Preferred Drug List Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 1 ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS amphetamine salt combo er armodafinil atomoxetine hcl benzphetamine hcl caffeine citrated caffeine/sodium benzoate [INJ] clonidine hcl er dexmethylphenidate er dexmethylphenidate hcl dexmethylphenidate hcl er dextroamphetamine sulfate dextroamphetamine sulfate er diethylpropion hcl guanfacine er methamphetamine hcl methylphenidate cd methylphenidate er methylphenidate hcl methylphenidate hcl er (cd) methylphenidate la modafinil phendimetrazine tartrate phendimetrazine tartrate er phentermine hcl VYVANSE AMINOGLYCOSIDES AMIKACIN [INJ] gentamicin sulfate gentamicin sulfate [INJ] gentamicin sulfate in ns KITABIS PAK neomycin sulfate paromomycin sulfate tobramycin sulfate [INJ] tobramycin sulfate in ns ANALGESICS - ANTI-INFLAMMATORY celecoxib diclofenac potassium diclofenac sodium diclofenac sodium/misoprostol del rel ENBREL [INJ] etodolac etodolac er fenoprofen calcium flurbiprofen HUMIRA [INJ] ibuprofen ibuprofen lysine indomethacin indomethacin er ketoprofen er ketorolac tromethamine leflunomide meclofenamate sodium mefenamic acid meloxicam nabumetone naproxen naproxen sodium OTEZLA oxaprozin piroxicam RINVOQ sulindac tolmetin sodium XELJANZ XELJANZ XR ANALGESICS - NonNarcotic acetaminophen-diphenhydramine butalbital compound butalbital/apap/caffeine butalbital/aspirin/caffeine choline mag trisalicylate clonidine [INJ] diflunisal SALICYLAMIDE salsalate ANALGESICS - OPIOID acetaminophen/codeine alfentanil hcl [INJ]
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Preferred Drug List
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 1
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
amphetamine salt combo er armodafinil atomoxetine hcl benzphetamine hcl caffeine citrated caffeine/sodium benzoate [INJ] clonidine hcl er dexmethylphenidate er dexmethylphenidate hcl dexmethylphenidate hcl er dextroamphetamine sulfate dextroamphetamine sulfate er diethylpropion hcl guanfacine er methamphetamine hcl methylphenidate cd methylphenidate er methylphenidate hcl methylphenidate hcl er (cd) methylphenidate la modafinil phendimetrazine tartrate phendimetrazine tartrate er phentermine hcl VYVANSE
AMINOGLYCOSIDES AMIKACIN [INJ] gentamicin sulfate gentamicin sulfate [INJ] gentamicin sulfate in ns KITABIS PAK neomycin sulfate paromomycin sulfate tobramycin sulfate [INJ] tobramycin sulfate in ns
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 2
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 3
nitroglycerin nitroglycerin er nitroglycerin spray nitroglycerin tablets ranolazine er
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 4
warfarin sodium XARELTO
ANTICONVULSANTS carbamazepine carbamazepine er clobazam clonazepam clonazepam odt diazepam rectal gel divalproex sodium divalproex sodium er ethosuximide felbamate fosphenytoin sodium gabapentin lamotrigine lamotrigine er levetiracetam levetiracetam er oxcarbazepine phenytoin phenytoin sodium pregabalin primidone rufinamide ROWEEPRA ROWEEPRA XR tiagabine hcl topiramate topiramate er valproate sodium valproic acid VALPROIC ACID vigabatrin zonisamide
bupropion hcl xl er bupropion sr citalopram hbr clomipramine hcl desipramine hcl desvenlafaxine succinate er doxepin hcl duloxetine escitalopram oxalate FETZIMA fluoxetine fluvoxamine maleate er imipramine hcl imipramine pamoate mirtazapine mirtazapine disintegrating nortriptyline hcl paroxetine hcl paroxetine hcl er phenelzine sulfate tranylcypromine sulfate trazodone hcl trimipramine maleate venlafaxine hcl venlafaxine hcl er
ANTIDIABETICS acarbose BAQSIMI FARXIGA FIASP FIASP FLEXTOUCH glimepiride glipizide glipizide er glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON glyburide glyburide micronized glyburide/metformin HUMULIN R 500 UNITS [INJ] [OTC] HUMULIN R U-500 KWIKPEN
Preferred Drug List
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 5
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 6
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 7
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 8
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 9
CALCIUM CHANNEL BLOCKERS amlodipine besylate diltiazem [INJ] diltiazem 24hr cd diltiazem er diltiazem er 24 hour diltiazem hcl felodipine er isradipine nicardipine hcl nimodipine verapamil er
Preferred Drug List
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 10
verapamil er pm verapamil hcl [INJ]
CARDIOTONICS digoxin milrinone in 5% dextrose milrinone lactate [INJ]
CONTRACEPTIVES altavera alyacen amethia amethia lo amethyst apri aranelle aubra [INJ] aviane azurette balziva briellyn camrese camrese lo caziant chateal cryselle cyclafem dasetta daysee drospirenone/eth estra/levomef elinest eluryng ring emoquette enpresse enskyce errin estarylla etonogestrel-ethinyl estradiol ring falmina gianvi gildagia gildess gildess fe heather introvale jencycla jolessa jolivette junel
Preferred Drug List
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 11
junel fe kariva kelnor 1-35 kurvelo leena lessina levonorgestrel levora LO LOESTRIN FE loryna low-ogestrel lutera lyza marlissa microgestin microgestin fe MINASTRIN 24 FE mono-linyah mononessa myzilra NATAZIA necon nora-be norethin-eth estra ferrous fum norethindrone/eth estradiol/iron norethindrone/ethinyl estradiol nortrel ocella ogestrel orsythia philith pirmella portia quasense reclipsen sprintec sronyx syeda tilia fe tri-estarylla tri-legest fe tri-linyah trinessa
trivora velivet viorele wera wymzya fe zarah zenchent zenchent fe zeosa zovia
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 12
phenylephrine/chlorpheniramine 10peh-4cpm promethazine vc/codeine promethazine w/codeine promethazine/dextromethorphan pseudoephedrine hcl er
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 13
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 14
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 15
HEMATOPOIETIC AGENTS centratex DROXIA EPOGEN fabb ferocon ferraplus 90 ferrocite plus ferrogels forte folbee folic acid folplex 2.2 hematinic plus hematinic with folic acid hematogen hematogen fa hematogen forte hemetab hydroxocobalamin iferex 150 forte miglustat multigen multigen folic multigen plus NEULASTA [INJ] NEUPOGEN [INJ]
poly-iron 150 forte polysaccharide iron forte PROCRIT [INJ] se-tan plus taron forte therapeutic hematinic tl gard rx tl icon tl-hem 150 er 24 hr tricon trigels-f forte ZARXIO [INJ]
HEMOSTATICS tranexamic acid
Hepatitis C Agent - Combinations EPCLUSA HARVONI MAVYRET VOSEVI
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 16
MACROLIDES azithromycin [INJ] clarithromycin clarithromycin er erythromycin erythromycin del rel erythromycin ethylsuccinate erythromycin stearate erythromycin/sulfisoxazole
MEDICAL DEVICES ACCU-CHEK SOFTCLIX LANCETS DEVICE [OTC] FORA LANCING DEVICE FREESTYLE CONTROL SOLUTION FREESTYLE FREEDOM KIT [OTC] FREESTYLE FREEDOM LITE FREESTYLE FREEDOM LITE METER [OTC] FREESTYLE INSULINX FREESTYLE INSULINX GLUCOSE SYSTEM [OTC] FREESTYLE INSULINX TEST STRIPS [OTC] FREESTYLE LITE METER [OTC] FREESTYLE LITE TEST STRIPS [OTC] FREESTYLE TEST STRIPS [OTC] MINIMED MINIMED RESERVOIR NOVOFINE NOVOFINE AUTOCOVER ONE TOUCH ULTRA 2 ONE TOUCH ULTRA TEST STRIPS ONE TOUCH VERIO ONE TOUCH VERIO FLEX ONE TOUCH VERIO IQ ONE TOUCH VERIO SYNC PRECISION XTRA B-KETONE STRIPS [OTC]
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 17
MULTIVITAMINS advanced am/pm b-complex bal-care dha complete natal dha corvita dailyvite elite ob elite-ob folbee plus folcaps folivane-ob folivane-plus folivane-prx dha nf hemenatal ob hemenatal ob + dha inatal advance inatal ultra LEVOMEFOLATE DHA
m.v.i. adult [INJ] M.V.I.-12 [INJ] macnatal cn dha multivitamin w/fluoride & iron multivitamin with fluoride mynatal mynatal advance mynatal caps mynatal plus mynatal-z mynate 90 plus er mynephrocaps obstetrix dha pnv ob+dha pnv-dha pnv-omega pnv-select pnv-total pr natal 400 pr natal 400 ec pr natal 430 pr natal 430 ec prena1 prena1 chew prenaissance prenaissance 90 dha prenaissance dha prenaissance harmony dha prenaissance next prenaissance plus prenaplus prenatabs fa prenatabs rx prenatal low iron prenatal plus prenatal-u relnate dha rena-vite rx renal caps reno caps se-natal 19 strovite taron-bc
Preferred Drug List
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 18
taron-c dha tl g-fol os tl-care dha tl-fol 500 er tl-select triadvance trinatal gt trinatal rx 1 trinate triphrocaps triveen-duo dha triveen-prx rnf ultimatecare one ultimatecare one nf v-c forte vemavite-prx 2 vena-bal dha venatal-fa vinacal vinate dha vinate ic vinate ii vinate one vinate-m virt-pn virt-pn dha virt-pn plus virt-select vol-care rx vol-nate vol-plus vol-tab rx vp-ch plus vp-ch-pnv vp-heme one vp-zel zatean-ch zatean-pn dha zatean-pn plus
Neprilysin Inhib (ARNI)-Angiotensin II Recept Antag Comb
ENTRESTO
NEUROMUSCULAR AGENTS anectine [INJ] riluzole
NUTRIENTS dextrose in water intralipid
OPHTHALMIC AGENTS ALPHAGAN P 0.001% apraclonidine ophth solution atropine sulfate azelastine hcl ophth solution bacitracin/polymyxin ophth oint balanced salt ophth irrigation BESIVANCE betaxolol ophth solution BETOPTIC S
Preferred Drug List
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 19
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 20
REPATHA SYRINGE
PENICILLINS
amoxicillin amoxicillin/clavulanate er ampicillin [INJ] ampicillin/sulbactam [INJ] dicloxacillin sodium nafcillin dextrose [INJ] nafcillin sodium [INJ] oxacillin sodium [INJ] penicillin g potassium [INJ] penicillin g procaine penicillin g sodium [INJ] penicillin v potassium piperacillin-tazobactam [INJ]
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 21
Key: [INJ], [inj] – Injectable Drug [OTC] – Over the Counter Drug Updated June 01, 2021 [SP], [sp] – Specialty Drug This list is subject to change at any time and ER, er – Extended Release coverage is based on your specific benefit plan Brand name drugs are listed in CAPITAL letters; Example: HUMIRA Brand medications not listed are non-preferred Generic drugs are listed in lower case letters; Example: azithromycin Page 22
vitamin a VITAMIN A VITAMINS, HEMATINICS & ELECTROLYTES