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1199SEIU Preferred Drug List Please take this guide with you the next time you visit your doctor.
© 2010 Medco Health Solutions, Inc. All rights reserved. Medco is a registered trademark of Medco Health Solutions, Inc. If you have questions about your prescription drug benefit, visit www.medco.com or call Medco Member Services at (800) 818-6720. For questions about your 1199SEIU benefits, call the 1199SEIU Benefit Funds’ Member Services representatives at (646) 473-9200. FPO
MG40118C FPO (Ed. 4/10)
Medco manages your prescription drug benefit for the 1199SEIU Benefit Funds. MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 1
This Preferred Drug List includes classes of widely used drugs that are preferred by the 1199SEIU Benefit Funds. These medications have been carefully selected to provide safety and value. If you receive any generic drug or preferred brand, you will have no out-of-pocket expense (except for GNY Benefit Fund and Rochester-area members, who may have small co-payments for certain brand-name drugs). However, if you get a nonpreferred brand when a preferred drug is available, you will be responsible for the difference in cost between the preferred and nonpreferred drugs. (Please note that this list is subject to change.)
Section II provides a listing of nonpreferred brands and their possible preferred alternatives.
SAFETY CONSIDERATION SYMBOLS Here is a quick guide that explains our safety symbols. These symbols appear next to certain medications. A dose lower than the manufacturer’s guidelines is often recommended for people 65 and older. ▲ Use by people 65 and older is associated with increased risk; safer alternatives may be available. If used, the dosage should generally be lowered. Weigh the risk of birth defects and other adverse outcomes. Do not use during pregnancy.
PRESCRIPTION PROGRAM CONSIDERATION SYMBOLS For more information, please call Medco: (800) 753-2851.
[PA] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program. [ST] This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program. [QD] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.
OTHER SYMBOLS: [AC] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo. Please call Accredo: (800) 803-2523.
Shaded areas indicate the most recent additions to the Preferred Drug List.
Drugs Not Covered by the 1199SEIU Benefit Funds Cosmetic Drugs Non-Sedating Antihistamines Fertility Drugs All Over-the-Counter drugs (except diabetic supplies) Investigational/experimental drugs Select Cough & Cold Drugs Erectile Dysfunction Drugs
Please refer to your Summary Plan Description for a complete list of excluded drugs.
Information was in effect at the time of printing and may be subject to change. For the most up-to-date 1199SEIU Benefit Funds Preferred Drug List go to www.1199SEIUBenefits.org.
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SECTION I: THERAPEUTIC DRUG CATEGORIES
ANTICONVULSANTS (EFFECTIVE 7-1-10) G carbamazepine G phenobarbital P Lamictal ODT G carbamazepine XR G phenytoin extended-release P Lyrica [PA] G clonazepam G primidone P Peganone G divalproex sodium G topiramate [PA] P Vimpat G divalproex sodium ER G valproic acid G divalproex sodium sprinkles P Banzel G ethosuximide P Celontin G gabapentin P Diastat G lamotrigine P Dilantin 30mg G levetiracetam P Felbatol G mephobarbital P Gabitril
ANTI-INFECTIVES (Antibiotics) Oral Penicillins Oral Cephalosporins Oral Quinolones G amoxicillin trihydrate G cefaclor G ciprofloxacin HCl tablet G amoxicillin trihydrate/ G cefadroxil hydrate G ofloxacin potassium clavulanate G cefdinir P Avelox G ampicillin trihydrate G cefpodoxime proxetil tablet P Cipro Suspension G dicloxacillin sodium G cefprozil P Cipro Tablet 100mg G penicillin v potassium G cefuroxime axetil tablet P Augmentin Chewable Tablet G cefuroxime suspension 125 - 31.25mg, 250 - 62.5mg G cephalexin monohydrate P Augmentin Suspension G cephradine 125 - 31.25mg/5, 250 - 62.5mg/5 Oral Erythromycins and other Oral Tetracyclines Macrolides G doxycycline hyclate capsule G azithromycin G doxycycline hyclate tablet G clarithromycin G doxycycline monohydrate G erythromycin base G minocycline HCl G erythromycin ethylsuccinate G tetracycline HCl G erythromycin ethylsuccinate/ sulfisoxazole acetyl G erythromycin stearate
ANTIPARKINSONISM AGENTS (EFFECTIVE 1-1-10) G amantadine G pramipexole Di-HCl 0.125mg, 0.25mg, P Comtan G benztropine 0.5mg, 1mg, 1.5mg P Lodosyn G bromocriptine G ropinirole P Mirapex 0.75mg G carbidopa/levadopa G selegiline G carbidopa/levadopa ER P Apokyn
ANTIVERTIGO & ANTIEMETIC DRUGS (EFFECTIVE 4-1-10)
G ondansetron HCl [QD] G granisetron HCl [QD] P Emend [QD]
Key: G = Preferred generic medication. [PA] This symbol next to a drug name indicates that this medication is subject to P = Preferred brand-name medication. the Prior Authorization Program. [ST] This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for the Step Therapy Program. people 65 and older. [QD] This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives the Quantity Duration Program. may be available. If used, the dosage should generally be lowered. [AC] This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes. through Accredo. Please call: (800) 501-7210. = Do not use in pregnancy. 2 MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 3
BENIGN PROSTATE HYPERPLASIA (BPH) THERAPY G doxazosin G tamsulosin HCl G terazosin G finasteride [ST]
BIOTECHNOLOGY DRUGS (EFFECTIVE 7-1-10) Factor VIII - Recombinant Drugs P Helixate FS
CARDIOVASCULAR (Blood Pressure/Heart/Cholesterol) Beta Blockers ACE Inhibitors G benazepril HCl/ G acebutolol HCl G benazepril HCl hydrochlorothiazide G atenolol G captopril G bisoprolol fumarate/ G betaxolol HCl G enalapril maleate hydrochlorothiazide G bisoprolol fumarate G fosinopril sodium G captopril/ hydrochlorothiazide G carvedilol G lisinopril G enalapril maleate/ G labetalol HCl G moexipril HCl hydrochlorothiazide G metoprolol succinate XL G perindopril G fosinopril/ hydrochlorothiazide G hydralazine/ hydrochlorothiazide G metoprolol tartrate G quinapril G nadolol G lisinopril/ hydrochlorothiazide G ramipril capsules G methyldopa/ hydrochlorothiazide G pindolol G trandolapril G propranolol HCl G metoprolol/ hydrochlorothiazide G propranolol HCl capsule, sustained Angiotensin II Blockers G moexipril/ hydrochlorothiazide action 24 hr G losartan/hydrochlorthiazide [ST] G propranolol/ hydrochlorothiazide G timolol maleate G losartan potassium [ST] G quinapril/ hydrochlorothiazide Calcium Channel Blockers P Micardis [ST] P Lotrel 5-40mg & 10-40mg P Micardis HCT [ST] G diltiazem HCl Long Acting Nitrates (Topical) G diltiazem HCl capsule, sustained Antilipidemics - Statin Drugs (EFFECTIVE 7-1-10) release 12 hr G lovastatin G nitroglycerin patches G diltiazem HCl capsule, sustained G pravastatin release 24 hr G simvastatin Antiplatelet Agents G nimodipine P Lipitor (EFFECTIVE 7-1-10) G verapamil HCl Other Antilipidemics G cilostazol G verapamil HCl capsule, 24 hr G ticlopidine sustained release pellets G colestipol HCl P Aggrenox G verapamil HCl tablet, sustained G cholestyramine/aspartame P Effient action G cholestyramine/sucrose P Plavix G fenofibrate, micronized Dihydropyridines Calcium G gemfibrozil Channel Blocker G niacin G amlodipine besylate P Niaspan ER G felodipine P Welchol G isradipine P Zetia G nicardipine Select Combination G nifedipine Antihypertensives G nifedipine tablet, sustained action G nifedipine tablet, sustained release G amlodipine besylate/benazepril osmotic push G atenolol/chlorthalidone
DRUGS TO TREAT OVERACTIVE BLADDER (EFFECTIVE 1-1-10)
G ▲flavoxate G ▲oxybutynin chloride ER P Vesicare G ▲oxybutynin chloride
Key: G = Preferred generic medication. [PA] This symbol next to a drug name indicates that this medication is subject to P = Preferred brand-name medication. the Prior Authorization Program. [ST] This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for the Step Therapy Program. people 65 and older. [QD] This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives the Quantity Duration Program. may be available. If used, the dosage should generally be lowered. [AC] This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes. through Accredo. Please call: (800) 501-7210. = Do not use in pregnancy. 3 MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 4
ENDOCRINE (Diabetes/Hormones/Contraceptives)
Insulin Therapy Blood Glucose Test Strips G Next Choice P Apidra P Accu-Chek Active Test Strips G norethindrone P Humalog P Accu-Chek Aviva Test Strips G norethindrone a-e estradiol P Humalog Mix 50/50 P Accu-Chek Comfort Curve Test G norethindrone a-e P Humalog Mix 75/25 Strips estradiol/ferrous fumarate P Humulin P Accu-Chek Compact Test Strips G norethindrone-ethinyl estradiol P Iletin P Accu-Chek Advantage G norethindrone-mestranol P Lantus P Accu-Chek Simplicity G norgestimate-ethinyl estradiol P Levemir P Breeze2 Ten-Test Discs G norgestrel-ethinyl estradiol P Novolin P Chemstrip P Plan B One-Step P Novolog P Chemstrip BG Estrogen Agents (oral/vaginal) P Novolog Mix P Chemstrip K (EFFECTIVE 1-1-09) Oral Hypoglycemic Agents P Contour Test Strips G estradiol tabs P Ketostix (REVISED – EFFECTIVE 4-1-10) G estropipate P Multistix G acarbose P Cenestin G chlorpropamide Blood Glucose Monitoring P Enjuvia G glimepiride Devices P Estring G glipizide, glipizide ER P Accu-Chek Active Meter P Premarin Vaginal Cream G glipizide/metformin HCl P Accu-Chek Aviva Meter Androgen Replacement Agents G glyburide P Accu-Chek Comfort Curve Meter G metformin HCl, P Accu-Chek Compact Meter (REVISED – EFFECTIVE 10-1-09) metformin HCl ER P Accu-Chek Advantage Meter G danazol [PA] G tolazamide P Accu-Chek Simplicity Meter G fluoxymesterone [PA] G tolbutamide P Breeze2 Meter G methyltestosterone tabs [PA] G glyburide micronized P ContourMeter G testosterone propionate injection G nateglinide Contraceptive Agents [PA] P Avandamet P Androderm Patch [PA] P Avandaryl (EFFECTIVE 10-1-09) P Androgel [PA] P Avandia G desogestrel-ethinyl estradiol Estrogen Patches (EFFECTIVE 7-1-09) P ActoPlusMet G desogestrel-ethinyl G estradiol P Actos estradiol/ethinyl estradiol P Estraderm P Janumet G ethinyl estradiol/drospirenone P Vivelle P Januvia G ethynodiol d-ethinyl estradiol P Vivelle-Dot P Onglyza G levonorgestrel-ethinyl estradiol P Prandin
G I (Ulcer)
Ulcer Drugs G misoprostol P Axid Oral Solution G cimetidine HCl liquid G nizatidine P Nexium [QD] G cimetidine tablet G omeprazole [QD] G famotidine G ranitidine HCl
GROWTH HORMONES (REVISED – EFFECTIVE 7-1-10)
P Norditropin [PA/AC] P Tev-Tropin [PA/AC] P Norditropin Nordiflex [PA/AC] P Zorbtive [PA/AC]
IMMUNOGLOBULIN AGENTS (INJECTABLES) (EFFECTIVE 5-1-09)
P Gamunex [PA/AC] P Vivaglobin [PA/AC]
INTERFERONS (EFFECTIVE 10-1-09)
Hepatitis C Agents P Intron A [PA/AC] P Roferon-A [PA/AC] P Infergen [PA/AC] P PEG-Intron [PA/AC]
Key: G = Preferred generic medication. [PA] This symbol next to a drug name indicates that this medication is subject to P = Preferred brand-name medication. the Prior Authorization Program. [ST] This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for the Step Therapy Program. people 65 and older. [QD] This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives the Quantity Duration Program. may be available. If used, the dosage should generally be lowered. [AC] This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes. through Accredo. Please call: (800) 501-7210. = Do not use in pregnancy. 4 MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 5
MISCELLANEOUS GASTROINTESTINAL AGENTS (EFFECTIVE 7-1-10)
Ulcerative Colitis Agents G mesalamine enema P Pentasa G balsalazide disodium G sulfasalazine P Asacol
MISCELLANEOUS RHEUMATOLOGICAL AGENTS (EFFECTIVE 7-1-10)
Rheumatoid Arthritis Agents P Humira [PA] P Remicade [ST/PA] (Injectables) P Kineret [PA] P Rituxan [PA] P Orencia [PA] P Enbrel [PA]
MUSCLE RELAXANTS (EFFECTIVE 10-1-09)
G carisoprodol G meprobamate G orphenadrine cmpd G carisoprodol cmpd/codeine G metaxalone G orphenadrine cmpd forte G clorzoxazone G methocarbamol G tizanidine G cyclobenzaprine G orphenadrine citrate
NARCOTIC ANALGESICS (Pain Relievers)
Narcotics G codeine phosphate/aspirin G oxycodone/aspirin G acetaminophen/butalbital G codeine sulfate G oxycodone HCl G acetaminophen/caffeine/ G fentanyl patch P Oxycontin butalbital G hydrocodone bit/ Miscellaneous Analgesic G aspirin/caffeine/butalbital acetaminophen Therapy (EFFECTIVE 1-1-09) G codeine/apap/caffeine/ G hydrocodone/ibuprofen butalbital G hydromorphone G butorphanol tartrate spray G codeine/aspirin/caffeine/ G meperidine HCl G pentazocine/acetaminophen butalbital G methadone G pentazocine/naloxone G codeine phosphate/ G morphine sulfate G tramadol acetaminophen G morphine sulfate, sustained action G tramadol ER G oxycodone/acetaminophen G tramadol/acetaminophen
NON-NARCOTIC ANALGESICS (Pain Relievers)
NSAIDs G meloxicam Migraine/Headache Therapy G etodolac G nabumetone (EFFECTIVE 1-1-09) G etodolac tablet, sustained Gnaproxen G sumatriptan (tabs, nasal spray, release 24 hr G naproxen sodium injection) [QD] G flurbiprofen G naproxen sodium tablet, P Maxalt [QD] G ibuprofen sustained action P Maxalt MLT [QD] G ▲indomethacin G oxaprozin P Relpax [QD] G ▲indomethacin capsule, G piroxicam Osteoarthritis Agents sustained action G sulindac G ketoprofen G tolmetin sodium (Injectable) (EFFECTIVE 7-1-09) G ketoprofen capsule, 24 hr NSAID COX-2 Inhibitors P Hyalgan [QD/AC] P Synvisc [QD/AC] sustained release pellets P Celebrex [ST] G meclofenamate sodium P Synvisc-One [QD/AC]
Key: G = Preferred generic medication. [PA] This symbol next to a drug name indicates that this medication is subject to P = Preferred brand-name medication. the Prior Authorization Program. [ST] This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for the Step Therapy Program. people 65 and older. [QD] This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives the Quantity Duration Program. may be available. If used, the dosage should generally be lowered. [AC] This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes. through Accredo. Please call: (800) 501-7210. = Do not use in pregnancy. 5 MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 6
OPHTHALMICS (Eye Preparations)
Ophthalmic-Steroids Ophthalmic Carbonic Anhdyrase G erythromycin base ointment (EFFECTIVE 1-1-10) Inhibitors (EFFECTIVE 1-1-10) G gentamicin sulfate ointment, G dorzolamide drops G dexamethasone G neomycin sulfate/bacitracin/ G fluorometholone P Trusopt Ophthalmic Beta-Blockers polymyxin B ointment G prednisolone G neomycin sulfate/gramicidin D/ Miscellaneous Ophthalmics (EFFECTIVE 1-1-10) polymyxin B drops (EFFECTIVE 1-1-09) G betaxolol HCL G ofloxacin drops P Alocril G carteolol G polymyxin B/trimethoprim drops P Alomide G levobunolol G tobramycin sulfate drops P Pataday G metipranolol P Ciloxan Oph Ointment P Patanol G timolol maleate P Tobrex Oph Ointment Miscellaneous Glaucoma Agents Antibiotic-Ophthalmics P Vigamox (EFFECTIVE 1-1-09) (EFFECTIVE 5-1-09) G bacitracin P Xalatan G ciprofloxacin drops
OSTEOPOROSIS/PAGET’S DISEASE
G alendronate tab [QD] P Actonel 30mg [QD] P Fosamax Solution [QD] G alendronate weekly [QD] P Boniva [QD] P Miacalcin Injection G calcitonin-salmon nasal spray P Evista
OTICS (Ear Preparations) (EFFECTIVE 4-1-10)
G neomycin/polymyxin/HC G ofloxacin
PSYCHOTHERAPEUTICS (Anxiety/Depression)
Hypnotic Agents Anxiolytics P Fazaclo G chloral hydrate G alprazolam P Geodon G estazolam G alprazolam ER P Haldol Deconate G ▲flurazepam HCl G buspirone HCl P Moban G temazepam G ▲chlordiazepoxide HCl P Orap G triazolam G ▲clorazepate dipotassium P Risperdal Consta G zaleplon [QD] G ▲diazepam P Risperdal M G zolpidem [QD] G lorazepam P Seroquel G oxazepam P Seroquel XR Miscellaneous Antidepressants P Zyprexa G ▲amitriptyline HCl SSRI Antidepressants P Zyprexa Zydis ▲ G amoxapine G citalopram HBr Attention Deficit Hyperactivity G bupropion HCl tablet G fluoxetine HCl Disorder (EFFECTIVE 5-1-09) G bupropion HCl tablet, sustained G ▲fluvoxamine maleate action G paroxetine HCl tablet, G amphetamine and G ▲clomipramine HCl suspension dextroamphetamine salts [PA] G ▲desipramine HCl G sertraline HCl G amphetamine and dextroamphetamine salts ER [PA] G doxepin HCl Antipsychotics G ▲imipramine HCl G D-amphetamine [PA] G maprotiline HCl G chlorpromazine G dexmethylphenidate [PA] G mirtazapine tablet G clozapine G methylphenidate [PA] G mirtazapine tablet, rapid dissolve G fluphenazine G methylphenidate ER [PA] G nortriptyline HCl G haloperidol P Concerta [PA] G trazodone HCl G loxapine P Strattera [PA] G venlafaxine HCl G perphenazine P Vyvanse [PA] P Cymbalta G risperidone P Nardil G thiothixene G trifluoperazine HCl
Key: G = Preferred generic medication. [PA] This symbol next to a drug name indicates that this medication is subject to P = Preferred brand-name medication. the Prior Authorization Program. [ST] This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for the Step Therapy Program. people 65 and older. [QD] This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives the Quantity Duration Program. may be available. If used, the dosage should generally be lowered. [AC] This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes. through Accredo. Please call: (800) 501-7210. = Do not use in pregnancy. 6 MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 7
RESPIRATORY (Allergy/Asthma/COPD) Beta Agonist Inhalers P ProAir HFA P Flovent Diskus (UPDATED 5-1-09) P Serevent Diskus P Pulmicort Respules 1mg/2mL PQVAR G albuterol sulfate inhalant solution Nasal Corticosteroids G albuterol sulfate solution, non-oral G flunisolide Miscellaneous Pulmonary Agents G isoetharine HCl inhalant solution G fluticasone propionate (EFFECTIVE 1-1-09) G isoetharine HCl solution, non-oral P Nasonex P Advair Diskus G levalbuterol inhalation solution Inhaled Corticosteroid Therapy P Advair HFA (conc.), 0.25%, (1.25 mg/0.5 mL) G metaproterenol sulfate inhalant (EFFECTIVE 1-1-09) solution G budensonide soln 0.5mg/2mL, G metaproterenol sulfate solution, 0.25mg/2mL non-oral P Flovent HFA
TOPICAL ACNE THERAPY (EFFECTIVE 1-1-09)
G benzoyl peroxide G erythromycin base/ethyl alcohol gel G sulfacetamide sodium/sulfur G clindamycin phosphate G erythromycin base/ ethyl alcohol G tretinoin [PA] G erythromycin base/benzoyl peroxide swabs P Azelex G erythromycin base/ethyl alcohol G metronidazole cream, gel, lotion P Finacea
TOPICAL ANTIFUNGALS
G ciclopirox (lotion, cream) G econazole nitrate G nystatin w/triamcinolone G clotrimazole G ketoconazole (shampoo, cream) G clotrimazole/betamethasone G nystatin
TOPICAL ANTIVIRAL THERAPY (EFFECTIVE 1-1-09)
P Denavir Cream P Zovirax Ointment
TOPICAL CORTICOSTEROIDS (Topical Skin Products)
Low Potency G mometasone G desoximetasone (cream 0.25%, gel G desonide 0.05% (cream, lotion, G desoximetasone 0.05% cream 0.05%) ointment) G triamcinolone 0.1% (cream, G diflorasone diacetate cream 0.05% G alclometasone dip ointment) G fluocinonide G fluocinolone solution 0.01% G triamcinolone lotion (0.025%, 0.1%) G fluocinonide-E G hydrocortisone 2.5% (cream, lotion, P Cordran Tape G Proctosol-HC ointment) High Potency G triamcinolone acetonide cream 0.5% P Capex Shampoo 0.01% G amcinonide Very High Potency Medium Potency G apexicon E G betamethasone augmented G betamethasone valerate cr 0.1% G betamethasone dipropionate G clobetasol propionate G fluocinolone 0.025% (cream, oint.) (cream, gel, lotion, ointment) G diflorasone diacetate ointment G fluticasone (cream, ointment) G betamethasone DP augmented G halobetasol propionate G hydrocortisone butyrate G betamethasone valerate ointment G hydrocortisone valerate 0.1%
VITAMINS — All generics are preferred (Most commonly used listed below) (EFFECTIVE 1-1-09)
Prenatal Vitamin Therapy G Ferrex 150 Forte G Vita Forte G Prenatal Plus G Foltrin G Vitaplex Plus G OB-Natal Plus G Hematogen Forte Vitamin B Therapy G Poly-Iron 150 Forte G PNV-DHA G Folbain Plus G Taron-Prex Prenatal Multivitamin Therapy G Folbee G Pruet DHA G Formula B Plus G Folbic Iron Supplement Therapy G Therobec Plus G Renal Caps G Ferotrinsic G Vitacon Forte G Vitaplex
Key: G = Preferred generic medication. [PA] This symbol next to a drug name indicates that this medication is subject to P = Preferred brand-name medication. the Prior Authorization Program. [ST] This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for the Step Therapy Program. people 65 and older. [QD] This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives the Quantity Duration Program. may be available. If used, the dosage should generally be lowered. [AC] This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes. through Accredo. Please call: (800) 501-7210. = Do not use in pregnancy. 7 MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 8
If your prescribed drug is in the “non-preferred” column, ask your doctor if she or he can prescribe one of the alternatives listed.
SECTION II: NONPREFERRED DRUGS AND THEIR POSSIBLE PREFERRED ALTERNATIVES
Nonpreferred Product Possible Preferred Alternatives Nonpreferred Product Possible Preferred Alternatives Abilify® clozapine (generic), risperidone (generic), Geodon® Azmacort® Flovent HFA® (GlaxoSmithKline), Flovent Diskus® (Pfizer), Seroquel® (AstraZeneca), Zyprexa® (Lilly) (GlaxoSmithKline), Pulmicort Respules® (AstraZeneca), Qvar® (IVAX) Acanya® clindamycin (generic) + benzoyl peroxide (generic) Azopt® dorzolamide (generic) Accuneb® albuterol (generic) Azor® amlodipine/benazepril (generic) Aciphex® omeprazole (generic), Nexium® (AstraZeneca) ® ® ® Beconase AQ flunisolide (generic), fluticasone propionate (generic), Actonel 35mg Boniva (Roche), alendronate 35mg (generic), alendronate Nasonex® (Schering) 70mg (generic) Benicar® losartan potassium (generic), Micardis® (BIPI) Actonel 5mg® Boniva® (Roche), alendronate 5mg (generic), alendronate Benicar HCT® losartan/HCTZ (generic), Micardis HCT® (BIPI) 10mg (generic) ® ® ® Benzaclin clindamycin phosphate (generic), benzoyl peroxide Actonel with Calcium Boniva (Roche), alendronate (generic) (generic) ® ® Advate Helixate FS (CSL Behring LLC) Benziq® benzoyl peroxide (generic) ® Advicor lovastatin (generic), niacin (generic), simvastatin (generic), Bepreve® Alocril® (Allergan), Alomide® (Alcon) ® pravastatin (generic), Lipitor (Pfizer), ® ® Niaspan ER® (Abbott) Besivance Vigamox (Alkon) Betimol® betaxolol (generic), carteolol (generic), timolol (generic), Aerobid® Flovent HFA® (GlaxoSmithKline), Flovent Diskus® levobunolol (generic), metipranolol (generic) (GlaxoSmithKline), Pulmicort Respules® (AstraZeneca), Qvar® (IVAX) Betoptic S® betaxolol (generic), carteolol (generic), timolol (generic), ® ® ® levobunolol (generic), metipranolol (generic) Aerobid-M Flovent HFA (GlaxoSmithKline), Flovent Diskus ® (GlaxoSmithKline), Pulmicort Respules® (AstraZeneca), Biaxin XL clarithromycin (generic) Qvar® (IVAX) Brevoxyl® benzoyl peroxide (generic) Aeroseb-Dex® fluocinolone acetonide solution, non oral (generic) Brovana® Solution albuterol inhalant solution (generic) Akne-Mycin® erythromycin (generic) Butisol® chloral hydrate (generic), temazepam (generic), triazolam (generic) Alamast® Alocril® (Allergan), Alomide® (Alcon) ® ® Bystolic acebutolol HCl (generic), atenolol HCl (generic), Ala-Scalp hydrocortisone (generic) metoprolol tartrate (generic), metoprolol succinate Alora® estradiol (generic), Estraderm (Novartis),Vivelle (generic), propranolol HCl (generic) (Novartis),Vivelle-Dot (Novartis) Caduet® amlodipine besylate (generic), Lipitor® (Pfizer) Aloxi® ondansetron (generic), granisetron (generic), Emend® Carbatrol® carbamazepine ER(generic) (Merck) Cardene SR® amlodipine besylate (generic), nifedipine ER (generic) ® Alrex fluorometholone (generic), prednisolone (generic) Cardizem LA® diltiazem HCl capsule, sustained release 24 hr (generic) ® Altoprev lovastatin (generic), simvastatin (generic), pravastatin Carimune NF® Gamunex® (Talecris Biotherapeutics),Vivaglobin® (ZLB (generic), Lipitor® (Pfizer) Behring LLC) Alupent Inhaler® ProAir HFA® (Teva) Cartrol® acebutolol HCl (generic), atenolol tablet (generic), Ambien CR® zolpidem (generic), temazepam (generic), triazolam metoprolol tartrate tablet (generic), propranolol HCl (generic), zaleplon (generic) tablet (generic), propranolol HCl capsule, sustained action 24 hr (generic), timolol maleate tablet (generic) Amerge® sumatriptan (generic), Maxalt (Merck), Relpax (Pfizer) Cedax® cefpodoxime (generic), cefaclor (generic), cefuroxime Android® methyltestosterone (generic) axetil (generic), cefdinir (generic) Antara® fenofibrate (generic), gemfibrozil (generic) Cerefolin NAC® Folbain Plus (generic),Vitaplex (generic), Folbic (generic), Anzemet® ondansetron (generic), granisetron (generic), Emend® Folbee (generic), Renal Caps (generic) (Merck) Cerefolin® Folbain Plus (generic),Vitaplex (generic), Folbic (generic), Apriso® mesalamine (generic),Asacol® (Procter & Gamble), Folbee (generic), Renal Caps (generic) Pentasa® ( Shire US) Chromagen FA® Foltrin (generic), Ferrex 150 Forte (generic), Hematogen ® ® Forte (generic), Ferotrinsic (generic), Poly-Iron 150 Forte Arthrotec diclofenac (generic), misoprostol (generic), Celebrex (generic) (Pfizer) Chromagen Forte® Foltrin (generic), Ferrex 150 Forte (generic), Hematogen Asmanex® Flovent HFA® (GlaxoSmithKline), Flovent Diskus® Forte (generic), Ferotrinsic (generic), Poly-Iron 150 Forte (GlaxoSmithKline), Pulmicort Respules® (AstraZeneca), (generic) Qvar® (IVAX) Chromagen® Foltrin (generic), Ferrex 150 Forte (generic), Hematogen Atacand® losartan potassium (generic), Micardis® (BIPI) Forte (generic), Ferotrinsic (generic), Poly-Iron 150 Forte Atacand HCT® losartan/HCTZ (generic), Micardis HCT® (BIPI) (generic) ® ® ® Augmentin XR® amoxicillin trihydrate/potassium clavulanate (generic) Cimzia (RA Indication Only) Enbrel (Amgen), Humira (Abbott) Ciprodex® neomycin/polymyxin/HC (generic), ofloxacin (generic) Avalide® losartan/HCTZ (generic), Micardis HCT® (BIPI) Cipro HC® neomycin/polymyxin/HC (generic), ofloxacin (generic) Avapro® losartan potassium (generic), Micardis® (BIPI) Cipro XR® ciprofloxacin HCl (generic) Avinza® morphine sulfate ER (generic) Clindagel® clindamycin phosphate (generic) Avodart® finasteride (generic), tamsulosin (generic) Clobex® clobetasol propionate (generic) Axert® sumatriptan (generic), Maxalt® (Merck), Relpax® (Pfizer) Cloderm® betamethasone valerate cream (generic), Azasite® erythromycin ointment (generic), ciprofloxacin drops desoximetasone cream (generic), fluocinolone acetonide (generic), tobramycin sulfate drops (generic),Vigamox cream (generic), hydrocortisone valerate cream (generic), (Alcon) triamcinolone acetonide cream (generic) Azilect® selegiline (generic) Coly-Mycin S® neomycin/polymyxin/HC (generic), ofloxacin (generic)
*Branded generics have the same co-payment as regular generics. 8 MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 9
Nonpreferred Product Possible Preferred Alternatives Nonpreferred Product Possible Preferred Alternatives Combunox® oxycodone w/acetaminophen (generic), Exelderm® econazole nitrate (generic), ketoconazole (generic), oxycodone w/aspirin (generic) nystatin (generic) Cordran SP® betamethasone valerate cream (generic), desoximetasone Exforge® amlodipine/benazepril (generic) cream (generic), fluocinolone acetonide cream (generic), ® hydrocortisone valerate cream (generic), triamcinolone Exforge HCT amlodipine (generic), benazepril (generic), acetonide cream (generic) hydrochlorothiazide (generic) ® ® Coreg CR® carvedilol (generic) Factive ciprofloxacin (generic), Avelox (Schering) ® ® Cortisporin-TC® neomycin/polymyxin/HC (generic), ofloxacin (generic) Fanapt clozapine (generic), risperidone (generic), Geodon (Pfizer), Seroquel® (AstraZeneca), Zyprexa® (Lilly) Corvite® Therobec Plus (generic),Vitaplex Plus (generic),Vitacon Plus (generic), Formula B Plus (generic),Vita Forte Fast Take® Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® (generic) (Bayer), Contour® (Bayer) Covera-HS® verapamil HCl tablet, sustained action (generic) Femcon Fe® estradiol/norethindrone (generic) Crestor® simvastatin (generic), Lipitor® (Pfizer) Femring® Estring® (Pfizer) Cutivate® Lotion triamcinolone lotion (generic) Femtrace® estradiol tabs (generic) Daytrana® methylphenidate ER (generic), Concerta® (McNeil Fentora® fentanyl lozenge (generic) ® Consumer),Adderall XR (Shire US Inc.) First Testosterone® Androderm® (Watson Pharmaceuticals),Androgel® Decaspray® fluocinolone acetonide solution, non oral (generic) (Unimed) Desonate® Gel desonide (generic), alclometasone (generic), Flarex® fluorometholone (generic) hydrocortisone (generic) Flebogamma® Gamunex® (Talecris Biotherapeutics),Vivaglobin® (ZLB Detrol® flavoxate( generic), oxybutynin (generic), oxybutynin ER Behring LLC) ® (generic),Vesicare (GlaxoSmithKline) ® ® Flector Patch naproxen (generic), etodolac (generic), ibuprofen Detrol LA flavoxate( generic), oxybutynin (generic), oxybutynin ER (generic) (generic),Vesicare® (GlaxoSmithKline) FML-Forte® fluorometholone (generic) Differin® tretinoin (generic), Azelex® (Allergan), Finacea® (Bayer) FML-S.O.P.® dexamethasone ointment (generic) Diovan® losartan potassium (generic), Micardis® (BIPI) Focalin XR® dexmethylphenidate (generic), methylphenidate ER Diovan HCT® losartan/HCTZ (generic), Micardis HCT® (BIPI) (generic), Concerta® (McNeil Consumer), Dipentum® sulfasalazine (generic), balsalazide (generic),Asacol® Adderall XR® (Shire US Inc.) (Procter & Gamble), Pentasa® ( Shire US) Foradil® Serevent Diskus® (GSK) Diprolene® Lotion betamethasone dipropionate (generic) Fosamax D® alendronate (generic) Divigel® estradiol patch (generic) ® ® ® ® ® Freestyle Accu-Chek (Roche), Ascensia (Bayer), Breeze2 Doryx doxycycline hyclate (generic) (Bayer), Contour® (Bayer) ® Duac clindamycin phosphate (generic), benzoyl peroxide Frova® sumatriptan (generic), Maxalt (Merck), Relpax (Pfizer) (generic) Gammagard® Liquid Gamunex® (Talecris Biotherapeutics),Vivaglobin® (ZLB Duet® Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® (Bayer), Contour® (Bayer) Behring LLC) ® ® ® Duetact® glimepiride (generic) + Actos® (Takeda) Gammagard S-D Gamunex (Talecris Biotherapeutics),Vivaglobin (ZLB Behring LLC) ® Duet DHA Stuartnatal Prenatal Plus (generic), OB-Natal Plus (generic), PNV- ® DHA (generic),Taron-Prex Prenatal (generic), Pruet DHA Gelnique 10% Packets oxybutynin (generic), oxybutynin ER (generic) (generic) Genotropin® Norditropin® (Nov Nordisk),Tev-Tropin® (Gate Duoneb® ProAir HFA® (Teva) Pharmaceuticals) Durezol® prednisolone (generic) Glumetza® metformin ER (generic) DynaCirc CR® amlodipine besylate (generic), nifedipine ER (generic) Glyset® acarbose (generic) Edluar® zolpidem (generic) Halog® desoximetasone cream (generic), fluocinonide cream Effexor XR® venlafaxine HCl (generic), citalopram HBr (generic), (generic) fluoxetine HCl (generic), paroxetine HCl (generic), Humatrope® Norditropin® (Nov Nordisk),Tev-Tropin® (Gate sertraline HCl (generic), Cymbalta® (Eli Lilly) Pharmaceuticals) Elestat® Patanol® (Alcon), Pataday® (Alcon) Hycet® acetaminophen w/codeine (generic) Emadine® Patanol® (Alcon), Pataday® (Alcon) Innopran® propranolol LA (generic) Embeda® morphine SR (generic) Intuniv® dextroamphetamine/amphetamine (generic), Emsam® Nardil® (Parke-Davis) methylphenidate (generic), methylphenidate ER (generic), Concerta® (Janssen) Enablex® flavoxate( generic), oxybutynin (generic), oxybutynin ER (generic),Vesicare® (GlaxoSmithKline) Invega® risperidone (generic), Seroquel® (AstraZeneca), Zyprexa® Epiduo® tretinoin (generic), benzoyl peroxide (generic) (Eli Lilly) ® ® Ertaczo® econazole nitrate (generic), ketoconazole (generic), Iquix ciprofloxacin drops (generic),Vigamox (Alcon) nystatin (generic) Istalol® betaxolol (generic), carteolol (generic), timolol (generic), Estrace® Vaginal Cream Premarin® Vaginal Cream (Wyeth) levobunolol (generic), metipranolol (generic) Estrasorb® estradiol patch (generic), Estraderm® (Novartis),Vivelle® Kadian® morphine sulfate ER (generic) (Novartis),Vivelle-DOT® (Novartis) Kapidex® omeprazole (generic), Nexium® (AstraZeneca) ® Estrogel estradiol patch (generic) Keppra XR® levetiracetam (generic) ® ® ® Estrostep Fe Apri (Barr-branded generic*), Kariva Kogenate® Helixate FS® (CSL Behring LLC) (Barr-branded generic*), Microgestin Fe® (Watson-branded generic*) Lamictal XR® lamotrigine (generic) Euflexxa® Hyalgan® (Sanofi Pharm), Synvisc® (Genzyme), Lamisil® Granules terbinafine (generic) ® Synvisc-One (Genzyme) Lescol® lovastatin (generic), simvastatin (generic), Evoclin® clindamycin phosphate (generic) pravastatin (generic), Lipitor® (Pfizer) Exalgo® hydromorphone (generic), morphine ER (generic), Lescol XL® lovastatin (generic), simvastatin (generic), Oxycontin® (Purdue Pharma) pravastatin (generic), Lipitor® (Pfizer)
*Branded generics have the same co-payment as regular generics. 9 MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 10
Nonpreferred Product Possible Preferred Alternatives Nonpreferred Product Possible Preferred Alternatives Levaquin® ciprofloxacin (generic), ofloxacin (generic),Avelox® Nutropin Depot® Norditropin® (NovoNordisk), (Schering) Tev-Tropin® (Gate Pharmaceuticals) Levatol® acebutolol HCl (generic), atenolol (generic), metoprolol Nuvaring® Aviane® (Barr), Lessina® (Barr) tartrate (generic) OB Complete 400 ® Prenatal Plus (generic), OB-Natal Plus (generic), Lexapro Solution® citalopram solution (generic), fluoxetine HCl solution PNV-DHA (generic),Taron-Prex Prenatal (generic), (generic) Pruet DHA (generic) Lexapro® citalopram (generic), fluoxetine HCl (generic), paroxetine Octagam® Gamunex® (Talecris Biotherapeutics),Vivaglobin® (ZLB HCl (generic), sertraline HCl (generic) Behring LLC) Lialda® balsalazide (generic),Asacol® (Procter & Gamble), Olux® clobetasol propionate (generic) Pentasa® ( Shire US) Omnaris® flunisolide (generic), fluticasone propionate (generic), Lipsovir® acyclovir (generic) Nasonex® (Schering) Livalo® lovastatin (generic), pravastatin( generic), simvastatin Omnitrope® Norditropin® (Nov Nordisk),Tev-Tropin® (Gate (generic), Lipitor® (Pfizer) Pharmaceuticals) ® Lofibra fenofibrate (generic) OneTouch Ultra® Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® Loprox Shampoo® selenium sulfide shampoo (generic) (Bayer), Contour® (Bayer) Lorabid® cefaclor (generic), cefuroxime axetil (generic), OneTouch® Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® cefdinir (generic), cefpodoxime (generic) (Bayer), Contour® (Bayer) LoSeasonique® Levora® (Watson), Portia® (Barr) Onsolis® fentanyl lozenge (generic) Lotemax® fluorometholone (generic), prednisolone (generic) Opana® morphine sulfate (generic) Lovaza® fenofibrate (generic), Niaspan ER® (Abbott) Opana ER® morphine sulfate ER (generic), Oxycontin® (Purdue Lumigan® Xalatan® (Pfizer) Pharma) ® ® ® Lunesta® temazepam (generic), triazolam (generic), zolpidem Optivar Patanol (Alcon), Pataday (Alcon) (generic), zaleplon (generic) Oracea® doxycycline monohydrate (generic) Luvox® CR fluvoxamine (generic) Ortho Evra® MonoNessa® (Watson),TriNessa® (Watson) Luxiq® betamethasone valerate cream (generic) Ortho Tri-Cyclen Lo® TriNessa® (Watson),Tri-Sprintec® (Barr) Lybrel® Aviane® (Barr), Lessina® (Barr) Orthovisc® Hyalgan® (Sanofi Pharm), Synvisc® (Genzyme), Mavik® trandolapril HCl (generic), benazepril HCl (generic), Synvisc-One® (Genzyme) enalapril maleate (generic), lisinopril (generic), quinapril Oxistat® econazole nitrate (generic), ketoconazole (generic), (generic),Altace® (Monarch) nystatin (generic) ® ® Maxair Autohaler ProAir HFA (Teva) Oxytrol® oxybutynin (generic), oxybutynin ER (generic) ® Maxaquin ciprofloxacin HCl (generic) Pandel® betamethasone valerate cream (generic), Maxidex® fluorometholone (generic), prednisolone (generic) desoximetasone cream (generic), Menest® estradiol (generic), estropipate (generic), Cenestin fluocinolone acetonide cream (generic), (Barr/Duramed), Enjuvia (Barr/Duramed) hydrocortisone valerate cream (generic), triamcinolone acetonide cream (generic) ® Menostar estradiol (generic), Estraderm (Novartis),Vivelle ® (Novartis),Vivelle-Dot (Novartis) Parcopa carbidopa/levadopa (generic), carbidopa/levadopa ER (generic) ® Mentax econazole nitrate (generic), ketoconazole (generic), ® nystatin (generic) PCE erythromycin base (generic) ® ® Metanx® Folbain Plus (generic),Vitaplex (generic), Folbic (generic), Pegasys PEG-Intron (Schering) Folbee (generic), Renal Caps (generic) Pennsaid® etodolac (generic), ibuprofen (generic), naproxen Metrogel® metronidazole gel (generic) (generic) ® Metrolotion® metronidazole lotion (generic) Pexeva paroxetine HCl (generic) Minitran Patch® nitroglycerin patch (generic) Ponstel® etodolac (generic), ibuprofen (generic), indomethacin (generic), naproxen (generic), sulindac (generic) Mirapex ER® pramopexole (generic), Mirapex® 0.75mg (Boehringer Ingelheim) Potaba® aminobenzoate (generic) Naftin® econazole nitrate (generic), ketoconazole (generic), Prandimet® metformin (generic),+ Prandin® (Novo Nordisk) nystatin (generic) Precision QID® Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® Nalfon® etodolac (generic), ibuprofen (generic), indomethacin (Bayer), Contour® (Bayer) (generic), naproxen (generic), sulindac (generic) Precision XTRA® Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® Naprelan® 375mg naproxen (generic) (Bayer), Contour® (Bayer) Nasacort AQ® flunisolide (generic), fluticasone propionate (generic), Premarin Tabs® estradiol (generic), Cenestin® (Barr/Duramed), Enjuvia® Nasonex® (Schering) (Barr/Duramed) Nasarel® flunisolide (generic), fluticasone propionate (generic), Prenexa® Prenatal Plus (generic), OB-Natal Plus (generic), Nasonex® (Schering) PNV-DHA (generic),Taron-Prex Prenatal (generic), Niferex-150 Forte® Foltrin (generic), Ferrex 150 Forte (generic), Pruet DHA (generic) Hematogen Forte (generic), Ferotrinsic (generic), Prestige® Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® Poly-Iron 150 Forte (generic) (Bayer), Contour® (Bayer) Nitro-Dur Patch® nitroglycerin patch (generic) Prevacid-Naprapac® omeprazole (generic), naproxen (generic) Noritate® metronidazole cream (generic) Pristiq® venlafaxine HCl (generic), citalopram HBR (generic), Noroxin® ciprofloxacin (generic), ofloxacin (generic),Avelox® fluoxetine HCL (generic), paroxetine HCl (generic), (Schering) sertraline HCl (generic), Cymbalta® (Eli Lilly) Nucynta® tramadol (generic) Promar® Therobec Plus (generic),Vitaplex Plus (generic),Vitacon ® ® Plus (generic), Formula B Plus (generic),Vita Forte Nutropin Norditropin (NovoNordisk), (generic) Tev-Tropin® (Gate Pharmaceuticals) ® ® Nutropin AQ® Norditropin® (NovoNordisk), Proventil HFA ProAir HFA (Teva) Tev-Tropin® (Gate Pharmaceuticals) Psorcon E Oint® diflorasone diacetate (generic) *Branded generics have the same co-payment as regular generics.
10 MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 11
Nonpreferred Product Possible Preferred Alternatives Nonpreferred Product Possible Preferred Alternatives Pulmicort Flexhaler® Flovent HFA® (GlaxoSmithKline), Flovent Diskus® Tazorac® (Acne use only) tretinoin (generic),Azelex® (Allergan), Finacea® (Bayer) ® (GlaxoSmithKline), Pulmicort Respules (AstraZeneca), Tekturna® losartan potassium (generic), Micardis® (BIPI) Qvar® (IVAX) Tekturna/HCT® losartan/HCTZ (generic), Micardis HCT® (BIPI) Quixin® ciprofloxacin drops (generic),Vigamox® (Alcon) Tequin® ciprofloxacin (generic), ofloxacin (generic),Avelox® Recombinate® Helixate FS® (CSL Behring LLC) (Schering) ® Replica 21-7 Foltrin (generic), Ferrex 150 Forte (generic), Hematogen ® ® ® Forte (generic), Ferotrinsic (generic), Poly-Iron 150 Forte Testim Androderm (Watson Pharmaceuticals),Androgel (generic) (Unimed Pharm) ® Requip XL® ropinirole (generic) Testred methyltestosterone (generic) ® ® Retin-A® tretinoin (generic) Teveten losartan potassium (generic), Micardis (BIPI) Rhinocort AQ® flunisolide (generic), fluticasone propionate (generic), Teveten HCT® losartan/HCTZ (generic), Micardis HCT® (BIPI) Nasonex® (Schering) Texacort® fluocinolone acetonide solution, non oral (generic) ® Riomet Solution metformin (generic) Travatan® Xalatan® (Pfizer) ® Rosac sodium sulfacetamide 10% and sulfur 5% (generic) Travatan Z® Xalatan® (Pfizer) ® Rosanil sodium sulfacetamide 10% and sulfur 5% (generic) Tretin-X Gel® tretinoin (generic) ® Rosula sodium sulfacetamide 10% and sulfur 5% (generic) Treximet® sumatriptan (generic), naproxen (generic) ® Rozerem temazepam (generic), triazolam (generic), Triaz® benzoyl peroxide (generic) zolpidem (generic), zaleplon (generic) Tricor® fenofibrate (generic) Ryzolt® tramadol (generic) Triglide® fenofibrate (generic) Sabril® divalproex (generic), lamotrigine (generic), levetiracetam (generic), topiramate (generic), Gabitril® (Cephalon) Twynsta® amlodipine (generic) + Micardis® (BIPI) Saizen® Norditropin® (NovoNordisk),Tev-Tropin® (Gate Univasc® benazepril HCl (generic), enalapril (generic), Pharmaceuticals) fosinopril (generic), lisinopril (generic), quinapril (generic), ® Sanctura®/Sanctura XR® flavoxate( generic), oxybutynin (generic), oxybutynin ER Altace (Monarch) (generic),Vesicare® (GlaxoSmithKline) Uroxatral® doxazosin (generic), terazosin (generic), tamsulosin Sancuso® ondansetron (generic), granisetron (generic), Emend® (generic) (Merck) Vagifem® Premarin® Vaginal Cream (Wyeth) ® ® Saphris cloxapine (generic), risperidone (generic), Seroquel Valturna® amlodipine (generic) + losarten (generic) or Micardis® (AstraZeneca) (BIPI) ® Sarafem fluoxetine HCl (generic) Vanos® clobetasol propionate (generic), betamethasone dp Seasonique® Levora® (Watson), Portia® (Barr) augmented (generic), diflorasone diacetate (generic) Seconal® chloral hydrate (generic), temazepam (generic), triazolam Vantin Suspension® cefaclor suspension (generic), cefdinir (generic), (generic) cefpodoxime (generic) Select-OB® + DHA Prenatal Plus (generic), OB-Natal Plus (generic), Ventolin HFA® ProAir HFA® (Teva)
PNV-DHA (generic),Taron-Prex Prenatal (generic), ® Pruet DHA (generic) Veramyst flunisolide (generic), fluticasone propionate (generic), Nasonex® (Schering) Serostim® Norditropin® (NovoNordisk),Tev-Tropin® (Gate Pharmaceuticals) Verdeso® desonide (generic) Simcor® simvastatin (generic) + Niaspan ER® (Abbott) Vexol® fluorometholone (generic) Simponi® (RA Indication Only) Enbrel® (Amgen), Humira® (Abbott) Vitafol-OB®+DHA Prenatal Plus (generic), OB-Natal Plus (generic), Sotret® isotretinoin capsule (generic) PNV-DHA (generic),Taron-Prex Prenatal (generic), Pruet DHA (generic) Stalevo® carbidopa/levadopa (generic) + Comtan® (Novartis) Voltaren® Gel etodolac (generic), ibuprofen (generic), naproxen ® ® ® Striant Androderm (Watson Pharmaceuticals),Testim (generic) (Auxilium Pharmaceuticals) ® ® ® Vytorin simvastatin (generic), Zetia (Merck-Schering Plough), Strovite Advance Therobec Plus (generic),Vitaplex Plus (generic),Vitacon Lipitor® (Pfizer) Plus (generic), Formula B Plus (generic),Vita Forte (generic) Xopenex® albuterol inhalant solution (generic) Strovite Plus® Therobec Plus (generic),Vitaplex Plus (generic),Vitacon Xopenex HFA® ProAir HFA® (Teva) Plus (generic), Formula B Plus (generic),Vita Forte Xyntha® Helixate FS® (CSL Behring LLC) (generic) Yaz ® Aviane® (Barr), Lessina® (Barr) Strovite® Therobec Plus (generic),Vitaplex Plus (generic),Vitacon Plus (generic), Formula B Plus (generic),Vita Forte Zagam® ciprofloxacin HCl (generic), Avelox® (Schering) (generic) Zanaflex® 4mg & 6mg tizanidine(generic) Sumavel® sumatriptan (generic) Zegerid® omeprazole (generic), Nexium® (AstraZeneca) ® ® ® Supartz Hyalgan (Sanofi Pharm), Synvisc (Genzyme), Zelapar® selegiline (generic) Synvisc-One® (Genzyme) Ziana® clindamycin phosphate (generic), tretinoin (generic) Suprax susp® cefuroxime axetil (generic), cefdinir (generic) Zoderm® benzoyl peroxide (generic) Surestep® Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® (Bayer), Contour® (Bayer) Zomig® (all dosage forms) sumatriptan (generic), Maxalt® (Merck), Relpax® (Pfizer) Surmontil® imipramine (generic) Zonalon® alclometasone dipropionate (generic), fluocinolone acetonide (generic), hydrocortisone (generic) Symbicort® Advair HFA® (GlaxoSmithKline), Advair Diskus® (GlaxoSmithKline) Zovirax Cream® Denavir® Cream (Novartis) Symbyax® fluoxetine HCl (generic), Zyprexa® (Eli Lilly) Zydone® hydrocodone w/acetaminophen (generic) Tasmar® Comtan® (Novartis) Zymar® ciprofloxacin drops (generic),Vigamox® (Alcon)
*Branded generics have the same co-payment as regular generics. 11