BLOOD CANCER DRUGS-OTHER (ANTINEOPLASTICS) BLOOD MODIFIERS CANCER DRUGS-OTHER (ANTINEOPLASTICS) anagrelide (P) NEUPOGEN SYLATRON (P) pentoxifylline (M) (P) PROCRIT CANCER DRUGS -ORAL BLOOD THINNERS (ANTICOAGULANTS) (ANTINEOPLASTICS) COUMADIN (M) CANCER DRUGS -ORAL (ANTINEOPLASTICS) enoxaparin (M) anastrozole fondaparinux (P) AFINITOR FRAGMIN (M) bicalutamide PRADAXA (P) (M) BOSULIF warfarin (P) CAPRELSA (M) STROKE PREVENTION exemestane ERIVEDGE (P) (M) GLEEVEC (P) clopidogrel (P) ticlopidine (M) HYCAMTIN INLYTA (P) (M) CANCER DRUGS-OTHER letrozole NEXAVAR (P) (ANTINEOPLASTICS) (P) REVLIMID (P) CANCER DRUGS-OTHER SPRYCEL (ANTINEOPLASTICS) JAKAFI (P) KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication CANCER DRUGS -ORAL CENTRAL NERVOUS SYSTEM (ANTINEOPLASTICS) ANTI-PARKINSON DRUGS CANCER DRUGS -ORAL (M) (ANTINEOPLASTICS) pramipexole ropinirole (M) STIVARGA (P) selegiline (M) SUTENT (P) TARCEVA (P) ATTENTION DEFICIT DISORDER (ADD), TASIGNA (P) NARCOLEPSY (P) TEMODAR (M) (P) amphetamine/dextroamphetamine THALOMID (M) (P) dexmethylphenidate TYKERB (M) (P) dextroamphetamine VOTRIENT (M) (P) methamphetamine XALKORI (M) (P) methylphenidate sr XELODA (M) XTANDI (P) methylphenidate ZELBORAF (P) (P) SEIZURE MEDICATIONS (ANTICONVULSANTS) ZOLINZA (P) ZYTIGA carbamazepine extended release (M) carbamazepine (M) CENTRAL NERVOUS SYSTEM clonazepam (M) diazepam (M) ALZHEIMER'S DRUGS divalproex (M) (M) (M) divalproex sodium ARICEPT-23 (M) (M) ethosuximide donepezil (M) NAMENDA (M) gabapentin lamotrigine (M) (M) ANTI-PARKINSON DRUGS levetiracetam phenytoin (M) amantadine (M) primidone (M) APOKYN topiramate (M) bromocriptine (M) valproic acid (M) levodopa/carbidopa (M) zonisamide (M) KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication CENTRAL NERVOUS SYSTEM DIABETES & HIGH BLOOD SUGAR SLEEP AIDS ANTIDIABETIC DRUGS temazepam LEVEMIR (M) zaleplon metformin xr (M) zolpidem metformin (M) nateglinide (M) CHEST PAIN & HEART DISEASE NOVO INSULIN (M) NOVOLOG (M) CHEST PAIN & HEART DISEASE ONGLYZA (M) (M) (M) piogliazone/metformin isosorbide dinitrate pioglitazone (M) isosorbide mononitrate (M) (M) (M) PRANDIN nitroglycerin sl VICTOZA (M) transdermal nitroglycerin (M) BLOOD SUGAR TEST STRIPS DIABETES & HIGH BLOOD SUGAR ACCU-CHEK meter test strips (Q,M) ANTIDIABETIC DRUGS ONE TOUCH meter test strips (Q,M) (M) acarbose DISEASES BYETTA (M) (M) glimepiride ARTHRITIS (RHEUMATOID) glipizide extended release (M) glipizide (M) ENBREL (P) glyburide and metformin (M) HUMIRA (P) glyburide (M) leflunomide (M) JANUMET XR (M) methotrexate (M) JANUMET (M) JANUVIA (M) BONE DISEASE KOMBIGLYZE (M) alendronate (M) KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication DISEASES ENT (EAR/NOSE/THROAT) BONE DISEASE ALLERGIES & COLDS (NASAL) calcitonin salmon nasal spray (M) fluticasone propionate (M) etidronate (M) triamcinolone (M) EVISTA (M) ibandronate (M) ALLERGIES (ORAL) (M) GOUT desloratadine levocetirizine (M) allopurinol (M) COLCRYS (M) MISCELLANEOUS HEPATITIS lidocaine viscous INTRON A (M) EYE PEGASYS (P) ribavirin ANTI-INFLAMMATORY DROPS MULTIPLE SCLEROSIS DRUGS prednisolone acetate COPAXONE (P,M) COMBINATION EYE INFECTION DROPS REBIF (P,M) dexamethasone/neomycin/polymyxin THYROID DISEASE dexamethasone/tobramycin levothyroxine (M) EYE INFECTION DROPS liothyronine (M) methimazole (M) ciprofloxacin propylthiouracil (M) ENT (EAR/NOSE/THROAT) ALLERGIES & COLDS (NASAL) azelastine KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication EYE EYE EYE INFECTION DROPS MISCELLANEOUS DRUGS ofloxacin ketorolac tromethamine 0.5% polymyxin b/bacitracin RESTASIS (M) polymyxin b/trimethoprim polymyxin/neomycin/gramicidin sol. HEART RHYTHM DISORDERS sodium sulfacetamide tobramycin drops HEART RHYTHM DISORDERS trifluridine (M) VIGAMOX acebutolol amiodarone (M) (M) GLAUCOMA DRUGS digoxin disopyramide controlled release (M) acetazolamide (M) disopyramide (M) ALPHAGAN P 0.1% (M) propafenone (M) AZOPT (M) sotalol (M) brimonidine 0.15% (M) COMBIGAN (M) HIGH BLOOD PRESSURE & HEART (M) dorzolamide/timolol DISEASE dorzolamide (M) (M) latanoprost ACE INHIBITORS levobunolol (M) LUMIGAN (M) benazepril (M) methazolamide (M) enalapril (M) pilocarpine (M) lisinopril (M) timolol (M) moexipril (M) quinapril (M) MISCELLANEOUS DRUGS trandolapril (M) atropine ALPHA BETA BLOCKERS flurbiprofen ketoralac tromethamine, 0.4 % carvedilol (M) KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication HIGH BLOOD PRESSURE & HEART HIGH BLOOD PRESSURE & HEART DISEASE DISEASE ALPHA BETA BLOCKERS CALCIUM CHANNEL BLOCKERS doxazosin (M) nisoldipine (M) labetalol (M) verapamil extended release (M) prazosin (M) verapamil (M) ANGIOTENSIN II BLOCKERS COMBINATION DRUGS DIOVAN (M) amlodipine/benazepril (M) EDARBI (M) atenolol/chlorthalidone (M) irbesartan (M) benazepril/hctz (M) losartan (M) bisoprolol/hctz (M) EDARBYCLOR (M) BETA BLOCKERS irbesartan/hctz (M) (M) (M) lisinopril/hctz acebutolol (M) (M) losartan/hctz atenolol (M) (M) moexipril/hct BYSTOLIC valsartan/hctz (M) metoprolol xl (M) (M) metoprolol SYMPATHOLYTICS nadolol (M) propranolol extended rel. (M) clonidine (M) propranolol (M) guanfacine (M) CALCIUM CHANNEL BLOCKERS WATER PILLS OR DIURETICS amlodipine (M) furosemide (M) diltiazem extended release (M) hydrochlorothiazide (M) diltiazem (M) metolazone (M) nifedipine extended release (M) spironolactone (M) nifedipine sustained release (M) torsemide (M) KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication HIGH BLOOD PRESSURE & HEART HIV & AIDS DISEASE COMBINATION DRUGS WATER PILLS OR DIURETICS KALETRA (M) (M) triamterene/hctz (M) lamivudine/zidovudine STRIBILD (M) TRIZIVIR (M) HIGH CHOLESTEROL DRUGS (M) (ANTILIPEMICS) TRUVADA NON-NUCLEOSIDE REVERSE TRANSCRIPTASE HIGH CHOLESTEROL DRUGS INHIBITORS (ANTILIPEMICS) (M) (M) EDURANT atorvastatin (M) (M) INTELENCE cholestyramine (M) (M) nevirapine colestipol (M) (M) RESCRIPTOR fluvastatin (M) (M) SUSTIVA gemfibrozil lovastatin (M) (M) NUCLEOSIDE REVERSE TRANSCRIPTASE pravastatin INHIBITORS simvastatin (M) abacavir (M) HIV & AIDS didanosine (M) EMTRIVA (M) MISCELLANEOUS FUZEON (M) HIVID (M) (M) ATRIPLA lamivudine (M) (M) ISENTRESS stavudine (M) (M) SELZENTRY VIDEX Powder (M) VIREAD (M) COMBINATION DRUGS zidovudine capsules (M) zidovudine tablets and syrup (M) COMPLERA (M) (M) EPZICOM PROTEASE INHIBITORS APTIVUS (M) KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication HIV & AIDS HORMONES PROTEASE INHIBITORS MISCELLANEOUS CRIXIVAN (M) desmopressin acetate tablets (M) FORTOVASE, INVIRASE (M) LEXIVA (M) STEROID REPLACEMENT MEDICATION NORVIR (M) PREZISTA (M) hydrocortisone REYATAZ (M) VIRACEPT (M) IMMUNE SYSTEM HORMONES ANTI-REJECTION (IMMUNOSUPPRESSANTS) azathioprine (M) GROWTH cyclosporine (M) (M) (P) mercaptopurine NORDITROPIN (M) SEROSTIM (P) mycophenolate RAPAMUNE (M) (M) HORMONE REPLACEMENT DRUGS tacrolimus ethinyl estradiol/norethindrone (M) INFECTIONS MALE BACTERIAL (CEPHALOSPORINS) ANDRODERM (M) cefuroxime AXIRON (M) cephalexin capsules oxandrolone BACTERIAL (COMBINATION ANTIBIOTICS) MISCELLANEOUS trimethoprim/sulfamethoxazole desmopressin acetate nasal spray (M) KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication INFECTIONS INFECTIONS BACTERIAL (FLUROQUINOLONES) FUNGAL (ANTIFUNGAL DRUGS) ciprofloxacin er itraconazole ciprofloxacin ketoconazole levofloxacin terbinafine BACTERIAL (MACROLIDES) MISCELLANEOUS ANTI-INFECTIVE DRUGS azithromycin suspension (Q) atovaquone/proguanil azithromycin tablets (Q) chloroquine phosphate clarithromycin extended release hydroxychloroquine clarithromycin ZYVOX erythromycin ethylsuccinate TUBERCULOSIS (ANTITUBERCULOSIS DRUG) BACTERIAL (MISCELLANEOUS (M) ANTIBIOTICS) ethambutol isoniazid/rifampin (M) clindamycin metronidazole URINARY TRACT BACTERIAL (PENICILLINS) nitrofurantoin (macrocrystals) nitrofurantoin exten. rel. amoxicillin/clavulanate amoxicillin/pot.clavulanate VIRAL (ANTIVIRAL DRUGS) BACTERIAL (TETRACYCLINES) acyclovir famciclovir doxycycline monohydrate valacyclovir doxycycline VALCYTE minocycline MENTAL HEALTH FUNGAL (ANTIFUNGAL DRUGS) ANTIDEPRESSANTS fluconazole bupropion xl 150mg (M) KEY: Preferred Brand-name Drugs (Tier 2) Generic Drugs (Tier 1) P = Prior Authorization Required, Q = Quantity Limit, M = Maintenance Medication MENTAL HEALTH MENTAL HEALTH ANTIDEPRESSANTS MANIC-DEPRESSION OR BIPOLAR DRUGS bupropion (M) lithium carbonate ext. rel. (M) citalopram (M) clomipramine (M) MISCELLANEOUS DRUGS desipramine (M) escitilopram (M) MISCELLANEOUS DRUGS fluoxetine (M) (M) Novofine needles (M) imipramine (M) mirtapazine orally disintegrating (M) Novotwist needles mirtazapine (M) nortriptyline (M) MUSCLE RELAXERS paroxetine controlled release (M) paroxetine (M) MUSCLE RELAXERS phenelzine (M) protriptyline (M) carisoprodol sertraline (M) cyclobenzaprine tranylcypromine (M) metaxalone venlafaxine (M) methocarbamol tizanidine ANTIPSYCHOTIC DRUGS NARCOLEPSY olanzapine (M) quetiapine fumurate (M) NARCOLEPSY risperidone