2012 High-Cost Generic Tier 2 Drugs The listing below identifies select generic medications that are covered under the Tier 2 coinsurance level. Consult with your prescriber to identify which alternative medications are right for you. This listing is subject to change. Generics Covered Form Tier 1 Generic Alternative Under Tier 2 acetazolamide sustained action • acetazolamide tablet capsule acetic acid/ drops • aa/antpy/bcaine/polico/al acet drops • neomy sulf/polymyx b sulf/hc suspension drops hydrocortisone • acetic acid/aluminum acetate drops • ofloxacin drops • antipyrine/benzocaine/glycerin drops • hc/pramoxine hcl/chloroxylenol drops alprazolam sustained release 24hr • alprazolam tablet • diazepam solution oral tablet • buspirone tablet • lorazepam tablet • chlordiazepoxide capsule • lorazepam concentrate oral rapid dissolve tablet • clorazepate tablet • oxazepam capsule • diazepam tablet amlodipine- tablet • amlodipine + simvastatin • amlodipine + lovastatin atorvastatin • amlodipine + pravastatin amphet asp/amphet/ sustained release 24 • amphet asp/amphet/d-amphet • dextroamphetamine tablet d-amphet hr capsule (amphetamine salt combo) immediate release tablet • dextroamphetamine capsule sustained action apraclonidine hcl drops • brimonidine drops • levobunolol drops • dorzolamide drops • timolol maleate gel-forming solution • dorzolamide/timolol drops • timolol maleate drops • latanoprost drops atorvastatin calcium tablet • simvastatin tablet • lovastatin tablet • pravastatin tablet Generics Covered Form Tier 1 Generic Alternative Under Tier 2 azelastine hcl drops • ketorolac drops betamethasone gel • alclometasone cream • fluocinolone cream dipropionate • alclometasone ointment • fluocinolone ointment • amcinonide cream • fluticasone ointment • amcinonide ointment • fluticasone cream • amcinonide lotion • halobetasol ointment • betamethasone cream • halobetasol cream • betamethasone ointment • hydrocortisone cream • betamethasone lotion • hydrocortisone ointment • clobetasol ointment • hydrocortisone lotion • clobetasol ream • hydrocortisone solution non-oral • clobetasol solution non-oral • mometasone cream • clobetasol gel • mometasone ointment • desonide cream • mometasone solution non-oral • desonide lotion • prednicarbate cream • desonide ointment • triamcinolone cream • desoximetasone cream • triamcinolone ointment • diflorasone ointment • triamcinolone lotion • fluocinolone solution • triamcinolone cream bromfenac sodium drops • diclofenac drops • ketorolac drops budesonide delayed & extended • dexamethasone tablet • methylprednisolone tablet release capsule • dexamethasone elixir • prednisolone solution oral • dexamethasone solution oral • prednisone tablet • hydrocortisone tablet clindamycin foam • clindamycin lotion • clindamycin solution non-oral phosphate • clindamycin gel • clindamycin swab medicated Generics Covered Form Tier 1 Generic Alternative Under Tier 2 clobetasol propionate foam • alclometasone cream • fluocinolone cream • alclometasone ointment • fluocinolone ointment • amcinonide cream • fluticasone ointment • amcinonide ointment • fluticasone cream • amcinonide lotion • halobetasol ointment • betamethasone cream • halobetasol cream • betamethasone ointment • hydrocortisone cream • betamethasone lotion • hydrocortisone ointment • clobetasol ointment • hydrocortisone lotion • clobetasol ream • hydrocortisone solution non-oral • clobetasol solution non-oral • mometasone cream • clobetasol gel • mometasone ointment • desonide cream • mometasone solution non-oral • desonide lotion • prednicarbate cream • desonide ointment • triamcinolone cream • desoximetasone cream • triamcinolone ointment • diflorasone ointment • triamcinolone lotion • fluocinolone solution • triamcinolone cream clonidine transdermal weekly • clonidine tablet patch cyclobenzaprine hcl sustained release 24 • baclofen tablet • dantrolene capsule hr capsule • carisoprodol tablet • methocarbamol tablet • carisoprodol/aspirin tablet • methocarbamol tablet • chlorzoxazone tablet • orphenadrine tablet sustained action • cyclobenzaprine immediate release tablet • tizanidine tablet desipramine hcl tablet • amitriptyline tablet • doxepin capsule • amoxapine tablet • imipramine tablet • clomipramine capsule • maprotiline tablet • doxepin capsule • nortriptyline capsule • doxepin concentrate oral Generics Covered Form Tier 1 Generic Alternative Under Tier 2 desoximetasone gel • alclometasone cream • fluocinolone cream • alclometasone ointment • fluocinolone ointment ointment • amcinonide cream • fluticasone ointment • amcinonide ointment • fluticasone cream • amcinonide lotion • halobetasol ointment • betamethasone cream • halobetasol cream • betamethasone ointment • hydrocortisone cream • betamethasone lotion • hydrocortisone ointment • clobetasol ointment • hydrocortisone lotion • clobetasol ream • hydrocortisone solution non-oral • clobetasol solution non-oral • mometasone cream • clobetasol gel • mometasone ointment • desonide cream • mometasone solution non-oral • desonide lotion • prednicarbate cream • desonide ointment • triamcinolone cream • desoximetasone cream • triamcinolone ointment • diflorasone ointment • triamcinolone lotion • fluocinolone solution • triamcinolone cream dextroamphetamine sustained action • amphet asp/amphet/d-amphet • dextroamphetamine tablet sulfate capsule (amphetamine salt combo) tablet Generics Covered Form Tier 1 Generic Alternative Under Tier 2 diflorasone diacetate cream • alclometasone cream • fluocinolone cream • alclometasone ointment • fluocinolone ointment • amcinonide cream • fluticasone ointment • amcinonide ointment • fluticasone cream • amcinonide lotion • halobetasol ointment • betamethasone cream • halobetasol cream • betamethasone ointment • hydrocortisone cream • betamethasone lotion • hydrocortisone ointment • clobetasol ointment • hydrocortisone lotion • clobetasol ream • hydrocortisone solution non-oral • clobetasol solution non-oral • mometasone cream • clobetasol gel • mometasone ointment • desonide cream • mometasone solution non-oral • desonide lotion • prednicarbate cream • desonide ointment • triamcinolone cream • desoximetasone cream • triamcinolone ointment • diflorasone ointment • triamcinolone lotion • fluocinolone solution • triamcinolone cream dihydroergotamine ampule • ergotamine tartrate/caffeine tablet • naratriptan tablet mesylate • isomethept/acetaminop/dichlphn capsule • sumatriptan spray non-aerosol • sumatriptan tablet diltiazem hcl (Matzim sustained release 24hr • amlodipine tablet • isradipine capsule LA™) tablet • diltiazem capsule degradable controlled- • nicardipine capsule release • nifedipine tablet sustained action • diltiazem capsule sustained release 24 hr • nifedipine tablet extended release 24 hr • diltiazem capsule sustained release 12 hr • nifedipine capsule • diltiazem capsule sustained action • verapamil tablet sustained action • diltiazem tablet • verapamil capsule 24hr sustained release pellets • felodipine tablet sustained release 24hr • verapamil tablet dronabinol capsule • ondansetron tablet • prochlorperazine tablet • ondansetron solution • promethazine suppository • prochlorperazine suppository • promethazine hcl tablet epinastine hcl drops • ketorolac drops Generics Covered Form Tier 1 Generic Alternative Under Tier 2 eplerenone tablet • amiloride tablet • spironolactone tablet eprosartan tablet • losartan famotidine oral suspension • cimetidine solution oral • ranitidine syrup • nizatidine solution oral fentanyl citrate lozenge • morphine solution oral (solution) • oxycodone tablet • morphine tablet • oxycodone capsule flavoxate hcl tablet • oxybutynin tablet • oxybutynin extended release 24 hr • oxybutynin syrup hydroxyzine hcl vial • hydroxyzine tablet • promethazine vial • hydroxyzine syrup • promethazine ampul • hydroxyzine capsule • promethazine syrup • promethazine tablet imipramine pamoate capsule • amitriptyline tablet • doxepin capsule • amoxapine tablet • imipramine tablet • clomipramine capsule • maprotiline tablet • doxepin capsule • nortriptyline capsule • doxepin concentrate oral Sotret™ capsule • adapalene gel • tretinoin gel Claravis™, • adapalene cream • tretinoin cream Amnesteem™ (active • tretinoin cream ingredient: isotretinoin) levofloxacin drops • ciprofloxacin drops • ofloxacin drops • gentamicin drops • polymyxin b sulfate/tmp drops • gentamicin drops • tobramycin sulfate drops • neomycin/polymyxn b/gramicidin drops lindane lotion • permethrin cream Generics Covered Form Tier 1 Generic Alternative Under Tier 2 malathion lotion • permethrin cream meclofenamate capsule • diclofenac tablet • etodolac tablet sustained release 24hr sodium • diclofenac tablet sustained release 24hr • fenoprofen tablet • diclofenac tablet delayed release • flurbiprofen tablet • etodolac capsule • ibuprofen tablet • etodolac tablet • indomethacin capsule mefenamic acid capsule • diclofenac tablet • etodolac tablet sustained release 24hr • diclofenac tablet sustained release 24hr • fenoprofen tablet • diclofenac tablet delayed release • flurbiprofen tablet • etodolac capsule • ibuprofen tablet • etodolac tablet • indomethacin capsule meprobamate tablet • alprazolam tablet • diazepam solution oral • buspirone tablet • lorazepam tablet • chlordiazepoxide capsule • lorazepam concentrate oral • clorazepate tablet • oxazepam capsule • diazepam tablet mesalamine kit • mesalamine enema (not kit) w/cleansing wipes metaxalone tablet • baclofen tablet • dantrolene capsule • carisoprodol tablet • methocarbamol tablet • carisoprodol/aspirin tablet