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RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
A/T/S SOLUTION (SWABS, PADS & PLEDGETS EXCLUDED) TRIAL OF SINGULAIR (PA for 10 MG STRENGTH) REQUIRED ACCU-CHEK COMPACT PLUS TEST STRIPS / DRUM (QL) Lisinopril (ZESTRIL), Benazepril (LOTENSIN), Captopril (CAPOTEN), Fosinopril Acetaminophen 2.5 / Hydrocodone 1.67 Elixir Acetaminophen 325 / Hydrocodone 5 Tablets Acetaminophen 500 / Hydrocodone 5 Tablets Acetaminophen 650 / Hydrocodone 7.5 Tablets Acetic Acid 2% / Hydrocortisone 1% Otic Solution Acetic Acid Otic Aluminum Acetate Solution Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, OPANA ER, AVINZA, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Fentanyl patches (DURAGESIC), PERCOCET 5/325, PERCODAN 5/325 CLIMARA PRO, PREMPRO, PREMPHASE, Medroxyprogesterone (PROVERA) plus Estradiol tablets (ESTRACE), Estradiol patches (CLIMARA), ESTRADERM, VIVELLE, VIVELLE-DOT or Estropipate (OGEN, ORTHO-EST) Acyclovir Oral Tablets / Capsules / Suspension Amphetamine mixture, immediate release (ADDERALL), Methylphenidate (RITALIN, RITALIN SR, METADATE ER), dextroamphetamine (DEXEDRINE, DESTROSTAT), ADDERALL XR CAPSULES (QL) (BRAND ONLY ON TIER 3) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Alclometasone Dipropionate Cream / Ointment Loratadine (CLARITIN), Cetirizine (ZYRTEC) - BOTH AVAILABLE OTC Loratadine / Pseudephedrine (CLARITIN-D), Cetirizine / Pseudoephedrine (ZYRTEC-D) Estradiol Transdermal System (CLIMARA), VIVELLE PATCH, VIVELLE DOT PATCH Lovastatin (MEVACOR), Simvastatin (ZOCOR), Pravastatin (PRAVACHOL) Zolpidem (AMBIEN), Temazepam (RESTORIL), Lorazepam (ATIVAN), Flurazepam Lactulose (CEPHULAC), Polethylene Glycol 3350 (MIRALAX) Amitrptyline (ELAVIL) AND Perphenazine (TRILAFON)
RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Amoxicillin Capsules / Suspension / Chewable Tablets Amoxicillin Clavulanate Potassium SR Tablets Amoxicillin Clavulanate Potassium Tablets / Suspension Amphetamine / Dextroamphetamine SR 24 hr Capsule (QL) Ondansetron (ZOFRAN), Ondansetron Orally Disintegrating Tablet (ZOFRAN ODT) APAP / Dichloralphenazone / Isometheptene Capsules Azathioprine, Hydroxychloroquine (PLAQUENIL), Methotrexate (RHEUMATREX), Diclofenac (VOLTAREN) AND Misoprostol (CYTOTEC), Etodolac IR (LODINE),
Ibuprofen (MOTRIN), Indomethacin (INDOCIN/SR), Meloxicam (MOBIC), Naproxen
USE ACCU-CHEK AVIVA, ACCU-CHEK COMPACT PLUS, ACCU-CHEK COMFORT RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Atropine Sulfate Ophthalmic Solution & Ointment Augmented Betamethasone Dipropionate Cream Finasteride (PROSCAR) (PA), Doxazosin (CARDURA), Terazosin (HYTRIN), Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R) AZULFIDINE TABLETS (ENTERIC COATED NOT COVERED) B-D BRAND DISPOSABLE INSULIN NEEDLES & SYRINGES Belladonna / Phenobarbital Tablets/ Elixir Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Betamethasone Dipropionate Cream / Ointment Hydralazine (APRESOLINE) PLUS Isosorbide (ISORDIL)
Brompheniramine 12 mg / Pseudoephedrine 120 mg SEREVENT, Ipratropium Inhaler, ATROVENT HFA INHALER Butalbital 50 / Acetaminophen 325 / Caffeine 40 Tablets Butalbital 50 / Aspirin 325 / Caffeine 40 Tablets / Capsules Acetaminophen and codeine (TYLENOL/CODEINE), Hydrocodone and Acetaminophen (VICODIN, LORTAB), Tramadol (ULTRAM),Oxycodone 5 / Acetaminophen 325, Oxycodone 4.5 / Aspirin 325, Propoxyphene Napsylate / APAP, Propoxyphene BYETTA INJECTION (PA) (Covered under Pharmacy only if Plan has a Atenolol (TENORMIN), Metoprolol/SR (LOPRESSOR, TOPROL XL), Carvedilol Desmopressin Tablets / Spray, Megestrol Tablets, SYNAREL NASAL SOLUTION Amlodipine (NORVASC) PLUS Simvastatin (ZOCOR), or VYTORIN, or CRESTOR, or
lovastatin (MEVACOR), or pravastatin (PRAVACHOL) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Divalproex SR (DEPAKOTE ER), Topiramate (TOPAMAX) Divalproex SR (DEPAKOTE ER), Topiramate (TOPAMAX) Carbinoxamine 4 / Pseudoephedrine 60 / DM 15 Syrup Nifedipine SR (ADALAT CC), Felodipine (PLENDIL), SULAR, Verapamil SA Tabs Nifedipine SR (ADALAT CC), Felodipine (PLENDIL), SULAR, Verapamil SA Tabs Diltiazem Coated Beads 24 HR (CARDIZEM CD CAPSULES) (QL) Ibuprofen (MOTRIN), Meloxicam (MOBIC), Indomethacin/SR (INDOCIN/SR), Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin (DAYPRO), Sulindac (CLINORIL), Diclofenac (VOLTAREN), Piroxicam (FELDENE) Ibuprofen (MOTRIN), Meloxicam (MOBIC), Indomethacin/SR (INDOCIN/SR), Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin (DAYPRO), Sulindac (CLINORIL), Diclofenac (VOLTAREN), Piroxicam (FELDENE) PREMARIN, Estradiol (ESTRACE), Estradiol patch (CLIMARA, VIVELLE/DOT), Cephalexin Capsules / Suspension (750mg is non-Formulary) Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN), prochlorperazine (COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN) NOT COVERED BY ALL PLANS - CHECK BENEFITS AND SPECIFIC COPAY RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Chlorhexidine Gluconate (Covered Only If Dental Rider purchased) Chlorpheniramine 2/ Phenylephrine 10/ Methscopolamine 1.25-Syrup Chlorpheniramine 4 / Pseudoephedrine 60 Capsules Chlorpheniramine 4.5 / Phenylephrine 5 Suspension Chlorpheniramine 8/ Phenylephrine 20/ Methscopolamine 2.5 Caps Methocarbamol (ROBAXIN), Carisoprodol (SOMA), Cyclobenzaprine (FLEXERIL) NOT COVERED BY ALL PLANS - CHECK BENEFITS AND SPECIFIC COPAY Ketoconazole (NIZORAL), Econazole (SPECTAZOLE), LAMISIL OTC, Nystatin Cream / Hydrocortisone / Neomycin / Polymyxin Otic Solution / Suspension (CORTISPORIN OTIC), TOBRADEX, ZYLET SUSPENSION, CIPRODEX OTIC SOLUTION Loratadine (CLARITIN), Cetirizine (ZYRTEC) - BOTH AVAILABLE OTC Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), (RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R), Metronidazole Clindamycin Solution 1% (Swabs & Pads Excluded) Clobetasol Propionate Cream / Ointment/ Gel / Solution / Emollient Clobetasol Propionate Solution (TEMOVATE), Augmented Betamethasone Dipropionate Cream, Diflorasone Diacetate Cream / Oinment NOT COVERED BY ALL PLANS - CHECK BENEFITS AND SPECIFIC COPAY NOT COVERED BY ALL PLANS - CHECK BENEFITS AND SPECIFIC COPAY Clotrimazole / Betamethasone Cream / Lotion (QL) Codeine 10 / Brompheniramine 2 / Phenylephrine 12.5 Syrup Codeine 10 / Chlorpheniramine 2 / Pseudoephedrine 30 Liq RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Codeine 10 / Guaifenesin 100 / Pseudoephedrine 30 Solution Codeine 10/ Bromodiphenhydramine 12.5 Syrup Timolol (TIMOPTIC) plus Brimodine (ALPHAGAN P) or LUMIGAN or TRAVATAN PREMPRO, PREMPHASE, PREMARIN and Medroxyprogesterone (PROVERA), PROVENTIL HFA AND ATROVENT HFA
Oxycodone (OXYIR) AND Ibuprofen (MOTRIN)
Betamethasone Dip. (DIPROSONE), Betamethasone Val. (VALISONE), Fluocinolone (SYNALAR), ELOCON, Triamcinolone (KENALOG, ARISTOCORT) Carvedilol (COREG) - Immediate Release Tablets CORTISPORIN OPHTHALMIC SOLUTION & OINTMENT Betamethasone Dip. (DIPROSONE), Betamethasone Val. (VALISONE), Fluocinolone (SYNALAR), Fluocinonide (LIDEX), Triamcinolone (KENALOG, ARISTOCORT), RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
MYCOBUTIN CAPSULES, Ethambutol Tablets, Isoniazid Tablets, TRECATOR Amphetamine mixture, immediate release (ADDERALL), Methylphenidate (RITALIN, RITALIN SR, METADATE ER), dextroamphetamine (DEXEDRINE, DESTROSTAT), DECADRON OPHTHALMIC SOLUTION & OINTMENT ABREVA (AVAILABLE OTC-NOT COVERED), Acyclovir (ZOVIRAX (oral), VALTREX Methylphenidate SR/ER (Ritalin SR, Metadate ER), Dextroamphetamine SR (DEXEDRINE), Amphetamine Mixture (ADDERALL), CONCERTA, VYVANSE Dexamethasone / Neomycin / Polymyxin Ophth. Soln & Oint Dexamethasone Ophthalmic Solution & Ointment RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Ibuprofen (MOTRIN), Meloxicam (MOBIC), Indomethacin/SR (INDOCIN/SR), Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin (DAYPRO), Sulindac (CLINORIL), Diclofenac (VOLTAREN), Piroxicam (FELDENE) Choline Magnesium Salicylate Tablets (TRILISATE), Salsalate (DISALCID, SALFLEX) Oxybutinin Immediate Release Tabs., DETROL, DETROL LA, TOVIAZ Lorazepam (ATIVAN), Temazepam (RESTORIL),Flurazepam (DALMANE) Doxycycline Hyclate 20mg, 40mg Capsules / Tablets Doxycycline Hyclate 50mg, 100mg Capsules / Tablets Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN), prochlorperazine (COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
DYNACIN -NOT COVERED (USE MINOCYCLINE CAPSULES)
Amlodipine (NORVASC), Nifedipine SR (ADALAT CC, PROCARDIA XL), Felodipine Furosemide (LASIX), Bumetanide (BUMEX), Metolazone (ZAROXOLYN) Cromolyn (CROLOM),ALOMIDE, PATANOL, PATADAY PROTOPIC (PA), Betamethasone dipropionate, Augmented betamethasone dipropionate (DIPROLENE), Betamethasone valerate 0.1% (BETA-VAL), Clobetasol proprionate (TEMOVATE), Desoximetasone (TOPICORT), Diflorasone cream & ointment (APEXICON, APEXICON E, PSORCON E), Fluocinolone 0.025% (SYNALAR), Fluocinonide (LIDEX, LIDEX E), Halobetasol propionate (ULTRAVATE), Mometasone (ELOCON), Triamcinolone 0.1% (ARISTOCORT, KENALOG) Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN), prochlorperazine (COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN) Amitriptyline (ELAVIL),Bupropion/SR (WELLBUTRIN/SR),Citalopram (CELEXA), Desipramine (NORPRAMIN), Doxepin (SINEQUAN), Fluoxetine (PROZAC), Imipramine (TOFRANIL), Mirtazapine/soltab (REMERON/ SOLTAB), Nortriptyline (AVENTYL, PAMELOR), Paroxetine (PAXIL), Sertraline (ZOLOFT), Trazodone (DESYREL), Oxybutinin Immediate Release Tabs., DETROL, DETROL LA, TOVIAZ PREMARIN, Estradiol (ESTRACE), Estradiol patch (CLIMARA, VIVELLE/DOT), RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
EPIPEN INJECTION (QL) (Covered under Pharmacy only if Plan has a EPIPEN JR. INJECTION (QL) (Covered under Pharmacy only if Plan has a Ergotamine / Caffeine Tablets / Suppositories Ergotamine/ Belladonna/ Phenobarbital Tablets / Elixir Nystatin, Econazole (SPECTAZOLE), LAMISIL AT (OTC-NOT COVERED) ERYCETTE SOLN (SWABS & PADS EXCLUDED) Erythromycin 1.5 % Solution (Swabs & Pads EXCLUDED) Erythromycin 2.0 % Soln (Swabs & Pads EXCLUDED) Zolpidem (AMBIEN), Zaleplon (SONATA), Lorazepam (ATIVAN), Temazepam ESTRADERM, Estradiol Patches (CLIMARA), VIVELLE, VIVELLE-DOT Estradiol patches (CLIMARA), ESTRADERM, VIVELLE, VIVELLE-DOT, ESTRACE PREMARIN, Estropipate (OGEN, ORTHO-EST), Esterified Estrogens (MENEST, ESTRATAB), Estradiol Tablets (ESTRACE), Estradiol patches (CLIMARA), VIVELLE, VIVELLE-DOT, ESTRADERM, ESTRACE VAGINAL CR, PREMARIN VAGINAL CR RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Nystatin (MYCOSTATIN), LAMISIL AT CREAM (OTC AVAILABLE - NOT COVERED), Econazole (SPECTAZOLE), Ketoconazole Tablets (NIZORAL) USE ACCU-CHEK AVIVA, ACCU-CHEK COMPACT PLUS, ACCU-CHEK COMFORT CLIMARA PRO, PREMPRO, PREMPHASE, Medroxyprogesterone (PROVERA) PLUS Estradiol Tablets (ESTRACE), Estradiol patches (CLIMARA), VIVELLE, VIVELLE-DOT, ESTRADERM, or Estropipate (OGEN, ORTHO-EST) Estradiol Patches (CLIMARA), ESTRADERM, VIVELLE, VIVELLE-DOT, ESTRACE Fenofibrate Micronized Tablets 67mg, 134 mg, 160 mg, 200 mg Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, OPANA ER, AVINZA, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, OPANA ER, AVINZA, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Loratadine / Pseudephedrine (CLARITIN-D), Cetirizine / Pseudoephedrine (ZYRTEC-D) Fexofenadine / Pseudoephedrine Tablets (PA) Fexofenadine 30 MG, 60 MG Tablets/Capsules (EST) Loratadine (CLARITIN), Cetirizine (ZYRTEC) - BOTH AVAILABLE OTC RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Fluconazole 150 mg Tab – Females Only (QL) Fluocinolone Acetonide 0.01% Cream / Ointment / Solution Fluocinolone Acetonide 0.025% Cream / Ointment Fluoride / Polyvitamins (Without Iron; Drops & Tabs) Fluoride / Vitamins A,D,C (Without Iron; Drops & Tabs) Fluorometholone Ophthalmic Suspension & Ointment Fluoxetine Tablets/Capsules Only - 10mg, 20mg Only Betamethasone Dip. (DIPROSONE), Betamethasone Val. (VALISONE), Fluocinolone (SYNALAR), ELOCON, Triamcinolone (KENALOG, ARISTOCORT) Fluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL), Venlafaxine (EFFEXOR), EFFEXOR XR, Bupropion (WELLBUTRIN, WELLBUTRIN Methylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE), Amphetamine Mixture (ADDERALL), CONCERTA, VYVANSE Methylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE), Amphetamine Mixture (ADDERALL), CONCERTA, VYVANSE RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Methsuximide (CELONTIN) , Valproic Acid/ER (DEPAKOTE ER), Felbamate (FELBATOL), Carbamazepine SR (TEGRETOL SR), Topiramate (TOPAMAX), Gentamicin Ophthalmic Solution & Ointment USE BRAND YAZ AT TIER 1
GLUCAGEN (QL) (Covered under Pharmacy only if Plan has a "Specialty Tier") GLUCAGON (QL) (Covered under Pharmacy only if Plan has a "Specialty Tier") Guaifenesin 10 / Codeine Phosphate 100 Liq NR Expectorant Guaifenesin 100 / Codeine 10 / Pseudoephedrine 30 Guaifenesin 600 / Pseudoephedrine 120 Tablets Augmented Betamethasone Dip. (DIPROLENE AF), Betamethasone Val. (VALISONE), Fluocinonide (LIDEX/E), Diflorasone cream (MAXIFLOR, PSORCON E) Methenamine Mandelate (MANDELAMINE) Tablets HUMALOG MIX 50/50 INSULIN PENS / KWIKPENS (QL) HUMALOG MIX 75/25 INSULIN / KWIKPENS (QL) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
HUMALOG MIX 75/25 INSULIN PENS / KWIKPENS (QL) Hydrochlorothiazide (HCTZ) 12.5mg Capsules Hydrochlorothiazide (HCTZ) Tablets 25mg, 50mg Hydrocodone 2.5 / Phenylephrine 5 / Chlorpheniramine 2 Syrup Hydrocodone 2.5 / Guaifenesin 100 / Pseudoephedrine 30 Soln Hydrocodone 5 / Guaifenesin 100 Expectorant Hydrocortisone / Neomycin / Polymyxin Ophth. Susp & Oint Hydrocortisone / Neomycin / Polymyxin Otic Solution/ Susp.
Hydrocortisone Butyrate Cream / Ointment Fluocinolone (SYNALAR), Triamcinolone (KENALOG), Mometasone (ELOCON) Hydrocortisone Valerate Cream / Ointment Fluocinolone, Triamcinolone, Mometasone (ELOCON) INFLAMASE FORTE OPHTHALMIC SOLUTION & OINTMENT RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Iodinated Glycerol / Dextromethorphan Syrup Atenolol (TENORMIN), Metoprolol/SR (LOPRESSOR, TOPROL XL) Amoxicillin/clavulanate (AUGMENTIN), Azithromycin (ZITHROMAX), Doxycycline (VIBRAMYCIN), Clarithromycin/SR (BIAXIN XL) Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN), prochlorperazine (COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN) Lantoprazole Delayed Release Capsules (PA) (QL) ACIPHEX, Omeprazole (PRILOSEC) 10 MG, 20 MG Azathioprine, Hydroxychloroquine (PLAQUENIL), Methotrexate (RHEUMATREX), Lovastatin (MEVACOR), Pravastatin (PRAVACHOL), Simvastatin (ZOCOR) Lovastatin (MEVACOR), Pravastatin (PRAVACHOL), Simvastatin (ZOCOR) Lovastatin (MEVACOR), Pravastatin (PRAVACHOL), Simvastatin (ZOCOR), VYTORIN, RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Lovastatin (MEVACOR), Pravastatin (PRAVACHOL), Simvastatin (ZOCOR), VYTORIN, Betamethasone dipropionate lotion, Betamethasone valerate 0.1% cream (BETA-VAL), Fluocinolone 0.025% (SYNALAR), Mometasone (ELOCON), Triamcinolone 0.1% Losartan Potassium / Hydrochlorothiazide Tablets (PA) Niacin SR, Gemfibrozil (LOPID), TRICOR. TRILIPIX Flurazepam (DALMANE),Temazepam (RESTORIL), Triazolam (HALCION), Zolpidem Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN), prochlorperazine (COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN) Lisinopril (ZESTRIL), Benazepril (LOTENSIN), Captopril (CAPOTEN), Fosinopril MAXITROL OPHTHALMIC SOLUTION & OINTMENT RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Lorazepam (ATIVAN), Diazepam (VALIUM), Alprazolam (XANAX), Oxazepam (SERAX) Methylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE), Amphetamine Mixture (ADDERALL), CONCERTA, VYVANSE Metronidazole Tablets 250 mg and 500 mg Only Benazepril/HCTZ (LOTENSIN HCT), Lisinopril /HCTZ (ZESTORETIC), BENICAR HCT , Benazepril (LOTENSIN), Lisinopril (ZESTRIL), BENICAR, DIOVAN RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Lorazepam (ATIVAN), Diazepam (VALIUM), Alprazolam (XANAX), Oxazepam (SERAX) MINIPRESS CAPSULESMINOCIN CAPSULES 50 MG, 100 MG (IMMEDIATE RELEASE ONLY- MINOCIN TABLETS (PA) 50 MG, 100 MG (IMMEDIATE RELEASE ONLY- Minocycline Capsules (MINOCIN CAPSULES 50 MG, 100 MG; IMMEDIATE RELEASE Ketoconazole (NIZORAL), Econazole (SPECTAZOLE), LAMISIL OTC - NOT RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Naproxen Tablets (Enteric Coated Not Covered) NASONEX, Fluticasone Nasal (FLONASE), VERAMYST NASONEX, Fluticasone Nasal (FLONASE), VERAMYST Neomycin / Bacitracin / Polymyxin Ophthalmic Solution & Oint.
Neomycin / Polymyxin / Prednisone Ophth. Soln.
Diclofenac ophthalmic solution (VOLTAREN), ACULAR (LS) OPHTHALMIC SOLUTION ACIPHEX, Omeprazole (PRILOSEC) 10 MG, 20MG Nifedipine SR (ADALAT CC), Felodipine (PLENDIL), SULAR, Amlodipine (NORVASC) Ranitidine (ZANTAC), Famotidine (PEPCID), Cimetidine (TAGAMET) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
NASONEX, Fluticasone Nasal (FLONASE), VERAMYST Ondansetron Orally Disintegrating Tablets (QL) USE ACCU-CHEK AVIVA, ACCU-CHEK COMPACT PLUS, ACCU-CHEK COMFORT USE ACCU-CHEK AVIVA, ACCU-CHEK COMPACT PLUS, ACCU-CHEK COMFORT Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, OPANA ER, AVINZA, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Fentanyl patches (DURAGESIC), ALOMIDE, PATANOL, PATADAY, ZADITOR (AVAILABLE OTC - NOT COVERED) Orphenadrine / Aspirin / Caffeine Tablets RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Nystatin, Econazole (SPECTAZOLE), LAMISIL AT (AVAILABLE OTC - NOT COVERED), LOTRIMIN (AVAILABLE OTC-NOT COVERED) Morphine Sulfate (MSIR, MS CONTIN), DILAUDID, KADIAN, OPANA ER, AVINZA, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Fentanyl patches (DURAGESIC), PERCOCET 5/325, PERCODAN 5/325 Oxybutynin Immediate Release Tablets, DETROL, DETROL LA, TOVIAZ Ketoconazole (NIZORAL), Econazole (SPECTAZOLE), LAMISIL OTC-NOT COVERED RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Fluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL), Bupropion Polymixin B Sulfate / Trimethoprim Ophthalmic Solution POLY-VI-FLOR TABLETS / DROPS (age limit 6 years and younger) Ibuprofen (MOTRIN), Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin (DAYPRO), Sulindac (CLINORIL), Diclofenac (VOLTAREN), Piroxicam (FELDENE) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Prednisolone Acetate Ophthalmic Suspension 1% Prednisolone Phosphate Ophthalmic Solution CLIMARA PRO, PREMPRO, PREMPHASE, Medroxyprogesterone (PROVERA) PLUS Estradiol tablets (ESTRACE), Estradiol patches (CLIMARA), VIVELLE, VIVELLE-DOT, Prenatal Multivitamins / Folic Acid (Rx Strength) USE ACCU-CHEK AVIVA, ACCU-CHEK COMPACT PLUS, ACCU-CHEK COMFORT ACIPHEX, Omeprazole (PRILOSEC) 10 MG, 20 MG ACIPHEX or Omeprazole PLUS Naproxen
ACIPHEX, Omeprazole (PRILOSEC) 10 MG, 20 MG ACIPHEX or Omeprazole PLUS amoxicillin PLUS clarithromycin
PRILOSEC 40MG CAPSULES Not Covered - USE 2 x 20 MG ACIPHEX, Omeprazole (PRILOSEC) 10 MG, 20 MG MUST HAVE TRIED A PREFERRED GENERIC ANTIDEPRESSANTS Promethazine/ Phenylephrine/ Codeine Syrup Medroxyprogesterone (PROVERA), Norethindrone (AYGESTIN) Propranolol / Hydrochlorothiazide Tablets RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Temazepam (RESTORIL), Flurazepam (DALMANE), Oxazepam (SERAX), Triazolam ACIPHEX, Omeprazole (PRILOSEC) 10 MG, 20 MG Methylphenidate (RITALIN, RITALIN SR), Dextroamphetamine (DEXEDRINE, DEXEDRINE SPANSULE), Amphetamine / Dextroamphetamine (ADDERALL) PROZAC CAPSULES ONLY - 10 MG & 20 MG ONLY Fluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL), Bupropion PROZAC TABLETS (10 MG & 20 MG Capsules Covered Tier 1) Fluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL), Bupropion Quinidine Sulfate Sustained Release Tablets Calcium Carbonate (OTC AVAILABLE: NOT COVERED), Calcium Acetate (PHOSLO) Calcium Carbonate (OTC AVAILABLE: NOT COVERED), Calcium Acetate (PHOSLO) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Ropinirole Tablets (REQUIP) - Immmediate Release NASONEX, Fluticasone Nasal (FLONASE), VERAMYST Methylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE), Amphetamine Dextroamphetamine (ADDERALL), CONCERTA, VYVANSE Dicyclomine (BENTYL), Clinidium/Chlordiazepoxide (LIBRAX), Metoclopramide Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R) Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R) Flurazepam (DALMANE), Temazepam (RESTORIL), Triazolam (HALCION), Zolpidem Oxybutynin Immediate Release Tablets (DITROPAN), DETROL, DETROL LA, TOVIAZ Ondansetron (ZOFRAN) Tablets, metoclopramide (REGLAN), prochlorperazine (COMPAZINE), promethazine (PHENERGAN), trimethobenzamide (TIGAN) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
ORTHO-NOVUM, MODICON, ORTHO-CEPT, MICROGESTIN (LOESTRIN), ORTHO- SEASONALE (3 MONTH SUPPLY) (Quasense, Jolessa) Calcium Carbonate (OTC AVAILABLE: NOT COVERED) , Calcium Acetate (PHOSLO) NOT COVERED BY ALL PLANS - CHECK BENEFITS AND SPECIFIC COPAY Cefdinir (OMNICEF), Cefprozil (CEFZIL), Cefuroxime (CEFTIN), Cefadroxil (DURICEF), RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Acetaminophen and codeine (TYLENOL/CODEINE), Hydrocodone and Acetaminophen Valproic Acid (DEPAKENE), Divalproex sodium/ER (DEPAKOTE/ER) Methylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE), Amphetamine Mixture (ADDERALL), CONCERTA, VYVANSE SULAR EXTENDED RELEASE TABLETS WITH GEOMATRIX DELIVERY Sulfacetamide / Prednisolone Acetate Susp. & Oint.
Sulfacetamide / Prednisolone Ophthalmic Ointment Sulfamethoxazole / Trimethoprim (SMZ / TMP) Tablets Sulfamethoxazole / Trimethoprim DS (SMZ / TMP DS) Tablets Sulfasalazine Tablets (Enteric Coated Tablets Not Covered) USE ACCU-CHEK AVIVA, ACCU-CHEK COMPACT PLUS, ACCU-CHEK COMFORT Amitriptyline (ELAVIL), Doxepin (SINEQUAN), Nortriptyline (PAMELOR), Imipramine (TOFRANIL), Paroxetine (PAXIL), Citalopram (CELEXA), Fluoxetine (PROZAC), ZYPREXA PLUS Fluoxetine (Prozac)
SYMLIN INJECTION (PA) (Covered under Pharmacy only if Plan has a Propoxyphene (DARVON), Hydrocodone and Acetaminophen (VICODIN, LORTAB) Verapamil SR (CALAN SR) PLUS Benazepril (LOTENSIN), Captopril (CAPOTEN),
Lisinopril (ZESTRIL), Enalapril (VASOTEC), Fosinopril (MONOPRIL), Quinapril
RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
TEMOVATE CREAM / OINTMENT/ GEL/ SOLUTION/ EMOLLIENT MONISTAT (AVAILABLE OTC - NOT COVERED), GYNE LOTRIMIN (AVAILABLE OTC - NOT COVERED), VAGISTAT (AVAILABLE OTC - NOT COVERED), Fluconazole (DIFLUCAN 150mg) (one tablet) Benazepril/HCTZ (LOTENSIN HCT), Lisinopril /HCTZ (ZESTORETIC), BENICAR HCT , Benazepril (LOTENSIN), Lisinopril (ZESTRIL), BENICAR, DIOVAN Levothyroxine (SYNTHROID, LEVOXYL, LEVOTHROID), CYTOMEL, ARMOUR Metronidazole (FLAGYL), Paramomycin (HUMATIN) Methocarbamol (ROBAXIN), Carisoprodol 350 mg (SOMA 350 mg), Cyclobenzaprine Tobramycin / Dexamethasone Ophthalmic Suspension (QL) Tobramycin Ophthalmic Solution & Ointment Amitriptyline (ELAVIL), Desipramine (NORPRAMIN), Imipramine (TOFRANIL), RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Tramadol (ULTRAM) PLUS Acetaminophen (TYLENOL)
Lisinopril (ZESTRIL), Benazepril (LOTENSIN), Captopril (CAPOTEN), Fosinopril Naproxen Sodium (NAPROXEN) PLUS Sumatriptan (IMITREX)
Triamcinolone / Nystatin Cream / Ointment Triamcinolone Acetonide Cream / Ointment / Lotion RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
USE ACCU-CHEK AVIVA, ACCU-CHEK COMPACT PLUS, ACCU-CHEK COMFORT TWINJECT INJECTION (QL) (Covered under Pharmacy only if Plan has a Tramadol (ULTRAM) PLUS Acetaminophen (TYLENOL)
Doxazosin (CARDURA), Terazosin (HYTRIN), Finasteride (PROSCAR) (PA) Estradiol patches (CLIMARA), ESTRADERM, VIVELLE, VIVELLE-DOT, ESTRACE Venlafaxine Tablets (Sustained Release 24 Hr) (EST) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Verapamil SA Tabs (CALAN SR), Felodipine (PLENDIL), Nifedipine SA (ADALAT CC) Verapamil SA Tabs (CALAN SR, ISOPTIN SR), Felodipine (PLENDIL), Nifedipine SA Oxybutynin Immediate Release Tablets , DETROL, DETROL LA, TOVIAZ Dexamethasone (DEXASOL), Fluorometholone (FML, FML FORTE) Prednisolone NOT COVERED BY ALL PLANS - CHECK BENEFITS AND SPECIFIC COPAY Hydrocodone and Acetaminophen (VICODIN, LORTAB) plus Ibuprofen (MOTRIN) VICTOZA INJECTION (PA) (Covered under Pharmacy only if Plan has a VIDAYLIN/F TABLETS / DROPS (age limit 6 years and younger) Amitriptyline (ELAVIL), Desipramine (NORPRAMIN), Imipramine (TOFRANIL), Ibuprofen (MOTRIN), Etodolac Immediate Release (LODINE), Naproxen (NAPROSYN), Oxaprozin (DAYPRO), Sulindac (CLINORIL), Diclofenac (VOLTAREN), Piroxicam Cholestyramine Powder (QUESTRAN, QUESTRAN LIGHT - BULK POWDER ONLY) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
Fluocinolone (SYNALAR), Mometasone (ELOCON), Triamcinolone (ARISTOCORT, Alprazolam (XANAX), Lorazepam (ATIVAN), Oxazepam (SERAX), Diazepam (VALIUM) Methylphenidate/SR/ER (RITALIN, RITALIN SR, METADATE ER) Loratadine (CLARITIN), Cetirizine (ZYRTEC) - BOTH AVAILABLE OTC Methocarbamol (ROBAXIN), Carisoprodol 350 mg (SOMA 350 mg), Cyclobenzaprine Lovastatin (MEVACOR), VYTORIN, Pravastatin (PRAVACHOL), Simvastatin (ZOCOR), OTC BENADRYL CREAM-NOT COVERED, Hydroxyzine (VISTARIL) RECOMMENDED DRUG LIST ALPHABETICAL
TIER GENERIC
DRUG NAME
SUGGESTED ALTERNATIVE DRUGS / MESSAGES
ZOVIRAX ORAL TABLETS / CAPSULES / SUSPENSION

Source: https://www.ljcds.org/uploaded/Human_Resources/Benefits/rdl_alpha_list.pdf