WellDyneRx Formulary Member Guide Please bring this guide with you on your next doctor visit. WellDyneRx manages your prescription drug benefit for your health plan.
WellDyneRx Formulary Member GuidePlease bring this guide with you on your next doctor visit.
WellDyneRx manages your prescription drug benefit for your health plan.
NOTES
WellDyneRx Formulary Member Guide is a formulary list of medications that may be covered under your prescription drugplan.This list was reviewed by an independent group of practicingdoctors and pharmacists, and it contains medications made bymost pharmaceutical manufacturers. It includes medications formany covered conditions.
SAVING MONEY ON PRESCRIPTIONSYour plan may prefer some medications over others. These arecalled preferred drugs.
You may pay:• Lowest co-payment/co-insurance for generic drugs• Higher co-payment/co-insurance for preferred brand-name
drugs• Highest co-payment/co-insurance for nonpreferred
brand-name drugs
Your doctor may be able to help you save money by prescribinggeneric and preferred brand-name drugs if appropriate. So be sureto bring this guide with you on every visit to your doctor. Somecommonly prescribed nonpreferred drugs are also listed in thisguide for your reference.
Please note: This guide does not contain a complete list of preferred and nonpreferred drugs. It only lists the most commonly prescribed drugs.
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FINDING MEDICATIONS WITH LOWERCO-PAYMENTS/CO-INSURANCEThis guide lists medications two ways to help you find somegeneric, preferred, and nonpreferred brand-name drugs.
SECTION I - ALPHABETICALLY BY DRUG CATEGORY (SUCH AS RESPIRATORY)Within each category, medications are listed in alphabetical order, with generic, preferred brand-name, and nonpreferredbrand-name drugs sorted separately:
G Means a preferred generic medicationP Means a preferred brand-name medicationNP Means a nonpreferred brand-name medication
SECTION II - ALPHABETICALLY BY BRAND NAMEAfter each nonpreferred brand-name drug, you will find possible generic and preferred brand-name alternatives.
SAFETY CONSIDERATION SYMBOLSHere is a quick guide for you and your doctor, which explains our safety symbols. These symbols appear next to certain medications.
Means weigh risk of birth defects or other adverse outcomes.
Means do not use in pregnancy.
The information in this guide was in effect at the time of printing and maybe subject to change.
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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SECTION I: THERAPEUTIC DRUG CATEGORIES
Oral PenicillinsG amoxicillin trihydrateG amoxicillin trihydrate/
potassium clavulanateG ampicillin trihydrateG dicloxacillin sodiumG penicillin v
potassiumP Augmentin Chewable
Tablet 250 - 62.5mgP Augmentin
Suspension 125 - 31.25mg/5
NP AmoxilNP Augmentin Chewable
Tablet 200 - 28.5mg,400 - 57mg
NP Augmentin ESNP Augmentin
Suspension 200 - 28.5mg/5, 250 - 62.5mg/5,400 - 57mg/5
NP Augmentin TabletNP Augmentin XRNP Moxatag
Oral TetracyclinesG doxycycline hyclateG doxycycline
monohydrateG minocycline HClG tetracycline HCl
P OraceaNP AdoxaNP Adoxa PakNP DoryxNP DynacinNP MinocinNP MonodoxNP PeriostatNP SolodynNP Vibramycin
Oral CephalosporinsG cefaclorG cefadroxil hydrateG cefdinirG cefpodoxime proxetilG cefprozilG cefuroxime axetilG cephalexin
monohydrateNP Ceclor CDNP CedaxNP CeftinNP DuricefNP KeflexNP OmnicefNP SpectracefNP SupraxNP Vantin
ANTI-INFECTIVES (Antibiotics/Antifungals)
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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Oral ErythromycinsG azithromycinG clarithromycinG clarithromycin ERG erythromycin baseG erythromycin
ethylsuccinateG erythromycin
ethylsuccinate/sulfisoxazole acetyl
G erythromycin stearateP DificidNP BiaxinNP Biaxin XLNP EryPedNP PCENP ZithromaxNP Zmax
Oral QuinolonesG ciprofloxacin HClG levofloxacinG ofloxacinP AveloxP Cipro SuspensionNP Cipro TabletNP Cipro XRNP FactiveNP FloxinNP LevaquinNP NoroxinNP Proquin XR
Oral SulfasG erythromycin
ethylsuccinate/sulfisoxazole acetyl
G sulfadiazine
G sulfamethoxazole/trimethoprim
G sulfisoxazoleNP Bactrim DSNP GantrisinNP Septra DS
Oral Urinary TractAgentsG methenamine
hippurateG methenamine
mandelateG nitrofurantoinG nitrofurantoin
macrocrystalG phenazopyridine HClG trimethoprimNP FuradantinNP HiprexNP MacrobidNP MacrodantinNP MonurolNP Primsol
Oral AntifungalAgentsG clotrimazoleG fluconazoleG flucytosineG griseofulvin G griseofulvin
ultramicrosizeG itraconazoleG ketoconazoleG nystatinG terbinafine HClG voriconazole
Hypnotic AgentsG chloral hydrateG estazolamG flurazepam HClG temazepamG triazolamG zaleplonG zolpidem tartrateP LunestaP SilenorNP AmbienNP Ambien CRNP DoralNP EdluarNP HalcionNP IntermezzoNP Restoril NP RozeremNP SonataNP Zolpimist
TricyclicAntidepressantsG amitriptyline HClG amoxapineG clomipramine HClG desipramine HClG doxepin HClG imipramine HClG imipramine
pamoate G nortriptyline HClG protriptyline HClG trimipramine maleateNP AnafranilNP NorpraminNP PamelorNP SurmontilNP TofranilNP Tofranil-PMNP Vivactil
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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P Lamisil Oral GranulesP NoxafilP Sporanox Oral
SolutionNP AncobonNP DiflucanNP Grifulvin VNP Gris-PegNP Lamisil TabletNP MycostatinNP Mycelex Troche NP Nizoral
NP OravigNP Sporanox CapsuleNP Vfend
PSYCHOTHERAPEUTICS (Anxiety/Depression)
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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MiscellaneousAntidepressantsG bupropion HCl G maprotiline HClG mirtazapineG trazodone HClG venlafaxine HClP CymbaltaP PristiqNP DesyrelNP EffexorNP Effexor XRNP Oleptro ERNP RemeronNP WellbutrinNP Wellbutrin SRNP Wellbutrin XL
AntipsychoticsG chlorpromazine HClG clozapineG fluphenazine HClG haloperidolG haloperidol lactate
concentrate, oralG loxapine succinateG olanzapineG perphenazineG quetiapine fumarateG risperidoneG thiothixeneG trifluoperazine HClG ziprasidone HCl
P AbilifyP ClozarilP LatudaP MobanP OrapP Seroquel XRNP FanaptNP GeodonNP InvegaNP RisperdalNP SaphrisNP SeroquelNP SymbyaxNP ZyprexaNP Zyprexa Zydis
AnxiolyticsG alprazolamG alprazolam XRG buspirone HClG chlordiazepoxide
HClG clorazepate
dipotassiumG diazepamG lorazepamG oxazepamNP AtivanNP BusparNP LibriumNP NiravamNP Tranxene T-TabNP ValiumNP XanaxNP Xanax XR
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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MAOIAntidepressantsG phenelzine sulfateG tranylcypromine
sulfateNP EmsamNP NardilNP Parnate
SSRI AntidepressantsG citalopram HBrG escitalopram oxalateG fluoxetine HClG fluvoxamine maleateG paroxetine HClG sertraline HClP ViibrydNP CelexaNP LexaproNP Luvox CRNP PaxilNP Paxil CRNP PexevaNP ProzacNP Prozac WeeklyNP SarafemNP Zoloft
MiscellaneousPsychotherapeuticAgentsG amphetamine
aspartate/amphetamine sulfate/dextroamphetamine
G dextroamphetaminesulfate
G lithium carbonate
G lithium citrateG methamphetamine
HClG methylphenidate HClG modafinilP DaytranaP IntunivP Metadate CDP StratteraP Vyvanse P XyremNP AdderallNP Adderall XRNP ConcertaNP DesoxynNP DexedrineNP FocalinNP Focalin XRNP KapvayNP LiquaddNP LithobidNP Methylin Oral
SolutionNP Methylin Chewable
TabletNP NuvigilNP ProvigilNP RitalinNP Ritalin LANP Ritalin SR
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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Beta BlockersG acebutolol HClG atenololG betaxolol HClG bisoprolol fumarateG carvedilolG labetalol HClG metoprolol succinateG metoprolol tartrateG nadololG pindololG propranolol HClG timolol maleateP BystolicP Coreg CRNP CoregNP CorgardNP InderalNP Inderal LANP Innopran XLNP KerloneNP LevatolNP LopressorNP SectralNP TenorminNP Toprol XLNP TrandateNP Zebeta
Calcium BlockersG diltiazem HClG nimodipineG verapamil HClP Cardizem LA 120mg
NP Calan SRNP CardizemNP Cardizem CDNP Cardizem LA 180mg,
240mg, 300mg,360mg, 420mg
NP Cardizem SRNP Covera-HSNP Dilacor XRNP Isoptin S.R.NP NimotopNP TiazacNP VerelanNP Verelan PM
DihydropyridinesG amlodipine besylateG felodipineG isradipineG nifedipineG nisoldipineNP Adalat CCNP Cardene SRNP DynaCirc CRNP NorvascNP Procardia XLNP Sular
Nitroglycerin PatchesG nitroglycerin patchP Nitro-Dur PatchNP Minitran Patch
CARDIOVASCULAR(Blood Pressure/Heart/Cholesterol)
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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AdrenergicAntagonists &Related DrugsG clonidine HClG doxazosin mesylateG guanfacine HClG methyldopaG prazosin HClG reserpineG terazosin HClNP CarduraNP Cardura XLNP CatapresNP Catapres-TTSNP HytrinNP MinipressNP Nexiclon XRNP Tenex
Angiotensin IIBlockers & ReninInhibitorsG eprosartan
mesylateG irbesartanG irbesartan/
hydrochlorothiazideG losartan potassiumG losartan/
hydrochlorothiazideG valsartan/
hydrochlorothiazideP AmturnideP AtacandP Atacand HCTP BenicarP Benicar HCTP DiovanP MicardisP Micardis HCT
P TekamloP TekturnaP Tekturna HCTP ValturnaNP AvalideNP AvaproNP CozaarNP Diovan HCTNP EdarbiNP EdarbyclorNP HyzaarNP TevetenNP Teveten HCT
AntilipidemicsG atorvastatin calciumG cholestyramine/
aspartameG cholestyramine/
sucroseG colestipol HClG fenofibrate,
micronizedG fluvastatin sodiumG gemfibrozilG lovastatinG pravastatinG simvastatinP AltoprevP AntaraP CrestorP FenoglideP LipofenP LovazaP NiaspanP SimcorP TricorP TriglideP TrilipixP VytorinP Welchol
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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P ZetiaNP AdvicorNP CaduetNP ColestidNP FibricorNP LescolNP Lescol XLNP LipitorNP LivaloNP LofibraNP LopidNP MevacorNP PravacholNP QuestranNP Questran LightNP Zocor
ACE InhibitorsG benazepril HClG captoprilG enalapril maleateG fosinopril sodiumG lisinoprilG moexiprilG perindopril erbumineG quinaprilG ramiprilG trandolaprilNP AccuprilNP AceonNP AltaceNP LotensinNP MavikNP MonoprilNP PrinivilNP UnivascNP VasotecNP Zestril
CombinationAntihypertensivesG amlodipine
besylate/benazeprilG atenolol/
chlorthalidoneG benazepril HCl/
hydrochlorothiazideG bisoprolol fumarate/
hydrochlorothiazideG captopril/
hydrochlorothiazideG enalapril maleate/
hydrochlorothiazideG fosinopril/
hydrochlorothiazideG hydralazine HCl/
hydrochlorothiazideG lisinopril/
hydrochlorothiazideG methyldopa/
hydrochlorothiazideG metoprolol/
hydrochlorothiazideG moexipril/
hydrochlorothiazideG propranolol HCl/
hydrochlorothiazideG quinapril/
hydrochlorothiazideG trandolapril/
verapamilP AzorP ExforgeP Exforge HCTP TarkaP TribenzorP TwynstaNP AccureticNP Clorpres
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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Insulin TherapyP ApidraP Apidra SolostarP HumalogP Humalog Mix 50/50P Humalog Mix 75/25P HumulinP LantusP Lantus SoloStarP LevemirP NovoLogP NovoLog Mix 70/30NP Novolin
Non-InsulinHypoglycemic AgentsG acarboseG chlorpropamideG glimepirideG glipizideG glipizide/
metformin HClG glyburideG glyburide/
metformin HClG glyburide, micronizedG metformin HClG nateglinide
G pioglitizone HClG pioglitizone HCl/
metformin HClG tolazamideG tolbutamideP Actoplus Met XRP BydureonP ByettaP DuetactP JanumetP Janumet XRP JanuviaP JentaduetoP JuvisyncP Kombiglyze XRP OnglyzaP PrandimetP PrandinP RiometP SymlinP TradjentaP VictozaNP Actoplus MetNP ActosNP AmarylNP AvandametNP AvandarylNP Avandia
ENDOCRINE (Diabetes/Hormones/Contraceptives)
NP CorzideNP DutoprolNP Lopressor HCTNP Lotensin HCTNP LotrelNP Prinzide
NP TenoreticNP UnireticNP VasereticNP ZestoreticNP Ziac
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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NP CyclosetNP DiaBetaNP FortametNP GlucophageNP Glucophage XRNP GlucotrolNP Glucotrol XLNP GlucovanceNP GlumetzaNP GlynaseNP GlysetNP MetaglipNP PrecoseNP Starlix
Blood Glucose TestStripsG alcohol antiseptic
padsP Accu-Chek Active Test
StripsP Accu-Chek Aviva Plus
Test StripsP Accu-Chek Aviva Test
StripsP Accu-Chek Comfort
Curve Test StripsP Accu-Chek Compact
Test StripsP Accu-Chek Smartview
Test StripsP Fast Take Test StripsP One Touch Test StripsP One Touch Ultra Test
Strips P One Touch Verio Test
Strips P Surestep Pro Test
StripsP Surestep Test Strips
Contraceptive AgentsG desogestrel-ethinyl
estradiolG desogestrel-ethinyl
estradiol/ethinylestradiol
G ethinyl estradiol/drospirenone
G ethynodiol d-ethinylestradiol
G levonorgestrelG levonorgestrel-
ethinyl estradiolG levonorgestrel-
ethinyl estradiol/ethinyl estradiol
G norethindroneG norethindrone a-e
estradiolG norethindrone a-e
estradiol/ferrousfumarate
G norethindrone-ethinyl estradiol
G norethindrone-ethinyl estradiol/ferrous fumarate
G norethindrone-mestranol
G norgestimate-ethinyl estradiol
G norgestrel-ethinylestradiol
P BeyazP EllaP Loestrin 24 FeP Lo Loestrin FeP NataziaP NuvaRingP Safyral
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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P YazNP AlesseNP BreviconNP CyclessaNP DemulenNP DesogenNP Estrostep FeNP Femcon FeNP LevliteNP LoestrinNP Loestrin FeNP Lo/OvralNP LoSeasoniqueNP LybrelNP MircetteNP ModiconNP NordetteNP NorinylNP Ortho-CeptNP Ortho-CyclenNP Ortho EvraNP Ortho MicronorNP Ortho-NovumNP Ortho Tri-CyclenNP Ortho Tri-Cyclen LoNP OvconNP OvralNP Plan B One-StepNP SeasonaleNP SeasoniqueNP Tri-NorinylNP Yasmin
Estrogens/EstrogenCombinationsG estradiolG estradiol/
norethindroneacetate
G estropipate
G methyl-testosterone/estrogens, esterified
G norethindrone/ethinyl estradiol
P CenestinP ClimaraP CombipatchP DivigelP EnjuviaP Estrace Vaginal
CreamP EstradermP EstringP EvamistP Premarin Tablet P PremphaseP PremproP VagifemP VivelleP Vivelle-DotNP ActivellaNP AloraNP AngeliqNP Climara ProNP ElestrinNP Estrace TabletNP EstrasorbNP EstrogelNP FemhrtNP FemringNP FemtraceNP MenestNP MenostarNP OgenNP Ortho-PrefestNP PrefestNP Premarin Vaginal
Cream
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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NSAIDsG etodolacG flurbiprofenG ibuprofenG indomethacinG ketoprofenG meclofenamate
sodiumG meloxicamG nabumetoneG naproxenG naproxen sodiumG oxaprozinG piroxicamG sulindacG tolmetin sodiumP Flector
P VimovoP Voltaren GelNP Anaprox DSNP AnsaidNP ArthrotecNP CambiaNP CataflamNP ClinorilNP DayproNP diclofenac
potassiumNP diclofenac sodiumNP DuexisNP EC-NaprosynNP FeldeneNP IndocinNP LodineNP Mobic
NSAIDS (Pain Relievers)
Ulcer DrugsG cimetidine HCl liquidG cimetidine tabletG famotidineG lansoprazoleG misoprostolG nizatidineG omeprazoleG omeprazole/sodium
bicarbonateG pantoprazole sodiumG ranitidine HCl
P Axid Oral SolutionP Nexium NP AciphexNP Axid CapsuleNP CytotecNP DexilantNP PepcidNP PrevacidNP Prilosec RxNP ProtonixNP TagametNP Zantac RxNP Zegerid Rx
G I (Ulcer)
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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NP MotrinNP NalfonNP NaprelanNP NaprosynNP PennsaidNP RelafenNP Sprix
NP ToradolNP Voltaren TabletsNP Voltaren-XR
NSAID COX-2InhibitorsP Celebrex
G flavoxateG oxybutynin chloride G tolterodine tartrateG trospium chlorideP Detrol LAP EnablexP Gelnique
P OxytrolP Sanctura XRP ToviazP VesicareNP DetrolNP Ditropan XLNP Sanctura
DRUGS TO TREAT OVERACTIVE BLADDER
Beta Agonists OralG albuterol sulfateG metaproterenol
sulfateG terbutaline sulfateNP AlupentNP Proventil
Beta Agonist InhalersG albuterolG albuterol sulfateG levalbuterol HClG metaproterenol
sulfate
P ForadilP PerforomistP Proair HFAP Serevent DiskusP Ventolin HFANP AccunebNP Arcapta NeohalerNP BrovanaNP Maxair AutohalerNP Proventil HFANP XopenexNP Xopenex HFA
Inhaled SteroidsG budesonide
RESPIRATORY (Allergy/Asthma)
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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P AlvescoP AsmanexP Pulmicort FlexhalerP Pulmicort 1mg/2mL
RespulesP QVARNP AerobidNP Aerobid-MNP AzmacortNP Flovent DiskusNP Flovent HFANP Pulmicort 0.25mg/2mLNP Pulmicort 0.5mg/2mL
Nasal CorticosteroidsG flunisolideG fluticasone propionateG triamcinolone
acetonide P NasonexP QnaslP Rhinocort AquaP VeramystNP Beconase AQNP FlonaseNP Nasacort AQNP Omnaris
MiscellaneousPulmonary AgentsG acetylcysteineG cromolyn sodium
ampul for nebulization
G ipratropium/albuterolsulfate
G ipratropium bromidesolution
G montelukast sodiumG zafirlukastP AdcircaP Advair DiskusP Advair HFAP Atrovent HFAP BerinertP CinryzeP CombiventP Combivent RespimatP DalirespP DuleraP Intal InhalerP KalydecoP LetairisP PulmozymeP RevatioP SpirivaP SymbicortP TracleerP TyvasoP VentavisNP AccolateNP DuonebNP FirazyrNP KalbitorNP SingulairNP XolairNP ZyfloNP Zyflo CR
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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G alendronate sodiumG calcitonin, salmon,
syntheticG ibandronate sodiumP Actonel P AtelviaP EvistaP ForteoNP Actonel with CalciumNP Boniva
NP FosamaxNP Fosamax Plus DNP Miacalcin Nasal SprayNP Prolia
OSTEOPOROSIS/PAGET’S DISEASE
Anticonvulsants/Anti-SeizureG carbamazepineG clonazepamG diazepamG divalproex sodiumG ethosuximideG felbamateG gabapentinG lamotrigineG levetiracetamG mephobarbitalG oxcarbazepineG phenobarbitalG phenytoinG phenytoin sodium
extendedG primidoneG topiramateG valproic acid
P Banzel TabletP CelontinP DiastatP Dilantin Chewable
TabletP Dilantin 30mgP GabitrilP Lamictal ODTP Lamictal XRP LyricaP PeganoneP Tegretol XR 100mgP PotigaP VimpatNP Banzel SuspensionNP CarbatrolNP DepakoteNP Depakote ERNP Depakote SprinkleNP Dilantin 100mg
Capsule
NEUROLOGICALS
Key:G = Means a preferred generic medication.P = Means a preferred brand-name medication.NP = Means a nonpreferred brand-name medication.
= Means weigh risk of birth defects or other adverse outcomes.= Means do not use in pregnancy.
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NP Dilantin OralSuspension
NP EquetroNP Felbatol NP GraliseNP KeppraNP Keppra XRNP KlonopinNP LamictalNP MebaralNP MysolineNP NeurontinNP OnfiNP PhenytekNP SabrilNP TegretolNP Tegretol XR 200mg,
400mgNP TopamaxNP TrileptalNP ZarontinNP Zonegran
Migraine/HeadacheTherapyG acetaminophen/
butalbitalG acetaminophen/
caffeine/butalbital G aspirin/caffeine/
butalbitalG dihydroergotamine
mesylateG ergotamine/caffeineG isometheptene
mucate/acetaminophen/dichloralphenazone
G naratriptan HClG sumatriptan succinate
P ErgomarP MaxaltP Maxalt MLTP RelpaxP TreximetP ZomigP Zomig ZMTNP AlsumaNP AmergeNP AxertNP Cafergot tabletNP FrovaNP ImitrexNP MidrinNP MigranalNP PhrenilinNP Phrenilin ForteNP Sumavel
Drugs to treatAlzheimers DiseaseG donepezil HClG galantamine HBrG rivastigmine tartrateP Aricept 23mgP Exelon PatchP Exelon SolutionP NamendaNP Aricept 5mg, 10mgNP Aricept ODTNP CognexNP Exelon CapsulesNP RazadyneNP Razadyne ER
Nonpreferred Possible Preferred ProductsProduct
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SECTION II: NONPREFERRED DRUGS AND THEIR POSSIBLE PREFERRED
ALTERNATIVES
Accolate® zafirlukast (various)Accuneb® albuterol sulfate (generic)Accupril® quinapril (generic)Accuretic® quinapril/hydrochlorothiazide (generic)Aceon® perindopril erbumine (generic)Aciphex® omeprazole (generic), Nexium® (AstraZeneca)Activella® estradiol/norethindrone acetate (generic)Actonel® alendronate sodium (generic), ibandronate sodium
with Calcium (generic)Actoplus Met® pioglitazone/metformin (generic)Actos® pioglitazone HCl (generic)Adalat CC® nifedipine ER (generic), amlodipine besylate (generic),
nisoldipine (generic)Adderall® amphetamine salt combo (generic)Adderall XR® dextroamphetamine-amphetamine ER (generic)Adoxa® doxycycline monohydrate (generic)Adoxa Pak® doxycycline monohydrate (generic)Advicor® atorvastatin calcium (generic), lovastatin (generic),
pravastatin (generic), simvastatin (generic), Crestor®
(AstraZeneca), Niaspan® (Abbott), VytorinTM
(Merck/Schering)Aerobid® Asmanex® (Schering), Pulmicort Flexhaler®
(AstraZeneca), QVAR® (Ivax)Aerobid-M® Asmanex® (Schering), Pulmicort Flexhaler®
(AstraZeneca), QVAR® (Ivax)Alesse® Aviane® (Barr-branded generic*), Lessina® (Barr-
branded generic*), Lutera® (Watson-branded generic*),Lybrel® (Wyeth)
Alora® estradiol patch (generic), Climara® (Berlex), Estraderm®
(Novartis), Vivelle® (Novartis)Alsuma® sumatriptan succinate (generic)Altace® ramipril (generic)Amaryl® glimepiride (generic)Ambien® zolpidem tartrate (generic)Ambien CR® zolpidem tartrate ER (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
20*Branded generics have the same co-payment as regular generics.
Amerge® naratriptan HCl (generic)Amoxil® amoxicillin trihydrate (generic)Anafranil® clomipramine HCl (generic)Anaprox DS® naproxen sodium (generic)Ancobon® flucytosine (generic)Angeliq® estradiol/norethindrone acetate (generic),
Premphase® (Wyeth), Prempro® (Wyeth)Ansaid® flurbiprofen (generic)Arcapta Neohaler® Foradil® (Schering), Serevent Diskus® (GlaxoSmithKline)Aricept® 5mg,10mg donepezil HCl (generic)Aricept ODT® donepezil HCl (generic)Arthrotec® ibuprofen (generic), naproxen (generic), Celebrex®
(Pfizer)Ativan® lorazepam (generic)Augmentin® amoxicillin trihydrate/potassium clavulanate (generic)chewable tablet200-28.5mg,400-57mg
Augmentin® amoxicillin trihydrate/potassium clavulanate (generic)suspension200-28.5mg/5, 250-62.5mg/5,400-57mg/5
Augmentin® amoxicillin trihydrate/potassium clavulanate (generic)tablet
Augmentin ES® amoxicillin trihydrate/potassium clavulanate (generic)Augmentin XR® amoxicillin trihydrate/potassium clavulanate (generic)Avalide® irbesartan/hydrochlorothiazide (generic)Avapro® irbesartan (generic)Axert® naratriptan HCl (generic), sumatriptan succinate
(generic), Maxalt® (Merck), Relpax® (Pfizer), Zomig®
(AstraZeneca)Axid® Capsule nizatidine (generic)Azmacort® Asmanex® (Schering), Pulmicort Flexhaler®
(AstraZeneca), QVAR® (Ivax)Bactrim DS® sulfamethoxazole/trimethoprim (generic)Banzel® Banzel® Tablet (Eisai)Oral Suspension
Beconase AQ® flunisolide (generic), fluticasone propionate (generic),triamcinolone acetonide (generic), Nasonex®
(Schering), Rhinocort Aqua® (AstraZeneca), Veramyst®
(GlaxoSmithKline)
Nonpreferred Possible Preferred ProductsProduct
21
Biaxin® clarithromycin (generic)Biaxin XL® clarithromycin ER (generic)Boniva® ibandronate sodium (generic)Brevicon® Necon® (Watson-branded generic*), Nortrel®
(Barr-branded generic*)Brovana® Foradil® (Schering), Perforomist® (Dey Labs), Proair HFA®
(Teva), Serevent Diskus® (GlaxoSmithKline)Buspar® buspirone HCl (generic)Butisol Sodium® chloral hydrate (generic), temazepam (generic),
triazolam (generic)Caduet® amlodipine besylate (generic), atorvastatin calcium
(generic)Calan SR® verapamil HCl tablet, sustained action (generic)Cambia® etodolac (generic), ibuprofen (generic), naproxen
(generic)Carbatrol® carbamazepine (generic)Cardene SR® amlodipine besylate (generic), nifedipine ER (generic)Cardizem® diltiazem HCl (generic)Cardizem CD® diltiazem HCl capsule, sustained release 24 hr
(generic)Cardizem LA® diltiazem ER (generic)180mg, 240mg,300mg, 360mg, 420mg
Cardizem SR® diltiazem HCl capsule, sustained release 12 hr (generic)
Cardura® doxazosin mesylate (generic)Cataflam® etodolac (generic), ibuprofen (generic), naproxen
(generic)Catapres® clonidine HCl tablet (generic)Catapres-TTS® clonidine HCl patch (generic)Ceclor CD® cefaclor (generic), cefdinir (generic),
cefuroxime axetil (generic)Cedax® cefaclor (generic), cefdinir (generic),
cefuroxime axetil (generic)Ceftin® cefuroxime axetil (generic)Celexa® citalopram (generic)Cipro Tablet® ciprofloxacin HCl tablet (generic)Climara Pro® Combipatch® (Novartis)Clinoril® sulindac (generic)Clorpres® chlorthalidone (generic), clonidine HCl (generic)
*Branded generics have the same co-payment as regular generics.
22
Cognex® donepezil HCl (generic), galantamine (generic), rivastigmine tartrate (generic)
Colestid® cholestyramine (generic), Welchol® (Sankyo)Coreg® carvedilol (generic)Corgard® nadolol (generic)Corzide® bisoprolol fumarate/hydrochlorothiazide (generic),
metoprolol/hydrochlorothiazide (generic), propranololHCl/hydrochlorothiazide (generic)
Covera-HS® verapamil HCl capsule, 24 hr sustained release (generic)Cozaar® losartan potassium (generic)Cyclessa® Caziant® (Watson-branded generic*), Cesia® (Prasco
Labs-branded generic*), Velivet® (Barr-branded generic*)Cycloset® metformin HCl (generic), Byetta® (Amylin Pharma),
Janumet® (Merck), Januvia® (Merck), Onglyza®
(Bristol-Myers Squibb)Cytotec® misoprostol (generic)Daypro® oxaprozin (generic)Demulen® Zovia® (Watson-branded generic*)Depakote® divalproex sodium (generic)Depakote ER® divalproex sodium ER (generic)Depakote® Sprinkle divalproex sodium (generic)Desogen® Apri® (Barr-branded generic*),
Solia® (Prasco Labs-branded generic*)Desoxyn® methamphetamine HCl (generic)Desyrel® trazodone HCl (generic)Detrol® tolterodine tartrate (generic)Dexedrine® dextroamphetamine sulfate (generic)Dexilant® omeprazole (generic), Nexium® (AstraZeneca)DiaBeta® glyburide (generic)Diclofenac etodolac (generic), ibuprofen (generic), naproxen
Potassium (generic)Diclofenac etodolac (generic), ibuprofen (generic), naproxen
Sodium (generic)Diflucan® fluconazole (generic)Dilacor XR® diltiazem XR (generic)Dilantin® phenytoin sodium capsule (generic)
100mg CapsuleDilantin® Oral phenytoin (generic)
SuspensionDiovan HCT® valsartan/hydrochlorothiazide (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
Nonpreferred Possible Preferred ProductsProduct
23
Ditropan XL® oxybutynin chloride ER (generic)Doral® temazepam (generic), triazolam (generic), zaleplon
(generic), zolpidem tartrate (generic)Doryx® doxycycline hyclate (generic)Duexis® famotidine (generic), ibuprofen (generic), naproxen
(generic), omeprazole (generic)Duoneb® ipratropium/albuterol sulfate (generic)Duricef® cefadroxil hydrate (generic)Dutoprol® hydrochlorothiazide (generic), metoprolol succinate
(generic)Dynacin® minocycline HCl (generic)DynaCirc CR® amlodipine besylate (generic), nifedipine ER (generic),
nisoldipine (generic)EC-Naprosyn® naproxen (generic)Edarbi® losartan potassium (generic), Atacand® (AstraZeneca),
Benicar® (Daiichi Sankyo), Diovan® (Novartis), Micardis®
(BIPI)Edarbyclor® irbesartan/hydrochlorothiazide (generic),
losartan/hydrochlorothiazide (generic),valsartan/hydrochlorothiazide (generic), Atacand HCT®
(AstraZeneca), Benicar HCT® (Daiichi Sankyo), MicardisHCT® (Boehringer Ingelheim)
Edluar® zolpidem tartrate (generic)Effexor® venlafaxine HCl (generic)Effexor XR® venlafaxine HCl (generic)Elestrin® estradiol patch (generic), Climara® (Berlex), Divigel®
(Upsher Smith), Estraderm® (Novartis), Vivelle®
(Novogyne)Emsam® phenelzine sulfate (generic), tranylcypromine sulfate
(generic)Equetro® carbamazepine (generic), divalproex sodium (generic),
lithium carbonate (generic)EryPed erythromycin ethylsuccinate (generic)Suspension®
400mg/5mlEstrace® Tablet estradiol (generic)Estrasorb® estradiol patch (generic), Divigel® (Upsher Smith)Estrogel® estradiol patch (generic), Climara® (Berlex), Divigel®
(Upsher Smith), Estraderm® (Novartis), Vivelle®
(Novartis)Estrostep Fe® Apri® (Barr-branded generic*), Kariva® (Barr-branded
generic*), Microgestin Fe® (Watson-branded generic*)
*Branded generics have the same co-payment as regular generics.
24
Exelon® Capsules rivastigmine tartrate (generic)Factive® ciprofloxacin (generic), levofloxacin (generic)Fanapt® clozapine (generic), olanzapine (generic), quetiapine
fumarate (generic), risperidone (generic), ziprasidoneHCl (generic), Seroquel XR® (AstraZeneca)
Felbatol® felbamate (generic)Feldene® piroxicam (generic)Femhrt® Jinteli® (Teva-branded generic*)Femcon Fe® Zeosa® (Teva-branded generic*)Femring® Estrace Vaginal Cream® (Warner Chilcott), Estring®
(Pfizer)Femtrace® estradiol (generic)Fibricor® fenofibrate (generic), Tricor® (Abbott), Triglide® (Sciele),
Trilipix® (Abbott)Firazyr® Berinert® (CSL Behring), Cinryze® (Viropharma)Flonase® fluticasone propionate (generic)Floxin® ofloxacin (generic)Focalin® dexmethylphenidate HCl (generic)Focalin XR® dextroamphetamine-amphetamine ER (generic),
methylphenidate ER (generic), Daytrana® (Shire US Inc.),Metadate CD® (Celltech Pharm), Methylin ER®
(Mallinckrodt Pharmaceuticals)Fortamet® metformin HCl ER (generic), metformin HCl tablet
(generic)Fosamax® Tablets alendronate sodium (generic)Fosamax Plus D® alendronate sodium (generic), ibandronate sodium
(generic)Furadantin® nitrofurantoin (generic)Gantrisin® sulfisoxazole (generic)Geodon® ziprasidone HCl (generic)Glucophage® metformin HCl (generic)Glucophage XR® metformin HCl ER (generic), metformin HCl tablet
(generic)Glucotrol® glipizide (generic)Glucotrol XL® glipizide ER (generic)Glucovance® glyburide/metformin HCl (generic)Glynase® glyburide, micronized (generic)Glyset® acarbose (generic)Gralise® gabapentin (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
Nonpreferred Possible Preferred ProductsProduct
25
Grifulvin V® griseofulvin ultramicrosize (generic), itraconazole(generic), ketoconazole (generic), terbinafine HCl(generic)
Gris-Peg® griseofulvin ultramicrosize (generic), itraconazole(generic), ketoconazole (generic), terbinafine HCl(generic)
Guanabenz clonidine HCl (generic), methyldopa (generic)Acetate®
Halcion® triazolam (generic)Hiprex® methenamine hippurate (generic)Hytrin® terazosin (generic)Hyzaar® losartan/hydrochlorothiazide (generic)Imitrex® sumatriptan succinate (generic)Inderal® propranolol HCl (generic)Inderal LA® propranolol capsule, sustained action (generic)Indocin® indomethacin (generic)Innopran XL® propranolol capsule, sustained action (generic)Intermezzo® zaleplon (generic)Invega® olanzapine (generic), quetiapine fumarate (generic),
risperidone (generic), ziprasidone HCl (generic),Seroquel XR® (AstraZeneca)
Isoptin S.R.® verapamil HCl tablet, sustained action (generic)Kalbitor® Berinert® (CSL Behring)Kapvay® clonidine HCl (generic), Intuniv® (Shire US Inc.)Keflex® cephalexin monohydrate (generic)Keppra® levetiracetam (generic)Keppra XR® levetiracetam (generic)Kerlone® betaxolol HCl (generic)Klonopin® clonazepam (generic)Lamictal® lamotrigine (generic)Lamisil® tablet terbinafine HCl (generic)Lescol® fluvastatin sodium (generic)Lescol XL® atorvastatin calcium (generic), lovastatin (generic),
simvastatin (generic), Altoprev® (Andrx), Crestor®
(AstraZeneca), VytorinTM (Merck/Schering)Levaquin® levofloxacin (generic)Levatol® acebutolol HCl (generic), atenolol (generic),
metoprolol tartrate (generic)Levlite® Aviane® (Barr-branded generic*), Lessina®
(Barr-branded generic*), Lybrel® (Wyeth)
*Branded generics have the same co-payment as regular generics.
26
Lexapro® escitalopram oxalate (generic)Librium® chlordiazepoxide HCl (generic)Lipitor® atorvastatin calcium (generic)Liquadd® dextroamphetamine sulfate (generic)Lithobid® lithium carbonate tablet, sustained action (generic)Livalo® atorvastatin calcium (generic), lovastatin (generic),
pravastatin (generic), simvastatin (generic), Crestor®
(AstraZeneca)Lodine® etodolac (generic)Loestrin® Junel® (Barr-branded generic*), Microgestin®
(Watson-branded generic*)Loestrin Fe® Junel Fe® (Barr-branded generic*), Microgestin Fe®
(Watson-branded generic*)Lofibra® fenofibrate (generic), Tricor® (Abbott), Triglide® (First
Horizon), Trilipix® (Abbott)Lo/Ovral® Low-Ogestrel® (Watson-branded generic*)Lopid® gemfibrozil (generic)Lopressor® metoprolol tartrate (generic)Lopressor HCT® metoprolol/hydrochlorothiazide (generic)LoSeasonique® Amethia Lo® (Watson-branded generic*), Camrese Lo®
(Teva-branded generic*)Lotensin® benazepril HCl (generic)Lotensin HCT® benazepril HCl/hydrochlorothiazide (generic)Lotrel® amlodipine besylate/benazepril (generic)Luvox CR® fluvoxamine maleate (generic)Lybrel® Amethyst® (Watson-branded generic*)Macrobid® nitrofurantoin macrocrystal (generic)Macrodantin® nitrofurantoin (generic)Mavik® trandolapril HCl (generic)Maxair Autohaler® Proair HFA® (Teva)Mebaral® mephobarbital (generic)Menest® estradiol (generic), estropipate (generic), Cenestin®
(Duramed/Barr), Enjuvia® (Duramed/Barr),Premarin® (Wyeth)
Menostar Patch® Climara Patch® (Berlex), Vivelle Patch® (Novartis)Metaglip® glipizide/metformin (generic)Methylin® methylphenidate HCl (generic)
Oral SolutionMethylin® methylphenidate HCl (generic)
Chewable TabletMevacor® lovastatin (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
Nonpreferred Possible Preferred ProductsProduct
27
Miacalcin® calcitonin-salmon (generic)Midrin® isometheptene/apap/dichloralphenazone (generic)Migranal® naratriptan HCl (generic), sumatriptan nasal spray
(generic), Maxalt® (Merck), Relpax® (Pfizer), Zomig® NasalSpray (AstraZeneca)
Minipress® prazosin HCl (generic)Minitran® nitroglycerin patch (generic), Nitro-Dur® (Schering)Minocin® minocycline HCl (generic)Mircette® Kariva® (Barr-branded generic*)Mobic® meloxicam (generic)Modicon® Necon® (Watson-branded generic*), Nortrel®
(Barr-branded generic*)Monistat 3 Vaginal miconazole 3 vaginal suppository (generic)
Suppository®
Monodox® doxycycline monohydrate (generic)Monopril® fosinopril sodium (generic)Monurol® ciprofloxacin HCl (generic), sulfamethoxazole/
trimethoprim (generic), trimethoprim (generic)Motrin® ibuprofen (generic)Moxatag® amoxicillin (generic)Mysoline® primidone (generic)Nalfon® etodolac (generic), ibuprofen (generic), indomethacin
(generic), meclofenamate sodium (generic), naproxen (generic), sulindac (generic)
Naprelan® naproxen sodium (generic)Naprosyn® naproxen (generic)Nardil® phenelzine sulfate (generic)Nasacort AQ® triamcinolone acetonide (generic)Nembutal chloral hydrate (generic), temazepam (generic),
Sodium® triazolam (generic)Neurontin® gabapentin (generic)Nexiclon XR® clonidine HCl (generic)Nimotop® nimodipine (generic)Niravam® alprazolam (generic)Nizoral® ketoconazole (generic)Nordette® Levora® (Watson-branded generic*), Portia®
(Barr-branded generic*)Norinyl® Necon® (Watson-branded generic*), Nortrel®
(Barr-branded generic*)Norpramin® desipramine HCl (generic)
*Branded generics have the same co-payment as regular generics.
28
Norvasc® amlodipine besylate (generic)Novolin® Humulin® (Eli Lilly)Nuvigil® modafinil (generic)Ogen® estropipate (generic)Oleptro ER® trazodone HCl (generic)Omnaris® flunisolide (generic), fluticasone propionate (generic),
triamcinolone acetonide (generic), Nasonex®
(Schering), Rhinocort Aqua® (AstraZeneca), Veramyst®
(GlaxoSmithKline)Omnicef® cefdinir (generic)Onfi® felbamate (generic), lamotrigine (generic), topiramate
(generic), Banzel® Tablet (Eisai)Oravig® clotrimazole (generic), fluconazole (generic), nystatin
suspension (generic)Ortho-Cept® Apri®(Barr-branded generic*), Solia®
(Prasco Labs-branded generic*)Ortho-Cyclen® MonoNessa® (Watson-branded generic*), Previfem®
(Teva-branded generic*), Sprintec® (Barr-branded generic*)
Ortho Evra® MonoNessa® (Watson-branded generic*), TriNessa®
(Watson-branded generic*)Ortho Micronor® norethindrone acetate (generic)Ortho-Novum® Necon® (Watson-branded generic*), Nortrel®
1/35, 7/7/7 (Barr-branded generic*)Ortho-Novum® Necon® (Watson-branded generic*)
1/50Ortho-Prefest® estradiol/norethindrone acetate (generic),
Premphase® (Wyeth), Prempro® (Wyeth)Ortho Tri-Cyclen® TriNessa® (Watson-branded generic*), Tri-Previfem®
(Teva-branded generic*), Tri-Sprintec® (Barr-brandedgeneric*)
Ortho Tri-Cyclen TriNessa® (Watson-branded generic*), Tri-Previfem®
Lo® (Teva-branded generic*), Tri-Sprintec® (Barr-brandedgeneric*)
Ovcon® Necon® (Watson-branded generic*)Ovral® Ogestrel® (Watson-branded generic*)Pamelor® nortriptyline HCl (generic)Parnate® tranylcypromine sulfate (generic)Paxil® paroxetine HCl (generic)Paxil CR® paroxetine HCl sustained release tab (generic)PCE® erythromycin (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
Nonpreferred Possible Preferred ProductsProduct
29
Pennsaid® etodolac (generic), ibuprofen (generic), naproxen(generic)
Pepcid® famotidine (generic), cimetidine HCl liquid (generic),Suspension Axid Oral Solution® (Braintree)
Pepcid® Tablet famotidine (generic)Periostat® doxycycline hyclate (generic)Pexeva® paroxetine HCl (generic)Phenytek® phenytoin sodium (generic)Phrenilin® acetaminophen/butalbital (generic)Plan B One-Step® Next Choice One Dose® (Watson-branded generic*)Ponstel® etodolac (generic), ibuprofen (generic), indomethacin
(generic), meclofenamate sodium (generic), naproxen (generic), sulindac (generic)
Pravachol® pravastatin (generic)Precose® acarbose (generic)Prefest® estradiol/norethindrone acetate (generic),
Premphase® (Wyeth), Prempro® (Wyeth)Premarin® Estrace® Vaginal Cream (Warner Chilcott)Vaginal Cream
Prevacid® lansoprazole (generic), omeprazole (generic), Nexium®
(AstraZeneca)Prilosec Rx® omeprazole (generic), Nexium® (AstraZeneca)Primsol® trimethoprim (generic)Prinivil® lisinopril (generic)Prinzide® lisinopril/hydrochlorothiazide (generic)Procardia XL® nifedipine ER (generic)Prolia® alendronate sodium (generic), ibandronate sodium
(generic), Evista® (Eli Lilly), Forteo® (Eli Lilly)Proquin XR® ciprofloxacin HCl (generic)Protonix® Nexium® Suspension (AstraZeneca)
SuspensionProtonix® Tablet pantoprazole sodium (generic), omeprazole (generic),
Nexium® (AstraZeneca)Proventil HFA® Proair HFA® (Teva)Provigil® modafinil (generic)Prozac® fluoxetine HCl (generic)Prozac Weekly® fluoxetine HCl (generic)Pulmicort® budesonide (generic)0.25mg/2mL,0.5mg/2mL
Questran® cholestyramine (generic), prevalite (generic)
*Branded generics have the same co-payment as regular generics.
30
Questran Light® cholestyramine/aspartame (generic), prevalite (generic)Razadyne® galantamine (generic)Razadyne ER® galantamine ER (generic)Relafen® nabumetone (generic)Remeron® mirtazapine soltabs (generic), mirtazapine tabs
(generic)Restoril® temazepam (generic)Risperdal® risperidone (generic)
Oral SolutionRisperdal® Tablet risperidone (generic)Ritalin® methylphenidate HCl (generic)Ritalin LA® methylphenidate ER (generic), dextroamphetamine
sulfate (generic), dextroamphetamine-amphetamineER (generic), Daytrana® (Shire US Inc.), Metadate CD®
(Celltech Pharm)Ritalin SR® methylphenidate ER (generic)Rozerem® estazolam (generic), temazepam (generic), triazolam
(generic), zolpidem tartrate (generic)Sabril® divalproex sodium (generic), lamotrigine (generic),
levetiracetam (generic), topiramate (generic), Gabitril®
(Cephalon)Sanctura® trospium chloride (generic)Saphris® clozapine (generic), olanzapine (generic), quetiapine
fumarate (generic), risperidone (generic), ziprasidoneHCl (generic), Seroquel XR® (AstraZeneca)
Sarafem® fluoxetine HCl (generic)Seasonale® Amethyst® (Watson-branded generic*), Jolessa®
(Barr-branded generic*), Quasense® (Watson-brandedgeneric*),
Seasonique® Amethia® (Watson-branded generic*), Camrese®
(Teva-branded generic*)Seconal Sodium® chloral hydrate (generic), temazepam (generic),
triazolam (generic)Sectral® acebutolol HCl (generic)Septra DS® sulfamethoxazole/trimethoprim (generic)Seroquel® quetiapine fumarate (generic)Singulair® montelukast sodium (generic)Solodyn® minocycline HCl (generic), doxycycline monohydrate
(generic)Sonata® zaleplon (generic)Spectracef® cefaclor (generic), cefdinir (generic), cefuroxime axetil
(generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
Nonpreferred Possible Preferred ProductsProduct
31
Sporanox® itraconazole (generic)Capsule
Sprix® etodolac (generic), ibuprofen (generic), naproxen(generic)
Starlix® nateglinide (generic)Sular® nisoldipine (generic), amlodipine besylate (generic),
isradipine (generic), nifedipine ER (generic)Suprax® cefdinir (generic), cefuroxime axetil (generic)Surmontil® trimipramine maleate (generic)Symbyax® fluoxetine HCl (generic), olanzapine (generic),
quetiapine fumarate (generic), risperidone (generic),Seroquel XR® (AstraZeneca)
Tagamet® cimetidine (generic)Tegretol® carbamazepine (generic)Tegretol XR® carbamazepine XR (generic)
200mg, 400mgTenex® guanfacine HCl (generic)Tenoretic® atenolol/chlorthalidone (generic)Tenormin® atenolol (generic)Teveten® eprosartan mesylate (generic), losartan potassium
(generic), Atacand® (AstraZeneca), Benicar® (DaiichiSankyo), Diovan® (Novartis), Micardis® (BIPI)
Teveten HCT® losartan/hydrochlorothiazide (generic),valsartan/hydrochlorothiazide (generic), Atacand HCT®
(AstraZeneca), Benicar HCT® (Daiichi Sankyo), MicardisHCT® (BIPI)
Thioridazine HCl® chlorpromazine HCl (generic), haloperidol (generic),quetiapine fumarate (generic), risperidone (generic)
Tiazac® diltiazem HCl capsule, sustained release 24 hr (generic)Tofranil® imipramine HCl (generic)Tofranil-PM® imipramine pamoate (generic)Topamax® topiramate (generic)Toprol XL® metoprolol succinate (generic)Toradol® etodolac (generic), ibuprofen (generic), indomethacin
(generic), meclofenamate sodium (generic), naproxen (generic), sulindac (generic)
Trandate® labetalol HCl (generic)Tranxene T-Tab® clorazepate dipotassium (generic)Trileptal® carbamazepine (generic)Tri-Norinyl® Necon® (Watson-branded generic*), Nortrel®
(Barr-branded generic*)Uniretic® moexipril/hydrochlorothiazide (generic)
*Branded generics have the same co-payment as regular generics.
32
Univasc® moexipril HCl (generic)Valium® diazepam (generic)Vantin® cefpodoxime proxetil (generic)Vaseretic® enalapril maleate/hydrochlorothiazide (generic)Vasotec® enalapril maleate (generic)Verelan® verapamil ER (generic)Verelan PM® verapamil ER PM (generic)Vfend® voriconazole (generic)Vibramycin® Syrup Vibramycin® Suspension (Pfizer)Vivactil® protriptyline HCl (generic)Voltaren® Tablets etodolac (generic), ibuprofen (generic), naproxen
(generic)Voltaren-XR® etodolac (generic), ibuprofen (generic), naproxen
(generic)Wellbutrin® bupropion HCl (generic)Wellbutrin SR® bupropion HCl tablet, sustained release (generic)Wellbutrin XL® bupropion HCl tablet, extended release (generic)Wytensin® clonidine HCl (generic), methyldopa (generic)Xanax® alprazolam (generic)Xanax XR® alprazolam XR (generic)Xolair® Asmanex® (Schering), Pulmicort Flexhaler®
(AstraZeneca), QVAR® (Ivax)Xopenex® levalbuterol HCl (generic)
1.25mg/0.5Yasmin® Ocella® (Barr-branded generic*)Zantac Rx Syrup® ranitidine HCl tablet (generic), Axid Oral Solution®
(Braintree)Zantac Rx Tablet® ranitidine HCl tablet (generic)Zarontin® ethosuximide (generic)Zebeta® bisoprolol fumarate (generic)Zegerid Rx® omeprazole/sodium bicarbonate (generic), omeprazole
(generic), Nexium® (AstraZeneca)Zestoretic® lisinopril/hydrochlorothiazide (generic)Zestril® lisinopril (generic)Ziac® bisoprolol fumarate/hydrochlorothiazide (generic)Zithromax® azithromycin (generic)Zmax® azithromycin (generic)Zocor® simvastatin (generic)Zoloft® sertraline HCl (generic)Zolpimist® zolpidem tartrate (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
33
Zonegran® carbamazepine (generic), clonazepam (generic) ethosuximide (generic,) phenobarbital (generic), phenytoin sodium (generic), Lyrica® (Pfizer)
Zyflo® montelukast sodium (generic)Zyflo CR® montelukast sodium (generic)Zyprexa® olanzapine (generic)Zyprexa Zydis® olanzapine ODT (generic)
*Branded generics have the same co-payment as regular generics.
Nonpreferred Possible Preferred ProductsProduct
This guide does not contain a complete list of formulary and nonformulary drugs. It only liststhe most commonly prescribed drugs. For anupdated and complete listing of your prescriptionbenefit, you can visit www.mywdrx.com.
www.mywdrx.com
© 2012 Used under License.
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