 1.5/30, MIBELAS 24 FE, MELODETTA 24 FE XULANE norelgestromin-ethinyl estradiol YAZ, YASMIN 28, GIANVI, OCELLA, LORYNA, SYEDA, ZARAH, VESTURA, drospirenone-ethinyl estradiol NIKKI COUGH AND COLD SSKI potassium iodide (expectorant) DEMENTIA ARICEPT donepezil hydrochloride EXELON rivastigmine NAMENDA, NAMENDA XR memantine hcl NAMZARIC memantine hcl-donepezil hcl RAZADYNE ER, RAZADYNE galantamine hydrobromide RIVASTIGMINE TARTRATE rivastigmine tartrate DEPRESSION APLENZIN bupropion hydrobromide CELEXA citalopram hydrobromide CYMBALTA duloxetine hcl DESVENLAFAXINE ER desvenlafaxine fumarate EFFEXOR XR, EFFEXOR venlafaxine hcl FETZIMA levomilnacipran hcl FLUVOXAMINE MALEATE, FLUVOXAMINE fluvoxamine maleate MALEATE ER FORFIVO XL, WELLBUTRIN SR, bupropion hcl WELLBUTRIN XL KHEDEZLA desvenlafaxine
90 Day Supply Drug List Effective 04-01-20 10 Brand Drug Name Generic Drug Name
LEXAPRO escitalopram oxalate MAPROTILINE HCL maprotiline hcl NEFAZODONE HCL nefazodone hcl PAXIL, PAXIL CR paroxetine hcl PEXEVA paroxetine mesylate PRISTIQ desvenlafaxine succinate PROZAC WEEKLY, PROZAC fluoxetine hcl REMERON, REMERON SOLTAB mirtazapine TRAZODONE HCL trazodone hcl TRINTELLIX vortioxetine hbr VIIBRYD vilazodone hcl ZOLOFT sertraline hcl DIABETES ACTOPLUS MET XR, ACTOPLUS MET pioglitazone hcl-metformin hcl ACTOS pioglitazone hcl ADLYXIN lixisenatide AMARYL glimepiride APIDRA, APIDRA SOLOSTAR insulin glulisine BASAGLAR KWIKPEN, TOUJEO SOLOSTAR, TOUJEO MAX SOLOSTAR, LANTUS insulin glargine SOLOSTAR, LANTUS BYETTA, BYDUREON exenatide CHLORPROPAMIDE chlorpropamide CYCLOSET bromocriptine mesylate (diabetes) DUETACT pioglitazone hcl-glimepiride GLIPIZIDE/METFORMIN HCL glipizide-metformin hcl GLUCOPHAGE, GLUCOPHAGE XR, metformin hcl FORTAMET, GLUMETZA, RIOMET GLUCOTROL XL, GLUCOTROL glipizide GLUCOVANCE glyburide-metformin GLYBURIDE glyburide GLYNASE glyburide micronized GLYSET miglitol GLYXAMBI empagliflozin-linagliptin
90 Day Supply Drug List Effective 04-01-20 11 Brand Drug Name Generic Drug Name HUMALOG MIX 75/25, HUMALOG MIX 50/50, HUMALOG MIX 75/25 KWIKPEN, insulin lispro protamine & lispro HUMALOG MIX 50/50 KWIKPEN HUMALOG, HUMALOG JUNIOR KWIKPEN, HUMALOG KWIKPEN, ADMELOG, insulin lispro ADMELOG SOLOSTAR INVOKAMET, INVOKAMET XR canagliflozin-metformin hcl INVOKANA canagliflozin JANUMET XR, JANUMET sitagliptin-metformin hcl JANUVIA sitagliptin phosphate JARDIANCE empagliflozin JENTADUETO, JENTADUETO XR linagliptin-metformin hcl KAZANO alogliptin-metformin hcl KOMBIGLYZE XR saxagliptin-metformin hcl LEVEMIR, LEVEMIR FLEXTOUCH insulin detemir NESINA alogliptin benzoate NOVOLIN 70/30, HUMULIN 70/30, HUMULIN 70/30 KWIKPEN, NOVOLIN insulin nph isophane & reg (human) 70/30 RELION NOVOLIN N, HUMULIN N, HUMULIN N KWIKPEN, NOVOLIN N RELION, insulin nph (human) (isophane) NOVOLIN N U-100 NOVOLIN R, RELION R, HUMULIN R, HUMULIN R U-500 (CONCENTRATED), insulin regular (human) HUMULIN R U-500 KWIKPEN, NOVOLIN R RELION, AFREZZA NOVOLOG MIX 70/30, NOVOLOG MIX insulin aspart protamine & aspart (human) 70/30 PREFILLED FLEXPEN NOVOLOG, FIASP, FIASP FLEXTOUCH, NOVOLOG PENFILL, NOVOLOG insulin aspart FLEXPEN ONGLYZA saxagliptin hcl OSENI alogliptin-pioglitazone OZEMPIC, RYBELSUS semaglutide PRANDIN repaglinide PRECOSE acarbose
90 Day Supply Drug List Effective 04-01-20 12 Brand Drug Name Generic Drug Name
QTERN dapagliflozin-saxagliptin REPAGLINIDE/METFORMIN repaglinide-metformin hcl HYDROCHLORIDE SEGLUROMET ertugliflozin-metformin hcl SOLIQUA 100/33 insulin glargine-lixisenatide STARLIX nateglinide STEGLATRO ertugliflozin l-pyroglutamic acid STEGLUJAN ertugliflozin-sitagliptin SYMLINPEN pramlintide acetate SYNJARDY, SYNJARDY XR empagliflozin-metformin hcl TANZEUM albiglutide TOLAZAMIDE tolazamide TOLBUTAMIDE tolbutamide TRADJENTA linagliptin TRESIBA FLEXTOUCH insulin degludec TRIJARDY XR empagliflozin-linagliptin-metformin tab er 24hr TRULICITY dulaglutide VICTOZA liraglutide XIGDUO XR dapagliflozin-metformin hcl XULTOPHY 100/3.6 insulin degludec-liraglutide DIABETIC SUPPLIES BLOOD GLUCOSE CALIBRATION blood glucose calibration LANCETS lancets ENDOCRINE AND METABOLIC DEMSER metyrosine DIBENZYLINE phenoxybenzamine hcl PROGLYCEM diazoxide ROCALTROL calcitriol GASTROINTESTINAL, MISC AMITIZA lubiprostone LEVBID, SYMAX-SR, OSCIMIN SR hyoscyamine sulfate LINZESS linaclotide
90 Day Supply Drug List Effective 04-01-20 13 Brand Drug Name Generic Drug Name
LOTRONEX alosetron hcl MOTEGRITY prucalopride succinate MOVANTIK naloxegol oxalate RELISTOR methylnaltrexone bromide SYMPROIC naldemedine tosylate TRULANCE plecanatide VIBERZI eluxadoline ZENPEP, CREON, PANCREAZE, VIOKACE, pancrelipase (lipase-protease-amylase) PERTZYE GLAUCOMA ALPHAGAN P brimonidine tartrate DIAMOX acetazolamide IOPIDINE apraclonidine hcl ISOPTO CARPINE pilocarpine hcl LUMIGAN bimatoprost NEPTAZANE methazolamide RHOPRESSA netarsudil dimesylate ROCKLATAN netarsudil dimesylate-latanoprost SIMBRINZA brinzolamide-brimonidine tartrate TRAVATAN Z travoprost VYZULTA latanoprostene bunod XALATAN latanoprost ZIOPTAN tafluprost GOUT COLCRYS, MITIGARE, GLOPERBA colchicine DUZALLO lesinurad-allopurinol PROBENECID probenecid PROBENECID/COLCHICINE colchicine w/ probenecid ULORIC febuxostat ZURAMPIC lesinurad ZYLOPRIM allopurinol
90 Day Supply Drug List Effective 04-01-20 14 Brand Drug Name Generic Drug Name
HORMONE MODIFYING AGENTS EVISTA raloxifene hcl OSPHENA ospemifene HYPERTHYROIDISM PROPYLTHIOURACIL propylthiouracil TAPAZOLE methimazole INFLAMMATORY CONDITIONS ARAVA leflunomide AZULFIDINE, AZULFIDINE EN sulfasalazine DELZICOL, ROWASA, APRISO, PENTASA, mesalamine CANASA, ASACOL HD, LIALDA DIPENTUM olsalazine sodium GIAZO, COLAZAL balsalazide disodium RIDAURA auranofin ROWASA mesalamine w/ cleanser INSOMNIA PHENOBARBITAL phenobarbital IV ADMINISTRATION SUPPLIES INSULIN PEN NEEDLE insulin pen needle INSULIN SYRINGES insulin syringes KIDNEY DISEASE AURYXIA ferric citrate FOSRENOL lanthanum carbonate PHOSLYRA, PHOSLO, CALPHRON, calcium acetate (phosphate binder) ELIPHOS RENAGEL sevelamer hcl RENVELA sevelamer carbonate VELPHORO sucroferric oxyhydroxide MALE AND FEMALE HORMONE REPLACEMENT ANDROXY fluoxymesterone ANGELIQ drospirenone-estradiol AYGESTIN norethindrone acetate BIJUVA estradiol-progesterone
90 Day Supply Drug List Effective 04-01-20 15 Brand Drug Name Generic Drug Name
CLIMARA PRO estradiol-levonorgestrel COMBIPATCH, ACTIVELLA, MIMVEY LO, estradiol & norethindrone acetate MIMVEY, AMABELZ, LOPREEZA COVARYX, COVARYX HS, EEMT, EEMT HS esterified estrogens & methyltestosterone DUAVEE conjugated estrogens-bazedoxifene ESTRING, IMVEXXY, VAGIFEM, ESTRACE, estradiol vaginal YUVAFEM ESTROPIPATE estropipate EVAMIST, ESTROGEL, MENOSTAR, ALORA, DIVIGEL, MINIVELLE, VIVELLE-DOT, estradiol ESTRACE, CLIMARA, ESTRADIOL FEMHRT LOW DOSE, JINTELI, JEVANTIQUE norethindrone acetate-ethinyl estradiol LO, FYAVOLV FEMRING estradiol acetate vaginal MENEST esterified estrogens METHITEST, TESTRED, ANDROID methyltestosterone PREFEST estradiol-norgestimate PREMARIN estrogens, conjugated PREMARIN estrogens, conjugated vaginal PREMPRO, PREMPHASE conjugated estrogens-medroxyprogesterone acetate PROMETRIUM progesterone micronized PROVERA medroxyprogesterone acetate STRIANT, ANDROGEL, ANDRODERM, testosterone VOGELXO MISC THROAT PRODUCTS EVOXAC cevimeline hcl SALAGEN pilocarpine hcl (oral) MISC WOMEN’S HEALTH BRISDELLE paroxetine mesylate (vasomotor) INTRAROSA prasterone vaginal NEUROLOGIC GRALISE gabapentin (once-daily) HORIZANT gabapentin enacarbil LYRICA CR pregabalin (once-daily) SAVELLA milnacipran hcl
90 Day Supply Drug List Effective 04-01-20 16 Brand Drug Name Generic Drug Name
NEUROMUSCULAR DISORDERS MESTINON, MESTINON TIMESPAN pyridostigmine bromide ONCOLOGY ARIMIDEX anastrozole AROMASIN exemestane FARESTON toremifene citrate FEMARA letrozole SOLTAMOX tamoxifen citrate OPTHALAMIC AGENTS AZOPT brinzolamide BETAGAN levobunolol hcl BETIMOL timolol BETOPTIC-S betaxolol hcl (ophth) CARTEOLOL HCL carteolol hcl (ophth) COMBIGAN brimonidine tartrate-timolol maleate COSOPT PF, COSOPT dorzolamide hcl-timolol maleate METIPRANOLOL metipranolol TIMOPTIC OCUDOSE, ISTALOL, TIMOPTIC, timolol maleate (ophth) TIMOPTIC-XE TRUSOPT dorzolamide hcl OSTEOPOROSIS ACTONEL, ATELVIA risedronate sodium BINOSTO, FOSAMAX alendronate sodium BONIVA ibandronate sodium ETIDRONATE DISODIUM etidronate disodium FOSAMAX PLUS D alendronate sodium-cholecalciferol OVERACTIVE BLADDER / INCONTINENCE DETROL, DETROL LA tolterodine tartrate ENABLEX darifenacin hydrobromide FLAVOXATE HCL flavoxate hcl GELNIQUE, DITROPAN XL oxybutynin chloride MYRBETRIQ mirabegron
90 Day Supply Drug List Effective 04-01-20 17 Brand Drug Name Generic Drug Name
OXYTROL FOR WOMEN, OXYTROL oxybutynin TOVIAZ fesoterodine fumarate TROSPIUM CHLORIDE trospium chloride VESICARE solifenacin succinate PARKINSON'S DISEASE AZILECT rasagiline mesylate BENZTROPINE MESYLATE benztropine mesylate COMTAN entacapone INBRIJA levodopa inhal powder cap LODOSYN carbidopa MIRAPEX, MIRAPEX ER pramipexole dihydrochloride NEUPRO rotigotine OSMOLEX ER, GOCOVRI amantadine hcl PARLODEL bromocriptine mesylate REQUIP XL, REQUIP ropinirole hydrochloride RYTARY, SINEMET, SINEMET CR carbidopa-levodopa STALEVO carbidopa-levodopa-entacapone TASMAR tolcapone TRIHEXYPHENIDYL HCL trihexyphenidyl hcl XADAGO safinamide mesylate ZELAPAR, ELDEPRYL selegiline hcl PREMENSTRUAL DYSPHORIC DISORDER SARAFEM fluoxetine hcl (pmdd) PROSTATIC HYPERTROPHY AVODART dutasteride CARDURA XL doxazosin mesylate (bph) FLOMAX tamsulosin hcl JALYN dutasteride-tamsulosin hcl PROSCAR finasteride RAPAFLO silodosin UROXATRAL alfuzosin hcl
90 Day Supply Drug List Effective 04-01-20 18 Brand Drug Name Generic Drug Name
PSYCHOSIS CAPLY TA lumateperone tosylate SEIZURE DISORDERS APTIOM eslicarbazepine acetate BANZEL rufinamide BRIVIACT brivaracetam CELONTIN methsuximide DEPAKENE valproate sodium DEPAKENE valproic acid DEPAKOTE ER, DEPAKOTE SPRINKLES, divalproex sodium DEPAKOTE DILANTIN phenytoin DILANTIN, PHENYTEK phenytoin sodium extended FELBATOL felbamate GABITRIL tiagabine hcl KLONOPIN clonazepam LAMICTAL CHEWABLE DISPERSIBLE, LAMICTAL, LAMICTAL XR, LAMICTAL lamotrigine ODT LYRICA pregabalin MYSOLINE primidone NEURONTIN gabapentin OXTELLAR XR, TRILEPTAL oxcarbazepine PEGANONE ethotoin POTIGA ezogabine SPRITAM, KEPPRA, KEPPRA XR levetiracetam TEGRETOL, TEGRETOL-XR, CARBATROL, carbamazepine EPITOL TROKENDI XR, QUDEXY XR, TOPAMAX, topiramate TOPAMAX SPRINKLE VIMPAT lacosamide ZARONTIN ethosuximide ZONEGRAN zonisamide
90 Day Supply Drug List Effective 04-01-20 19 Brand Drug Name Generic Drug Name
THYROID REPLACEMENT ARMOUR THYROID, NATURE-THROID, WP thyroid THYROID, WESTHROID CYTOMEL liothyronine sodium TIROSINT, SYNTHROID, UNITHROID levothyroxine sodium DIRECT, LEVO-T, LEVOXYL, UNITHROID ULCER/ACID REFLUX/GERD ACIPHEX rabeprazole sodium AXID nizatidine CARAFATE sucralfate CIMETIDINE HCL cimetidine hcl CYTOTEC misoprostol DEXILANT dexlansoprazole ESOMEPRAZOLE STRONTIUM esomeprazole strontium NEXIUM, NEXIUM 24HR esomeprazole magnesium PEPCID AC MAXIMUM STRENGTH, PEPCID famotidine PREVACID 24HR, PREVACID SOLUTAB, lansoprazole PREVACID PRILOSEC omeprazole PRILOSEC omeprazole magnesium PROTONIX pantoprazole sodium TAGAMET cimetidine ZANTAC ranitidine hcl ZEGERID, OMEPPI omeprazole-sodium bicarbonate VITAMINS, MINERALS, ELECTROLYTES DRISDOL, VITAMIN D ergocalciferol EFFER-K potassium bicarbonate-citric acid EFFERVESCENT POTASSIUM/CHLORIDE potassium bicarb & chloride FOLIC ACID folic acid K-EFFERVESCENT, K-VESCENT, K-PRIME, potassium bicarbonate KLOR-CON/EF KLOR-CON M15, KLOR-CON M10, KLOR- potassium chloride microencapsulated crystals er CON M20 K-PHOS potassium phosphate monobasic
90 Day Supply Drug List Effective 04-01-20 20 Brand Drug Name Generic Drug Name K-PHOS NEUTRAL, PHOSPHO-TRIN, pot phosphate monobasic w/ sod phosphate dibasic PHOSPHA & monobasi K-TAB, MICRO-K, KLOR-CON, KLOR-CON 10, KLOR-CON 8, KLOR-CON/25, potassium chloride KLOR-CON SPRINKLE NASCOBAL cyanocobalamin POTASSIUM GLUCONATE ER potassium gluconate
90 Day Supply Drug List Effective 04-01-20 21