Pharmacodynamics of Voriconazole in Children: Further Steps ...
2018 Preferred Drug List -...
Transcript of 2018 Preferred Drug List -...
2018 Preferred Drug List
Effective 07/01/2018
The Formulary List is a guide providing copay designation for common medicines within select therapeutic categories. The Formulary List may not include all drugs covered by your prescription drug benefit. Generic medicines are available within many of the therapeutic categories listed, in addition to categories not listed, and should be considered as the first line of prescribing.
For benefit coverage or restrictions please check your benefit plan document(s). This listing is revised periodically as new drugs and new prescribing information becomes available. It is recommended that you bring this list of medications when you or a covered family member sees a physician or other healthcare provider.
Abbreviations:
(ST) Step Therapy(PA) Prior Authorization
Major Drug Class OverviewNon-Preferred Drugs With Preferred Options
2018
PreferredNon-PreferredDrug Class
ANALGESICSANTIARTHRITICS EUFLEXXA, GEL-ONE, HYALGAN,
MONOVISC, ORTHOVISC
DUROLANE, GELSYN-3, SUPARTZ FX,
SYNVISC, SYNVISC ONE
NARCOTICS ABSTRAL, HYSINGLA ER, KADIAN,
OXYCONTIN, ZOHYDRO ER
fentanyl, fentanyl citrate oral
transmucosal, morphine sulfate er,
oxycodone hcl, EMBEDA, FENTORA,
NUCYNTA ER
ANTI-INFECTIVESANTIVIRALS REBETOL moderiba, ribavirin, ribavirin, RIBASPHERE
RIBAPAK
HEPATITIS C DAKLINZA, EPCLUSA, HARVONI, SOVALDI,
TECHNIVIE, VIEKIRA PAK, ZEPATIER
MAVYRET
TETRACYCLINES DOXYCYCLINE, ORACEA
CARDIACANGIOTENSIN RECEPTOR BLOCKER BENICAR HCT, EDARBI, EDARBYCLOR candesartan cilexetil/hydrochlorothiazide,
irbesartan/hydrochlorothiazide, losartan
potassium/hydrochlorothiazide,
valsartan/hydrochlorothiazide
ANTICOAGULANTS PRADAXA clopidogrel, ELIQUIS, XARELTO
STATINS VYTORIN atorvastatin calcium, rosuvastatin calcium,
simvastatin, LIVALO
CNSADHD ADDERALL XR amphetamine/dextroamphetamine,
amphetamine/dextroamphetamine
ANTIDEPRESSANTS PEXEVA, SARAFEM citalopram hydrobromide, escitalopram
oxalate, escitalopram oxalate, fluoxetine
hcl, fluvoxamine maleate, paroxetine hcl er,
sertraline hcl, trazodone hcl, VIIBRYD
ANTI-PSYCHOTIC FANAPT, REXULTI aripiprazole, olanzapine, olanzapine odt,
quetiapine fumarate, quetiapine fumarate
er, LATUDA, SAPHRIS
SLEEP ZOLPIMIST eszopiclone, zaleplon, zolpidem tartrate er,
BELSOMRA, ROZEREM
DIABETESDPP-4 ALOGLIPTIN, KAZANO, KOMBIGLYZE XR,
NESINA, ONGLYZA, OSENI
JANUMET XR, JANUVIA, JENTADUETO,
TRADJENTA
INCRETINS BYDUREON PEN, BYETTA, TANZEUM OZEMPIC, TRULICITY, VICTOZA
INSULIN AFREZZA, APIDRA FIASP, FIASP FLEXTOUCH, HUMALOG,
HUMALOG MIX 50/50, HUMALOG MIX
75/25, HUMULIN 70/30, HUMULIN N,
HUMULIN R, NOVOLIN 70/30, NOVOLOG
FLEXPEN, NOVOLOG MIX 70/30,
NOVOLOG PENFILL
INSULIN: LONG ACTING BASAGLAR KWIKPEN LANTUS, LANTUS SOLOSTAR, LEVEMIR,
TOUJEO SOLOSTAR, TRESIBA
FLEXTOUCH
OTHER GLUMETZA, RIOMET metformin hcl
SGLT-2 INVOKAMET, INVOKANA FARXIGA, JARDIANCE, SYNJARDY,
XIGDUO XR
PreferredNon-PreferredDrug Class
TESTING ACCU-CHEK AVIVA CONNECT, ACCU-CHEK
AVIVA PLUS, ADVOCATE BLOOD GLUCOSE
MONITORING SYSTEM, BAYER BREEZE 2
TEST DISC, BAYER CONTOUR BLOOD
GLUCOSE TEST STRIPS, EMBRACE BLOOD
GLUCOSE TEST STRIPS, PRODIGY
AUTOCODE BLOOD GLUCOSE MONITORING
SYSTEM, TRUE METRIX BLOOD
GLUCOSETEST STRIPS, TRUE METRIX SELF
MONITORING BLOOD GLUCOSE STRIPS,
TRUETEST STRIPS, TRUETRACK SMART
SYSTEM, UNISTRIP1 GENERIC
FREESTYLE TEST STRIPS, ONETOUCH
ULTRA BLUE, ONETOUCH VERIO TEST
STRIPS
ENDOCRINEESTROGENS estradiol, ESTRING, PREMARIN
GONADOTROPIN PREGNYL W/DILUENT
BENZYLALCOHOL/NACL
CETROTIDE, GANIRELIX ACETATE,
NOVAREL
OVULATORY STIMULANTS BRAVELLE, FOLLISTIM AQ, FOLLISTIM AQ clomiphene citrate, GONAL-F, MENOPUR
PROGESTINS CRINONE, ENDOMETRIN
TESTOSTERONE AXIRON, FORTESTA, NATESTO, STRIANT,
TESTIM, VOGELXO
ANDROGEL PUMP
GASTROINTESTINALDIGESTIVE ENZYMES PANCREAZE, PERTZYE, VIOKACE CREON, ZENPEP
OTHER DIPENTUM, LIALDA, LINZESS, PENTASA balsalazide disodium, AMITIZA, APRISO,
DELZICOL
PROTON PUMP INHIBITORS DEXILANT lansoprazole, omeprazole, pantoprazole
sodium
GROWTH HORMONESGENOTROPIN, HUMATROPE, NUTROPIN AQ
NUSPIN 10, OMNITROPE, SAIZEN
CLICK.EASY, ZOMACTON, ZORBTIVE
NORDITROPIN FLEXPRO
HEMATOLOGYARANESP ALBUMIN FREE, EPOGEN, MIRCERA PROCRIT
MUSCULOSKELETALANTI-INFLAMMATORY ** ACTEMRA, CIMZIA, ENBREL SURECLICK,
OTEZLA, REMICADE, SILIQ, SIMPONI,
STELARA, TALTZ, TALTZ, XELJANZ
COSENTYX, COSENTYX SENSOREADY
PEN, ENTYVIO, HUMIRA PEN, ORENCIA
OPHTHALMICGLAUCOMA COSOPT PF, SIMBRINZA, ZIOPTAN dorzolamide hcl, AZOPT, COMBIGAN,
TRAVATAN Z
NSAIDS ACUVAIL bromfenac, diclofenac sodium, ketorolac
tromethamine, ILEVRO, NEVANAC,
PROLENSA
OTICMISCELLANEOUS CETRAXAL ciprofloxacin
RESPIRATORYDULERA, TUDORZA PRESSAIR ADVAIR DISKUS, ANORO ELLIPTA, BREO
ELLIPTA, INCRUSE ELLIPTA, SPIRIVA
HANDIHALER, STIOLTO RESPIMAT,
SYMBICORT
BETA AGONISTS ARCAPTA NEOHALER, PERFOROMIST,
PROVENTIL HFA, XOPENEX HFA
PROAIR HFA, SEREVENT DISKUS,
VENTOLIN HFA
INHALED STEROIDS ALVESCO, ASMANEX TWISTHALER 120
METERED DOSES, PULMICORT FLEXHALER
ARNUITY ELLIPTA, FLOVENT DISKUS,
FLOVENT HFA, QVAR
NASAL STEROIDS BECONASE AQ, NASONEX, OMNARIS,
ZETONNA
flunisolide, DYMISTA, QNASL
TOPICALACNE ATRALIN, AVAGE, AZELEX, BENZACLIN
WITH PUMP, EPIDUO, TAZORAC, VELTIN
adapalene, clindamycin
phosphate/tretinoin, clindamycin/benzoyl
peroxide, erythromycin, tretinoin, ACANYA
PreferredNon-PreferredDrug Class
MISCELLANEOUS ALDARA, FLUOROURACIL, ZYCLARA PUMP fluorouracil, imiquimod, PICATO
ROSACEA metronidazole, FINACEA
UROLOGICALANTISPASMODICS ENABLEX, GELNIQUE, TOVIAZ tolterodine tartrate, MYRBETRIQ,
VESICARE
ERECTILE DYSFUNCTION LEVITRA, STAXYN, STENDRA, VIAGRA sildenafil, sildenafil citrate, CIALIS
Additional covered alternatives m ay be available. Costs for covered alternatives m ay vary. Other
prescription benefit considerations m ay apply.
ANALGESICSANTIARTHRITICS
Prefilled Syringe
DUROLANE Preferred Brand
Solution Prefilled Syringe
GELSYN-3 Preferred Brand
Solution Prefilled Syringe
SUPARTZ Preferred Brand
Solution Prefilled Syringe
SUPARTZ FX Preferred Brand
Solution Prefilled Syringe
SYNVISC Preferred Brand
Solution Prefilled Syringe
SYNVISC ONE Preferred Brand
HEADACHE
Solution
dihydroergotamine mesylate Generic
Capsule
isometheptene/dichloralphenazone/acetaminophen Generic
Tablet
naratriptan hcl Generic
Tablet
rizatriptan benzoate Generic
Solution
sumatriptan Generic
Tablet
sumatriptan succinate Generic
Solution Auto-injector
sumatriptan succinate Generic
Tablet
zolmitriptan Generic
Tablet Disintegrating
zolmitriptan odt Generic
Solution Jet-injector
SUMAVEL DOSEPRO Preferred Brand
Solution
ZOMIG Preferred Brand
MISCELLANEOUS
Tablet
diflunisal Generic
Tablet
salsalate Generic
Tablet
tramadol hcl Generic
Tablet Extended Release 24 Hour
tramadol hcl er Generic
Tablet
tramadol hydrochloride/acetaminophen Generic
NARCOTIC ANTAGONISTS
Tablet Sublingual
buprenorphine hcl/naloxone hcl Generic
Tablet
naltrexone hcl Generic
Solution Auto-injector
EVZIO Preferred Brand
Liquid
NARCAN Preferred Brand
Film
SUBOXONE Preferred Brand
NARCOTICS
Solution
acetaminophen/codeine Generic
Tablet
acetaminophen/codeine Generic
Tablet Sublingual
buprenorphine hcl Generic
Tablet
butalbital/acetaminophen/caffeine Generic
Capsule
butalbital/acetaminophen/caffeine/codeine Generic
Capsule
butalbital/aspirin/caffeine Generic
Capsule
butalbital/aspirin/caffeine/codeine Generic
Tablet
codeine sulfate Generic
Patch 72 Hour
fentanyl Generic
Lozenge on a Handle
fentanyl citrate oral transmucosal Generic
Solution
hydrocodone bitartrate/acetaminophen Generic
Tablet
hydrocodone/acetaminophen Generic
Tablet
hydrocodone/ibuprofen Generic
Tablet
hydromorphone hcl Generic
Solution
meperidine hcl Generic
Solution
methadone hcl Generic
Tablet Soluble
methadone hcl Generic
Suppository
morphine sulfate Generic
Tablet Extended Release
morphine sulfate er Generic
Solution
oxycodone hcl Generic
Tablet
oxycodone/acetaminophen Generic
Tablet
oxycodone/aspirin Generic
Tablet
oxycodone/ibuprofen Generic
Tablet
oxymorphone hydrochloride Generic
Capsule Extended Release
EMBEDA Preferred Brand
Tablet
FENTORA Preferred Brand
Patch
FLECTOR Preferred Brand
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NARCOTICS
Tablet
NUCYNTA Preferred Brand
Tablet Extended Release 12 Hour
NUCYNTA ER Preferred Brand
NSAIDS
Capsule
celecoxib Generic
Tablet
diclofenac potassium Generic
Tablet Extended Release 24 Hour
diclofenac sodium er Generic
Tablet Delayed Release
diclofenac sodium/misoprostol Generic
Tablet
etodolac Generic
Tablet
fenoprofen calcium Generic
Tablet
flurbiprofen Generic
Capsule
indomethacin Generic
Capsule
ketoprofen Generic
Tablet
ketorolac tromethamine Generic
Capsule
meclofenamate sodium Generic
Capsule
mefenamic acid Generic
Suspension
meloxicam Generic
Tablet
meloxicam Generic
Tablet
nabumetone Generic
Tablet
naproxen Generic
Tablet
naproxen sodium Generic
Tablet
oxaprozin Generic
Capsule
piroxicam Generic
Tablet
sulindac Generic
Capsule
tolmetin sodium Generic
ANTI-INFECTIVESANTIFUNGAL
Troche
clotrimazole Generic
Suspension Reconstituted
fluconazole Generic
Tablet
fluconazole Generic
Capsule
flucytosine Generic
Tablet
griseofulvin microsize Generic
Suspension
griseofulvin microsize Generic
Tablet
griseofulvin ultramicrosize Generic
Capsule
itraconazole Generic
Tablet
ketoconazole Generic
Suspension
nystatin Generic
Tablet
nystatin Generic
Tablet
terbinafine hcl Generic
Tablet
voriconazole Generic
Suspension Reconstituted
voriconazole Generic
Suspension
NOXAFIL Preferred Brand
Solution
SPORANOX Preferred Brand
ANTIMALARIALS
Tablet
atovaquone/proguanil hcl Generic
Tablet
chloroquine phosphate Generic
Tablet
hydroxychloroquine sulfate Generic
Tablet
mefloquine hcl Generic
Capsule
quinine sulfate Generic
Tablet
COARTEM Preferred Brand
Tablet
DARAPRIM Preferred Brand
Tablet
PRIMAQUINE PHOSPHATE Preferred Brand
ANTIMYCOBACTERIALS
Capsule
cycloserine Generic
Tablet
ethambutol hcl Generic
Tablet
isoniazid Generic
Tablet
pyrazinamide Generic
Capsule
rifampin Generic
Tablet
SIRTURO Preferred Brand
ANTIPARASITICS
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ANTIPARASITICS
Tablet
metronidazole Generic
Capsule
paromomycin sulfate Generic
Tablet
tinidazole Generic
Tablet
ALBENZA Preferred Brand
Tablet
ALINIA Preferred Brand
Suspension Reconstituted
ALINIA Preferred Brand
Tablet
BILTRICIDE Preferred Brand
ANTIVIRALS
Capsule
acyclovir Generic
Tablet
acyclovir Generic
Suspension
acyclovir Generic
Syrup
amantadine hcl Generic
Capsule
amantadine hcl Generic
Tablet
famciclovir Generic
Tablet
lamivudine Generic
Tablet
moderiba Generic
Capsule
ribasphere Generic
Capsule
ribavirin Generic
Tablet
ribavirin Generic
Tablet
rimantadine hcl Generic
Tablet
valacyclovir hcl Generic
Solution
EPIVIR HBV Preferred Brand
Tablet
RIBASPHERE RIBAPAK Preferred Brand
CEPHALOSPORINS
Capsule
cefaclor Generic
Suspension Reconstituted
cefaclor Generic
Capsule
cefadroxil Generic
Suspension Reconstituted
cefadroxil Generic
Capsule
cefdinir Generic
Suspension Reconstituted
cefdinir Generic
Suspension Reconstituted
cefprozil Generic
Tablet
cefprozil Generic
Capsule
ceftibuten Generic
Suspension Reconstituted
ceftibuten Generic
Tablet
cephalexin Generic
Suspension Reconstituted
cephalexin Generic
ERYTHROMYCINS/MACROLIDS
Suspension Reconstituted
azithromycin Generic
Tablet
clarithromycin Generic
Suspension Reconstituted
clarithromycin Generic
Tablet Extended Release 24 Hour
clarithromycin er Generic
Tablet Delayed Release
ery-tab Generic
Tablet
erythromycin base Generic
Tablet
erythromycin ethylsuccinate Generic
HEPATITIS C
Tablet
MAVYRET Preferred Brand
HIV
Tablet
abacavir Generic
Tablet
abacavir sulfate/lamivudine/zidovudine Generic
Capsule Delayed Release
didanosine Generic
Tablet
lamivudine/zidovudine Generic
Suspension
nevirapine Generic
Tablet
nevirapine Generic
Solution Reconstituted
stavudine Generic
Capsule
stavudine Generic
Syrup
zidovudine Generic
Capsule
zidovudine Generic
Tablet
zidovudine Generic
Solution
APTIVUS Preferred Brand
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HIV
Capsule
APTIVUS Preferred Brand
Tablet
ATRIPLA Preferred Brand
Tablet
COMPLERA Preferred Brand
Capsule
CRIXIVAN Preferred Brand
Tablet
DESCOVY Preferred Brand
Tablet
EDURANT Preferred Brand
Capsule
EMTRIVA Preferred Brand
Solution
EMTRIVA Preferred Brand
Tablet
GENVOYA Preferred Brand
Tablet
INTELENCE Preferred Brand
Tablet
INVIRASE Preferred Brand
Tablet
ISENTRESS Preferred Brand
Tablet
KALETRA Preferred Brand
Suspension
LEXIVA Preferred Brand
Tablet
NORVIR Preferred Brand
Solution
NORVIR Preferred Brand
Tablet
ODEFSEY Preferred Brand
Suspension
PREZISTA Preferred Brand
Tablet
PREZISTA Preferred Brand
Tablet
RESCRIPTOR Preferred Brand
Tablet
SELZENTRY Preferred Brand
Tablet
STRIBILD Preferred Brand
Tablet
TIVICAY Preferred Brand
Tablet
TRUVADA Preferred Brand
Solution Reconstituted
VIDEXPEDIATRIC Preferred Brand
Tablet
VIRACEPT Preferred Brand
MISCELLANEOUS
Capsule
clindamycin hcl Generic
Solution Reconstituted
clindamycin palmitate hcl Generic
Tablet
dapsone Generic
Tablet
linezolid Generic
Tablet
methenamine hippurate Generic
Tablet
methenamine mandelate Generic
Capsule
nitrofurantoin macrocrystals Generic
Capsule
nitrofurantoin monohydrate Generic
Tablet
sulfadiazine Generic
Tablet
sulfamethoxazole/trimethoprim Generic
Suspension
sulfamethoxazole/trimethoprim Generic
Tablet
trimethoprim Generic
Capsule
vancomycin hcl Generic
Capsule
TOBI PODHALER Preferred Brand
Tablet
XIFAXAN Preferred Brand
PENICILLINS
Tablet
amoxicillin Generic
Suspension Reconstituted
amoxicillin Generic
Suspension Reconstituted
amoxicillin/clavulanate potassium Generic
Tablet
amoxicillin/clavulanate potassium Generic
Tablet Extended Release 12 Hour
amoxicillin/clavulanate potassium er Generic
Suspension Reconstituted
ampicillin Generic
Capsule
ampicillin Generic
Capsule
dicloxacillin sodium Generic
Tablet
penicillin v potassium Generic
Solution Reconstituted
penicillin v potassium Generic
QUINOLONES
Tablet Extended Release 24 Hour
ciprofloxacin er Generic
Tablet
ciprofloxacin hcl Generic
Solution
levofloxacin Generic
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QUINOLONES
Tablet
levofloxacin Generic
TETRACYCLINES
Tablet
demeclocycline hcl Generic
Tablet
doxycycline hyclate Generic
Capsule
doxycycline monohydrate Generic
Capsule
minocycline hcl Generic
Capsule
morgidox 1x100mg Generic
Capsule
tetracycline hcl Generic
Tablet Extended Release 24 Hour
SOLODYN Preferred Brand
VAGINAL
Cream
clindamycin phosphate Generic
Gel
metronidazole vaginal Generic
Suppository
miconazole 3 Generic
Suppository
terconazole Generic
Cream
terconazole Generic
CARDIACACE INHIBITORS
Capsule
amlodipine besylate/benazepril hydrochloride Generic
Tablet
benazepril hcl Generic
Tablet
benazepril hcl/hydrochlorothiazide Generic
Tablet
captopril Generic
Tablet
captopril/hydrochlorothiazide Generic
Tablet
enalapril maleate Generic
Tablet
fosinopril sodium Generic
Tablet
fosinopril sodium/hydrochlorothiazide Generic
Tablet
lisinopril Generic
Tablet
lisinopril/hydrochlorothiazide Generic
Tablet
moexipril hcl Generic
Tablet
moexipril/hydrochlorothiazide Generic
Tablet
perindopril erbumine Generic
Tablet
quinapril hcl Generic
Tablet
quinapril/hydrochlorothiazide Generic
Capsule
ramipril Generic
Tablet
trandolapril Generic
ANGIOTENSIN RECEPTOR BLOCKER
Tablet
candesartan cilexetil Generic
Tablet
candesartan cilexetil/hydrochlorothiazide Generic
Tablet
eprosartan mesylate Generic
Tablet
irbesartan Generic
Tablet
irbesartan/hydrochlorothiazide Generic
Tablet
losartan potassium Generic
Tablet
losartan potassium/hydrochlorothiazide Generic
Tablet
olmesartan medoxomil Generic
Tablet
olmesartan medoxomil Generic
Tablet
telmisartan Generic
Tablet
telmisartan/amlodipine Generic
Tablet
telmisartan/hydrochlorothiazide Generic
Tablet
valsartan Generic
Tablet
valsartan/hydrochlorothiazide Generic
Tablet
TEKAMLO Preferred Brand
Tablet
TEKTURNA Preferred Brand
Tablet
TEKTURNA HCT Preferred Brand
ANTIARRHYTHMIC
Tablet
amiodarone hcl Generic
Tablet
digoxin Generic
Solution
digoxin Generic
Capsule
disopyramide phosphate Generic
Tablet
flecainide acetate Generic
Capsule
mexiletine hcl Generic
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ANTIARRHYTHMIC
Tablet
pacerone Generic
Solution
procainamide hcl Generic
Tablet
propafenone hcl Generic
Solution
quinidine gluconate Generic
Tablet
quinidine sulfate Generic
Tablet Extended Release
quinidine sulfate er Generic
Tablet
sorine Generic
Tablet
sotalol hcl Generic
Tablet
sotalol hcl (af) Generic
Tablet
MULTAQ Preferred Brand
Capsule Extended Release 12 Hour
NORPACE CR Preferred Brand
ANTICOAGULANTS
Tablet
cilostazol Generic
Tablet
clopidogrel Generic
Tablet
dipyridamole Generic
Solution
enoxaparin sodium Generic
Solution
fondaparinux sodium Generic
Solution
heparin sodium Generic
Tablet
jantoven Generic
Tablet Extended Release
pentoxifylline er Generic
Tablet
ticlopidine hcl Generic
Tablet
warfarin sodium Generic
Tablet
BRILINTA Preferred Brand
Tablet
ELIQUIS Preferred Brand
Solution
FRAGMIN Preferred Brand
Tablet
MEPHYTON Preferred Brand
Tablet
XARELTO Preferred Brand
Tablet Therapy Pack
XARELTO STARTER PACK Preferred Brand
BETA BLOCKERS
Capsule
acebutolol hcl Generic
Tablet
atenolol Generic
Tablet
atenolol/chlorthalidone Generic
Tablet
betaxolol hcl Generic
Tablet
bisoprolol fumarate Generic
Tablet
bisoprolol fumarate/hydrochlorothiazide Generic
Tablet
carvedilol Generic
Tablet
labetalol hcl Generic
Tablet
metoprolol tartrate Generic
Tablet
nadolol Generic
Tablet
nadolol/bendroflumethiazide Generic
Tablet
pindolol Generic
Tablet
propranolol hcl Generic
Solution
propranolol hcl Generic
Tablet
propranolol/hydrochlorothiazide Generic
Tablet
timolol maleate Generic
Tablet
BYSTOLIC Preferred Brand
Solution
HEMANGEOL Preferred Brand
CALCIUM CHANNEL BLOCKERS
Tablet Extended Release 24 Hour
afeditab cr Generic
Tablet
amlodipine besylate Generic
Capsule Extended Release 24 Hour
cartia xt Generic
Capsule Extended Release 24 Hour
diltiazem cd Generic
Tablet
diltiazem hcl Generic
Capsule Extended Release 24 Hour
diltiazem hcl er Generic
Tablet Extended Release 24 Hour
felodipine er Generic
Capsule
isradipine Generic
Capsule
nifedipine Generic
Tablet Extended Release 24 Hour
nifedipine er Generic
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CALCIUM CHANNEL BLOCKERS
Capsule
nimodipine Generic
Tablet Extended Release 24 Hour
nisoldipine er Generic
Capsule Extended Release 24 Hour
taztia xt Generic
Tablet
verapamil hcl Generic
Capsule Extended Release 24 Hour
verapamil hcl er Generic
DIURETICS
Tablet
acetazolamide Generic
Tablet
amiloride hcl Generic
Tablet
amiloride/hydrochlorothiazide Generic
Tablet
bumetanide Generic
Tablet
chlorothiazide Generic
Tablet
eplerenone Generic
Solution
furosemide Generic
Tablet
hydrochlorothiazide Generic
Tablet
indapamide Generic
Tablet
methazolamide Generic
Tablet
methyclothiazide Generic
Tablet
metolazone Generic
Tablet
spironolactone Generic
Tablet
spironolactone/hydrochlorothiazide Generic
Tablet
torsemide Generic
Tablet
triamterene/hydrochlorothiazide Generic
NITRATES
Tablet
isosorbide dinitrate Generic
Tablet
isosorbide mononitrate Generic
Patch 24 Hour
minitran Generic
Aerosol Solution
nitroglycerin lingual Generic
Patch 24 Hour
nitroglycerin transdermal Generic
Capsule Extended Release
DILATRATE SR Preferred Brand
Ointment
NITRO-BID Preferred Brand
Patch 24 Hour
NITRO-DUR Preferred Brand
OTHER
Tablet
ENTRESTO Preferred Brand
Tablet Extended Release 12 Hour
RANEXA Preferred Brand
OTHER ANTI-HYPERTENSIVES
Tablet
clonidine hcl Generic
Tablet
clorpres Generic
Tablet
doxazosin mesylate Generic
Tablet
guanfacine hcl Generic
Tablet
hydralazine hcl Generic
Tablet
methyldopa Generic
Tablet
methyldopa/hydrochlorothiazide Generic
Tablet
minoxidil Generic
Capsule
prazosin hcl Generic
Tablet
reserpine Generic
Capsule
terazosin hcl Generic
STATINS
Tablet
amlodipine besylate/atorvastatin calcium Generic
Tablet
atorvastatin calcium Generic
Packet
cholestyramine Generic
Tablet
colestipol hcl Generic
Tablet
fenofibrate Generic
Capsule Delayed Release
fenofibric acid dr Generic
Capsule
fluvastatin Generic
Tablet
gemfibrozil Generic
Tablet
lovastatin Generic
Tablet Extended Release
niacin er Generic
Tablet
pravastatin sodium Generic
Packet
prevalite Generic
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STATINS
Tablet
rosuvastatin calcium Generic
Tablet
simvastatin Generic
Tablet
LIVALO Preferred Brand
Solution Pen-injector
PRALUENT Preferred Brand
Solution Prefilled Syringe
PRALUENT Preferred Brand
Capsule
VASCEPA Preferred Brand
Tablet
WELCHOL Preferred Brand
Packet
WELCHOL Preferred Brand
CNSADHD
Capsule Extended Release 24 Hour
amphetamine/dextroamphetamine Generic
Tablet
amphetamine/dextroamphetamine Generic
Tablet
dexmethylphenidate hcl Generic
Capsule Extended Release 24 Hour
dexmethylphenidate hcl er Generic
Solution
dextroamphetamine sulfate Generic
Tablet
dextroamphetamine sulfate Generic
Tablet
guanidine hcl Generic
Tablet
methylphenidate hcl Generic
Tablet
methylphenidate hcl Generic
Capsule Extended Release
methylphenidate hcl cd Generic
Solution
methylphenidate hydrochloride Generic
Patch
DAYTRANA Preferred Brand
Capsule Extended Release 24 Hour
MYDAYIS Preferred Brand
Tablet Chewable Extended Release
QUILLICHEW ER Preferred Brand
Suspension Reconstituted
QUILLIVANT XR Preferred Brand
Tablet Chewable
VYVANSE Preferred Brand
Capsule
VYVANSE Preferred Brand
ALZHEIMER'S
Capsule Extended Release 24 Hour
galantamine hydrobromideer Generic
Capsule
rivastigmine tartrate Generic
Capsule Extended Release 24 Hour
NAMENDA XR Preferred Brand
Capsule ER 24 Hour Therapy Pack
NAMZARIC Preferred Brand
Capsule Extended Release 24 Hour
NAMZARIC Preferred Brand
ANTICONVULSANTS
Tablet
carbamazepine Generic
Suspension
carbamazepine Generic
Tablet Extended Release 12 Hour
carbamazepine er Generic
Tablet Extended Release 12 Hour
carbamazepine er Generic
Tablet
clonazepam Generic
Tablet Disintegrating
clonazepam odt Generic
Gel
diazepam Generic
Tablet Delayed Release
divalproex sodium dr Generic
Tablet Extended Release 24 Hour
divalproex sodium er Generic
Tablet
epitol Generic
Capsule
ethosuximide Generic
Capsule
ethosuximide Generic
Solution
ethosuximide Generic
Tablet
felbamate Generic
Suspension
felbamate Generic
Solution
fosphenytoin sodium Generic
Capsule
gabapentin Generic
Tablet
gabapentin Generic
Tablet
lamotrigine Generic
Tablet
levetiracetam Generic
Solution
levetiracetam Generic
Suspension
oxcarbazepine Generic
Tablet
oxcarbazepine Generic
Elixir
phenobarbital Generic
Printed Date:6/27/2018
Page 12 | 2018 Preferred Drug ListData Last Updated:6/27/2018
ANTICONVULSANTS
Tablet
phenobarbital Generic
Suspension
phenytoin Generic
Capsule
phenytoin sodium extended Generic
Tablet
primidone Generic
Tablet
tiagabine hydrochloride Generic
Tablet
topiramate Generic
Solution
valproic acid Generic
Capsule
valproic acid Generic
Capsule
zonisamide Generic
Tablet
BANZEL Preferred Brand
Tablet
FYCOMPA Preferred Brand
Tablet
GABITRIL Preferred Brand
Kit
LAMICTAL XR Preferred Brand
Capsule
LYRICA Preferred Brand
Tablet Extended Release 24 Hour
LYRICA CR Preferred Brand
Suspension
ONFI Preferred Brand
Tablet Extended Release 24 Hour
OXTELLAR XR Preferred Brand
Tablet
PEGANONE Preferred Brand
Tablet
POTIGA Preferred Brand
Tablet
SABRIL Preferred Brand
Capsule Extended Release 24 Hour
TROKENDI XR Preferred Brand
Tablet
VIMPAT Preferred Brand
Solution
VIMPAT Preferred Brand
ANTIDEPRESSANTS
Tablet
amitriptyline hcl Generic
Tablet
amoxapine Generic
Tablet
bupropion hcl Generic
Tablet Extended Release 24 Hour
bupropion hcl xl Generic
Tablet
chlordiazepoxide/amitriptyline Generic
Solution
citalopram hydrobromide Generic
Tablet
citalopram hydrobromide Generic
Capsule
clomipramine hcl Generic
Tablet
desipramine hcl Generic
Capsule
doxepin hcl Generic
Concentrate
doxepin hcl Generic
Capsule Delayed Release Particles
duloxetine hcl Generic
Tablet
escitalopram oxalate Generic
Solution
escitalopram oxalate Generic
Capsule
fluoxetine hcl Generic
Solution
fluoxetine hcl Generic
Tablet
fluvoxamine maleate Generic
Tablet
imipramine hcl Generic
Capsule
imipramine pamoate Generic
Tablet
maprotiline hcl Generic
Tablet
mirtazapine Generic
Tablet
nefazodone hcl Generic
Capsule
nortriptyline hcl Generic
Solution
nortriptyline hcl Generic
Tablet
paroxetine hcl Generic
Tablet Extended Release 24 Hour
paroxetine hcl er Generic
Tablet
perphenazine/amitriptyline Generic
Tablet
phenelzine sulfate Generic
Tablet
protriptyline hcl Generic
Tablet
sertraline hcl Generic
Tablet
tranylcypromine sulfate Generic
Tablet
trazodone hcl Generic
Printed Date:6/27/2018
Page 13 | 2018 Preferred Drug ListData Last Updated:6/27/2018
ANTIDEPRESSANTS
Tablet
venlafaxine hcl Generic
Capsule Extended Release 24 Hour
venlafaxine hcl er Generic
Capsule Extended Release 24 Hour
FETZIMA Preferred Brand
Capsule ER 24 Hour Therapy Pack
FETZIMA TITRATION PACK Preferred Brand
Tablet
TRINTELLIX Preferred Brand
Kit
VIIBRYD Preferred Brand
Tablet
VIIBRYD Preferred Brand
Kit
VIIBRYD STARTER PACK Preferred Brand
ANTIPARKINSONISM
Tablet
benztropine mesylate Generic
Tablet
bromocriptine mesylate Generic
Tablet
carbidopa/levodopa Generic
Tablet Extended Release
carbidopa/levodopa er Generic
Tablet
carbidopa/levodopa/entacapone Generic
Tablet
entacapone Generic
Tablet
ropinirole hcl Generic
Tablet
selegiline hcl Generic
Tablet
trihexyphenidyl hcl Generic
Elixir
trihexyphenidyl hcl Generic
Patch 24 Hour
NEUPRO Preferred Brand
Tablet
XADAGO Preferred Brand
Tablet Disintegrating
ZELAPAR Preferred Brand
ANTI-PSYCHOTIC
Tablet
aripiprazole Generic
Tablet
chlorpromazine hcl Generic
Tablet
clozapine Generic
Tablet Disintegrating
clozapine odt Generic
Concentrate
fluphenazine hcl Generic
Tablet
fluphenazine hcl Generic
Tablet
haloperidol Generic
Concentrate
haloperidol Generic
Solution
haloperidol decanoate Generic
Capsule
loxapine succinate Generic
Tablet
olanzapine Generic
Tablet Disintegrating
olanzapine odt Generic
Capsule
olanzapine/fluoxetine Generic
Tablet
perphenazine Generic
Tablet
quetiapine fumarate Generic
Tablet Extended Release 24 Hour
quetiapine fumarate er Generic
Tablet
risperidone Generic
Tablet Disintegrating
risperidone odt Generic
Tablet
thioridazine hcl Generic
Capsule
thiothixene Generic
Tablet
trifluoperazine hcl Generic
Capsule
ziprasidone hcl Generic
Prefilled Syringe
ABILIFY MAINTENA Preferred Brand
Suspension
INVEGA SUSTENNA Preferred Brand
Suspension
INVEGA TRINZA Preferred Brand
Suspension
INVEGA TRINZA Preferred Brand
Tablet
LATUDA Preferred Brand
Suspension Reconstituted
RISPERDAL CONSTA Preferred Brand
Tablet Sublingual
SAPHRIS Preferred Brand
Capsule Therapy Pack
VRAYLAR Preferred Brand
Capsule
VRAYLAR Preferred Brand
ANXIOLYTICS
Tablet
alprazolam Generic
Tablet Extended Release 24 Hour
alprazolam er Generic
Tablet Disintegrating
alprazolam odt Generic
Printed Date:6/27/2018
Page 14 | 2018 Preferred Drug ListData Last Updated:6/27/2018
ANXIOLYTICS
Tablet Extended Release 24 Hour
alprazolam xr Generic
Tablet
buspirone hcl Generic
Capsule
chlordiazepoxide hcl Generic
Tablet
clorazepate dipotassium Generic
Tablet
diazepam Generic
Concentrate
diazepam intensol Generic
Tablet
lorazepam Generic
Concentrate
lorazepam intensol Generic
Syrup
midazolam hcl Generic
Capsule
oxazepam Generic
MISCELLANEOUS
Tablet
armodafinil Generic
Solution
lithium Generic
Capsule
lithium carbonate Generic
Tablet Extended Release
lithium carbonate er Generic
Tablet
modafinil Generic
Tablet
BELVIQ Preferred Brand
Capsule
NUEDEXTA Preferred Brand
MS
Tablet Extended Release 12 Hour
AMPYRA Preferred Brand
Tablet
AUBAGIO Preferred Brand
Solution Prefilled Syringe
COPAXONE Preferred Brand
Capsule
GILENYA Preferred Brand
SLEEP
Tablet
estazolam Generic
Tablet
eszopiclone Generic
Capsule
flurazepam hcl Generic
Tablet
quazepam Generic
Capsule
temazepam Generic
Capsule
zaleplon Generic
Tablet Extended Release
zolpidem tartrate er Generic
Tablet
BELSOMRA Preferred Brand
Tablet
ROZEREM Preferred Brand
DIABETESDPP-4
Tablet
JANUMET Preferred Brand
Tablet Extended Release 24 Hour
JANUMET XR Preferred Brand
Tablet
JANUVIA Preferred Brand
Tablet
JENTADUETO Preferred Brand
Tablet
TRADJENTA Preferred Brand
INCRETINS
Solution Pen-injector
OZEMPIC Preferred Brand
Solution Pen-injector
TRULICITY Preferred Brand
Solution Pen-injector
VICTOZA Preferred Brand
INSULIN
Solution
FIASP Preferred Brand
Solution Pen-injector
FIASP FLEXTOUCH Preferred Brand
Suspension
NOVOLIN 70/30 Preferred Brand
Suspension
NOVOLIN N Preferred Brand
Solution
NOVOLIN R Preferred Brand
Solution
NOVOLOG Preferred Brand
Solution Pen-injector
NOVOLOG FLEXPEN Preferred Brand
Suspension
NOVOLOG MIX 70/30 Preferred Brand
Suspension Pen-injector
NOVOLOG MIX 70/30 PREFILLED FLEXPEN Preferred Brand
Solution Cartridge
NOVOLOG PENFILL Preferred Brand
Solution Pen-injector
SOLIQUA 100/33 Preferred Brand
Solution Pen-injector
XULTOPHY 100/3.6 Preferred Brand
INSULIN: LONG ACTING
Solution
LANTUS Preferred Brand
Solution Pen-injector
LANTUS SOLOSTAR Preferred Brand
Printed Date:6/27/2018
Page 15 | 2018 Preferred Drug ListData Last Updated:6/27/2018
INSULIN: LONG ACTING
Solution
LEVEMIR Preferred Brand
Solution Pen-injector
LEVEMIR FLEXTOUCH Preferred Brand
Solution Pen-injector
TOUJEO SOLOSTAR Preferred Brand
Solution Pen-injector
TRESIBA FLEXTOUCH Preferred Brand
OTHER
Tablet
acarbose Generic
Tablet
metformin hcl Generic
Tablet Extended Release 24 Hour
metformin hcl er Generic
Tablet
nateglinide Generic
Tablet
repaglinide Generic
Tablet
CYCLOSET Preferred Brand
Solution Reconstituted
GLUCAGEN HYPOKIT Preferred Brand
Kit
GLUCAGON EMERGENCY KIT Preferred Brand
Solution Pen-injector
SYMLINPEN 120 Preferred Brand
SGLT-2
Tablet
FARXIGA Preferred Brand
Tablet
JARDIANCE Preferred Brand
Tablet
SYNJARDY Preferred Brand
Tablet Extended Release 24 Hour
SYNJARDY XR Preferred Brand
Tablet Extended Release 24 Hour
XIGDUO XR Preferred Brand
SGLT-2 / DPP-4
Tablet
GLYXAMBI Preferred Brand
SULFONYLUREAS
Tablet
glimepiride Generic
Tablet Extended Release 24 Hour
glipizide er Generic
Tablet
glipizide/metformin hcl Generic
Tablet
glyburide Generic
Tablet
glyburide micronized Generic
Tablet
glyburide/metformin hcl Generic
TESTING
Miscellaneous
BD INSULIN SYRINGE MICROFINE IV/U-100/1ML/28G X 1/2"Preferred Brand
Miscellaneous
BD NEEDLE/27G X 1/2" Preferred Brand
Miscellaneous
BD PEN NEEDLE/MINI/ULTRAFINE/31G X 3/16" Preferred Brand
Device
DEXCOM G4 PLATINUM RECEIVER KIT Preferred Brand
Device
DEXCOM G5 MOBILE RECEIVERKIT Preferred Brand
Miscellaneous
INSULIN SYRINGE/U-100/1ML/28G X 1/2" Preferred Brand
Miscellaneous
NOVOFINE 30GX8MM Preferred Brand
Miscellaneous
NOVOFINE 32GX6MM Preferred Brand
Miscellaneous
NOVOFINE AUTOCOVER 30GX8MM Preferred Brand
Miscellaneous
NOVOFINE PLUS 32GX4MM Preferred Brand
Miscellaneous
NOVOTWIST 30GX8MM Preferred Brand
Miscellaneous
NOVOTWIST 32GX5MM Preferred Brand
Kit
ONETOUCH ULTRA 2 Preferred Brand
Strip
ONETOUCH ULTRA BLUE Preferred Brand
Kit
ONETOUCH VERIO FLEX BLOODGLUCOSE MONITORING SYSTEMPreferred Brand
Kit
ONETOUCH VERIO IQ BLOOD GLUCOSE MONITORING SYSTEMPreferred Brand
Kit
ONETOUCH VERIO SYNC BLOODGLUCOSE MONITORING SYSTEMPreferred Brand
Strip
ONETOUCH VERIO TEST STRIPS Preferred Brand
TZD
Tablet
pioglitazone hcl Generic
Tablet
pioglitazone hcl/metformin hcl Generic
Tablet
pioglitazone hcl-glimepiride Generic
ENDOCRINEADRENAL HORMONES
Tablet
dexamethasone Generic
Tablet
fludrocortisone acetate Generic
Tablet
hydrocortisone Generic
Suspension
methylprednisolone acetate Generic
Tablet Therapy Pack
methylprednisolone dose pack Generic
Solution
prednisolone Generic
Tablet
prednisone Generic
Printed Date:6/27/2018
Page 16 | 2018 Preferred Drug ListData Last Updated:6/27/2018
ADRENAL HORMONES
Solution Reconstituted
SOLU-CORTEF Preferred Brand
CONTRACEPTIVES
Tablet
altavera Generic
Tablet
alyacen 1/35 Generic
Tablet
amethia Generic
Tablet
amethyst Generic
Tablet
apri Generic
Tablet
aranelle Generic
Tablet
aubra Generic
Tablet
aviane Generic
Tablet
azurette Generic
Tablet
balziva Generic
Tablet
briellyn Generic
Tablet
camrese Generic
Tablet
caziant Generic
Tablet
chateal Generic
Tablet
cryselle-28 Generic
Tablet
cyclafem 1/35 Generic
Tablet
dasetta 7/7/7 Generic
Tablet
daysee Generic
Tablet
elinest Generic
Tablet
emoquette Generic
Tablet
enpresse-28 Generic
Tablet
enskyce Generic
Tablet
estarylla Generic
Tablet
falmina Generic
Tablet
gianvi Generic
Tablet
gildagia Generic
Tablet
introvale Generic
Tablet
jolessa Generic
Tablet
junel 1.5/30 Generic
Tablet
kariva Generic
Tablet
kelnor 1/35 Generic
Tablet
kurvelo Generic
Tablet
larin fe 1.5/30 Generic
Tablet
leena Generic
Tablet
lessina Generic
Tablet
levonest Generic
Tablet
levora 0.15/30-28 Generic
Tablet
lomedia 24 fe Generic
Tablet
loryna Generic
Tablet
low-ogestrel Generic
Tablet
lutera Generic
Tablet
marlissa Generic
Tablet
microgestin 1/20 Generic
Tablet
mono-linyah Generic
Tablet
mononessa Generic
Tablet
myzilra Generic
Tablet
necon 1/50-28 Generic
Tablet
nortrel 1/35 Generic
Tablet
ocella Generic
Tablet
orsythia Generic
Tablet
philith Generic
Tablet
pimtrea Generic
Tablet
pirmella 7/7/7 Generic
Tablet
portia-28 Generic
Printed Date:6/27/2018
Page 17 | 2018 Preferred Drug ListData Last Updated:6/27/2018
CONTRACEPTIVES
Tablet
previfem Generic
Tablet
quasense Generic
Tablet
reclipsen Generic
Tablet
sprintec 28 Generic
Tablet
sronyx Generic
Tablet
syeda Generic
Tablet
tilia fe Generic
Tablet
tri-estarylla Generic
Tablet
tri-linyah Generic
Tablet
trinessa Generic
Tablet
tri-previfem Generic
Tablet
tri-sprintec Generic
Tablet
trivora-28 Generic
Tablet
velivet Generic
Tablet
vestura Generic
Tablet
viorele Generic
Tablet
wera Generic
Tablet Chewable
wymzya fe Generic
Tablet
zarah Generic
Tablet
zenchent Generic
Tablet
zovia 1/35e Generic
Tablet
LO LOESTRIN FE Preferred Brand
Tablet
NATAZIA Preferred Brand
Ring
NUVARING Preferred Brand
Tablet
OGESTREL Preferred Brand
Tablet
SAFYRAL Preferred Brand
Intrauterine Device
SKYLA Preferred Brand
Capsule
TAYTULLA Preferred Brand
ESTROGENS
Tablet
esterified estrogens/methyltestosterone hs Generic
Patch Weekly
estradiol Generic
Tablet
estradiol/norethindrone acetate Generic
Tablet
jinteli Generic
Patch Twice Weekly
COMBIPATCH Preferred Brand
Gel
DIVIGEL Preferred Brand
Tablet
DUAVEE Preferred Brand
Ring
ESTRING Preferred Brand
Patch Twice Weekly
MINIVELLE Preferred Brand
Cream
PREMARIN Preferred Brand
Tablet
PREMARIN Preferred Brand
Tablet
PREMPHASE Preferred Brand
Tablet
PREMPRO Preferred Brand
GONADOTROPIN
Kit
CETROTIDE Preferred Brand
Solution
GANIRELIX ACETATE Preferred Brand
Solution Reconstituted
NOVAREL Preferred Brand
MISCELLANEOUS
Tablet
cabergoline Generic
Capsule
calcitriol Generic
Tablet
desmopressin acetate Generic
Solution
desmopressin acetate Generic
Tablet
ADDYI Preferred Brand
OVULATORY STIMULANTS
Tablet
clomiphene citrate Generic
Solution Reconstituted
GONAL-F Preferred Brand
Solution Reconstituted
MENOPUR Preferred Brand
PROGESTINS
Tablet
camila Generic
Tablet
errin Generic
Printed Date:6/27/2018
Page 18 | 2018 Preferred Drug ListData Last Updated:6/27/2018
PROGESTINS
Tablet
heather Generic
Tablet
jencycla Generic
Tablet
jolivette Generic
Tablet
lyza Generic
Tablet
nora-be Generic
Tablet
norethindrone Generic
Capsule
progesterone Generic
Gel
CRINONE Preferred Brand
Insert
ENDOMETRIN Preferred Brand
TESTOSTERONE
Tablet
androxy Generic
Capsule
danazol Generic
Tablet
oxandrolone Generic
Solution
testosterone cypionate Generic
Gel
ANDROGEL Preferred Brand
Gel
ANDROGEL PUMP Preferred Brand
THYROID
Tablet
levothyroxine sodium Generic
Tablet
levoxyl Generic
Tablet
liothyronine sodium Generic
Tablet
methimazole Generic
Tablet
nature-throid Generic
Tablet
unithroid Generic
GASTROINTESTINALANTIDIARRHEALS
Capsule
dicyclomine hcl Generic
Capsule
dicyclomine hcl Generic
Tablet
diphenoxylate/atropine Generic
Liquid
diphenoxylate/atropine Generic
Tablet
glycopyrrolate Generic
Solution
hyoscyamine sulfate Generic
Capsule
loperamide hcl Generic
Tablet
methscopolamine bromide Generic
ANTIEMETIC
Capsule
dronabinol Generic
Tablet
granisetron hcl Generic
Tablet
meclizine hcl Generic
Solution
ondansetron hcl Generic
Tablet
ondansetron hcl Generic
Tablet Disintegrating
ondansetron odt Generic
Suppository
prochlorperazine Generic
Tablet
prochlorperazine maleate Generic
Capsule
trimethobenzamide hcl Generic
Tablet Extended Release
BONJESTA Preferred Brand
Tablet Delayed Release
DICLEGIS Preferred Brand
BOWEL EVACUANTS
Solution Reconstituted
MOVIPREP Preferred Brand
DIGESTIVE ENZYMES
Capsule Delayed Release Particles
CREON Preferred Brand
Solution
SUCRAID Preferred Brand
Capsule Delayed Release Particles
ZENPEP Preferred Brand
H2 ANTAGONISTS
Tablet
cimetidine Generic
Solution
cimetidine hcl Generic
Tablet
famotidine Generic
Suspension Reconstituted
famotidine Generic
Tablet
misoprostol Generic
Capsule
nizatidine Generic
Syrup
ranitidine hcl Generic
Tablet
ranitidine hcl Generic
OTHER
Printed Date:6/27/2018
Page 19 | 2018 Preferred Drug ListData Last Updated:6/27/2018
OTHER
Capsule
balsalazide disodium Generic
Capsule Delayed Release Particles
budesonide Generic
Capsule
chlordiazepoxide hcl/clidinium bromide Generic
Solution
constulose Generic
Solution
lactulose Generic
Solution
metoclopramide hcl Generic
Tablet
metoclopramide hcl Generic
Tablet
sulfasalazine Generic
Tablet Delayed Release
sulfasalazine Generic
Capsule
ursodiol Generic
Capsule
AMITIZA Preferred Brand
Capsule Extended Release 24 Hour
APRISO Preferred Brand
Tincture
BELLADONNA Preferred Brand
Tablet
CHENODAL Preferred Brand
Capsule Delayed Release
DELZICOL Preferred Brand
Solution Reconstituted
KINEVAC Preferred Brand
Tablet
MOVANTIK Preferred Brand
Tablet Extended Release 24 Hour
UCERIS Preferred Brand
Tablet
VIBERZI Preferred Brand
OTHER ULCER THERAPY
Miscellaneous
lansoprazole/amoxicillin/clarithromycin Generic
Tablet
sucralfate Generic
Suspension
CARAFATE Preferred Brand
PROTON PUMP INHIBITORS
Capsule Delayed Release
lansoprazole Generic
Capsule Delayed Release
omeprazole Generic
Capsule
omeprazole/sodium bicarbonate Generic
Tablet Delayed Release
pantoprazole sodium Generic
Tablet Delayed Release
rabeprazole sodium Generic
RECTAL
Suppository
anucort-hc Generic
Enema
colocort Generic
Enema
mesalamine Generic
Foam
CORTIFOAM Preferred Brand
Foam
UCERIS Preferred Brand
GROWTH HORMONES
Solution
NORDITROPIN FLEXPRO Preferred Brand
HEMATOLOGY
Solution
PROCRIT Preferred Brand
Solution Prefilled Syringe
ZARXIO Preferred Brand
IMMUNOSUPPRESSANTS
Tablet
azathioprine Generic
Solution
cyclosporine modified Generic
Capsule
cyclosporine modified Generic
Solution
gengraf Generic
Capsule
gengraf Generic
Capsule
mycophenolate mofetil Generic
Tablet
sirolimus Generic
Capsule
tacrolimus Generic
Tablet
AZASAN Preferred Brand
Solution
RAPAMUNE Preferred Brand
Solution
SANDIMMUNE Preferred Brand
Tablet
ZORTRESS Preferred Brand
INTERFERONS
Solution
ACTIMMUNE Preferred Brand
Solution
ALFERON N Preferred Brand
Kit
BETASERON Preferred Brand
Solution Reconstituted
INTRON A W/DILUENT Preferred Brand
Solution
PEGASYS Preferred Brand
Printed Date:6/27/2018
Page 20 | 2018 Preferred Drug ListData Last Updated:6/27/2018
Kit
PEGINTRON Preferred Brand
Kit
PEG-INTRON REDIPEN Preferred Brand
Solution Prefilled Syringe
REBIF Preferred Brand
Solution Auto-injector
REBIF REBIDOSE Preferred Brand
Solution Auto-injector
REBIF REBIDOSE TITRATIONPACK Preferred Brand
Solution Prefilled Syringe
REBIF TITRATION PACK Preferred Brand
Kit
SYLATRON Preferred Brand
MISCELLANEOUS
Tablet Extended Release 12 Hour
bupropion hcl sr Generic
Solution
calcitonin salmon Generic
Capsule
cevimeline hcl Generic
Tablet
disulfiram Generic
Solution Auto-injector
epinephrine Generic
Solution Auto-injector
epinephrine Generic
Solution Auto-injector
epipen 2-pak Generic
Solution Auto-injector
epipen-jr 2-pak Generic
Tablet
etidronate disodium Generic
Tablet
midodrine hcl Generic
Tablet
riluzole Generic
Tablet
CARBAGLU Preferred Brand
Tablet
CHANTIX CONTINUING MONTHPAK Preferred Brand
Tablet Soluble
EXJADE Preferred Brand
MUSCULOSKELETALANTI-INFLAMMATORY
Solution Auto-injector
OTREXUP Preferred Brand
Solution Auto-injector
RASUVO Preferred Brand
Solution Prefilled Syringe
COSENTYX Preferred Brand
* Coverage based on indication.
Solution Auto-injector
COSENTYX SENSOREADY PEN Preferred Brand
* Coverage based on indication.
Solution Reconstituted
ENTYVIO Preferred Brand
* Coverage based on indication.
Pen-injector Kit
HUMIRA PEN Preferred Brand
* Coverage based on indication.
Solution Prefilled Syringe
KINERET Preferred Brand
* Coverage based on indication.
Solution Prefilled Syringe
ORENCIA Preferred Brand
* Coverage based on indication.
Solution Auto-injector
ORENCIA CLICKJECT Preferred Brand
* Coverage based on indication.
Tablet
SAVELLA Preferred Brand
* Coverage based on indication.
Tablet
SAVELLA Preferred Brand
* Coverage based on indication.
GOUT THERAPY
Tablet
allopurinol Generic
Tablet
probenecid Generic
Tablet
COLCRYS Preferred Brand
Tablet
ULORIC Preferred Brand
MUSCLE RELAXANTS
Tablet
baclofen Generic
Tablet
carisoprodol Generic
Tablet
carisoprodol/aspirin Generic
Tablet
carisoprodol/aspirin Generic
Tablet
carisoprodol/aspirin/codeine Generic
Tablet
chlorzoxazone Generic
Tablet
cyclobenzaprine hcl Generic
Capsule
dantrolene sodium Generic
Tablet
meprobamate Generic
Tablet
metaxalone Generic
Tablet
methocarbamol Generic
Tablet Extended Release 12 Hour
orphenadrine citrate er Generic
Tablet
tizanidine hcl Generic
Printed Date:6/27/2018
Page 21 | 2018 Preferred Drug ListData Last Updated:6/27/2018
OSTEOPOROSIS
Solution
alendronate sodium Generic
Tablet
alendronate sodium Generic
Tablet
ibandronate sodium Generic
Solution
FORTEO Preferred Brand
ONCOLOGY
Tablet
anastrozole Generic
Tablet
bicalutamide Generic
Solution
cytarabine Generic
Tablet
exemestane Generic
Capsule
flutamide Generic
Capsule
hydroxyurea Generic
Tablet
imatinib mesylate Generic
Tablet
letrozole Generic
Tablet
leucovorin calcium Generic
Suspension
megestrol acetate Generic
Tablet
megestrol acetate Generic
Tablet
mercaptopurine Generic
Tablet
methotrexate Generic
Tablet
tamoxifen citrate Generic
Capsule
temozolomide Generic
Tablet
AFINITOR Preferred Brand
Tablet Soluble
AFINITOR DISPERZ Preferred Brand
Capsule
ALECENSA Preferred Brand
Tablet
BOSULIF Preferred Brand
Tablet
CAPRELSA Preferred Brand
Capsule
DROXIA Preferred Brand
Kit
ELIGARD Preferred Brand
Capsule
EMCYT Preferred Brand
Tablet
FARESTON Preferred Brand
Tablet
GILOTRIF Preferred Brand
Capsule
HYCAMTIN Preferred Brand
Tablet
ICLUSIG Preferred Brand
Capsule
IMBRUVICA Preferred Brand
Tablet
INLYTA Preferred Brand
Tablet
JAKAFI Preferred Brand
Tablet
LEUKERAN Preferred Brand
Tablet
LYSODREN Preferred Brand
Capsule
MATULANE Preferred Brand
Tablet
MEKINIST Preferred Brand
Tablet
MESNEX Preferred Brand
Tablet
NEXAVAR Preferred Brand
Capsule
POMALYST Preferred Brand
Capsule
REVLIMID Preferred Brand
Tablet
SPRYCEL Preferred Brand
Tablet
STIVARGA Preferred Brand
Capsule
SUTENT Preferred Brand
Tablet
TABLOID Preferred Brand
Capsule
TAFINLAR Preferred Brand
Tablet
TARCEVA Preferred Brand
Capsule
TASIGNA Preferred Brand
Capsule
THALOMID Preferred Brand
Tablet
TREXALL Preferred Brand
Tablet
TYKERB Preferred Brand
Tablet
VOTRIENT Preferred Brand
Capsule
XALKORI Preferred Brand
Tablet
ZELBORAF Preferred Brand
Printed Date:6/27/2018
Page 22 | 2018 Preferred Drug ListData Last Updated:6/27/2018
Capsule
ZOLINZA Preferred Brand
Tablet
ZYTIGA Preferred Brand
OPHTHALMICANTIBIOTICS
Ointment
bacitracin Generic
Ointment
bacitracin Generic
Ointment
bacitracin/polymyxin b Generic
Solution
ciprofloxacin hcl Generic
Ointment
erythromycin Generic
Solution
gatifloxacin Generic
Solution
gentamicin sulfate Generic
Ointment
gentamicin sulfate Generic
Solution
levofloxacin Generic
Ointment
neomycin/bacitracin/polymyxin Generic
Ointment
neomycin/polymyxin/bacitracin/hydrocortisone Generic
Suspension
neomycin/polymyxin/dexamethasone Generic
Ointment
neomycin/polymyxin/dexamethasone Generic
Solution
neomycin/polymyxin/gramicidin Generic
Solution
neomycin/polymyxin/hc Generic
Suspension
neomycin/polymyxin/hydrocortisone Generic
Solution
ofloxacin Generic
Solution
sodium sulfacetamide Generic
Solution
sulfacetamide sodium/prednisolone sodium phosphateGeneric
Solution
tobramycin sulfate Generic
Suspension
tobramycin/dexamethasone Generic
Solution
trimethoprim sulfate/polymyxin b sulfate Generic
Solution
AZASITE Preferred Brand
Suspension
BESIVANCE Preferred Brand
Suspension
CIPRODEX Preferred Brand
Solution
MOXEZA Preferred Brand
Suspension
NATACYN Preferred Brand
Ointment
TOBRADEX Preferred Brand
Suspension
TOBRADEX ST Preferred Brand
Suspension
ZYLET Preferred Brand
BETA BLOCKERS
Solution
betaxolol hcl Generic
Solution
carteolol hcl Generic
Solution
levobunolol hcl Generic
Solution
metipranolol Generic
Solution
timolol maleate Generic
GLAUCOMA
Solution
dorzolamide hcl Generic
Solution
dorzolamide hcl/timolol maleate Generic
Solution
latanoprost Generic
Solution
pilocarpine hcl Generic
Suspension
AZOPT Preferred Brand
Solution
COMBIGAN Preferred Brand
Solution
LUMIGAN Preferred Brand
Kit
MITOSOL Preferred Brand
Solution
TRAVATAN Z Preferred Brand
Solution
VYZULTA Preferred Brand
MISCELLANEOUS
Solution
altacaine Generic
Solution
apraclonidine Generic
Solution
azelastine hcl Generic
Solution
brimonidine tartrate Generic
Solution
cromolyn sodium Generic
Solution
epinastine hcl Generic
Solution
flucaine Generic
Printed Date:6/27/2018
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MISCELLANEOUS
Solution
fluorescein-benoxinate Generic
Solution
proparacaine hcl Generic
Solution
tetravisc Generic
Solution
trifluridine Generic
Solution
ALPHAGAN P Preferred Brand
Solution
BEPREVE Preferred Brand
Solution
CYSTARAN Preferred Brand
Emulsion
RESTASIS Preferred Brand
Emulsion
RESTASIS MULTIDOSE Preferred Brand
Gel
ZIRGAN Preferred Brand
MYDRIATICS
Solution
atropine sulfate Generic
Solution
cyclopentolate hcl Generic
Solution
homatropine hbr Generic
Solution
tropicamide Generic
NSAIDS
Solution
bromfenac Generic
Solution
diclofenac sodium Generic
Solution
flurbiprofen sodium Generic
Solution
ketorolac tromethamine Generic
Suspension
ILEVRO Preferred Brand
Suspension
NEVANAC Preferred Brand
Solution
PROLENSA Preferred Brand
STEROIDS
Solution
dexamethasone sodium phosphate Generic
Suspension
fluorometholone Generic
Suspension
prednisolone acetate Generic
Suspension
ALREX Preferred Brand
Emulsion
DUREZOL Preferred Brand
Ointment
LOTEMAX Preferred Brand
Suspension
LOTEMAX Preferred Brand
Gel
LOTEMAX Preferred Brand
Suspension
PRED MILD Preferred Brand
VASOCONSTRICTOROTICMISCELLANEOUS
Solution
acetasol hc Generic
Solution
acetic acid Generic
Solution
ciprofloxacin Generic
Solution
hydrocortisone/acetic acid Generic
RESPIRATORY
Solution
ipratropium bromide/albuterol sulfate Generic
Packet
montelukast sodium Generic
Tablet
montelukast sodium Generic
Tablet
zafirlukast Generic
Tablet
ADCIRCA Preferred Brand
Aerosol Powder Breath Activated
ADVAIR DISKUS Preferred Brand
Aerosol
ADVAIR HFA Preferred Brand
Aerosol Powder Breath Activated
ANORO ELLIPTA Preferred Brand
Aerosol Powder Breath Activated
BREO ELLIPTA Preferred Brand
Aerosol Solution
COMBIVENT RESPIMAT Preferred Brand
Tablet
DALIRESP Preferred Brand
Aerosol Powder Breath Activated
INCRUSE ELLIPTA Preferred Brand
Tablet
KALYDECO Preferred Brand
Solution
PULMOZYME Preferred Brand
Capsule
SPIRIVA HANDIHALER Preferred Brand
Aerosol Solution
SPIRIVA RESPIMAT Preferred Brand
Aerosol Solution
STIOLTO RESPIMAT Preferred Brand
Solution Reconstituted
XOLAIR Preferred Brand
ANTIHISTAMINES
Printed Date:6/27/2018
Page 24 | 2018 Preferred Drug ListData Last Updated:6/27/2018
ANTIHISTAMINES
Tablet
arbinoxa Generic
Solution
carbinoxamine maleate Generic
Tablet
carbinoxamine maleate Generic
Tablet
clemastine fumarate Generic
Tablet
cyproheptadine hcl Generic
Tablet
desloratadine Generic
Elixir
diphenhydramine hcl Generic
Syrup
hydroxyzine hcl Generic
Tablet
hydroxyzine hcl Generic
Capsule
hydroxyzine pamoate Generic
Capsule
hydroxyzine pamoate Generic
Tablet
levocetirizine dihydrochloride Generic
Tablet
promethazine hcl Generic
ANTITUSSIVE
Capsule
benzonatate Generic
Syrup
bromfed dm Generic
Solution
guaifenesin/codeine Generic
Tablet
hydrocodone bitartrate/homatropine methylbromide Generic
Suspension Extended Release
hydrocodone polistirex/chlorpheniramine polistirex Generic
Syrup
promethazine vc/codeine Generic
Syrup
promethazine-dm Generic
Capsule Extended Release 12 Hour
TUSSICAPS Preferred Brand
BETA AGONISTS
Tablet
albuterol sulfate Generic
Syrup
albuterol sulfate Generic
Nebulization Solution
albuterol sulfate Generic
Nebulization Solution
levalbuterol hcl Generic
Syrup
metaproterenol sulfate Generic
Tablet
metaproterenol sulfate Generic
Tablet
terbutaline sulfate Generic
Aerosol Solution
PROAIR HFA Preferred Brand
Aerosol Powder Breath Activated
PROAIR RESPICLICK Preferred Brand
Aerosol Powder Breath Activated
SEREVENT DISKUS Preferred Brand
Aerosol Solution
STRIVERDI RESPIMAT Preferred Brand
Aerosol Solution
VENTOLIN HFA Preferred Brand
INHALED STEROIDS
Suspension
budesonide Generic
Aerosol Powder Breath Activated
ARNUITY ELLIPTA Preferred Brand
Aerosol Powder Breath Activated
FLOVENT DISKUS Preferred Brand
Aerosol
FLOVENT HFA Preferred Brand
Aerosol Solution
QVAR Preferred Brand
Aerosol Powder Breath Activated
TRELEGY ELLIPTA Preferred Brand
NASAL STEROIDS
Solution
flunisolide Generic
Suspension
fluticasone propionate Generic
Suspension
DYMISTA Preferred Brand
Aerosol Solution
QNASL Preferred Brand
OTHER
Solution
azelastine hcl Generic
Solution
ipratropium bromide Generic
Solution
theophylline Generic
Tablet Extended Release 12 Hour
theophylline er Generic
Miscellaneous
AEROCHAMBER PLUS FLOW-VU/SMALL MASK Preferred Brand
Miscellaneous
AEROCHAMBER/FLOWSIGNAL Preferred Brand
PAH
Tablet
ADEMPAS Preferred Brand
Tablet
LETAIRIS Preferred Brand
Tablet
TRACLEER Preferred Brand
TOPICALACNE
Gel
adapalene Generic
Printed Date:6/27/2018
Page 25 | 2018 Preferred Drug ListData Last Updated:6/27/2018
ACNE
Foam
benzoyl peroxide Generic
Capsule
claravis Generic
Swab
clindamycin phosphate Generic
Solution
clindamycin phosphate Generic
Lotion
clindamycin phosphate Generic
Foam
clindamycin phosphate Generic
Gel
clindamycin phosphate Generic
Gel
clindamycin phosphate/tretinoin Generic
Gel
clindamycin/benzoyl peroxide Generic
Solution
erythromycin Generic
Gel
erythromycin Generic
Gel
erythromycin/benzoyl peroxide Generic
Capsule
myorisan Generic
Liquid
pr benzoyl peroxide wash Generic
Lotion
sodium sulfacetamide/sulfur Generic
Emulsion
sodium sulfacetamide/sulfur cleanser in urea Generic
Gel
tretinoin Generic
Cream
tretinoin Generic
Gel
tretinoin microsphere Generic
Capsule
ABSORICA Preferred Brand
Gel
ACANYA Preferred Brand
Gel
ONEXTON Preferred Brand
ANESTHETICS
Ointment
lidocaine Generic
Cream
lidocaine hcl/hydrocortisone acetate Generic
Cream
lidocaine/prilocaine Generic
ANTIBACTERIALS
Ointment
mupirocin Generic
Cream
SULFAMYLON Preferred Brand
ANTIFUNGALS
Suspension
ciclopirox Generic
Shampoo
ciclopirox Generic
Gel
ciclopirox Generic
Cream
clotrimazole Generic
Solution
clotrimazole Generic
Lotion
clotrimazole/betamethasone dipropionate Generic
Cream
clotrimazole/betamethasone dipropionate Generic
Cream
econazole nitrate Generic
Shampoo
ketoconazole Generic
Cream
ketoconazole Generic
Ointment
nystatin Generic
Cream
nystatin/triamcinolone Generic
Solution
JUBLIA Preferred Brand
Cream
LUZU Preferred Brand
ANTIPSORIATIC
Capsule
acitretin Generic
Solution
calcipotriene Generic
Cream
calcipotriene Generic
Ointment
calcipotriene Generic
Ointment
calcitrene Generic
Cream
dritho-creme hp Generic
Lotion
selenium sulfide Generic
Shampoo
selenium sulfide Generic
Shampoo
sodium sulfacetamide Generic
Liquid
sodium sulfacetamide wash Generic
Suspension
TACLONEX Preferred Brand
ANTIVIRALS
Ointment
acyclovir Generic
CORTICOSTEROIDS HIGH POTENCY
Cream
amcinonide Generic
Printed Date:6/27/2018
Page 26 | 2018 Preferred Drug ListData Last Updated:6/27/2018
CORTICOSTEROIDS HIGH POTENCY
Lotion
amcinonide Generic
Ointment
amcinonide Generic
Cream
augmented betamethasone dipropionate Generic
Ointment
betamethasone dipropionate Generic
Lotion
betamethasone dipropionate Generic
Ointment
betamethasone valerate Generic
Ointment
desoximetasone Generic
Cream
desoximetasone Generic
Gel
desoximetasone Generic
Cream
diflorasone diacetate Generic
Ointment
fluocinonide Generic
Cream
fluocinonide Generic
Cream
fluocinonide Generic
Cream
fluocinonide emulsified base Generic
Cream
triamcinolone acetonide Generic
CORTICOSTEROIDS VERY HIGH POTENCY
Shampoo
clobetasol propionate Generic
Solution
clobetasol propionate Generic
Ointment
clobetasol propionate Generic
Cream
clobetasol propionate emollient Generic
Ointment
halobetasol propionate Generic
MISCELLANEOUS
Cream
fluorouracil Generic
Cream
imiquimod Generic
Lotion
malathion Generic
Cream
permethrin Generic
Solution
podofilox Generic
Cream
silver sulfadiazine Generic
Cream
thermazene Generic
Cream
ELIDEL Preferred Brand
Ointment
EUCRISA Preferred Brand
Shampoo
LINDANE Preferred Brand
Gel
PICATO Preferred Brand
Gel
REGRANEX Preferred Brand
Ointment
SANTYL Preferred Brand
Cream
TOLAK Preferred Brand
ROSACEA
Lotion
metronidazole Generic
Cream
metronidazole Generic
Gel
metronidazole Generic
Cream
rosadan Generic
Gel
rosadan Generic
Foam
FINACEA Preferred Brand
Cream
RHOFADE Preferred Brand
TOPICAL CORTICOSTEROIDS LOW POTENCY
Cream
alclometasone dipropionate Generic
Ointment
alclometasone dipropionate Generic
Ointment
desonide Generic
Lotion
desonide Generic
Solution
fluocinolone acetonide Generic
Cream
fluocinolone acetonide Generic
Cream
hydrocortisone Generic
TOPICAL CORTICOSTEROIDS MEDIUM POTENCY
Lotion
betamethasone valerate Generic
Cream
betamethasone valerate Generic
Lotion
fluticasone propionate Generic
Cream
fluticasone propionate Generic
Cream
hydrocortisone butyrate Generic
Solution
hydrocortisone butyrate Generic
Printed Date:6/27/2018
Page 27 | 2018 Preferred Drug ListData Last Updated:6/27/2018
TOPICAL CORTICOSTEROIDS MEDIUM POTENCY
Solution
mometasone furoate Generic
Ointment
mometasone furoate Generic
Ointment
prednicarbate Generic
Cream
triderm Generic
UROLOGICALANTISPASMODICS
Tablet
bethanechol chloride Generic
Tablet
flavoxate hcl Generic
Syrup
oxybutynin chloride Generic
Tablet
oxybutynin chloride Generic
Tablet Extended Release 24 Hour
oxybutynin chloride er Generic
Tablet
tolterodine tartrate Generic
Capsule Extended Release 24 Hour
tolterodine tartrate er Generic
Tablet
trospium chloride Generic
Tablet Extended Release 24 Hour
MYRBETRIQ Preferred Brand
Tablet
VESICARE Preferred Brand
BPH
Tablet
finasteride Generic
Capsule
RAPAFLO Preferred Brand
ERECTILE DYSFUNCTION
Tablet
sildenafil Generic
Tablet
sildenafil citrate Generic
Tablet
CIALIS Preferred Brand
VACCINES
Suspension
BOOSTRIX Preferred Brand
Suspension
CERVARIX Preferred Brand
Suspension
ENGERIX-B Preferred Brand
Suspension
GARDASIL Preferred Brand
Suspension
HAVRIX Preferred Brand
Suspension
INFANRIX Preferred Brand
Injectable
PNEUMOVAX 23/1 DOSE Preferred Brand
Suspension
PREVNAR 13 Preferred Brand
Suspension
RECOMBIVAX HB Preferred Brand
Solution
ROTATEQ Preferred Brand
Suspension
TWINRIX Preferred Brand
Suspension Reconstituted
ZOSTAVAX Preferred Brand
VITAMINS/ELECTROLYTES
Capsule
calcium acetate Generic
Tablet
dialyvite Generic
Tablet Chewable
fluoride Generic
Tablet
folic acid Generic
Packet
klor-con Generic
Solution
potassium chloride Generic
Solution
potassium chloride Generic
Tablet
ELITE-OB Preferred Brand
Solution
NASCOBAL Preferred Brand
Printed Date:6/27/2018
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Printed Date:6/27/2018
Page 29 | 2018 Preferred Drug ListData Last Updated:6/27/2018