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Drug Class Brand Or Label Name* Generic Name Generic Drug Class Brand or Label Name* Generic Name* Strength Dosage Form Limits Available? (Y / N) ALCOHOL DEPENDENCY ANTABUSE disulfiram all tablet Y ALCOHOL DEPENDENCY CAMPRAL acamprosate calcium all tablet Y ANTICOAGULANT PRADAXA dabigatran etexilate mesylate all capsule PA N ANTICOAGULANT COUMADIN, JANTOVEN warfarin all tablet Y ANTIPLATELET PLETAL cilostazol all tablet Y ANTIPLATELET EFFIENT prasugrel hcl all tablet N ANTIPLATELET PERSANTINE dipyridamole all tablet Y ANTIPLATELET AGGRENOX aspirin/dipyridamole all capsule 12 hr N ANTIPLATELET PLAVIX clopidogrel all tablet N ANTIPLATELET AGRYLIN anagrelide all capsule Y ANTIPSYCHOTIC ABILIFY aripiprazole all tablet AGE N ANTIPSYCHOTIC ABILIFY DISCMELT aripiprazole all dissolve tablet PA, AGE N ANTIPSYCHOTIC CLOZARIL clozapine all tablet AGE Y ANTIPSYCHOTIC FAZACLO clozapine all dissolve tablet PA, AGE N elixir, tablet & concentrate ANTIPSYCHOTIC fluphenazine hcl fluphenazine hcl all AGE Y solution ANTIPSYCHOTIC haloperidol haloperidol all tablet AGE Y ANTIPSYCHOTIC ESKALITH CR, LITHOBID lithium carbonate all tablet SA & capsule Y ANTIPSYCHOTIC lithium citrate lithium citrate all solution Y ANTIPSYCHOTIC LOXITANE loxapine succinate all capsule AGE Y ANTIPSYCHOTIC ZYPREXA olanzapine all tablet AGE Y ANTIPSYCHOTIC ZYPREXA ZYDIS olanzapine all dissolve tablet PA, AGE Y ANTIPSYCHOTIC perphenazine perphenazine all tablet AGE Y ANTIPSYCHOTIC SEROQUEL quetiapine fumarate all tablet AGE N ANTIPSYCHOTIC SEROQUEL XR quetiapine fumarate all tablet SR (24 hour) AGE N ANTIPSYCHOTIC RISPERDAL risperidone all oral solution & tablet AGE Y ANTIPSYCHOTIC RISPERDAL M-TAB risperidone all dissolve tablet PA, AGE Y ANTIPSYCHOTIC thioridazine hcl thioridazine hcl all tablet AGE Y ANTIPSYCHOTIC NAVANE thiothixene all capsule AGE Y ANTIPSYCHOTIC trifluoperazine hcl trifluoperazine hcl all tablet AGE Y ANTIPSYCHOTIC GEODON ziprasidone hcl all tablet AGE N ASTHMA & COPD aminophylline aminophylline all tablet Y ASTHMA & COPD QVAR beclomethasone dipropionate all oral inhalation N ASTHMA & COPD PULMICORT RESPULE budesonide all neb suspension Y ASTHMA & COPD PULMICORT FLEXHALER budesonide all oral inhalation N ASTHMA & COPD SYMBICORT FLEXHALER budesonide/formoterol all oral inhalation N ASTHMA & COPD INTAL cromolyn sodium all neb solution Y ASTHMA & COPD ADVAIR DISKUS fluticasone / salmeterol all oral inhalation N ASTHMA & COPD ADVAIR HFA fluticasone / salmeterol hfa all oral inhalation N ASTHMA & COPD FLOVENT DISKUS fluticasone propionate all oral inhalation N ASTHMA & COPD FLOVENT HFA fluticasone propionate hfa all oral inhalation N ASTHMA & COPD FORADIL formoterol fumarate all oral inhalation N ASTHMA & COPD ATROVENT ipratropium bromide all neb solution Y ASTHMA & COPD ATROVENT HFA ipratropium bromide all oral inhalation N ASTHMA & COPD COMBIVENT ipratropium/albuterol sulfate all oral inhalation N ASTHMA & COPD DUONEB ipratropium/albuterol sulfate all neb solution Y ASTHMA & COPD ASMANEX mometasone furoate all oral inhalation N ASTHMA & COPD DULERA mometasone furoate all oral inhalation N ASTHMA & COPD SINGULAIR montelukast sodium all oral N ASTHMA & COPD DALIRESP roflumilast all tablet PA N ASTHMA & COPD SEREVENT DISKUS salmeterol xinafoate all oral inhalation N ASTHMA & COPD theophylline theophylline all tablet SR (12 hour) Y ASTHMA & COPD UNIPHYL theophylline all tablet SR (24 hour) Y ASTHMA & COPD SPIRIVA tiotropium bromide all oral inhalation N Preventive Medications by Class‐‐*Preventive drug coverage is limited to the generic form when a generic is available. (05/2012) Page 1 of 4 Generic Drug Class Brand or Label Name* Generic Name* Strength Dosage Form Limits Available? (Y / N) BREAST CANCER NOLVADEX tamoxifen citrate all tablet Y CHOLESTEROL LIPITOR atorvastatin calcium all tablet QL Y CHOLESTEROL QUESTRAN cholestyramine all powder (can & packet) Y CHOLESTEROL QUESTRAN LIGHT, PREVALITE cholestyramine light all powder (can & packet) Y CHOLESTEROL COLESTID colestipol hcl all tablet Y CHOLESTEROL ZETIA ezetimibe all tablet N CHOLESTEROL LOFIBRA, TRIGLIDE fenofibrate all tablet & capsule Y CHOLESTEROL LOPID gemfibrozil all tablet Y CHOLESTEROL MEVACOR lovastatin all tablet Y CHOLESTEROL NIASPAN niacin (antihyperlipidemic) all tablet SR N CHOLESTEROL LOVAZA omega-3-acid ethyl esters all capsule ST N CHOLESTEROL PRAVACHOL pravastatin all tablet Y 5mg, 10mg, CHOLESTEROL ZOCOR simvastatin tablet Y 20mg CHOLESTEROL ZOCOR simvastatin 40mg tablet QL Y CHOLESTEROL ZOCOR simvastatin 80mg tablet PA Y DEPRESSION amitriptyline hcl amitriptyline hcl all tablet Y DEPRESSION WELLBUTRIN bupropion hcl all tablet Y DEPRESSION WELLBUTRIN SR bupropion hcl all tablet SA Y DEPRESSION WELLBUTRIN XL bupropion hcl all tablet SR (24 hour) Y DEPRESSION CELEXA citalopram hcl all solution & tablet Y DEPRESSION ANAFRANIL clomipramine hcl all capsule Y DEPRESSION NORPRAMIN desipramine hcl all tablet Y DEPRESSION doxepin hcl doxepin hcl all capsule Y DEPRESSION PROZAC fluoxetine hcl all capsule & solution Y DEPRESSION RAPIFLUX fluoxetine hcl all tablet Y DEPRESSION fluvoxamine maleate fluvoxamine maleate all tablet Y DEPRESSION TOFRANIL imipramine hcl all tablet Y DEPRESSION mirtazapine mirtazapine all tablet Y DEPRESSION REMERON mirtazapine all tablet Y DEPRESSION nefazodone hcl nefazodone hcl all tablet Y DEPRESSION PAMELOR nortriptyline hcl all capsule & solution Y DEPRESSION PAXIL paroxetine hcl all suspension & tablet Y DEPRESSION NARDIL phenelzine sulfate all tablet Y concentrate DEPRESSION ZOLOFT sertraline hcl all Y solution & tablet DEPRESSION PARNATE tranylcypromine sulfate all tablet Y DEPRESSION DESYREL trazodone hcl all tablet Y DEPRESSION EFFEXOR venlafaxine hcl all tablet Y DEPRESSION VENLAFAXINE ER venlafaxine hcl all tablet SR (24 hour) Y DEPRESSION VENLAFAXINE ER venlafaxine hcl all capsule SR (24 hour) Y DIABETES PRECOSE acarbose all tablet Y DIABETES CYCLOSET bromocriptine mesylate all tablet PA N DIABETES BYETTA exenatide all injection N DIABETES AMARYL glimepiride all tablet Y DIABETES GLUCOTROL glipizide all tablet Y DIABETES GLUCOTROL XL glipizide all tablet SR (24 hour) Y DIABETES METAGLIP glipizide / metformin all tablet Y DIABETES GLUCAGEN glucagon (rdna) all injection - vial N DIABETES GLUCAGEN HYPOKIT glucagon (rdna) all injection N DIABETES GLUCAGON KIT glucagon (rdna) all injection N DIABETES DIABETA, MICRONASE glyburide all tablet Y DIABETES GLUCOVANCE glyburide / metformin all tablet Y DIABETES GLYNASE glyburide micronized all tablet Y DIABETES LEVEMIR insulin detemir all injection - pen & vial ST N DIABETES LANTUS, LANTUS SOLOSTAR insulin glargine all injection - pen & vial N DIABETES HUMALOG insulin lispro all injection - pen & vial N insulin lispro / DIABETES HUMALOG MIX 75/25 all injection - pen & vial N insulin lispro protamine DIABETES HUMULIN 70/30 insulin isophane & regular (human) all injection - pen & vial N DIABETES HUMULIN N insulin isophane (human) all injection - pen & vial N DIABETES HUMULIN R U-1OO insulin regular (human) all injection - vial N DIABETES HUMULIN R U-500 insulin regular (human) all injection - vial N Preventive Medications by Class‐‐*Preventive drug coverage is limited to the generic form when a generic is available. (05/2012) Page 2 of 4 Generic Drug Class Brand or Label Name* Generic Name* Strength Dosage Form Limits Available? (Y / N) DIABETES VICTOZA liraglutide all injection - pen PA N DIABETES GLUCOPHAGE metformin hcl all tablet Y DIABETES GLUCOPHAGE XR metformin hcl all tablet SR (24 hour) Y DIABETES GLYSET miglitol all tablet N DIABETES STARLIX nateglinide all tablet Y DIABETES ACTOS pioglitazone hcl all tablet N DIABETES DUETACT pioglitazone hcl / glimepiride all tablet N DIABETES ACTOPLUS MET pioglitazone hcl / metformin hcl all tablet N DIABETES PRANDIN repaglinide all tablet N DIABETES JANUMET sitagliptin / metformin hcl all tablet N DIABETES JANUMET XR sitagliptin / metformin hcl all tablet ER (24 hour) N DIABETES JANUVIA sitagliptin phosphate all tablet N HYPERTENSION MODURETIC amiloride / hydrochlorothiazide all tablet Y HYPERTENSION amiloride amiloride hcl all tablet Y HYPERTENSION NORVASC amlodipine besylate all tablet Y HYPERTENSION LOTREL amlodipine besylate / benazepril all capsule Y HYPERTENSION TENORMIN atenolol all tablet Y HYPERTENSION TENORETIC atenolol / chlorthalidone all tablet Y HYPERTENSION LOTENSIN HCT benazepril / hydrochlorothiazide all tablet Y HYPERTENSION LOTENSIN benazepril hcl all tablet Y HYPERTENSION ZEBETA bisoprolol hcl all tablet Y HYPERTENSION ZIAC bisoprolol hcl / hydrochlorothiazide all tablet Y HYPERTENSION BUMEX bumetanide all tablet Y HYPERTENSION CAPOTEN captopril all tablet Y HYPERTENSION captopril / hydrochlorothiazide captopril / hydrochlorothiazide all tablet Y HYPERTENSION COREG carvedilol all tablet Y HYPERTENSION COREG CR carvedilol all capsule SR (24 hour) ST N HYPERTENSION chlorothiazide chlorothiazide all tablet Y HYPERTENSION CATAPRES clonidine hcl all tablet Y HYPERTENSION CATAPRES-TTS clonidine hcl all patch (weekly) Y HYPERTENSION CARDIZEM SR diltiazem hcl all capsule SR (12 hour) Y HYPERTENSION CARDIZEM CD, DILACOR XR diltiazem hcl all capsule SR (24 hour) Y HYPERTENSION TIAZAC diltiazem hcl all tablet SR (24 hour) Y HYPERTENSION CARDIZEM diltiazem hcl all tablet Y HYPERTENSION CARDURA doxazosin mesylate all tablet Y HYPERTENSION VASERETIC enalapril / hydrochlorothiazide all tablet Y HYPERTENSION VASOTEC enalapril maleate all tablet Y HYPERTENSION INSPRA eplerenone all tablet PA Y HYPERTENSION MONOPRIL HCT fosinopril / hydrochlorothiazide all tablet Y HYPERTENSION MONOPRIL fosinopril sodium
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