Swhp alpha

SCOTT AND WHITE HEALTH PLAN
FORMULARY
NOVEMBER 2010
ALPHAGAN P
Captopril /HCTZ
ACCU-CHEK
Alprazolam Tab
Aygestin*
Acebutolol
Azathioprine
CARAFATE SUSP
Acetazolamide
Amantadine
Carbachol Ophth
Acetic Acid /HC Otic
Carbamazepine
Acetic Acid Otic
Bacitracin
Carbamazepine SR
Amcinonide
Baclofen
CARBATROL
Aclovate*
Amiloride
Bactrim*
Carbidopa /Levodopa
Activella*
Amiloride /HCTZ
BACTROBAN CREA
Cardizem CD*
Aminocaproic Acid
BACTROBAN NASAL
Carisoprodol
ACTOPLUS MET
Aminophylline
Benazepril
Carisoprodol/ASA
Amiodarone
Benazepril & HCTZ
Carteolol Ophth
Casodex*
Acyclovir
Amitrip /Chlordiazepo
BENICAR HCT
Catapres-TTS*
Amitriptyline
BENZACLIN PUMP
CAVERJECT
Adderall XR*
Amoxicillin
Benzamycin
Adderall*
Ampicillin
Benztropine
Analpram-HC*
Betamethasone
Cefaclor
ADVAIR HFA
ANDRODERM
BETASERON
Cefaclor CD 500
Betaxolol
Cefadroxil
ANTABUSE
Bethanechol
Cefpodoxime
AEROBID-M
Antipyrine-Benzocaine
BETOPTIC-S
Cefprozil
AGGRENOX
APAP /Codeine
Biaxin XL*
Agrylin*
CELEBREX
AKNE-MYCIN
Bicitra*
CELLCEPT
ARGATROBAN
Bisoprolol
Cephalexin
Albuterol Nebules
Arimidex*
Bisoprolol /HCTZ
CERUMENEX
Albuterol Syrup
ARMOUR THYROID
BLEPHAMIDE OPTH
Chloral Hydrate Syrup
Albuterol Tab
AROMASIN
Brimonidine Opth
Chloramphenicol Opht
ALDACTAZIDE 50mg
Bumetanide
Chlordiazepox /Clindin
Bupropion
Chlordiazepoxide
Atenolol
Buspirone
Chlorhexidine
ALLEGRA SUSP
Atenolol/Chlorthal
Butalbital /APAP
Chloroquine
Allegra-D 12H*
Chlorothiazide
ALLEGRA-D 24H
Atropine Ophth
BYSTOLIC
Chlorpromazine
Allopurinol
ATROVENT HFA
Calcitonin
Chlorpropamide
Augmentin*
Chlorthalidone
Chlorzoxazone
ALOXI INJ
Captopril
Cholestyramine
A = A Tier Generic
B = B Tier Preferred Brand C= C Tier Nonpreferred
DRUG = Brand Drug drug = Generic Drug
P = Prior Authorization M = Maintenance Benefit
drug* = Brand name listed for reference only, a generic equivalent is available
I = Specialty Copay may apply
S = Step Therapy Required
+ = Preferred Test Strip
Brand name products where generic is availabe; copay penalties may apply
Prescription formularies continually change to reflect the most recent advances in drug therapy. Therefore, this list is not inclusive and does not guarantee coverage. However, it represents an abbreviation of the member's prescription drug coverage. Ciclopirox 0.77%
COUMADIN
DIAMOX SEQUEL
Cilostazol
Diastat*
Cimetidine
Diazepam
Duragesic*
DIBENZYLINE
DURICEF SUSP
CIPRODEX
CRIXIVAN
Diclofenac
Ciprofloxacin
Cromolyn Neb
Diclofenac Ophth
Ciprofloxacin (Ophth)
Cromolyn Ophth
Diclofenac XR
Citalopram
CUPRIMINE
Dicloxacillin
Econazole Cream
CLEOCIN 75MG CAP
Cyanocobalamin
Dicyclomine
CLEOCIN VAG SUPP
Cyclessa*
Didanosine
Effexor XR caps*
Climara*
Cyclobenzaprine
DIDRONEL
Clindamycin Cap
CYCLOGYL 0.5%
DIFFERIN
Clindamycin Sol
Cyclopentolate
Differin 0.1% CRM*
Elimite*
Clindamycin Topical
Cyclophosphamide tabs A
Differin Gel 0.1%*
Clindamycin-Benzoyl*
Cyclosporine
Diflorasone
Clobetasol Cream
Cyclosporine Inj
Diflunisal
Clobetasol Gel
CYMBALTA
Clobetasol Oint
Cyproheptadine
Dihistine DH*
Clobetasol Soln
CYTADREN
Dihydroergotamine
Enalapril
Clomipramine
Cytomel*
DILANTIN 100MG
Enalapril/HCTZ
Clonazepam
CYTOVENE INJ
Diltiazem ER Cap CR
Clonidine
Diltiazem ER Cap SA
Enoxaparin*
Clonidine /Chlorthal
DANTRIUM
Diltiazem ERCapSR12
ENTOCORT EC
Clorazepate
Diltiazem HCl Tab
Clotrimazole Troche
DARAPRIM
EPI-PEN-JR
Clozapine
DAYTRANA
DIOVAN HCT
Codeine*
DDAVP TABS
DIPENTUM
Ergoloid Mesylate
Colazal*
Demeclocycline
Diphenoxyl /Atropine
Ergotamine-Caffeine
Colchicine
Demulen*
Dipiverfrin Ophth
Colchicine /Probenicid
Depakene*
Diprolene AF*
Colestid*
DEPAKOTE
Diprolene* Cr & Oint
Erythromycin
COLYMYCIN-S
DEPAKOTE ER
Dipyridamole
Erythromycin Ophth
DEPO-PROVERA 400
Disopyramide
Erythromycin Stearate
COMBIGAN
DEPO-TESTOST
Disopyramide CR
Erythromycin Top
COMBIVENT
DERMASMOOTH
DIURIL SUSP
Erythromycin/Sulfisox
COMBIVIR
Desipramine
Divalproex sodium
Esgic-Plus*
Desmopressin
Divalproex Sodium ER
Eskalith Cr*
CONCERTA
Desmopressin Inj
Donnatal*
Estazolam
COPAXONE
Desogen*
Dostinex*
ESTRACE VAG
Desonide
DOVONEX CREAM
ESTRADERM
CORTIFOAM
Desoximetasone
Dovonex Sol*
Estradiol
Cortisone
DETROL LA
Doxazosin
Estradiol Inj.
CORTISPORIN OPTH
Dexamethasone
Estradiol Valerate Inj
Cortisporin Otic*
Dexamethasone Opth
Doxycycline 100mg
ESTRATEST
Corzide*
Dextroamphetamine
Doxycycline 50mg
ESTRATEST HS
Estrostep FE*
A = A Tier Generic
B = B Tier Preferred Brand C= C Tier Nonpreferred
DRUG = Brand Drug drug = Generic Drug
P = Prior Authorization M = Maintenance Benefit
drug* = Brand name listed for reference only, a generic equivalent is available
I = Specialty Copay may apply
S = Step Therapy Required
+ = Preferred Test Strip
Brand name products where generic is availabe; copay penalties may apply
Prescription formularies continually change to reflect the most recent advances in drug therapy. Therefore, this list is not inclusive and does not guarantee coverage. However, it represents an abbreviation of the member's prescription drug coverage. Ethambutol
Flutamide
Homatropine Ophth
Isotretinoin
Ethosuximide
Fluticasone Topical
Etodolac
FML FORTE
HUMALOG MIX
Etodolac XL
HUMULIN Insulins
Folic Acid
Hycodan*
Kayexalate*
EXELDERM
Hydralazine
KENALOG INJ
Exelon Caps*
Hydrochlorothiazide
KENALOG SPRAY
EXELON LIQUID
Fortical Nasal Spray*
Hydrocodone/ APAP
Keppra* oral
EXELON PATCH
Fosamax*
Hydrocodone/ IBU
Ketaconazole Cream
Fosinopril
Hydrocortisone Enema
Ketoconazole Rx Sham
EXFORGE HCT
Fosinopril/Hctz
Hydrocortisone Rectal
Ketoconazole Tab
Famciclovir
Hydrocortisone Supp.
Ketoprofen
FANSIDAR
FURADANTIN SUSP
Hydrocortisone Tablet
Ketoprofen SR
FARESTON
Furosemide
Hydrocortisone Top 2.5 A
Ketorolac
FELBATOL
Gabapentin
Hydrocortisone Valerat A
Felodipine
GABITRIL
Hydromorphone
K-Lyte CL*
Ganciclovir Cap
Hydroxychloroquine
Fenofibrate
GANTRISIN PED
Hydroxyurea
Fenoprofen Tab
Gemfibrozil
Hydroxyzine
K-Phos Neutral*
Fexofenadine
Hyoscyamine
K-PHOS-2
Fioricet #3*
Gentamicin
HYPER-SAL NEB 7%
Fioricet*
Gentamicin Ophth
Labetalol
Fiorinal w/codeine*
Ibuprofen
LACRISERT
Fiorinal*
Imipramine HCl
Lactulose
Glipizide
Imitrex Inj*
LAMICTAL
Flavoxate
Glipizide XL
Imitrex Nasal*
Lamisil*
Flecainide
GLUCAGON
Imitrex Tabs*
Lamotrigine
Glyburide
Indapamide
Flonase*
Glyburide Micro
Inderal LA*
Florinef*
Glyburide-Metformin
INDOCIN SUPP
FLOVENT DISKUS
Gold Sod Thiomalate
INDOCIN SUSP
Leucovorin
FLOVENT HFA
Golytely*
Indomethacin
LEUKERAN
Flubiprofen Ophth
Granulex*
INTAL INHALER
Leuprolide 5mg/ml
Fluconazole
GRIFULVIN Tab
INTRON-A
Flumadine*
Griseofulvin Susp*
INVERSINE
Levetiracetam oral
Fluocinolone Top
GRIS-PEG
INVIRASE
Levobunolol
Fluocinonide
Guaifenesin/Codeine
Iodoquinol / HC
Levocarnitine
FLUORI-METHA
Guanabenz
IOPIDINE
Levo-Dromoran*
Fluorometholone
Guanfacine
Ipratropium
Fluorouracil (Topical)
Isoniazid
Levothroid*
Fluoxetine
Haloperidol
ISOPTO HYOSCINE
Levothyroxine
Fluoxymesterone
ISOPTO-CARBACHO
Fluphenazine
ISORDIL TAB 40MG
Lidocaine
Flurazepam
Histussin HC*
Isosorbide Dinitrate
Lidocaine Viscous
Flurbiprofen
Isosorbide Mononitrate
Lidocaine/prilocaine C
A = A Tier Generic
B = B Tier Preferred Brand C= C Tier Nonpreferred
DRUG = Brand Drug drug = Generic Drug
P = Prior Authorization M = Maintenance Benefit
drug* = Brand name listed for reference only, a generic equivalent is available
I = Specialty Copay may apply
S = Step Therapy Required
+ = Preferred Test Strip
Brand name products where generic is availabe; copay penalties may apply
Prescription formularies continually change to reflect the most recent advances in drug therapy. Therefore, this list is not inclusive and does not guarantee coverage. However, it represents an abbreviation of the member's prescription drug coverage. Meperidine /Prometh
Morphine Sulfate CR
NOVOLIN INSULIN
Lisinopril
MEPHYTON
Lisinopril/Hctz
Meprobamate
Mupirocin Oint
NOVOLOG MIX
Lithium Carbonate
Mercaptopurine Tab
Lithium Citrate
Mesalamine Rectal
MYCOBUTIN
Nulytely*
Lithobid*
METADATE CD
Mycophenolate Mofetil
NUVARING
LITHOSTAT
Metaproterenol
MYFORTIC
LIVOSTIN
Metformin
Nystatin
Lo/Ovral*
Metformin ER
Nabumetone
Nystatin /Triamcinolon
Methadone
Nystatin Topical
LOESTRIN 24 FE
Methazolamide
Octreotide Acetate Inj
Loestrin Fe*
Methenamine Hippurat
NALFON CAP
Ofloxacin Ophth
Loestrin*
Methenamine Mandelat A
Naltrexone
Ofloxacin Otic
Loprox Shampoo*
METHERGINE
OGEN CREAM
LOPROX TOPICAL
Methimazole
Naproxen
Lorazepam
Methocarbamol
Naproxen EC
Ogestrel (Ovral*)
Methotrexate
Omnicef*
Methotrexate Inj.
NASACORT AQ
Optipranolol*
Lotrisone Cream*
Methyclothiazide
NASCOBAL
Oral Contraceptive*
Lotrisone Lotion*
Methyldopa
LOTRONEX
Methyldopa /HCTZ
NEBUPENT
Orphenadrine
Lovastatin
Methylphenidate
Oxaprozin
Methylphenidate SR
Neo-Decadron*
Oxazepam Cap
Methylprednisolone
Neomycin
Oxcarbazepine
Loxapine
Metoclopramide
Metolazone
NEPHROCAPS
OXSORALEN-UL
Metoprolol
Oxybutynin
LUPRON DEPOT
Metoprolol & HCTZ
Nifedipine XL
Oxycodone
METROGEL
Nimodipine
Oxycodone /APAP
Metrogel Vag*
NITRO-DUR 0.3MG
Oxycodone /ASA
MACRODANTIN 25M
Metrolotion*
Nitrofurantoin
OXYCONTIN
MALARONE
Metronidazole
Nitrofurantoin Monohy A
Panafil*
Marinol*
Mexiletene
Nitroglycerin Oint
PANCREASE
Microgestin
Nitroglycerin Patch
Pancrelipase
Micronor*
Nitroglycerin SR
Parlodel*
NITROLINGUAL SPR
Paroxetine
Maxitrol*
MIGRANAL
NITROSTAT
Minocycline Caps
Nizatidine
Paxil CR*
Mebendazole
Minoxidil
NORDITROPIN
Meclofenamate
Mirapex*
Norgesic Forte*
PEG-INTRON
MEDROL 2MG
Mircette*
Norgesic*
Penicillin VK
Medroxy 150mg INJ
Mirtazapine
NORITATE
Medroxyprogesterone
Misoprostol
NORPACE CR 100MG
Pentoxifylline
Megestrol
Modicon*
Nortriptyline
Phenazopyridine
Mometasone Topical
Norvasc*
Phenergan DM*
Meperidine
Morphine Sulfate
Phenergan VC*
A = A Tier Generic
B = B Tier Preferred Brand C= C Tier Nonpreferred
DRUG = Brand Drug drug = Generic Drug
P = Prior Authorization M = Maintenance Benefit
drug* = Brand name listed for reference only, a generic equivalent is available
I = Specialty Copay may apply
S = Step Therapy Required
+ = Preferred Test Strip
Brand name products where generic is availabe; copay penalties may apply
Prescription formularies continually change to reflect the most recent advances in drug therapy. Therefore, this list is not inclusive and does not guarantee coverage. However, it represents an abbreviation of the member's prescription drug coverage. Phenobarb /Belladonna
PROGLYCEM
SURMONTIL
Phenobarbital
Roxicodone*
Phenylephrine Ophth
Promethazine
SYMBICORT
Phenytoin
Promethazine / COD
TACLONEX
Promethazine VC
Salsalate
Tacrolimus*
PHOSPHOLINE
Propafenone
SANDOSTATIN
Talwin NX*
Pilocarpine
Propantheline 15mg
Tamoxifen
Pilocarpine Tabs
Propox /APAP 100/650
Seasonale*
Pilocarpine/Epineph
Propox /APAP 50/325
SEASONIQUE
TEGRETOL
Pindolol
Propoxyphene
Selegiline
TEGRETOL XR
Piroxicam
Propranolol
Selenium Sulfide
TEKTURNA
PKU Formula
Propranolol /HCTZ
SELZENTRY
TEKTURNA-HCT
Propylthiouracil
SEREVENT DISKUS
Temazepam 15mg
Podofilox
Proscar*
SEROQUEL
Temazepam 30mg
Polycitra-K*
PROTOPIC
SEROSTIM
Temazepam 7.5mg
POLY-PRED
PROVIGIL
Silver Sulfadiazine
Polysporin*
Psorcon E*
TERAZOL 3 SUPP
Polytrim*
Psorcon*
Simvastatin
Terazol Cr*
Poly-Vi-Flor + FE*
Pulmicort 1mg/2ml
SINGULAIR
Terazosin
Poly-Vi-Flor*
Pulmicort Neb*
Skelaxin*
Terbutaline
Pyrazinamide
Sodium Chloride Nebs
Tessalon*
Potasium Iodide
Pyridostigmine
Sodium Cit-Cit Acid
TESTIM GEL
Potassium Chloride
Quinidine Gluconate
Sodium Fluoride
Testosterone Cypionate
PRAMOSONE
Quinidine Sulfate
Sodium Poly Sulf
Testosterone Inj.
Pramoxine /HC
Quinidine Sulfate CR
Tetracycline
Pravachol*
SORIATANE
TEXACORT
Prazosin
THALITONE
Precose*
Ranitidine
PRED MILD
RAPAMUNE
Spironolactone
Theophylline
REGRANEX
Spironolactone /HCTZ
Theophylline SR
Prednisolone
Sporanox*
Thioridazine
Prednisolone Ophth
Stadol Nasal Soln*
Thiothixene Cap
Prednisone
Starlix*
Prelone Syrup*
RESCRIPTOR
THYROLAR
PREMARIN
Reserpine
STRATTERA
Ticlopidine
PREMARIN CREAM
RESTASIS
STROMECTOL
Timolide*
PREMPHASE
RETIN-A MICRO
Sucralfate
Retrovir* oral
Sulfacetamide / Pred
Timolol Ophth
Prenatal MVI (Rx Only
Sulfacetamide /Sulphur
Tizanidine
Prenate Advance*
Ribavirin
Sulfacetamide Ophth
PRIMAQUINE
Sulfadiazine
Tobradex*
Primidone
Rifampin
Sulfasalazine
Tobramycin Ophth Sol
PROAIR HFA
Sulfasalazine EC
TOBREX OINT
Probenecid
Risperdal*
Sulfasoxazole
Tolazamide
Prochlorperazine
RITALIN LA
Sulindac
Tolbutamide
PROCTOFOAM HC
Rocaltrol*
Tolmetin
A = A Tier Generic
B = B Tier Preferred Brand C= C Tier Nonpreferred
DRUG = Brand Drug drug = Generic Drug
P = Prior Authorization M = Maintenance Benefit
drug* = Brand name listed for reference only, a generic equivalent is available
I = Specialty Copay may apply
S = Step Therapy Required
+ = Preferred Test Strip
Brand name products where generic is availabe; copay penalties may apply
Prescription formularies continually change to reflect the most recent advances in drug therapy. Therefore, this list is not inclusive and does not guarantee coverage. However, it represents an abbreviation of the member's prescription drug coverage. Topamax*
VENTOLIN HFA
Topiramate
Verapamil
Toprol XL*
VESICARE
VIBRAMYCIN SYRUP B
Torsemide
TRANSDERM-SCOP
TRANXENE SD
VIRACEPT
Tranylcypromine Sulfa
VIRAMUNE
Trazadone
Tretinoin
Viroptic*
Triamcinolone
Vitamin D 50,000 IU
Triamcinolone/Orabase A
Triamterene /HCTZ
VIVELLE-DOT
Triazolam
VIVOTIF BERN
Tricitrates*
VOSPIRE ER
TRIDESILON
Trifluoperazine
Trihexiphenidyl
Warfarin
Trileptal*
TRILIPIX
Wellbutrin SR*
Trilisate*
Trimeth/Sulfameth
Trimethobenzamide
Trimethoprim
Triphasil*
Triple Antibiotic Opht
Triple Antibiotic+HC
Yohimbine
TRIZIVIR
Zantac syrup*
Tropicamide
Trusopt*
Tussi Organidin*
Tussionex*
Zithromax*
Zofran Inj*
Zofran ODT*
Ultravate*
Urocit-k*
Zonisamide*
UROXATRAL
ZOVIRAX OINT
Ursodiol
Valtrex*
VANCOCIN
VANTIN SUSP
Venlafaxine IR tab
A = A Tier Generic
B = B Tier Preferred Brand C= C Tier Nonpreferred
DRUG = Brand Drug drug = Generic Drug
P = Prior Authorization M = Maintenance Benefit
drug* = Brand name listed for reference only, a generic equivalent is available
I = Specialty Copay may apply
S = Step Therapy Required
+ = Preferred Test Strip
Brand name products where generic is availabe; copay penalties may apply
Prescription formularies continually change to reflect the most recent advances in drug therapy. Therefore, this list is not inclusive and does not guarantee coverage. However, it represents an abbreviation of the member's prescription drug coverage.

Source: http://www2.wacoisd.org/riskmanagement/pdf/2011SwhpFormularyAlpha.pdf