FORMULARY LIST
At
Northwest Pharmacy Services our formulary is developed and approved by
an independent Pharmacy and Therapeutics Committee. When considering a drug for inclusion on the
formulary, the decisions are based on specific criteria, which include:
· Efficacy
· Safety
· Uniqueness
· Cost
Medical and pharmacy experts research
the medical literature for “best practices” and utilize evidence and
value-based decision making to compare data that determines
inclusion/exclusion to the formulary. Our formulary products are
selected based on health outcome criteria. Cost is considered only after
other criteria have been evaluated and is never a consideration if it
compromises the quality of care.
We believe a well-managed formulary can have a
positive effect on both patient outcomes and total medical care cost.
Using flexible plan design, measurement and expertise, Northwest
Pharmacy Services can develop the appropriate formulary for varying
member populations helping our clients increase member satisfaction,
improve outcomes, and reduce costs.
NWPS PREFERRED DRUG
LIST
The drug list is a guide within select therapeutic
categories for plan participants and health care providers. Generics
should be considered the first line of prescribing. If there is no
generic available, there may be more than one brand-name medicine to
treat a condition. These preferred brand-name medicines are listed
to help identify products that are clinically appropriate and
cost-effective. Generics listed in therapeutic categories are for
representational purposes only. This is not an all-inclusive list.
This list represents brand products in CAPS, branded generics in
upper- and lowercase
Italics,
and generic products in lowercase
italics.
|
PLAN PARTICIPANT |
HEALTH CARE PROVIDER |
|
Your benefit plan provides you with a
prescription benefit program. Ask your doctor to
consider prescribing, when medically appropriate, a
preferred medicine from this list. Take this list along
when you or a covered family member sees a doctor.
Please note:
-
Your
specific prescription benefit plan design may not
cover certain categories, regardless of their
appearance in this document.
-
Unless specifically indicated, drug list products
will include all dosage forms.
|
Your patient is covered under a
prescription benefit plan. As a way to help manage
health care costs, authorize generic substitution
whenever possible. If you believe a brand-name product
is necessary, consider prescribing a brand name on this
list.
Please note:
-
Generics should be considered the first line of
prescribing.
-
This
drug list represents a summary of prescription
coverage. It is not inclusive and does not guarantee
coverage.
-
The
plan participant's specific prescription benefit
plan may have a different copay1 for
specific products on the list.
-
Unless specifically indicated, drug list products
will include all dosage forms.
|
NWPS PREFERRED DRUG
LIST - BY CATEGORY
Please click on a menu item below
for a category of medications:
Use of generic drugs can save both you and
your health plan money. This list is not all-inclusive and is
not a guarantee of coverage. Plan Benefit design is the final
determinate of coverage.
Effective Date:
April 2011
| |
|
ANTIBACTERIALS |
|
§
Cephalosporins |
| cefaclor |
SUPRAX |
| cefdinir |
|
| cephalexin |
|
|
§
Erythromicins / Macrolides |
| azithromycin |
|
| clarithromycin |
|
| clarithromycin ext-rel |
|
| erythromycins |
|
|
§
Fluoroquinolones |
| ciprofloxacin ext-rel |
AVELOX |
| ciprofloxacin tablet |
CIPRO SUSPENSION |
| |
LEVAQUIN |
|
§
Penicillins |
| amoxicillin |
|
| amoxicillin-clavulanate |
|
| dicloxacillin |
|
| penicillin VK |
|
|
§
Tetracyclines |
| doxycycline hyclate |
|
| minocycline |
|
| tetracycline |
|
| |
|
§
ANTIFUNGALS |
| fluconazole |
|
| itraconazole |
|
| terbinafine tablet |
|
| |
|
ANTIVIRALS |
|
§
Herpes
Agents |
| acyclovir |
|
| valcyclovir |
|
|
§
Influenza Agents |
| amantadine |
RELENZA |
| rimantadine |
TAMIFLU |
| |
|
§
MISCELLANEOUS |
| clindamycian |
|
| metronidazole |
|
| nitrofurantoin |
|
| sulfamethoxazole-trimethoprim |
|
| |
|
§
ACE INHIBITORS |
| fosinopril |
|
| lisinopril |
|
| quinapril |
|
| ramipril |
|
| |
|
§
ACE INHIBITOR / CALCIUM
CHANNEL BLOCKERS |
| trandolapril-verapamil
ext-rel |
|
| |
|
§
ACE INHIBITOR / DIURETIC
COMBINATIONS |
| fosinopril-hydrochlorothiazide |
|
| lisinopril-hydrochlorothiazide |
|
| quinapril-hydrochlorothiazide |
|
| |
|
ANGIOTENSIN II RECEPTOR
ANTAGONISTS / DIURETIC COMBINATIONS |
| losartan /
losartan-hydrochlorothiazide |
BENICAR / BENICAR HCT |
| |
DIOVAN / DIOVAN
HCT |
| |
MICARDIS /
MICARDIS HCT |
| |
|
ANGIOTENSIN II RECEPTOR
ANTAGONISTS / DIRECT RENIN INHIBITOR COMBINATIONS |
| |
VALTURNA |
| |
|
ANTILIPEMICS |
|
§
Bile Acid
Resins |
| cholesyramine |
WELCHOL |
|
Cholesterol
Absorption Inhibitors |
| |
ZETIA |
|
§
Fibrates |
| fenofibrate |
TRICOR |
| |
TRILIPIX |
|
§
HMG-CoA
Reductase Inhibitors |
| pravastatin |
CRESTOR |
| simvistatin |
LIPITOR |
|
Niacins /
Combinations |
| |
NIASPAN |
| |
SIMCOR |
| |
|
§
BETA BLOCKERS |
| atenolol |
BYSTOLIC |
| carvedilol |
COREG CR |
| metoprolol |
|
| metoprolol succinate ext-rel |
|
| nadolol |
|
| propanolol |
|
| |
|
§
CALCIUM CHANNEL BLOCKERS |
| amlodipine |
|
| diltiazem ext-rel |
|
| nifedipine ext-rel |
|
| verapamil ext-rel |
|
| |
|
CALCIUM CHANNEL BLOCKER /
ANTILIPEMIC COMBINATIONS |
| |
CADUET |
| |
|
§
DIGITALIS GLYCOSIDES |
| digoxin |
|
| |
| DIRECT
RENIN INHIBITORS / DIURETIC COMBINATIONS |
| |
TEKTURNA /
TEKTURNA HCT |
| |
| DIRECT
RENIN INHIBITORS / CALCIUM CHANNEL BLOCKER
COMBINATIONS |
| |
TEKAMLO |
| |
|
§
DIURETICS |
| furosemide |
|
| hydrochlorothiazide |
|
| metolazone |
|
| spironolcatone-hydrochlorothiazide |
|
| torsemide |
|
| triamterene-hydrochlorothiazide |
|
| |
|
ANTIDEPRESSANTS |
|
§
Selective
Serotonin Reuptake Inhibitors (SSRIs)2 |
| citalopram |
LEXAPRO |
| fluoxetine |
|
| paroxetine |
|
| paroxetine ext-rel |
|
| sertraline |
|
|
§
Serotonin
Norepinephrine Reuptake Inhibitors (SNRIs)2 |
| venlafaxine |
CYMBALTA |
| venlafaxine ext-rel |
PRISTIQ |
| |
|
§
Miscellaneous Agents |
| bupropion |
|
| bupropion ext-rel |
|
| mirtazapine |
|
| |
|
§
HYPNOTICS,
NONBENZODIAZEPINES |
| zolpidem |
|
| zolpidem ext-rel |
|
| |
|
MIGRAINE |
|
§
Selective
Serotonin Agonists |
| naratriptan |
MAXALT |
| sumatriptan |
ZOMIG |
Selective Serotonin Agonist / Nonsteroidal
Anti-Inflammatory Drug (NSAID) Combinations |
| |
TRIXIMET |
| |
|
ANDROGENS |
| |
ANDRODERM |
| |
ANDROGEL |
| |
|
ANTIDIABETICS |
|
§
Biguanides / Sulfonylurea Combinations |
| glypizide-metformin |
|
|
Dipeptidyl
Peptidase-4 (DPP-4) Inhibitors |
| |
JANUVIA |
| |
ONGLYZA |
|
Dipeptidyl
Peptidase-4 (DPP-4) Inhibitor / Biguanide Combinations |
| |
JANUMET |
| |
KOMBIGLYZE XR |
|
Incretin
Mimetic Agents |
| |
BYETTA |
| |
VICTOZA |
|
Insulins |
| |
APIDRA |
| |
HUMALOG |
| |
HUMULIN |
| |
LANTUS |
| |
LEVEMIR |
| |
NOVOLIN |
| |
NOVOLOG |
|
Insulin
Sensitizers |
| |
ACTOS |
|
Insulin
Sensitizer / Biguanide Combinations |
| |
ACTOPLUS MET |
|
Insulin
Sensitizer / Sulfonylurea Combinations |
| |
DUETACT |
|
§
Meglitinides |
| |
PRANDIN |
|
§
Sulfonylureas |
| glimepiride |
|
| glipizide |
|
| glipizide ext-rel |
|
|
§
Sulfonylurea / Biguanide Combinations |
| glipizide-metformin |
|
|
Supplies |
| |
ACCU-CHEK STRIPS AND KITS |
| |
BD INSULIN SYRINGES AND
NEEDLES |
| |
ONETOUCH STRIPS AND KITS |
| |
|
CALCIUM REGULATORS |
|
§
Bisphosphonates |
| alendronate |
ACTONEL |
| |
BONIVA |
|
§
Calcitonins |
| calcitonin-salmon |
|
|
Parathyroid
Hormones |
| |
FORTEO |
| |
|
CONTRACEPTIVES |
|
§
Monophasic |
| ethinyl
estradiol-drospirenone |
BEYAZ |
| |
LO LOESTRIN FE |
| |
LOESTRIN 24 FE |
|
§
Triphasic |
| ethinyl
estradiol-norgestimate |
ORTHO TRI-CYCLEN LO |
| Four
Phase |
| |
NATAZIA |
|
§
Extended
Cycle |
| ethinyl
estradiol-levonorgestrel |
LOSEASONIQUE |
| |
SEASONIQUE
|
|
Transdermal |
| |
ORTHO EVRA
|
|
Vaginal |
| |
NUVARING |
| |
|
ESTROGENS |
|
§
Oral |
| estradiol |
ENJUVIA |
| estropipate |
PREMARIN |
|
§
Transdermal |
| estradiol |
ESTRADERM |
| |
EVAMIST |
| |
VIVELLE-DOT |
|
§
Estrogen / Progestins, Oral |
| estradiol-norethindrone |
PREMPHASE |
| |
PREMPRO |
| |
|
§
Progestins,
Oral |
| medroxyprogesterone |
PROMETRIUM |
| |
|
SELECTIVE ESTROGEN
RECEPTOR MODULATORS |
| |
EVISTA |
| |
|
§
THYROID SUPPLEMENTS |
| levothyroxine |
SYNTHROID |
| |
|
§
H2 RECEPTOR ANTAGONISTS |
| ranitidine |
|
| |
|
§
PROTON PUMP INHIBITORS |
| lansoprazole |
DEXILANT |
| omeprazole |
NEXIUM |
| pantoprazole |
|
| |
|
§
BENIGN PROSTATIC
HYPERPLASIA |
| doxazosin |
AVODART |
| finasteride |
RAPFLO |
| tamsulosin |
|
| terazosin |
|
| |
|
§
URINARY ANTISPASMODICS |
| oxybutynin |
DETROL |
| oxybutynin ext-rel |
DETROL LA |
| trospium |
ENABLEX |
| |
GELNIQUE |
| |
OXYTROL |
| |
SANCTURA XR |
| |
VESICARE |
| |
|
§
ANTICOAGULANTS |
| warfarin |
COUMADIN |
| |
PRADAXA |
| |
|
ANAPHYLAXIS TREATMENT
AGENTS |
| |
EPIPEN |
| |
EPIPEN JR |
| |
|
§
ANTICHOLINERGICS |
| |
SPIRIVA |
| |
|
§
ANTICHOLINERGIC / BETA
AGONIST COMBINATIONS |
| ipratropium-albuterol
inhalation solution |
COMBIVENT |
| |
|
§
ANTIHISTAMINES,
NONSEDATING |
| fexofenadine |
|
| |
|
BETA AGONISTS
INHALANTS |
|
§
Short Acting |
| albuterol |
PROAIR HFA |
| |
PROVENTIL HFA |
| |
VENTOLIN HFA |
|
Long Acting |
| |
FORADIL |
| |
SEREVENT |
| |
|
LEUKOTRIENE RECEPTOR
ANTAGONISTS |
| |
SINGULAIR |
| |
|
NASAL ANTIHISTAMINES |
| azelastine |
ASTEPRO |
| |
|
§
NASAL STEROIDS |
| fluticasone |
NASACORT AQ |
| |
NASONEX |
| |
VERAMYST |
| |
|
STEROID / BETA
AGONIST COMBINATIONS |
| |
ADVAIR |
| |
DULERA |
| |
SYMBICORT |
| |
|
STEROID INHALANTS |
| budesonide
inhalation suspension |
ASMANEX |
| |
FLOVENT |
| |
PULMICORT
FLEXHALER |
| |
QVAR |
| |
|
DERMATOLOGY |
|
§
Acne |
| adapalene |
ACANYA |
| clindamycin solution |
DIFFERIN |
| clindamycin-benzoyl
peroxide |
DUAC CS |
| erythromycin solution |
EPIDUO |
| erythromycin-benzoyl peroxide |
RETIN-A MICRO |
| tretinoin |
|
| |
|
OPHTHALMIC |
|
§
Beta-Blockers, Nonselective |
| timolol maleate solution |
BETIMOL |
|
Beta-Blockers, Selective |
| |
BETOPTIC S |
|
Prostaglandins |
| |
LUMIGAN |
| |
TRAVATAN Z |
| |
XALATAN |
|
§
Sympathomimetics |
| brimonidine 0.2% |
ALPHAGAN P |
NWPS PREFERRED DRUG
LIST -
ALPHABETICAL
| A |
F
|
P
|
|
ACANYA |
fenofibrate |
pantoprazole |
| ACCU-CHEK STRIPS & KITS |
fexofenadine |
paroxetine |
| ACTONEL |
finasteride |
paroxetine ext-reI |
| ACTOPLUS MET |
FLOVENT
|
penicillin VK |
| ACTOS |
fluconazole |
PRADAXA
|
|
acyclovir |
fluoxetine |
PRANDIN
|
| adapalene |
fluticasone |
pravastatin |
| ADVAIR |
FORADIL
|
PREMARIN
|
|
albuterol |
FORTEO
|
PREMPHASE
|
|
alendronate |
fosinopril |
PREMPRO
|
| ALPHAGAN P
|
fosinopril-hydrochlorothiazide |
PRESTIQ
|
|
amantadine |
furosemide |
PROAIR HFA
|
|
amlodipine |
|
PROMETRIUM
|
|
amoxlcillin |
G
|
propranolol |
|
amoxicillin-clavulanate |
GELNIQUE |
PROVENTIL HFA
|
| ANDRODERM
|
glimepiride |
PULMICORT
FLEXHALER
|
| ANDROGEL
|
glipizide |
|
| APIDRA |
glipizide ext-reI |
Q
|
| ASMANEX |
glipizide-metformin |
quinapril |
| ASTELIN |
|
quinapril-hydrochlorothiazide |
| ASTEPRO |
H
|
QVAR |
| atenolol |
HUMALOG
|
|
| AVELOX
|
HUMULIN
|
R
|
| AVODART |
hydrochlorothiazide |
ramipril |
| azestaline |
|
ranitidine |
| azithromycin |
I
|
RAPAFLO |
|
|
ipratropium-albuterol inhalation solution |
RELENZA |
| B
|
itraconazole |
RETlN-A MICRO
|
|
BD INSULIN SYRINGES/NEEDLES |
|
rimantadine
|
| BENICAR
|
J
|
|
| BENICAR HCT
|
JANUMET |
S |
| BENZACLIN |
JANUVIA |
SANCTURA XR
|
| BETIMOL |
|
SEASONIQUE
|
| BETOPTIC S |
K
|
SEREVENT
|
|
BEYAZ |
KOMBIGLYZE
XR |
sertraline |
|
BONIVA |
|
SIMCOR
|
|
brimonidine 0.2% |
L
|
simvastatin |
|
budesonide inhalation solution |
lansoprazole
|
SINGULAIR
|
|
bupropion |
LANTUS
|
SPIRIVA
|
|
bupropion ext-rel |
LEVAQUIN
|
spironolactone-hydrochlorothiazide |
| BYETTA
|
LEVEMIR
|
sulfamethoxazole-trimethoprim |
| BYSTOLIC
|
levothyroxine |
sumatriptan |
|
|
LEXAPRO
|
SUPRAX |
| C
|
LIPITOR
|
SYMBICORT
|
| CADUET
|
Iisinopril |
SYNTHROID
|
|
calcitonin-salmon |
lisinopril-hydrochlorothiazide |
|
|
carvedilol
|
LO
LOESTRIN FE
|
T
|
|
cefaclor |
LOESTRIN 24 FE |
TAMIFLU
|
|
cefdlnir |
losartan |
tamsulosin
|
|
cephalexin
|
losartan-hydrochlorothiazide |
TEKAMLO |
|
cholestyramine |
LOSEASONIQUE
|
TEKTURNA |
| CIPRO
SUSPENSION |
LUMIGAN
|
TEKTURNA HCT |
|
ciprofloxacin
ext-reI |
|
terazosin |
|
ciprofloxacin
tablet |
M
|
terbinafine tablet |
|
citolopram
|
MAXALT
|
tetracycline |
|
clarithromycin
|
medroxyprogesterone |
timolol maleate solution |
| clarithromycin ext-reI
|
metformin |
torsemide |
|
clindamycin solution |
metformin ext-rel |
trandolapril-verapamil
ext-rel
|
|
clindamycin-benzoyl peroxide |
metolazone |
TRAVATAN
Z
|
| COMBIVENT
|
meroprolol |
tretinoin |
| COREG CR
|
metoprolol succinate ext-rel |
TREXIMET |
| COUMADIN
|
metronidazole |
triamterene-hydrochlorothiazide |
| CRESTOR
|
MICARDIS
|
TRICOR
|
| CYMBALTA
|
MICARDIS HCT
|
TRILIPIX
|
|
|
minocycline |
trospium |
| D
|
mirtazapine |
|
| DETROL
|
|
V
|
| DETROL LA
|
N
|
valacyclovir |
| DEXILANT
|
nadolol |
VALTURNA |
|
dicloxacillin
|
naratriptan |
VELTIN |
| DIFFERIN
|
NASACORT
AQ
|
venlafaxine |
|
digoxin |
NASONEX
|
venlafaxine ext-rel |
|
diltiazem
ext-reI |
NATAZIA
|
VENTOLIN HFA |
|
DIOVAN |
NEXIUM
|
VERAMYST
|
|
DIOVAN HCT |
NIASPAN
|
verapamil ext-reI |
|
doxazosin |
nifedipine ext-reI |
VESICARE
|
|
doxycycline
hyclate |
nitro furantoin |
VICTOZA
|
| DUAC CS
|
NOVOLIN
|
VIVELLE-DOT
|
| DUETACT
|
NOVOLOG
|
|
|
DULERA
|
NUVARING
|
W
|
|
|
|
warfarin |
| E
|
O |
WELCHOL
|
| ENABLEX
|
omeprazole |
|
| ENJUVIA
|
ONETOUCH STRIPS
& KITS |
X
|
|
EPIDUO
|
ONGLYZA |
XALATAN
|
| EPIPEN JR
|
ORTHO EVRA |
|
| EPIPEN JR
|
ORTHO
TRI-CYCLEN LO |
Y
|
|
erythromycin solution |
oxybutynin |
YAZ |
|
erythromycin-benzoyl peroxide |
oxybutynin ext-reI |
|
|
erythromycins |
OXYTROL
|
Z
|
| ESTRADERM |
|
ZETIA
|
|
estradiol |
|
zolpidem |
|
estradiol-norethindrone |
|
zolpidem ext-rel |
|
estropipate |
|
ZOMIG
|
|
ethinyl estradiol-drospirenone |
|
|
|
ethinyl
estradiol-levonorgestrel |
|
|
|
ethinyl
estradiol-norgestimate |
|
|
| EVAMIST
|
|
|
| EVISTA
|
|
|
NWPS PREFERRED ALTERNATIVES
LIST
| DRUG NAME
|
PREFERRED ALTERNATIVES * |
| ACIPHEX |
lansoprazole,
omeprazole, pantoprozole |
| ADVICOR |
SIMCOR |
| AEROBID, AEROBID M |
ASMANEX,
FLOVENT, PULMICORT FLEXHALER, QVAR |
|
ALLEGRA-D |
fenofexadine-pseudoepherine |
| ALORA |
estradiol, ESTRADERM,
EVAMIST, VIVELLE-DOT |
| ALTOPREV |
pravastatin,
simvastatin |
| ALVESCO |
ASMANEX, FLOVENT,
PULMICORT FLEXHALER, QVAR |
| ANGELIQ |
estradiol-norethindrone, PREMPHASE, PREMPRO |
| ARMOUR THYROID |
levothyroxine, SYNTHROID |
| ASCENSIA
STRIPS & KITS |
ACCU-CHEK STRIPS AND KITS, ONETOUCH STRIPS AND KITS |
| ATACAND,
ATACAND HCT |
losartan,
losartan-hydrochlorothiazide |
| ATELVIA |
alendronate
70 mg |
| ATROVENT HFA |
SPIRIVA |
| AVAPRO,
AVALIDE |
losartan,
losartan-hydrochlorothiazide |
| AXERT |
naratriptan,
sumatriptan, MAXALT, ZOMIG |
| AZELEX |
erythromycin
solution |
| BECONASE AQ |
fluticasone |
| BENZAC AC, BENZAC W |
adapalene,
clindamycin solution, clindamycin-benzoyl
peroxide, erythromycin solution, erythromycin-benzoyl
peroxide, tretinoin, ACANYA, DIFFERIN, DUAC CS, EPIDUO, RETIN-A
MICRO, VELTIN |
| BENZAGEL |
adapalene,
clindamycin solution, clindamycin-benzoyl
peroxide, erythromycin solution, erythromycin-benzoyl
peroxide, tretinoin, ACANYA, DIFFERIN, DUAC CS, EPIDUO, RETIN-A
MICRO, VELTIN |
| BENZIQ |
adapalene,
clindamycin solution, clindamycin-benzoyl
peroxide, erythromycin solution, erythromycin-benzoyl
peroxide, tretinoin, ACANYA, DIFFERIN, DUAC CS, EPIDUO, RETIN-A
MICRO, VELTIN |
| BREVOXYL |
adapalene,
clindamycin solution, clindamycin-benzoyl
peroxide, erythromycin solution, erythromycin-benzoyl
peroxide, tretinoin, ACANYA, DIFFERIN, DUAC CS, EPIDUO, RETIN-A
MICRO, VELTIN |
| CARDURA XL |
doxazosin,
tamsulosin, terazosin, RAPAFLO |
| CENESTIN |
estradiol, estropipate, ENJUVIA, PREMARIN |
| CLARINEX |
fexofenadine |
| CLARINEX D |
fexofenadine-pseudoephedrine |
| CLINDAGEL |
erythromycin
solution |
| DESQUAM E, DESQUAM X |
adapalene,
clindamycin solution, clindamycin-benzoyl
peroxide, erythromycin solution, erythromycin-benzoyl
peroxide, tretinoin, ACANYA, DIFFERIN, DUAC CS, EPIDUO, RETIN-A
MICRO, VELTIN |
| DORAL |
zolpidem,
zolpidem ext-rel |
| DYNACIRC CR |
amlodipine, nifedipine ext-rel |
|
EDLUAR |
zolpidem |
| ESTRASORB |
estradiol, ESTRADERM,
EVAMIST, VIVELLE-DOT |
| ESTROGEL |
estradiol, ESTRADERM,
EVAMIST, VIVELLE-DOT |
| FEMHRT |
estradiol-norethindrone, PREMPHASE, PREMPRO |
| FEMTRACE |
estradiol, estropipate, ENJUVIA, PREMARIN |
| FENOGLIDE |
fenofibrate, TRICOR,
TRILIPIX |
| FIRST TESTOSTERONE |
ANDRODERM, ANDROGEL |
| FORTAMET |
metformin ext-rel |
| FOSAMAX PLUS D |
alendronate |
| FREESTYLE
STRIPS & KITS |
ACCU-CHEK STRIPS AND KITS, ONETOUCH STRIPS AND KITS |
| FROVA |
sumatripan |
| GLUMETZA |
metformin
ext-rel |
| INNOPRAN
XL |
atenolol,
propanolol ext-rel |
| ISTALOL |
timolol maleate solution, BETIMOL |
| LUNESTA |
zolpidem |
| MAXAIR |
PROAIR
HFA, PROVENTIL HFA, VENTOLIN HFA |
| MENEST |
estradiol, estropipate, ENJUVIA, PREMARIN |
| MENOSTAR |
estradiol,
ESTRADERM, EVAMIST, VIVELLE-DOT |
| OMNARIS |
fluticasone |
| PATANASE |
azelastine, ASTEPRO |
| PEXEVA |
citalopram, fluoxetine, paroxetine, paroxetine ext-rel,
sertraline, LEXAPRO |
| PRECISION XTRA
STRIPS & KITS |
ACCU-CHEK STRIPS AND KITS, ONETOUCH STRIPS AND KITS |
| PREFEST |
estradiol-norethindrone, PREMPHASE, PREMPRO |
| RELION INSULIN |
HUMULIN INSULIN, NOVOLIN INSULIN |
| RELPAX |
naratriptan,
sumatriptan, MAXALT, ZOMIG |
| RHINOCORT
AQUA |
fluticasone |
| SKELID |
alendronate, ACTONEL |
| STRIANT |
ANDRODERM, ANDROGEL |
| SURE-TEST
STRIPS & KITS |
ACCU-CHEK STRIPS AND KITS, ONETOUCH STRIPS AND KITS |
| TESTIM |
ANDROGEL |
| TEVETEN, TEVETEN HCT |
losartan,
losartan-hydrochlorothiazide |
| TOVIAZ |
oxybutin
ext-rel |
| TRIAZ |
adapalene,
clindamycin solution, clindamycin-benzoyl
peroxide, erythromycin solution, erythromycin-benzoyl
peroxide, tretinoin, ACANYA, DIFFERIN, DUAC CS, EPIDUO, RETIN-A
MICRO, VELTIN |
| TRIGLIDE |
fenofibrate, TRICOR,
TRILIPIX |
| TRUE CARE, TRUETEST, TRUETRACK
STRIPS & KITS |
ACCU-CHEK STRIPS AND KITS, ONETOUCH STRIPS AND KITS |
| TWINJECT |
EPIPEN, EPIPEN JR |
| UROXATRAL |
doxazosin,
tamsulosin, terazosin, RAPALFO |
| VANOS |
clobetasol |
| XOPENEX
HFA |
PROAIR
HFA, PROVENTIL HFA, VENTOLIN HFA |
| ZODERM |
adapalene,
clindamycin solution, clindamycin-benzoyl
peroxide, erythromycin solution, erythromycin-benzoyl
peroxide, tretinoin, ACANYA, DIFFERIN, DUAC CS, EPIDUO, RETIN-A
MICRO, VELTIN |
| ZYFLO, ZYFLO CR |
SINGULAIR |
* The preferred alternative
products in this list are a broad representation within therapeutic
categories of available treatment options and do not necessarily
represent clinical equivalency. Your specific prescription benefit
plan design may not cover certain products, regardless of their
appearance in this document.
FOR YOUR
INFORMATION: Generics should be considered the first
line of prescribing. This drug list represents a summary of
prescription coverage - It is not inclusive and does not
guarantee coverage. Specific prescription benefit plan design
may not cover certain categories, regardless of their appearance
in this document. The plan participant's prescription benefit
plan may have a different copay for specific products on the
list. Unless specifically indicated, drug list products will in
dude all dosage forms. This list represents brand products in
CAPS, branded generics in upper- and lowercase Italics, and
generic products in lowercase italics. Generics listed in
therapeutic categories are for representational purposes only.
This is not an all-inclusive list. Listed products may be
available generically in certain strengths or dosage forms.
Dosage forms on this list will be consistent with the category
and use where listed.
§
Generics
are available in this class and should be considered the first line of
prescribing.
1
Copayment, copay or coinsurance means the amount a plan participant is
required to pay for a prescription in accordance with a Plan, which may
be a deductible, a percentage of the prescription price, a fixed amount
or other charge, with the balance, if any, paid by a Plan.
2
Indicates the proposed mechanism of action, based on the American
Psychiatric Association Summary of Treatment Recommendations.
3
Higher copays may apply depending on the plan participant's specific
prescription benefit plan.
This drug list contains references to brand-name
prescription drugs that are trademarks or registered trademarks of
pharmaceutical manufacturers. Listed products are for informational
purposes only and are not intended to replace the clinical Judgment of
the prescriber.
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