High-Cost Drug Exclusions

Core Formulary

PHARMACY SERVICES

The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at the lowest cost, consider talking with your doctor about one of the therapeutically equivalent (similar safety and efficacy) or over-the-counter (OTC) alternatives listed below. We encourage you to talk to your doctor about whether one of these options is right for you. Coverage of alternatives will vary.

These high cost medications may be considered medically necessary when ALL of the alternatives in the table below have been ineffective, not tolerated or all are contraindicated, unless otherwise specified. If your doctor believes that the listed alternatives are not right for you, your doctor may request an exception by contacting Customer Service. Please visit your health plan’s website or contact Customer Service at the number listed on the back of your member ID card for more information about medication coverage.

Questions? Call the Customer Service number on your member ID card.

Asuris complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-344-6347 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-344-6347 (TTY: 711). High-Cost Drug Exclusion List Effective 10/1/2021 Core Formulary

Drug Alternatives

Absorica Amnesteem, Claravis, isotretinoin (generic Accutane), Myorisan, Zenatane

Absorica LD Amnesteem, Claravis, isotretinoin, Myorisan, Zenatane clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% Acanya gel

Accrufer over-the-counter (OTC) iron and ferrous sulfate doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin Acticlate capsule], minocycline IR capsule acyclovir 5% cream (generic Zovirax) acyclovir 5% ointment At least three of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and Aczone 0.025% gel adapalene 0.1% cream, adapalene 0.1% gel, and at least two of the following lower cost products: adapalene 0.3% gel, clindamycin phosphate 1% solution/ adapalene 0.1% pads, gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin solution (generic Differin) 0.01% and 0.025% gel

AirDuo Digihaler fluticasone-salmeterol (generic AirDuo), Advair Diskus, Advair HFA

Aklief cream tretinoin cream, tretinoin 0.01% and 0.025% gel desoximetasone 0.25% cream, fluocinonide 0.05% solution, hydrocortisone Ala-Scalp 2.5% lotion

Alkindi Sprinkle hydrocortisone tablet At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen-caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325-40mg capsule Allzital or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating almotriptan (generic Axert) tablet

Altoprev atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin betamethasone dipropionate 0.05% cream, desoximetasone 0.25% ointment, fluocinonide 0.05% cream, fluocinonide 0.05% gel, fluocinonide 0.05% amcinonide cream, lotion, ointment, fluticasone propionate 0.005% ointment, triamcinolone 0.5% cream, ointment triamcinolone 0.5% ointment generic naratriptan and at least one of the following lower cost triptan medications: eletriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally Amerge disintegrating tablet amlodipine-atorvastatin tablet amlodipine in combination with atorvastatin, amlodipine in combination with (generic Caduet) rosuvastatin or simvastatin cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, Amrix metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

Core Formulary Drug Alternatives At least three of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and Amzeeq 0.025% gel At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized Antara 43mg, 67mg, 130mg, 134mg, and 200mg capsule desoximetasone 0.05% cream, fluocinonide 0.05% cream, triamcinolone 0.5% ApexiCon E cream tazarotene 0.1% cream and at least two of the following lower cost products: adapalene 0.1% cream/gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/gel/lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and Arazlo 0.025% gel Arnuity Ellipta, Asmanex HFA, Asmanex Twisthaler, Flovent Diskus, Flovent ArmonAir Digihaler HFA

Atelvia alendronate, ibandronate, risedronate IR (immediate-release)

Belsomra eszopiclone, zaleplon, zolpidem benzonatate 100mg and 200mg capsule, guaifenesin-codeine 100-10mg/5ml solution, promethazine-codeine 6.25-10mg/5ml syrup, promethazine-dm 6.25- benzonatate 150mg capsule 15mg/5ml syrup betamethasone valerate 0.12% external foam (generic betamethasone dipropionate 0.05% cream, betamethasone valerate 0.1% Luxiq) ointment, mometasone furoate 0.1% solution (lotion), triamcinolone 0.5% cream

Bijuva estradiol in combination with progesterone, Fyavolv, Jevantique Lo, Jinteli

Binosto alendronate tablet, alendronate solution betamethasone dipropionate augmented 0.05% lotion, betamethasone valerate Bryhali 0.1% ointment, clobetasol propionate 0.05% lotion At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen-caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325-40mg capsule Bupap or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen-caffeine butalbital-acetaminophen 25- 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325-40mg capsule 325mg tablet or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50- butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen-caffeine 300mg capsule (generic 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325-40mg capsule Bupap) or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule amlodipine in combination with atorvastatin, amlodipine in combination with Caduet rosuvastatin or simvastatin At least one of the following lower cost ergot-containing medications: generic Cafergot ergotamine/ caffeine tablet, generic dihydroergotamine injection calcipotriene 0.005% foam (generic Sorilux) calcipotriene 0.005% cream/ ointment/ solution, tazarotene 0.1% cream calcitriol 3mcg/gm ointment (generic Vectical) calcipotriene 0.005% cream/ ointment/ solution, tazarotene 0.1% cream

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Core Formulary Drug Alternatives diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, Cambia packets nabumetone, naproxen, sulindac

Capex fluocinolone 0.01% oil (scalp oil), fluocinolone 0.01% solution

Carac fluorouracil 5% cream, fluorouracil 2% solution, fluorouracil 5% solution

Centany mupirocin 2% ointment

Chenodal ursodiol 300mg capsule, 250mg tablet, 500mg tablet chlorzoxazone 250mg, chlorzoxazone 500mg tablet at least two of the following lower cost products: 375mg, 750mg tablet (generic baclofen, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, Lorzone) methocarbamol tablet, tizanidine tablet clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% Cleocin-T gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% Clindacin-P gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% Clindacin ETZ gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% Clindagel gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene clindamycin 1% topical gel 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% (generic Clindagel) gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene clindamycin foam (generic 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% Evoclin) gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene clindamycin swab (generic 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% Clindacin-P, Clindacin ETZ) gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least clindamycin-benzoyl two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene peroxide 1.2-2.5% (generic 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% Acanya) gel clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene clindamycin-tretinoin topical 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel (generic Veltin, Ziana) gel clobetasol foam (generic At least two lower cost forms of clobetasol propionate including cream, gel, Olux) lotion, ointment, and solution clobetasol emulsion foam At least two lower cost forms of clobetasol propionate including cream, gel, (generic Olux-E) lotion, ointment, and solution

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Core Formulary Drug Alternatives clobetasol spray (generic At least two lower cost forms of clobetasol propionate including cream, gel, Clobex) lotion, ointment, and solution At least two lower cost forms of clobetasol propionate including cream, gel, Clobex lotion, ointment, and solution clocortolone 0.1% cream fluocinolone 0.025% ointment, mometasone 0.1% cream, triamcinolone 0.1% (generic Cloderm) cream fluocinolone 0.025% ointment, mometasone 0.1% cream, triamcinolone 0.1% Cloderm cream, pump cream amlodipine and at least two additional calcium channel blockers, such as Conjupri diltiazem, felodipine, nifedipine, or verapamil

Consensi amlodipine in combination with celecoxib fluocinonide 0.05% ointment, hydrocortisone 1% ointment, triamcinolone 0.1% Cordran tape ointment desonide 0.05% cream and lotion, fluocinonide 0.05% ointment, hydrocortisone Cordran 0.05% cream, 1% ointment, triamcinolone 0.1% ointment, triamcinolone 0.025% lotion and ointment ointment doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin CoreMino capsule], minocycline IR capsule

Cuprimine penicillamine 250mg tablet (generic Depen Titratabs) betamethasone dipropionate 0.05% lotion, fluocinolone 0.025% cream, Cutivate triamcinolone 0.1% lotion cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the cyclobenzaprine 7.5mg tablet following lower cost products: baclofen, chlorzoxazone 500mg tablet, (generic Fexmid) metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet cyclobenzaprine ER cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the (extended-release) capsule following lower cost products: baclofen, chlorzoxazone 500mg tablet, [generic Amrix] metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet At least three of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic dapsone 5% and 7.5% gel Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and (generic Aczone) 0.025% gel

Dayvigo eszopiclone, zaleplon, zolpidem

Desonate gel At least two lower cost forms of desonide including cream, lotion and ointment desonide 0.05% gel (generic Desonate) At least two lower cost forms of desonide including cream, lotion and ointment desoximetasone 0.05% gel betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% (generic Topicort gel) ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment desoximetasone 0.05% betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment (generic Topicort ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone ointment) propionate 0.005% ointment, triamcinolone 0.5% ointment betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% desoximetasone spray ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone (generic Topicort spray) propionate 0.005% ointment, triamcinolone 0.5% ointment

DesRx gel At least two lower cost forms of desonide including cream, lotion, and ointment

Dexabliss dexamethasone tablet dexamethasone dose pack (generic Dexpak) dexamethasone tablet

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Core Formulary Drug Alternatives

Dexpak dexamethasone tablet At least one of the following lower cost ergot-containing medications: generic D.H.E. 45 ergotamine/ caffeine tablet, generic dihydroergotamine injection diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, diclofenac 35mg capsule etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, (generic Zorvolex) nabumetone, naproxen, sulindac diclofenac topical patch diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution (generic (generic Flector) Pennsaid 1.5%), over-the-counter Voltaren gel adapalene 0.1% gel, adapalene 0.1% cream and at least one of the following lower cost products: adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin Differin 0.1% lotion 0.01% and 0.025% gel diflorasone cream, ointment desoximetasone 0.05% cream, fluocinonide 0.05% cream, ointment and (generic Psorcon) solution, triamcinolone 0.5% cream and ointment dihydroergotamine mesylate nasal spray (generic At least one of the following lower cost ergot-containing medications: generic Migranal) ergotamine/ caffeine tablet, generic dihydroergotamine injection At least two of the following lower cost products: betamethasone 0.05% cream, clobetasol propionate 0.05% cream, desoximetasone 0.25% cream, doxepin 5% cream (generic pimecrolimus 1% cream, tacrolimus 0.03% ointment, tacrolimus 0.1% ointment, Prudoxin, Zonalon) triamcinolone 0.5% cream Doryx, Doryx MPC (modified doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin polymer coat) capsule], minocycline IR capsule doxycycline hyclate DR (delayed-release) tablet doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin [generic Doryx, Doryx MPC] capsule], minocycline IR capsule doxycycline 40mg ER (extended-release) capsule doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin (for rosacea) [generic Oracea] capsule], minocycline IR capsule doxycycline hyclate 50mg, 75mg, 150mg tablet (generic doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin Acticlate, Targadox) capsule], minocycline IR capsule doxycycline monohydrate doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule, tablet capsule], minocycline IR capsule

Duaklir Pressair Anoro Ellipta, Stiolto Respimat

Duetact pioglitazone in combination with glimepiride

Duobrii halobetasol propionate 0.05% cream, tazarotene 0.1% cream clopidogrel bisulfate 75mg tablet in combination with over-the-counter aspirin Durlaza 81mg dutasteride in combination with tamsulosin and at least two of the following dutasteride-tamsulosin lower cost products: alfuzosin ER (extended-release) tablet, doxazosin, (generic Jalyn) dutasteride, finasteride, tamsulosin, terazosin

Dutoprol metoprolol in combination with hydrochlorothiazide

Dxevo dexamethasone tablet

Ecoza econazole nitrate 1% cream

Edarbi irbesartan, losartan, olmesartan, telmisartan, valsartan

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Core Formulary Drug Alternatives chlorothiazide, indapamide, irbesartan-hydrochlorothiazide (HCTZ), losartan- Edarbyclor HCTZ, metolazone, olmesartan-HCTZ, telmisartan-HCTZ, valsartan-HCTZ

Edluar eszopiclone, zaleplon, zolpidem levetiracetam IR (immediate-release) tablet, levetiracetam ER (extended- Elepsia XR release) tablet methylprednisolone, prednisolone syrup, prednisone oral solution, prednisone Emflaza tablet At least one of the following lower cost ergot-containing medications: generic Ergomar ergotamine/ caffeine tablet, generic dihydroergotamine injection At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the- Ertaczo counter terbinafine cream clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% Evoclin gel At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the- Exelderm 1% cream, solution counter terbinafine cream

Extina ketoconazole 2% cream, ketoconazole 2% shampoo ezetimibe-simvastatin tablet ezetimibe in combination with simvastatin, ezetimibe in combination with (generic Vytorin) atorvastatin or rosuvastatin tazarotene 0.1% cream and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and Fabior 0.025% gel fenofibrate 40mg tablet, At least two of the following lower cost fenofibrate products: choline fenofibrate; 120mg tablet (generic fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized Fenoglide) 43mg, 67mg, 130mg, 134mg, and 200mg capsule At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 50mg and 150mg fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized capsule (generic Lipofen) 43mg, 67mg, 130mg, 134mg, and 200mg capsule At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 160mg tablet fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized (generic Triglide) 43mg, 67mg, 130mg, 134mg, and 200mg capsule At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibric acid 35mg, 105mg fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized tablet (generic Fibricor) 43mg, 67mg, 130mg, 134mg, and 200mg capsule At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized Fenoglide 43mg, 67mg, 130mg, 134mg, and 200mg capsule fenoprofen calcium 600mg tablet and at least three of the following lower cost fenoprofen capsule (generic NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, Fenortho) meloxicam tablet, nabumetone, naproxen, sulindac fenoprofen calcium 600mg tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, Fenortho meloxicam tablet, nabumetone, naproxen, sulindac cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, Fexmid metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

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Core Formulary Drug Alternatives At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized Fibricor 43mg, 67mg, 130mg, 134mg, and 200mg capsule diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution (generic Flector Pennsaid 1.5%), over-the-counter Voltaren gel

Fluoroplex fluorouracil 2% solution, fluorouracil 5% solution fluorouracil 0.5% cream (generic Carac) fluorouracil 5% cream, fluorouracil 2% solution, fluorouracil 5% solution flurandrenolide 0.05% fluocinonide 0.05% ointment, hydrocortisone 1% ointment, triamcinolone 0.1% ointment (generic Cordran) ointment fluticasone propionate 0.05% betamethasone dipropionate 0.05% lotion, fluocinolone 0.025% cream, lotion (generic Cutivate) triamcinolone 0.1% lotion fluvastatin capsule (generic Lescol) atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin fluvastatin ER (extended- release) tablet [generic Lescol XL] atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin metformin, metformin ER (extended-release) [non-osmotic, non-modified Fortamet release]

Fosamax D alendronate in combination with over-the-counter vitamin D At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating Frova tablet At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating frovatriptan (generic Frova) tablet

Gimoti metoclopramide IR (immediate-release) tablet, metoclopramide solution metformin, metformin ER (extended-release) [non-osmotic, non-modified Glumetza release] glycopyrrolate 1.5mg tablet (generic Glycate) glycopyrrolate 1mg tablet, glycopyrrolate 2mg tablet

Gocovri amantadine capsule/syrup/ tablet, rasagiline, selegiline amitriptyline tablet, gabapentin capsule/solution/ tablet, pregabalin capsule/ Gralise solution halcinonide 0.1% cream betamethasone AF 0.05% cream, desoximetasone 0.25% cream, fluocinonide (generic Halog) 0.05% cream halobetasol 0.05% foam (generic Lexette) halobetasol cream, halobetasol ointment betamethasone AF 0.05% cream, desoximetasone 0.25% cream, fluocinonide Halog cream 0.05% cream betamethasone dipropionate 0.05% ointment, desoximetasone 0.25% ointment, Halog ointment fluocinonide 0.05% ointment betamethasone AF 0.05% cream, desoximetasone 0.25% cream, fluocinonide Halog solution 0.05% cream, fluocinonide 0.05% solution

Hemady dexamethasone tablet

Hidex dexamethasone tablet amitriptyline tablet, gabapentin capsule/solution/ tablet, pregabalin capsule/ Horizant solution

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Core Formulary Drug Alternatives hydrocortisone butyrate 0.1% betamethasone dipropionate 0.05% lotion, fluticasone propionate 0.05% cream, lotion (generic Locoid) triamcinolone 0.1% lotion hydrocortisone butyrate hydrophilic lipo base 0.1% cream (generic Locoid betamethasone valerate 0.1% cream, fluticasone propionate 0.05% cream, Lipocream) hydrocortisone valerate 0.2% cream imiquimod 3.75% cream (generic Zyclara pump) imiquimod 5% cream generic sumatriptan injection and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, zolmitriptan Imitrex injection tablet/ orally disintegrating tablet generic sumatriptan nasal spray and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, Imitrex nasal spray zolmitriptan tablet/ orally disintegrating tablet generic sumatriptan and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, zolmitriptan tablet/ orally Imitrex tablet disintegrating tablet At least two lower cost forms of clobetasol propionate including cream, gel, Impeklo 0.05% lotion lotion, ointment, and solution betamethasone 0.05% ointment, desoximetasone 0.25% cream, fluocinonide Impoyz 0.05% cream propranolol tablet and solution, propranolol ER (extended-release) capsule Inderal XL [generic Inderal LA], nadolol tablet, timolol tablet ibuprofen suspension 100mg/5ml, indomethacin 25mg capsule, indomethacin Indocin 50mg capsule, over-the-counter Voltaren gel indomethacin 25mg capsule, indomethacin 50mg capsule, and at least two of indomethacin 20mg capsule the following lower cost NSAID products: celecoxib, etodolac, indomethacin (generic Tivorbex) 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac propranolol tablet and solution, propranolol ER (extended-release) capsule InnoPran XL [generic Inderal LA], nadolol tablet, timolol tablet

Intermezzo eszopiclone, zaleplon, zolpidem

Isordil Titradose 40mg tablet isosorbide dinitrate tablet isosorbide tablet 40mg (generic Isordil Titradose) isosorbide dinitrate tablet isotretinoin (generic Absorica) Amnesteem, Claravis, isotretinoin (generic Accutane), Myorisan, Zenatane

Istalol (once daily) eye drops timolol maleate (twice daily) eye drops [generic Timoptic] dutasteride in combination with tamsulosin and at least two of the following lower cost products: alfuzosin ER (extended-release) tablet, doxazosin, Jalyn dutasteride, finasteride, tamsulosin, terazosin triamcinolone 0.025% cream, triamcinolone 0.1% cream, triamcinolone 0.025% Kenalog ointment, triamcinolone 0.1% ointment ketoconazole 2% foam (generic Extina) ketoconazole 2% cream, ketoconazole 2% shampoo ketodan (generic Extina) ketoconazole 2% cream, ketoconazole 2% shampoo ketoprofen 50mg capsule and at least three of the following lower cost NSAID products: celecoxib, etodolac, ketoprofen ER (extended-release) 200mg capsule, indomethacin 25mg and 50mg capsule, meloxicam tablet, ketoprofen 25mg capsule nabumetone, naproxen, sulindac

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Core Formulary Drug Alternatives At least four of the following lower cost NSAID products: celecoxib, etodolac, ketorolac nasal spray indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, (generic Sprix) naproxen, sulindac fluorouracil 2% solution, fluorouracil 5% solution, fluorouracil 5% cream, Klisyri imiquimod 5% cream, diclofenac 3% gel lactulose oral crystal packet lactulose solution, polyethylene glycol 3350 oral powder

Lescol atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Lescol XL atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Lexette halobetasol cream, halobetasol ointment diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution (generic Licart Pennsaid 1.5%), over-the-counter Voltaren gel lidocaine-tetracaine 7-7% lidocaine-prilocaine cream, lidocaine ointment, patch and solution, over-the- cream (generic Pliaglis) counter lidocaine gel At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized Lipofen 43mg, 67mg, 130mg, 134mg, and 200mg capsule

Livalo atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin betamethasone 0.05% lotion, fluticasone propionate 0.05% cream, Locoid lotion triamcinolone 0.1% lotion betamethasone valerate 0.1% cream, fluticasone propionate 0.05% cream, Locoid Lipocream hydrocortisone valerate 0.2% cream chlorzoxazone 500mg tablet at least two of the following lower cost products: baclofen, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, Lorzone methocarbamol tablet, tizanidine tablet betamethasone dipropionate 0.05% cream, betamethasone valerate 0.1% Luxiq ointment, mometasone furoate 0.1% solution (lotion), triamcinolone 0.5% cream At least two previous generic antifungals such as clotrimazole 1% cream, luliconazole cream (generic econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the- Luzu) counter terbinafine cream At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the- Luzu counter terbinafine cream generic rizatriptan and at least one of the following lower cost triptan medications: eletriptan, naratriptan, sumatriptan, zolmitriptan tablet/ orally Maxalt disintegrating tablet generic rizatriptan orally disintegrating tablet and at least one of the following Maxalt ODT (orally lower cost triptan medications: eletriptan, naratriptan, sumatriptan, zolmitriptan disintegrating tablet) tablet/ orally disintegrating tablet methylprednisolone tablet, prednisolone syrup, prednisone oral solution, Medrol tablet prednisone tablet generic meloxicam tablet and at least three of the following lower cost NSAID meloxicam capsule (generic products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, Vivlodex) nabumetone, naproxen, sulindac metaxalone 800mg tablet and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, metaxalone 400mg tablet methocarbamol tablet, tizanidine tablet metformin ER (extended- release) modified release metformin, metformin ER (extended-release) [non-osmotic, non-modified [generic Glumetza] release]

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Core Formulary Drug Alternatives metformin ER (extended- release) osmotic release metformin, metformin ER (extended-release) [non-osmotic, non-modified [generic Fortamet] release] metoclopramide ODT (orally disintegrating tablet) [generic Metozolv ODT] metoclopramide IR (immediate-release) tablet, metoclopramide solution metoprolol- hydrochlorothiazide ER (extended-release) tablet [generic Dutoprol] metoprolol in combination with hydrochlorothiazide miconazole-zinc oxide- At least two previous generic antifungals such as clotrimazole 1% cream, petroleum ointment (generic ketoconazole 2% cream, nystatin cream, ointment and powder, over-the- Vusion) counter terbinafine cream, over-the-counter miconazole cream At least one of the following lower cost ergot-containing medications: generic Migergot ergotamine/ caffeine tablet, generic dihydroergotamine injection At least one of the following lower cost ergot-containing medications: generic Migranal ergotamine/ caffeine tablet, generic dihydroergotamine injection methylprednisolone tablet, prednisolone syrup, prednisone oral solution, Millipred, Millipred DP prednisone tablet minocycline IR (immediate- doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin release) tablet capsule], minocycline IR capsule minocycline ER (extended- release) tablet [generic doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin Solodyn] capsule], minocycline IR capsule minocycline ER (extended- release) capsule [generic doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin Ximino] capsule], minocycline IR capsule doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin Minolira capsule], minocycline IR capsule doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin Mondoxyne NL capsule], minocycline IR capsule mupirocin calcium cream (generic Bactroban) mupirocin 2% ointment, over-the-counter bacitracin ointment over-the-counter Bismuth, diphenoxylate-atropine, loperamide, opium tincture Mytesi 1%, paregoric tincture 2mg/5ml ciclopirox 0.77% gel or cream, clotrimazole 1% cream, econazole 1% cream, naftifine gel (generic Naftin) ketoconazole 2% cream, terbinafine tablet, over-the-counter terbinafine cream ciclopirox 0.77% gel or cream, clotrimazole 1% cream, econazole 1% cream, Naftin gel ketoconazole 2% cream, terbinafine tablet, over-the-counter terbinafine cream fenoprofen calcium 600mg tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, Nalfon meloxicam tablet, nabumetone, naproxen, sulindac naproxen EC (enteric-coated), naproxen DR (delayed-release), naproxen sodium and at least one of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, Naprelan nabumetone, sulindac naproxen EC (enteric-coated), naproxen DR (delayed-release), naproxen sodium and at least one of the following lower cost NSAID products: celecoxib, naproxen ER (extended- etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, release) [generic Naprelan] nabumetone, sulindac

Nascobal cyanocobalamin 1000mcg/mL injection

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Core Formulary Drug Alternatives

Nexletol atorvastatin, ezetimibe, rosuvastatin, simvastatin

Nexlizet atorvastatin, ezetimibe, rosuvastatin, simvastatin niacin (antihyperlipidemic) [generic Niacor] niacin ER (extended-release) [generic Niaspan], over-the-counter niacin

Niacor niacin ER (extended-release) [generic Niaspan], over-the-counter niacin bethanechol, desmopressin nasal spray, desmopressin tablet, flavoxate, oxybutynin, tolterodine ER (extended-release), tolterodine IR (immediate- Nocdurna release), trospium IR orphenadrine ER (extended-release) and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and Norgesic Forte 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet metronidazole 0.75% cream, metronidazole 0.75% gel, metronidazole 1% gel, Noritate metronidazole 0.75% lotion doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin Okebo capsule], minocycline IR capsule At least two lower cost forms of clobetasol propionate including cream, gel, Olux, Olux-E lotion, ointment and solution clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% Onexton gel At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating Onzetra Xsail tablet doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin Oracea capsule], minocycline IR capsule Orapred ODT (orally methylprednisolone, prednisolone syrup, prednisone oral solution, prednisone disintegrating tablet) tablet

Oravig clotrimazole lozenge, clotrimazole troche, nystatin suspension orphenadrine-aspirin-caffeine orphenadrine ER (extended-release) and at least two of the following lower cost tablet (generic Norgesic products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and Forte) 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet orphenadrine ER (extended-release) and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and Orphengesic Forte 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, oxiconazole cream, terbinafine Oxistat 1% lotion tablet, over-the-counter terbinafine cream baclofen tablets and at least two of the following lower cost products: chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, Ozobax oral solution metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet betamethasone valerate 0.1% cream, fluocinolone 0.025% cream, Pandel cream hydrocortisone butyrate 0.1% cream penicillamine capsule (generic Cuprimine) penicillamine tablet (generic Depen Titratabs) diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution (generic Pennsaid 2% Pennsaid 1.5%), over-the-counter Voltaren gel pioglitazone-glimepiride tablet (generic Duetact) pioglitazone in combination with glimepiride

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Core Formulary Drug Alternatives lidocaine-prilocaine cream, lidocaine ointment, patch and solution, over-the- Pliaglis 7-7% cream, kit counter lidocaine gel prednisolone ODT (orally disintegrating tablet) [generic methylprednisolone tablet, prednisolone syrup, prednisone oral solution, Orapred ODT] prednisone tablet

Prestalia perindopril in combination with amlodipine albuterol sulfate HFA (generic ProAir HFA and generic Proventil HFA), Ventolin ProAir Digihaler HFA At least two of the following lower cost products: betamethasone 0.05% cream, clobetasol propionate 0.05% cream, desoximetasone 0.25% cream, pimecrolimus 1% cream, tacrolimus 0.03% ointment, tacrolimus 0.1% ointment, Prudoxin triamcinolone 0.5% cream desoximetasone 0.05% cream, fluocinonide 0.05% cream, ointment and Psorcon cream solution, triamcinolone 0.5% cream and ointment metronidazole 250mg tablets in combination with tetracycline capsules and Pylera over-the-counter (OTC) bismuth generic atomoxetine and at least one of the following: clonidine ER (extended- release) tablet, guanfacine ER tablet, generic methylphenidate (check your Qelbree covered drug list) Qmiiz ODT (orally ibuprofen 100mg/5ml suspension, meloxicam tablet, over-the-counter Voltaren disintegrating tablet) gel ramelteon tablet (generic Rozerem) eszopiclone, zaleplon, zolpidem dexamethasone tablet, methylprednisolone tablet, prednisolone syrup and Rayos solution, prednisone tablet and solution generic nabumetone and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, Relafen DS 1000mg tablet meloxicam tablet, naproxen, sulindac generic eletriptan and at least one of the following lower cost triptan medications: naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally Relpax disintegrating tablet

Reltone ursodiol 300mg capsule, 250mg tablet, 500mg tablet

Renagel 800mg tablet sevelamer carbonate 800mg tablet, sevelamer carbonate packet

Retin-A tretinoin cream, tretinoin 0.01% and 0.025% gel risedronate DR (delayed- release) tablet [generic Atelvia] alendronate, ibandronate, risedronate IR (immediate-release) ezetimibe in combination with rosuvastatin, ezetimibe in combination with Roszet atorvastatin or simvastatin

Rozerem eszopiclone, zaleplon, zolpidem At least two lower cost forms of betamethasone including cream, lotion, and Sernivo spray ointment sevelamer hydrochloride 800mg tablet (generic Renagel) sevelamer carbonate 800mg tablet, sevelamer carbonate packet doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin Seysara capsule], minocycline IR capsule

Sitavig clotrimazole troches, nystatin suspension

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Core Formulary Drug Alternatives doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin Solodyn capsule], minocycline IR capsule At least four of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, Sprix naproxen, sulindac At least two previous generic antifungals such as clotrimazole 1% cream, sulconazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the- solution (generic Exelderm) counter terbinafine cream sumatriptan-naproxen (generic Treximet) sumatriptan in combination with naproxen lidocaine-prilocaine cream, lidocaine ointment, lidocaine patch, lidocaine Synera solution

Taclonex calcipotriene-betamethasone dipropionate 0.005-0.064% suspension

Talicia rifabutin in combination with amoxicillin and over-the-counter (OTC) omeprazole

Taperdex dexamethasone tablet, prednisone tablet therapy pack doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin Targadox capsule], minocycline IR capsule tazarotene 0.1% cream and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and Tazorac 0.025% gel fluocinolone 0.025% cream, hydrocortisone 1% ointment, triamcinolone 0.1% Texacort ointment timolol maleate (once daily) eye drops [generic Istalol] timolol maleate (twice daily) eye drops [generic Timoptic]

Timoptic Ocudose timolol maleate (twice daily) eye drops [generic Timoptic] indomethacin 25mg, indomethacin 50mg capsule, and at least two of the following lower cost NSAID products: celecoxib, etodolac, meloxicam tablet, Tivorbex nabumetone, naproxen, sulindac

Tolsura itraconazole capsule, itraconazole solution

Tolak fluorouracil 2% solution, fluorouracil 5% solution betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone Topicort 0.05% gel propionate 0.005% ointment, triamcinolone 0.5% ointment betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone Topicort 0.05% ointment propionate 0.005% ointment, triamcinolone 0.5% ointment betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone Topicort spray propionate 0.005% ointment, triamcinolone 0.5% ointment generic sumatriptan nasal spray and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, Tosymra zolmitriptan tablet/ orally disintegrating tablet

Tovet calcipotriene 0.005% cream, ointment, and solution, tazarotene 0.1% cream

Trexall generic methotrexate tablets, methotrexate injection

Treximet sumatriptan in combination with over-the-counter naproxen

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Core Formulary Drug Alternatives triamcinolone 0.05% ointment (generic Trianex) triamcinolone 0.025% ointment, triamcinolone 0.1% ointment triamcinolone topical aerosol triamcinolone 0.025% cream, triamcinolone 0.1% cream, triamcinolone 0.025% spray (generic Kenalog) ointment, triamcinolone 0.1% ointment

Trianex ointment triamcinolone 0.025% ointment, triamcinolone 0.1% ointment At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized Triglide 43mg, 67mg, 130mg, 134mg, and 200mg capsule

Tritocin triamcinolone 0.025% ointment, triamcinolone 0.1% ointment At least one of the following lower cost ergot-containing medications: generic Trudhesa ergotamine/ caffeine tablet, generic dihydroergotamine injection hydrocodone-chlorpheniramine suspension, promethazine-codeine 6.25- TussiCaps 10mg/5ml syrup, promethazine-dm 6.25-15mg/5ml syrup

Ultravate 0.05% lotion halobetasol 0.05% cream, halobetasol 0.05% ointment vancomycin oral solution (reconstituted) Firvanq

Vectical calcipotriene 0.005% cream/ ointment/ solution, tazarotene 0.1% cream clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel, and at least one of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene Veltin 0.1% cream At least two lower cost other forms of desonide including cream, lotion, and Verdeso foam ointment generic meloxicam tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, Vivlodex nabumetone, naproxen, sulindac At least two previous generic antifungals such as clotrimazole 1% cream, ketoconazole 2% cream, nystatin cream, ointment and powder, over-the- Vusion counter terbinafine cream, over-the-counter miconazole cream ezetimibe in combination with simvastatin, ezetimibe in combination with Vytorin atorvastatin or rosuvastatin clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% Winlevi gel betamethasone 0.05% lotion, calcipotriene 0.005% ointment, calcipotriene- Wynzora cream betamethasone dipropionate 0.005-0.064% suspension

Xerese acyclovir ointment in combination with hydrocortisone 1% cream doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin Ximino capsule], minocycline IR capsule

Xolegel ketoconazole 2% cream, ketoconazole 2% shampoo generic sumatriptan injection and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, zolmitriptan Zembrace SymTouch tablet/ orally disintegrating tablet clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel, and at least one of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene Ziana 0.1% cream

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Core Formulary Drug Alternatives zileuton ER (extended- release) [generic Zyflo CR] montelukast tablet, montelukast chew tablet, zafirlukast tablet azelaic acid 15% gel, metronidazole 0.75% cream, metronidazole 0.75% gel, Zilxi metronidazole 1% gel, metronidazole 0.75% lotion, Soolantra diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, Zipsor nabumetone, naproxen, sulindac At least two of the following lower cost triptan medications: eletriptan, zolmitriptan nasal spray naratriptan, rizatriptan, sumatriptan (also available as a nasal spray), (generic Zomig nasal spray) zolmitriptan tablet/ orally disintegrating tablet zolpidem sublingual tablet (generic Intermezzo) eszopiclone, zaleplon, zolpidem

Zolpimist eszopiclone, zaleplon, zolpidem At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan (also available as a nasal spray), Zomig nasal spray zolmitriptan tablet/ orally disintegrating tablet generic zolmitriptan orally disintegrating tablet and at least one of the following Zomig ZMT (orally lower cost triptan medications: eletriptan, naratriptan, rizatriptan (also available disintegrating tablet) as an orally disintegrating tablet), sumatriptan generic zolmitriptan tablet and at least one of the following lower cost triptan Zomig tablet medications: eletriptan, naratriptan, rizatriptan, sumatriptan At least two of the following lower cost products: betamethasone 0.05% cream, clobetasol propionate 0.05% cream, desoximetasone 0.25% cream, pimecrolimus 1% cream, tacrolimus 0.03% ointment, tacrolimus 0.1% ointment, Zonalon triamcinolone 0.5% cream diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, Zorvolex nabumetone, naproxen, sulindac

Zovirax cream acyclovir 5% ointment

Ztlido lidocaine ointment, lidocaine patch, lidocaine solution

Zuplenz granisetron, ondansetron, ondansetron ODT (orally disintegrating tablet)

Zyclara imiquimod 5% cream

Zyflo (immediate-release) montelukast tablet, montelukast chew tablet, zafirlukast tablet

Zypitamag atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

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