Washtenaw Health Plan B Quick Drug 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 medications. 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) + Diuretic ANALGESIC erythromycin (E.E.S. or Erythrocin) lisinopril/HCTZ (Zestoretic) Antiarthritic Lincomycin Angiotensin II Receptor Blocker allopurinol (Zyloprim) clindamycin (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 > Sulfonamide Anticoagulant 60mg/day sulfamethoxazole/trimethoprim (Bactrim/Bactrim DS) warfarin (Coumadin) Muscle Relaxant sulfasalazine (Azulfidine) Antihypertensive - Misc. baclofen (Lioresal) TB clonidine (Catapres) carisoprodol (Soma) isoniazid (INH) guanfacine hcl (Tenex) cyclobenzaprine hcl (Flexeril) Tetracycline hydralazine Apresoline) methocarbamol (Robaxin) doxycycline 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) Beta Blocker 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) Calcium Channel Blocker 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 Bronchodilator ANTI-INFECTIVE bumetanide (Bumex) epinephrine (Epipen and Epipen JR) QL Antibacterial chlorthalidone (Hygroton) Cough and Cold metronidazole (Flagyl) furosemide (Lasix) benzonatate (Tessalon Perle) 100 mg cap only Antifungal 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) Lipid-lowering Agent hydrocodone-homatropine (Hycodan) Antimalarial atorvastatin (Lipitor) promethazine vc-codeine (Phenergan VC w/codeine) hydroxychloroquine (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 Laxative 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 sulfadiazine (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) Antipsychotic 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) pyrantel pamoate (Pin X) neomycin/bacitracin (Cortisporin/Neomycin) drops/oint. perphenazine (Trilafon) ofloxacin (Ocuflox) 0.3% quetiapine (Seroquel) Corticosteroid 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 Stimulant 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) Sedative/Hypnotic 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 Drugs 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) tinidazole (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 Anticonvulsant 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) VITAMIN 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) Antidepressants ondansetron (Zofran) aripiprazole (Abilify) MISCELLANEOUS prochlorperazine (Compazine) tablets perphenazine-amitriptyline (Etrafon, Triavil) Anesthetic 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 Vaccine 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