Washtenaw Health Plan B Quick List Brand names (in parentheses) are listed for reference only. If available, only the generic product is covered. Please check the WHP Plan A and B Drug Formulary for a complete listing of dosages and . Updated 08/01/2021

Prescription copays are listed on the health plan card. This list may change at any time. This is a partial listing. For the latest list, go to https://www.washtenaw.org/whp

For medications marked:  QL: Quantity is limited AL: Age limit  PA Req’d: Call (866) 291-8691

 clarithromycin (Biaxin) Angiotensin-Converting Enzyme (ACE) +  erythromycin (E.E.S. or Erythrocin)  lisinopril/HCTZ (Zestoretic) Antiarthritic Lincomycin Angiotensin II Receptor Blocker  allopurinol (Zyloprim)  (Cleocin)  losartan (Cozaar)  methotrexate sodium (Methotrexate) Penicillin Angiotensin II Receptor Blocker/Diuretic  salsalate (Disalcid)  amoxicillin (Amoxil)  losartan/HCTZ (Hyzaar) Anti-Migraine  amoxicillin/clavulanic acid (Augmentin)  valsartan (Diovan)  sumatriptan (Imitrex) QL  amox/potassium clavulanate (Augmentin) Antiarrhythmic  Maxalt (Rizatriptan) Quinolone  amiodarone (Cordarone) Long Acting Narcotic  ciprofloxacin (Cipro)  disopyramide (Norpace)  methadone (Dolophine) QL 30 mg/day  levofloxacin (Levaquin)  mexiletine (Mexitil)  morphine sulfate ER (MS Contin)--PA Req’d if > 60mg/day  sulfamethoxazole/trimethoprim (Bactrim/Bactrim DS)  warfarin (Coumadin)  sulfasalazine (Azulfidine) Antihypertensive - Misc.  baclofen (Lioresal) TB  clonidine (Catapres)  carisoprodol (Soma)  isoniazid (INH)  guanfacine hcl (Tenex)  cyclobenzaprine hcl (Flexeril)  hydralazine Apresoline) methocarbamol (Robaxin)   hyclate (Acticlate, Vibramycin)  methyldopa (Aldomet) Non-narcotic  minocycline (Minocin)  minoxidil (Loniten)  acetaminophen/butalbital/caffeine (Fioricet)  tetracycline (Sumycin) Antiplatelet  aspirin/butalbital/caffeine (Fiorinal) Urinary Tract  clopidogrel (Plavix)  diflunisal (Dolobid)  nitrofurantoin (Macrodantin)  tramadol (Ultram)  atenolol (Tenormin) Nonsteroidal BRONCHIAL  carvedilol (Coreg) Antihistamine/Allergy  diclofenac sodium (Voltaren)  metoprolol tartrate (Lopressor)  cetirizine (Zyrtec), tab, liq., chews  ibuprofen (Motrin), tab, solution, gtts  metroprolol succ (Kapspargo,Toprol XL) indomethacin (Indocin) clemastine fumarate (Tavist)    propranolol (Inderal LA only)  ketoprofen (Orudis)  cyproheptadine (Periactin) Beta Blocker + Diuretic  meloxicam (Mobic)  hydroxyzine (Atarax)  atenolol-chlorthalidone (Tenoretic)  naproxen (Anaprox)  hydroxyzine pamoate (Vistaril)  sulindac (Clinoril)  promethazine (Phenergan)  amlodipine besylate (Norvasc) Short Acting Narcotic QL= cumulative total of 180 Asthma/COPD  diltiazem (Cardizem and Cardizem CD) tabs/mo or 960 ml/mo liquid  aerochamber (Spacer) QL  nifedipine (Procardia and Procardia XL)  acetaminophen w/codeine (Tylenol #2,3,4)  albuterol inhaler, HFA, solution QL  verapamil (Calan)  hydrocodone/acetaminophen (Vicodin, Lorcet, Norco)  beclomethasone dipropionate (QVAR Redihaler) QL Coronary Vasodilator  hydrocodone/ibuprofen (Vicoprofen)  cromolyn sodium (Intal) solution  isosorbide dinitrate (Isordil)  hydromorphone (Dilaudid)  fluticasone propionate (Flovent) inhaler  isosorbide mononitrate (Imdur)  meperidine hcl (Demerol)  fluticasone sameterol (AirDuo)  nitroglycerin (Nitro-Bid 2% Ointment)  morphine sulfate IR (MSIR)  fluticasone/sameterol disk (Wixela)  nitroglycerin (Transderm-Nitro Patch)  oxycodone hcl (Oxycodone) 5 mg tab only  ipratropium (Atrovent HFA) inhaler/solution  nitroglycerin sublingual (Nitrostat)  oxycodone/Acetaminopehen (Percocet,Endocet)  metaproterenol (Alupent) solution/tab Digitalis Glycoside  oxycodone/Aspirin (Percodan)  montelukast (Singulair)  digoxin (Lanoxin)  tramadol/acetaminophen (Ultrcet)  theophylline (Theo-Dur) Diuretic ANTI-INFECTIVE  bumetanide (Bumex)  epinephrine (Epipen and Epipen JR) QL Antibacterial  chlorthalidone (Hygroton) Cough and Cold  (Flagyl)  furosemide (Lasix)  benzonatate (Tessalon Perle) 100 mg cap only  hydrochlorothiazide (Hydrodiuril)  promethazine hcl/codeine (Phenergan w/codeine)  fluconazole (Diflucan)  triamterene-hctz (Dyazide, Maxzide)  promethazine-dm (Phenergan DM)  griseofulvin microsize (Grifulvin V) 125 mg/5 ml only  spironolactone (Aldactone)  guaifenesin/codeine (Robitussin AC)  nystatin (Mycostatin) -lowering Agent  hydrocodone-homatropine (Hycodan) Antimalarial  atorvastatin (Lipitor)  promethazine vc-codeine (Phenergan VC w/codeine)  (Plaquenil)  cholestyramine (Questran/Questran Light) Nasal Steroid Antiviral  gemfibrozil (Lopid)  fluticasone (Flonase)  acyclovir (Zovirax); 400 and 800 mg tab only  lovastatin (Mevacor)  valacylovir (Valtrex) CARDIOVASCULAR  pravastatin (Pravachol) Cephalosporin Alpha Blocker  rosuvastatin (Crestor/Ezallor Sprinkle)  cefaclor (Ceclor)  doxazosin (Cardura)  simvastin (Zocor)  cefadroxil (Duricef)  tamsulosin (Flomax) Peripheral Vasodilator  cefuroxime (Ceftin)  terazosin (Hytrin)  isoxsuprine (Vasodilan)  cephalexin (Keflex) Angiotensin-Converting Enzyme (ACE) Inhibitor Potassium Supplement Macrolide  enalapril maleate (Vasotec)  potassium bicarbonate (Effer-K, K-Lyte)  azithromycin (Zithromax) QL  lisinopril (Zestril)  potassium chloride er (Micro K)  potassium chloride (Klor-Con)  propantheline (Pro-Banthine)  duloxetine (Cymbalta) Anti-Ulcer  escitalopram (Lexapro) DERMATOLOGIC sucralfate (Carafate)  fluoxetine (Prozac) Anti-Infective  imipramine (Tofranil)  bacitracin ointment  mirtazapine (Remeron)  erythromycin base (A/T/S 2%) gel/solution  lactulose (Cephulac) syrup  nortriptyline (Pamelor)  clindamycin ph 1% (Cleocin T 1%) solution  peg 3350/electrolyte solution (Colyte)  paroxetine (Paxil)  metronidazole 0.75% gel, cream, lotion  sertraline (Zoloft)  mupirocin 2% (Bactroban) Proton Pump Inhibitor  trazodone (Desyrel)  silver (Silvadene 1%) cream  omeprazole (Prilosec)  venlafaxine (Effexor)  omeprazole dr (Prilosec) Antimanic Antifungal  pantoprazole sod dr (Protonix)  lithium carbonate (Lithotabs)  betramethasone/clotrimazole (Lotrisone) Rectal Cream Antiparkinson  ciclopirox 8% solution (Penlac)  hydrocortisone cream (Miscort-HC)  amantadine hcl (Symmetrel)  clotrimazole (Lotrimin)  proctozone HC cream (Anusol-HC)  benztropine mesylate (Cogentin)  ketoconazole (Nizoral) 2% shampoo Rectal Prep  carbidopa/levodopa (Sinemet)  nystatin/triamcin (Mycolog II) cream/ointment  hydrocortisone (Anucort-HC) suppository  trihexyphenidyl (Artane)  nystatin (Mycotastin)  nystatin (Nystop, Pedi-dri) OPHTHALMIC  fluphenazine (Prolixin) tablets  terbinafine (Lamisil) Anti-Infective  haloperidol (Haldol)  ciprofloxacin 0.3% drops (Ciloxan)  loxapine succinate (Loxitane) Antiparasitic  erythromycin base (Ilotycin) ointment  permethrin (Elimite) 5% cream  gentamicin (Garamycin)  olanzapine (Zyprexa)  pamoate (Pin X)  /bacitracin (Cortisporin/Neomycin) drops/oint.  perphenazine (Trilafon)  ofloxacin (Ocuflox) 0.3%  quetiapine (Seroquel) topical  sulfacetamide 10%/sulfacetamide sodium 10% (Bleph-10)  risperidone (Risperdal)  betamethasone (Valisone)  tobramycin (Tobrex)  thiothixene (Navane)  desoximetasone (Topicort)  trifluoperazine hcl (Stelazine)  fluocinolone (Synalar) Anti-Inf/NSAID CNS  fluocinide (Lidex E)  flurbiprofen (ocufen) 0.03%  guanfacine (Intuniv)  methylphenidate (Ritalin and SR)  hydrocortisone 1%, 2.5% cream, oint., lotion Anti-Inf/Steroid

 triamcinolone .025%,0.1%,0.5% cream, oint., lotion  neomycin/polymixin/d (Maxitrol) / Miscellaneous  neomycin/polymysixB/hydrocortisone (Cortisporin) flurazepam hcl (Dalmane)  podofilox (Condylox 0.5%)  temazepam (Restoril)  selenium sulfide (Selsun 2.5%) shampoo Corticosteroid  triazolam (Halcion)  dexamethasone (Decadron 0.1%) drops   zolpidem tartrate (Ambien) QL DIABETES  prednisolone acetate (Pred Forte 1%)

Oral Dilator  chlorpropamide (Diabinese)  atropine sulfate (Isopto Atropine) Substance Abuse  glimepiride (Amaryl) Glaucoma  disulfiram (Antabuse)  glipizide (Glucotrol), ER/XL  acetazolamide (Diamox) 125 & 250mg tabs  naloxone nasal (Narcan)  glyburide (Diabeta/Micronase)  latanoprost (Xalatan) 0.005% drops naltrexone hcl (Revia) QL 1/day  metformin (Glucophage)  levobunolol (Betagan)   metformin HCL ER (Fortamet, Glucophage XR)  pilocarpine (Pilocarpine) WOMEN’S HEALTH Insulin - QL 3 vials/month  timolol maleate (Timoptic 0.25% & 0.5%) drops/ocudose Antifungal  Admelog 100 U/ML QL  brimonidine 0.2% drops  fluconazole (Diflucan)  Basaglar 100 U/ML Kwikpen  dorzolamide-timolol drops  miconazole 3, (Monistat 3) suppositories  Humalog Mix 75/25 QL  metronidazole 0.75% vaginal gel  Humulin N,R 100 U/ML QL OTIC (EAR)  (Tindamax) Anti-Infective  Levemir 100 U/ML, Flextouch AL 0-6, QL Estrogen/Antiestrogen  acetic acid (Vosol) solution  estradiol (Estrace)  Novolin, Novolog, Humulin 70/30 QL  ciprofloxacin hcl/dexamethasone (Ciprodex) 0.3% susp.  Novolin N 100 U/ML QL  anastrozole (Arimidex) Supplies PSYCHOTHERAPEUTIC/CNS  letrozole (Femara)  glucagon emergency kit QL Anti-Anxiety Oral Contraceptive  glucometer (Contour NextOne-*)  alprazolam (Xanax)  desogestrel/ethinyl Estradiol (Similya)  lancets, syringes, and needles  buspirone (Buspar)  norgestimate-ethinyl estradiol (Ortho-Cyclen)  test strips (Contour Next ) QL  chlordiazepoxide hcl (Librium)  norgestimate-ethinyl estradiol (Ortho-Tri-Cyclen) *WHP members may get a free Contour NextOne glucometer by calling  clorazepate (Tranxene)  progestin/estrogen (Hailey, Aurovela, Sprintec, Tri-Estarylla, Ascensia at 1-800-348-8100  diazepam (Valium) Mononessa, Mono-Linyah, Tri-Linyah, Tri-Sprintec,Tri-  lorazepam (Ativan) Previfem, Prvifem, Estarylla) GASTROINTESTINAL Progesterone Antagonist 2  carbamazepine (Tegretol)  medroxyprogesterone (Provera)  famotidine (Pepcid)  clonazepam (Klonopin) Progestin  ranitidine (Zantac), tab, syrup  divalproex sodium (Depakote & ER)  Norethindrone (Aygestin) Antidiarrheal  gabapentin (Neurontin) max 3600 mg/day diphenoxylate (Lomotil)  Sharobel (Micronor, Nor-Q-D)   lamotrigine (Lamictal) max 500 mg/day loperamide (Imodium)  Deblitane (Micronor, Nor-QD)   levetiracetam (Keppra) max 3000 mg/day Anti-inflammatory  phenobarbital (Phenobarbital) SUPPLEMENT  sulfasalazine (Azulfidine)  phenytoin (Dilantin)  vitamin d2 (Vitamin D 50000 IU) capsule Anti-nausea  primidone (Mysoline)  folic acid (Folic Acid)  meclizine (Antivert)  valproic acid (Depakene)  iron/multivits/min (B-Complex Vitamin Plus Tab)  metoclopramide (Reglan)  ondansetron (Zofran)  aripiprazole (Abilify) MISCELLANEOUS  prochlorperazine (Compazine) tablets  perphenazine-amitriptyline (Etrafon, Triavil)  promethazine (Phenergan)  amitriptyline (Elavil)  lidocaine (Xylocaine Viscous 2%) solution  promethazine (Phenergan) suppository 25mg  chlordiazepo-amitriptyline (Limbitrol) Anti-Thyroid Antispasmodic  bupropion SR (Wellbutrin)  methimazole (Tapazole)  belladonna (Donnatal) elixir only  bupropion XL (Aplenzin, Wellbutrin XL)  propylthiouracil (Propylthiouracil)  clidinium (Librax)  citalopram (Celexa) Corticosteroid  dicyclomine (Bentyl)  desipramine (Norpramin)  dexamethasone (Decadron)  hyoscyamine sulfate (Levsin/Levsinex)  doxepin (Sinequan)  methylprednisolone (Medrol Dosepak)  prednisone (Prednisone/Deltasone)  prednisolone (Orapred) Flu (Anti-Viral)  Oseltamivir (Tamiflu) Flu  IM injection; zero copay  nasal spray; zero copay Immunosuppressive  azathioprine (Imuran) Osteoporosis  alendronate sodium (Fosamax) 70 mg only QL Thyroid  levothyroxine (Synthroid)  np thyroid (Armour Thyroid) Urinary Tract  oxybutynin (Ditropan)  phenazopyridine (Pyridium)

WHP Formulary Contact Number Customer Service: toll free (866) 291-8691

Updated 08/01/2021