High Cost Generics (HCG) Drug List

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GlobalHealth, in partnership with MagellanRx, continually monitors generic medications to offer the best overall health care value at the lowest possible tier. A Generic Drug is equivalent to its brand name counterpart. While generic medications are usually less expensive than brand name medications, certain generics are not always the lowest cost option. There are times where a generic alternative can be more expensive than other generic medications within the same therapeutic class. We have identified options for members to reduce out-of-pocket costs, while offering the same clinical benefit.

The following is the 2021 list of High Cost Generics. For additional questions on lower cost options please consult your primary care physician or contact Magellan at 1-800-424-1789. Please Note: High Cost Generics will process at Tier 3 copays.

Drug Name Alternatives ACETAMN-CAF- ACETAMIN-CAF-DIHYDROCODEIN DIHYDRCODEIN 320.5 325 CAPSULE ALCLOMETASONE DIPR ALCLOMETASONE DIPRO 0.05% CRM 0.05% OINT BUTALBITAL- ALLZITAL 25-325 MG TABLET ACETAMINOPHN 50-325 ALMOTRIPTAN MALATE TAB NARATRIPTAN HCL sumatriptan zolmitriptan AMCINONIDE 0.1% CREAM aclometasone desonide AMCINONIDE 0.1% LOTION aclometasone desonide APREPITANT 125-80-80 MG PACK ondansetron Aprepitant capsule AVAR-E GREEN EMOLLIENT CREAM AVAR-E EMOLLIENT CREAM NEO-POLYCIN EYE BACITRACIN 500 UNIT/GM OPHTH GENTAMICIN 0.3% EYE DROP OINTMENT NEO-POLYCIN EYE BACITRACIN-POLYMYXIN EYE OINT GENTAMICIN 0.3% EYE DROP OINTMENT BENAZEPRIL-HCTZ TAB lisinopril/hydrochlorothiazide BENZONATATE CAPSULE OTC robitussin BENZTROPINE 2 MG/2 ML AMPULE trihexyphenidyl hcl Benztropine Vial BETAMETHASONE VALER 0.12% aclometasone desonide FOAM

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Drug Name Alternatives BIMATOPROST 0.03% EYE DROPS Latanoprost BIMATOPROST 0.03% EYELASH SOLN n/a BP 10-1 WASH AVAR-E EMOLLIENT CREAM BRIMONIDINE 0.2% EYE BRIMONIDINE TARTRATE 0.15% DRP DROP BROMFENAC SODIUM 0.09% EYE diclofenac flurbiprofen ketorolac DRP BROMOCRIPTINE 2.5 MG TABLET Carbidopa/Levodopa Benztropine BROMOCRIPTINE 5 MG CAPSULE Carbidopa/Levodopa Benztropine BUDESONIDE 0.25 MG/2 ML BUDESONIDE 0.5 MG/2 ML BUDESONIDE 1 MG/2 ML INH SUSP SUSP SUSP BUDESONIDE EC 3 MG CAPSULE prednisone BUMETANIDE TABLET torsemide furosemide Bumetanide 0.5mg BUTALBITAL- BUTALBITAL-ACETAMINOPHN 50-300 ACETAMINOPHEN 50-325 TABLET CAFFEINE CIT 60 MG/3 ML ORAL Butalbital/Caffiene/APAP CALCIPOTRIENE 0.005% CREAM CALCIPOTRIENE OINTMENT CALCIPOTRIENE SOLUTION TRIAMCINOLONE 0.025% CALCITRENE 0.005% OINTMENT OINT CALCIPOTRIENE 0.005% CALCIPOTRIENE 0.005% CALCITRIOL 3 MCG/G OINTMENT OINTMENT CREAM CAPTOPRIL TABLET Lisinopril CARBINOXAMINE MALEATE 6 MG CARBINOXAMINE MALEATE

TAB 4 MG TAB CARISOPRODOL 250 MG TABLET Carisoprodol 350mg CARVEDILOL ER CAPSULE Carvedilol CERAMAX SKIN BARRIER CREAM OTC emollient CHLORZOXAZONE 500 MG CHLORZOXAZONE 250 MG TABLET TABLET CLINDAMYCIN PH 1% CLINDACIN ETZ 1% PLEDGET SOLUTION CLINDAMYCIN PH 1% CLINDACIN P 1% PLEDGETS SOLUTION CLINDAMYCIN PHOSPHATE 1% CLINDAMYCIN PH 1%

FOAM SOLUTION CLINDA-TRETINOIN 1.2%-0.025% Clinda-Benzoyl Peroxide CLOBETASOL 0.05% TOPICAL LOTN aclometasone desonide CLOBETASOL EMOLLNT 0.05% FOAM aclometasone desonide CLOBETASOL EMULSION 0.05% aclometasone desonide FOAM CLOBETASOL PROP 0.05% FOAM aclometasone desonide CLOBETASOL PROP 0.05% SPRAY aclometasone desonide

Drug Name Alternatives CLOCORTOLONE 0.1% CREAM PUMP aclometasone desonide CLOCORTOLONE PIVALATE 0.1% CRM aclometasone desonide CLOBETASOL 0.05% CLODAN 0.05% SHAMPOO SHAMPOO CLONIDINE HCL ER 0.1 MG TABLET Clonidine CLONIDINE PATCH Clonidine Tablet CLOTRIMAZOLE-BETAMETHASONE CLOTRIMAZOLE-

LOT BETAMETHASONE CREAM COLESTIPOL HCL 1 GM TABLET FENOFIBRATE 54 MG TABLET COLESTIPOL HCL GRANULES FENOFIBRATE 54 MG TABLET COLESTIPOL HCL GRANULES PACKET FENOFIBRATE 54 MG TABLET COLESTIPOL MICRONIZED 1 GM TAB FENOFIBRATE 54 MG TABLET CORTISONE 25 MG TABLET Hydrocortisone CVS OMEPRAZOLE-BICARB 20-1,100 Omeprazole CYCLOBENZAPRINE 10 MG CYCLOBENZAPRINE 7.5 MG TABLET TABLET CYCLOBENZAPRINE 10 MG CYCLOBENZAPRINE ER TABLET CARISOPRODOL 350 mg CYCLOBENZAPRINE 10 MG DANTROLENE SODIUM CAP tablet TABLET SODIUM SULFACETAMIDE CLINDAMYCIN-BENZOYL DAPSONE 5% GEL LOTION PEROXIDE GEL DESLORATADINE ODT FEXOFENADINE FEXOFENADINE OTC DESMOPRESSIN AC 4 MCG/ML VIAL Desmopressin Tablet DESOXIMETASONE 0.05% CREAM aclometasone desonide DESOXIMETASONE 0.05% OINTMENT aclometasone desonide DESVENLAFAXINE ER TAB desvenlafaxine fumarate DEXAMETHASONE 1.5 MG DEXAMETHASONE 10 DAY 1.5 MG TB TABLET DEXAMETHASONE 1.5 MG DEXAMETHASONE 13 DAY 1.5 MG TB TABLET DEXAMETHASONE 1.5 MG DEXAMETHASONE 6 DAY 1.5 MG TAB TABLET

DEXCHLORPHENIRAMINE 2 MG/5 ML

DICLOFENAC 1.5% TOPICAL SOLN Diclofenac 1% DICLOFENAC EPOLAMINE 1.3% PTCH ACETAMINOPHEN (OTC) THERMACARE (OTC) IBUPROFEN (OTC) DICLOFENAC SOD DR 50 MG DICLOFENAC SOD DR 25 MG TAB TAB FLUOROURACIL 5% TOPICAL DICLOFENAC SODIUM 3% GEL SOLN DIFLORASONE 0.05% CREAM aclometasone desonide DIFLORASONE 0.05% OINTMENT aclometasone desonide

Drug Name Alternatives DIGOXIN 0.05 MG/ML SOLUTION Digoxin Tablet DOXEPIN 5% CREAM OTC Anti-Itch cream Doxycycline Hyclate DOXYCYCLINE HYC DR TAB Doxycycline Hyclate 50mg 100mg Doxycycline Hyclate DOXYCYCLINE HYCLATE TAB Doxycycline Hyclate 50mg 100mg Doxycycline Monohydrate DOXYCYCLINE IR-DR 40 MG CAP Doxycycline Monohydrate 50mg 100mg Doxycycline Monohydrate DOXYCYCLINE MONO CAP Doxycycline Monohydrate 50mg 100mg Doxycycline Monohydrate DOXYCYCLINE MONO TABLET Doxycycline Monohydrate 50mg 100mg DROSP-EE-LEVOMEF 3-0.03- DROSP-EE-LEVOMEF 3-0.02-0.451 0.451 ENDOCET TABLET Oxycodone/APAP 5-325mg

ENTACAPONE 200 MG TABLET Carbidopa/Levodopa/Entacapone

EPLERENONE TABLET Spironolactone BUTALB-ACETAMIN-CAFF 50-325- ESGIC CAPSULE 40 ESOMEPRAZOLE DR 49.3 MG CAP LANSOPRAZOLE OMEPRAZOLE ESOMEPRAZOLE DR PACKET LANSOPRAZOLE OMEPRAZOLE ESTRADIOL TDS 0.075 MG/DAY Estradiol tablet Estradiol patches ESTRADIOL VALERATE VL Estradiol tablet Estradiol patches ETHACRYNIC ACID 25 MG TABLET torsemide furosemide ETODOLAC ER 500 MG TABLET ibuprofen naproxen FAMOTIDINE 20 MG/5 ML-NS FAMOTIDINE 20 MG PIGGYBACK SYR FAMOTIDINE 40 MG/5 ML SUSP Famotidine Tablet FENOFIBRATE 48 MG FENOFIBRATE 50 MG CAPSULE FENOFIBRATE 54 MG TABLET TABLET FENOFIBRATE CAPSULE Fenofibrate 134mg FENOFIBRATE TABLET Fenofibrate 134mg FENOPROFEN CAPSULE Ibuprofen FENTANYL 100 MCG/HR FENTANYL 25 MCG/HR FENTANYL 37.5 MCG/HR PATCH FENTANYL 12 MCG/HR PATCH PATCH PATCH FENTANYL 100 MCG/HR FENTANYL 25 MCG/HR FENTANYL 62.5 MCG/HR PATCH FENTANYL 12 MCG/HR PATCH PATCH PATCH FENTANYL CIT OTFC Morphine Oxycodone ER FLUOCINOLONE 0.01% SCALP OIL aclometasone desonide FLUOCINOLONE 0.01% SOLUTION aclometasone desonide FLUOCINOLONE 0.025% CREAM aclometasone desonide FLUOCINOLONE 0.025% OINTMENT aclometasone desonide FLUOCINOLONE OIL 0.01% EAR FLAC OTIC OIL 0.01% EAR DROP DRP FLUOCINONIDE 0.1% CREAM aclometasone desonide

Drug Name Alternatives FLUOXETINE DR 90 MG CAPSULE Fluoxetine Capsule FLUOXETINE HCL TABLET Fluoxetine Capsule FLURANDRENOLIDE 0.05% CREAM aclometasone desonide FLURANDRENOLIDE 0.05% LOTION aclometasone desonide FLURANDRENOLIDE 0.05% aclometasone desonide OINTMENT FLUTICASONE PROP 0.05% LOTION aclometasone desonide FLUVASTATIN ER 80 MG TABLET atorvastatin lovastatin pravastatin FLUVASTATIN SODIUM CAP atorvastatin lovastatin pravastatin FROVATRIPTAN SUCC 2.5 MG TAB naratriptan sumatriptan zolmitriptan GATIFLOXACIN 0.5% EYE DROPS Moxifloxacin GAVILYTE-N SOLUTION GAVILYTE-C SOLUTION LIDOCAINE HCL 2% JEL GLYDO 2% JELLY SYRINGE UROJET AC GRISEOFULVIN MICRO 500 MG TAB Terbinafine GRISEOFULVIN ULTRA TAB Terbinafine DEXAMETHASONE 1.5 MG HIDEX 6 DAY 1.5 MG TABLET TABLET HYDROCOD-CPM-PSEUDOEP 5-4- Hydrocodone OTC PSEUDOEPHEDRINE 60/5 HYDROCODONE-ACETAMIN 10-300 Hydrocodone/APAP 10-325 MG HYDROCODONE-ACETAMIN 5-300 Hydrocodone/APAP 5-325 MG HYDROCODONE-ACETAMIN 7.5-300 Hydrocodone/APAP 7.5-325 HYDROCODONE-ACETAMN 7.5- Hydrocodone/APAP 5-325mg 325/15 HYDROCODONE-HOMATROPINE 5- HYDROCODONE-

1.5 HOMATROPINE SOLN HYDROCODONE-IBUPROFEN 10-200 Hydrocodone/APAP HYDROCODONE-IBUPROFEN 5-200 Hydrocodone/APAP MG HYDROCORT BUTY 0.1% LIPID CRM Hydrocortisone Buty Lotion HYDROCORT BUTY 0.1% LIPO CREAM Hydrocortisone Buty Lotion HYDROCORTISONE 1% HYDROCORTISONE 1% ABSORBASE CREAM HYDROMORPHONE 1 MG/ML MORPHINE SULF 10 MG/5

SOLUTION ML SOLN MORPHINE SULF 10 MG/5 HYDROMORPHONE 5 MG/5 ML SOLN ML SOLN HYDROMORPHONE HCL ER TAB Morphine Oxycodone ER IMIQUIMOD 5% CREAM IMIQUIMOD 3.75% CREAM PUMP PACKET IODOQUINOL-HYDROCORT-ALOE GEL n/a KETOCONAZOLE 2% FOAM Ketoconazole Cream KETOPROFEN 50 MG CAPSULE ibuprofen naproxen KETOPROFEN ER 200 MG CAPSULE ibuprofen naproxen 5 │ 2020. Magellan Rx Management, LLC. All rights reserved. MRX1305_1219

Drug Name Alternatives LACTULOSE 10 GM PACKET lactulose solution LANTHANUM CARB 1,000 MG TB SEVELAMER CARBONATE

CHW 800 MG TABLET LEVORPHANOL TABLET morphine LIDOCAINE HCL 2% JEL LIDOCAINE HCL 2% JELLY URO-JET UROJET AC LIDOCAINE HCL 3% LOTION LIDOCAINE 4% CREAM LIDOCAINE HCL 4% SOLUTION LIDOCAINE 4% CREAM LIDOCAINE-PRILOCAINE CREAM LIDOCAINE 4% CREAM LIDOCAINE-PRILOCAINE LIDOCAINE-TETRACAINE 7%-7% CRM CREAM LINDANE 1% SHAMPOO NIX Permethrin MALATHION 0.5% LOTION Permethrin NIX MECLOFENAMATE CAPSULE Allopurinol MEFENAMIC ACID 250 MG CAPSULE ibuprofen naproxen MELODETTA 24 FE CHEWABLE TAB JUNEL FE 24 TABLET BLISOVI 24 FE TABLET MESALAMINE 4 GM/60 ML KIT Mesalamine Tablet METAXALONE TABLET METHOCARBAMOL METFORMIN HCL ER 500 MG METFORMIN HCL ER 750 METFORMIN ER GASTR-TB TABLET MG TABLET METFORMIN HCL ER 500 MG METFORMIN HCL ER 750 METFORMIN ER OSM-TAB TABLET MG TABLET METHAMPHETAMINE 5 MG TABLET AMPHETAMINE DEXTROAMP-AMPHET METHAZOLAMIDE 50 MG TABLET Acetazolamide METHYLTESTOSTERONE 10 MG CAP Testosterone Cypionate Metoprolol and METOPROLOL ER-HCTZ Hydrochlorothiazide MIBELAS 24 FE CHEWABLE TABLET JUNEL FE 24 TABLET BLISOVI 24 FE TABLET DESITIN DIAPER RASH 40% MICONAZOLE-ZINC-PETRO 0.25-15% PASTE (OTC) JEVANTIQUE LO 0.5 MG-2.5 MIMVEY LO 0.5-0.1 MG TABLET MCG MINOCYCLINE ER CAPSULE MINOCYCLINE IR CAPSULE MINOCYCLINE ER TABLET Minocycline capsule MINOCYCLINE HCL TABLET Minocycline capsule Doxycycline Monohydrate Doxycycline Monohydrate MONDOXYNE NL 75 MG CAPSULE 50mg 100mg MONTELUKAST SOD 4 MG MONTELUKAST SOD TAB

GRANULES CHEW MORPHINE 2 MG/ML CARPUJECT Oxycodone ER MORPHINE SULF ER 200 MG TABLET Oxycodone ER MORPHINE SULFATE ER CAP Oxycodone ER MORPHINE SULFATE ER CAP Oxycodone ER ATENOLOL- NADOLOL-BENDROFLU 80-5 MG TAB BISOPROLOL-HCTZ CHLORTHALIDONE

Drug Name Alternatives NAFTIFINE HCL 1% GEL CLOTRIMAZOLE NAFTIFINE HCL CREAM Clotrimazole NAPROXEN 125 MG/5 ML SUSPEN ibuprofen NAPROXEN SOD CR TABLET ibuprofen NAPROXEN SOD ER 500 MG TABLET ibuprofen NAPROXEN SODIUM TAB ibuprofen NEOMYC-POLYM-DEXAMET NEO-POLYCIN HC EYE OINTMENT EYE OINTM NIACIN ER TABLET Niacin OTC NICARDIPINE 30 MG CAPSULE Nicardipine 20mg NISOLDIPINE ER TABLET diltiazem VERAPAMIL ER NIZATIDINE 15 MG/ML SOLUTION NIZATIDINE CAPSULE NORETH-ESTRAD-FE 1-0.02(24)-75 JUNEL FE 24 TABLET BLISOVI 24 FE TABLET NUDICLO SOLUPAK diclofenac capsaicin NUDICLO TABPAK diclofenac capsaicin TRIAMCINOLONE 0.1% NUTRIARX CREAMPAK CREAM NYSTATIN 100,000 UNIT/GM NYSTATIN-TRIAMCINOLONE OINTM CREAM OMEPRAZOLE-BICARB CAP Omeprazole OMEPRAZOLE-BICARB PKT Omeprazole OXAPROZIN 600 MG CAPLET ETODOLAC OXAPROZIN 600 MG TABLET ETODOLAC OXICONAZOLE NITRATE 1% CREAM Clotriamzole OXYCODON-ACETAMINOPHEN 2.5- Oxycodone/APAP 5-325mg 325 OXYCODONE HCL 100 MG/5 ML OXYCODONE ER TABLET CONC OXYCODONE HCL 5 MG OXYCODONE HCL 5 MG CAPSULE TABLET OXYCODONE HCL 5 MG/5 ML SOLN OXYCODONE ER TABLET OXYMORPHONE HCL ER 5 MG MORPHINE SULF ER TABLET TABLET OXYMORPHONE HCL ER TAB Morphine Oxycodone ER PHENOHYTRO TABLET n/a PHENOXYBENZAMINE HCL 10 MG prazosin terazosin CAP POTASSIUM CL 20 MEQ PACKET KLOR-CON 20 MEQ PACKET LIDOCAINE-PRILOCAINE PRIKAAN 2.5%-2.5% CREAM DRESS CREAM PROCTOZONE-HC 2.5% CREAM PROCTOSOL-HC 2.5% CREAM PYRIDOSTIGMINE BR 60 MG PYRIDOSTIGMINE BR 30 MG TABLET TABLET PYRIDOSTIGMINE ER 180 MG TAB Neostigmine DROSP-EE-LEVOMEF 3-0.03- RAJANI 28 TABLET 0.451 RISEDRONATE SOD DR TAB Alendronate

Drug Name Alternatives SEASONIQUE 0.15-0.03-0.01 JAIMIESS 0.15-0.03-0.01 RIVELSA TABLET TAB MG TAB DIPHENHYDRAMINE 25 MG RYVENT 6 MG TABLET CAPSULE SALICYCLIC ACID 6% SALICYLIC ACID 6% FOAM SALICYCLIC ACID 6% CREAM LOTION SALICYCLIC ACID 6% SALICYLIC ACID 6% GEL SALICYCLIC ACID 6% CREAM LOTION SALICYCLIC ACID 6% SALICYLIC ACID ER 28.5% SOLN SALICYCLIC ACID 6% CREAM LOTION SEVELAMER 2.4 GM POWDER SEVELAMER CARBONATE

PACKET 800 MG TAB SOD SULFACE-SULF 9.8-4.8% CLSR AVAR CLEANSER SOD SULFACETAM 10% CLNSNG GEL AVAR CLEANSER SOD SULFACETAMIDE 10% N/A SHAMPOO SOD SULFACETAMIDE-SULFUR LOTN AVAR -E EMOLLIENT CREAM SULFACLEANSE 8-4 SOD SULFACETAMIDE-SULFUR SUSP SUSPENSION SOD SULFACET-SULFUR 10-2% CLSR AVAR CLEANSER SOD SULFAC-SULFUR 9.8-4.8% CRM AVAR -E EMOLLIENT CREAM SOD SULFAC-SULFUR 9.8-4.8% LOT AVAR -E EMOLLIENT CREAM SODIUM SULFACET-SULFUR WASH AVAR CLEANSER SPINOSAD 0.9% TOPICAL SUSP Permethrin NIX SULFACETAMIDE-SULFUR CRM AVAR -E EMOLLIENT CREAM SUMATRIPTAN-NAPROXEN 85-500 SUMATRIPTAN NAPROXEN MG METAPROTERENOL 10 MG TERBUTALINE SULFATEG TAB TABLET TERCONAZOLE 80 MG SUPPOSITORY TERCONAZOLE 0.8% CREAM CYCLOBENZAPRINE 10 MG TIZANIDINE HCL CAPSULE TABLET TOLMETIN SODIUM 400 MG CAP ibuprofen naproxen CLOBETASOL EMOLLIENT TOVET EMOLLIENT 0.05% FOAM CLOBETASOL 0.05% CREAM 0.05% CRM TRAMADOL HCL ER CAPSULE Tramadol ER Tab TRETINOIN GEL MICRO PUMP TRETINOIN 0.05% CREAM TRETINOIN GEL MICRO TUBE TRETINOIN 0.05% CREAM

TRIAMCINOLONE 0.147 MG/G SPRAY TRIAMCINOLONE OINTMENT

URELLE TABLET n/a URIBEL CAPSULE USTELL CAPSULE UTIRA-C TABLET n/a VARDENAFIL HCL 10 MG ODT SILDENAFIL TABLET TADALAFIL TABLET VARDENAFIL HCL TABLET SILDENAFIL TABLET TADALAFIL TABLET VASHE WOUND THERAPY SOLUTION n/a VENLAFAXINE HCL ER TAB Venlafaxine ER Cap

Drug Name Alternatives VERAPAMIL 360 MG CAP PELLET Verapamil ER tablet VICODIN 5-300 MG TABLET Hydrocodone/APAP 5-325mg Hydrocodone/APAP 10- VICODIN HP 10-300 MG TABLET 325mg NORET-ESTR-FE 0.4- WYMZYA FE CHEWABLE TABLET 0.035(21)-75 XELITRAL PACK diclofenac capsaicin ZILEUTON ER 600 MG TABLET Zileuton IR ZOLPIDEM TART 1.75 MG TAB SL Zolpidem tablet ZOLPIDEM TART 3.5 MG TABLET SL Zolpidem tablet