BRAND NAME
Transcription
BRAND NAME
Complete Non-Preferred Drug List The brand name drugs on the list below are in the third tier and require the highest copayment. If you are taking one of these drugs and wish to reduce your out-of-pocket costs, please ask your doctor about taking a generic or preferred brand name alternative. A/T/S Accuhist Accuhist Dm Accuhist La Accuhist Pdx Accuneb Accupril Accuretic Accutane Accuzyme Aceon Acid Jelly Aciphex Aclovate Actigall Actiq Actonel Actoplus MET Adalat CC Adderall Adoxa Adoxa Pak Adrenalin Chloride Advicor Aerobid Aerobid-M Aerokid Aerotuss 12 Age Spot And Skin Lightening Agrylin Ah-Chew D Ah-Chew II Ah-Chew Ultra A-Hydrocort Airet Akne-Mycin Alacol Alacol Dm Ala-Cort Ala-Scalp Hp Ala-TET Albalon Albatussin Albatussin Cf Albatussin Dm Albatussin Pediatric Albatussin SR Albatussin SR F Albatussin SR Senior Alcaine Alcet Aldactazide Aldactone Aldex Aldex D Aldex Dm Aldex G Aldex-Ct Aldomet Alfenta Allegra Allegra-D Allegra-D 12 Hour Allegra-D 24 Hour Allertan Allerx Allerx DF Allerx PE Allerx-D Allfen Allfen C Allfen CX Allfen-DM Alocril Alora Alphagan P Alphatrex Altafluor Altocor Altoprev Amaryl Ambi 40/1000 Ambi 5/15/100 Ambi 60/1000 Ambi 60/1000/30 Ambien CR Ambifed-G Ambifed-G DM Amerge Americaine Amerifed Amerifed DM Amerituss AD Amicar Amikin Amikin Pediatric Amino-Cerv Amoxil Amphocin Anafranil Anamantle HC Anamantle HC Forte Anaplex DM Anaplex Dmx Anaplex HD Anaprox Anaprox DS Ancef Andehist Anestacon Ansaid Antivert Antivert/25 1 Anusol-HC Appformin Appformin-D Aquatab C Aquatab D Aquatab DM Aquatab-C Aquoral Aralen Phosphate Aranesp Arava Aridex Aridex-D Aristocort HP Arixtra Arthrotec 50 Arthrotec 75 Astramorph-PF Atacand Atacand HCT Atarax Ativan Atripla Atrovent Atuss DR Atuss DS Atuss EX Atuss G Atuss HC Atuss HD Atuss HS Atuss HX Atuss MR Atuss MS Atuss NX Atuss-12 DM Augmentin Augmentin ES-600 Augmentin XR Avandamet Avandaryl Avar Avar-E Avelox Avelox ABC Pack Avelox IV Aventyl HCL Avinza Avita Axert Axid Axocet Aygestin Azilect Azulfidine B & O Supprettes No.15-A B & O Supprettes No.16-A Bactrim Bactrim DS Bactrim IV Bactroban Balamine DM Baltussin Bancap HC Baraclude B-Complex B-Complex Plus Vitamin Beconase AQ Benicar Benicar HCT Bentyl Benzac AC Benzac W Wash Benzagel Wash Benzagel-10 Benzagel-5 Benzamycin Benzashave Berocca Berocca Plus Betagan Betapace Betapace AF Betatan Betoptic S Bextra Biaxin Biaxin XL Bicitra Bidex DM Biohist-LA Bleph-10 Blocadren Bonisara Boniva Brethine Brevibloc Brevoxyl-4 Brevoxyl-8 Brofed Bromfed Bromfed-DM Bromfed-PD Broncholate Broncopectol Broncotron-D Brontex Brontuss SF Brovex Brovex CT Brovex HC Brovex SR Brovex-D B-Tuss Bumex Buspar Byetta Caduet Cafcit Cafergot Calan Calan Sr Calci-Max Capex Shampoo Capoten Capozide Carafate Carb Pseudo-TAN Carbaphen 12 Carbaphen 12 PED Carbastat Carbatrol 2 Carbatuss-12 Carbatuss-CL Carba-XP Carboxine Cardene Cardene SR Cardizem Cardizem CD Cardizem LA Cardizem SR Cardura Carmol Carmol 40 Carmol HC Carmol Scalp Carnitor Caromega Cataflam Catapres Cavarest Cavirinse Ceclor Cedax Cefol Ceftin Cefzil Celebrex Celexa Celontin Cenocort A-40 Cenocort Forte Suspension Cenogen Ultra Cenogen-OB Centany Certuss Certuss-D Cesamet Cetacort Chantix ChlorpheniraminePseudo LA Ciloxan Cinalog Cipro Cipro HC Cipro XR Citracal Prenatal Rx Claforan Clarinex Clarinex-D 12 Hour Clarinex-D 24 Hour Claritin Clenia Cleocin Cleocin HCL Cleocin Phosphate Cleocin T Climara Clindareach Clindets Clinoril Cloderm Clomid Clorfed Clozaril Codiclear DH Codimal DH Codimal-A Cognex Coldmist JR Colestid Colocort Colrex Compound Coly-Mycin M Parenteral Colyte Colyte With Flavor Packets Colytrol Combunox Comhist Compazine Complex B Condylox Conison Conpec Conpec L.A. Conpec LA Control Rx Copegus Cophene-B Cordarone Cordran Cordran SP Coreg CR Corgard Cormax Cortane-B Cortef Cortifoam Cortisporin Cortisporin-TC Covera-HS Cozaar Crolom Cutivate Cyclocort Cyclogyl Cylert Cymbalta Cystospaz Cytotec Cytovene Cytoxan D.H.E.45 Dallergy Dallergy-Jr Dalmane Danocrine Dantrium Darvocet A500 Darvocet-N 100 Darvocet-N 50 Darvon Daypro Daytrana Ddavp Decadron Declomycin Deconamine Deconamine SR Deconex Deconex DM Decon-G 3 Deconsal CT Deconsal DM Deconsal II Deka Delatestryl Delestrogen Deltuss DMX Demadex Demerol Depo-Medrol Depo-Provera Depo-Testosterone Dermatop Desferal Desferal Mesylate Desonate Desowen Desoxyn Despec Despec DM Despec SR Desquam-X Desyrel Dexedrine Dextrom-PseudoGuaifen TR Diab Diabeta Diabetic Tussin C Diabinese Diatx Dicel Dicel Dm Didronel Diflucan Diflucan In Dextrose Diflucan In Saline Dilacor XR Dilaudid Dilaudid-5 Dilaudid-HP Dipentum Diphen-PE-CT Tann Diprolene Diprolene AF Diprosone Disophrol Dispermox Ditropan Ditropan XL Dmax Dolobid Dologesic Dolophine HCL Dolorex Domeboro Donatussin Donatussin DC Donatussin DM Donatussin Max Dopram Dostinex Drisdol Drysol Drysol Dab-O-Matic Duet Duetact Duonate-12 Durabac Duradex Duradex Forte Duraflu Duragesic Durahist Durahist D Durahist PE Duramax Duraphen 1000 Duraphen DM Duraphen Forte Duraphen II Duraphen II DM Durasal II Duratan DM Duratan Forte Dura-Tap/PD Duratuss Duratuss A Duratuss AC 12 Duratuss CS Duratuss DM Duratuss DM 12 Duratuss GP Duratuss HD Duratuss PE Duraxin Duricef Dyazide Dynabac Dynacin Dynacirc Dynacirc CR Dynex Dynex 12 Dynex HD Dynex LA Dynex VR Dytan Dytan-AT Dytan-CS Dytan-D Dytan-DM Dytan-HC E.E.S. 200 Easprin Ec-Naprosyn Econopred Plus Ed-A-Hist DM Ed-Dm Eemt D.S. Eemt H.S. Effexor Efudex Eldepryl Eldopaque Forte Eldoquin Forte Elestat Elimite Elocon Embrex 600 Emcin Clear Emend Emgel Emla Enablex 4 Endal HD Endal-HD Plus Entex Entex ER Entex HC Entex LA Entex PSE Ephedrine Sulfate Ephex SR Equagesic Equetro Eraxis Ertaczo Eryc Erygel Eryped 200 Ery-Tab Esgic Esgic-Plus Eskalith Eskalith CR Estrace Estraderm Estrasorb Estrogel Euflexxa Eulexin Evoclin Excof Excof-SF Exoderm Extendryl Extendryl DM Extendryl G Extendryl HC Extendryl Jr Exubera Combination Pack 12 Exubera Combination Pack 15 Exubera Inhaler Exubera Kit Exubera Patient Pack Factive Fazaclo Felbatol Feldene Femring Fentora Fero-Folic-500 Fioricet Fioricet W/Codeine Fiorinal Fiorinal W/Codeine #3 Flagyl Flagyl 375 Flexeril Flextra-DS Flonase Florinef Acetate Floxin Flumadine Fluorabon Fluoracaine Fluor-A-Day Fluorets Fluoride Fluor-I-Strip AT Flurate Flutuss HC Flutuss XP Fml Focalin Focalin XR Folgard Rx Folgard Rx 2.2 Folmor Foltx Fortamet Fortaz Forteo Frova Fulvicin U/F Fungizone Gabarone Garamycin Gastrografin Gelfoam Gelfoam Compressed Gel-Kam Genecof-HC Genecof-XP Genelan Genexa LA Genoptic Gentak Gentex HC Gentex LA Gentex LQ Gilchew IR Giltuss Giltuss HC Giltuss Ped-C Giltuss TR Glucophage Glucophage XR Glucotrol Glucotrol XL Glucovance Glumetza Glutofac-ZX Glynase Glyquin Glyquin XM Golytely Goniosol Granulex Grifulvin V Gris-Peg Guaifed Guaifed-PD Halcion Haldol Haldol Decanoate 100 Haldol Decanoate 50 Halog Halog-E Hdc Dm Helitene Hemocyte-F Hexafed Hexaflu Hiprex Histafed-LA Histalet 5 Histamax D Histatab Plus Histex Histex DA Histex HC Histex PD Histex SR Histor-D Histussin D Histussin HC Hpb Max Hpr End Humatin Humibid DM Humibid L.A. Hycet Hycodan Hycomine Compound Hycotuss Hydrea Hydrochlorothiazide Hydropramox Hytan Hytone Hytrin Hyzaar Iberet-Folic 500 Icar-C Plus Imdur Imuran Increlex Inderal Inderide-40/25 Inderide-80/25 Indocin SR Inflamase Forte Innopran XL Inspra Intal Invega Iplex Ismo Isochron Isoptin SR Isopto Atropine Isopto Carbachol Isopto Carpine Isopto Homatropine Isordil Istalol Isuprel Januvia Jaycof Jaycof-HC Jaycof-XP J-Max J-Tan D Just For Kids Kaochlor Kaon-CL Kay Ciel Kayexalate K-DUR Keflex Kenalog Kenalog In Orabase Kenalog-40 Keralac Kerlone Ketek Ketek Pak Key-Pred Klaron Klonopin K-Lor Klotrix K-Lyte K-Lyte/CL K-Tab Lac-Hydrin Lacticare-HC Lactinol Lactinol-E Lactocal-F Lamictal Lanzatuss-N.F Lariam Lartus Lasix Lavoclen-4 Lavoclen-8 Lescol Lescol XL Levall Levall 5.0 Levall G Levall-12 Levaquin Levatol Levbid Levo-Dromoran Levsin Levsin/SL Levsinex Lexapro Lexxel Librium Lidamantle Lidamantle HC Lidex Lidex-E Limbitrol Limbitrol DS Lincocin Liquibid-D Liquibid-D 1200 Liquibid-PD Liquicet Liquicough Dm Lister-V Lithobid Locoid Lodine Lodine XL Lodosyn Lodrane Lodrane 24D Lodrane D Lodrane XR Lofibra Lomotil Loniten Lopid Lopressor Lopressor HCT 6 Loprox Lorabid Lorcet 10/650 Lorcet Plus Lortab Lortuss DM Lortuss HC Lotensin Lotensin HCT Lotrel Lotrisone Loxitane Lozol Lufyllin Lufyllin-400 Lufyllin-GG Lumigan Luminal Sodium Lunesta Lupron Luride Lusonal Lusonex Lusonex Plus Lustra Lynox Lyrica Lytensopril Lytensopril-90 Macrobid Macrodantin Magnacet Mandelamine Mandelamine Hafgrams Marinol Marnatal F Mar-Spas Materna Maxaquin Maxidone Maxifed Maxifed DM Maxifed DMX Maxifed-G Maxiphen Maxiphen ADT Maxiphen DM Maxiphen G Maxiphen-G DM Maxitrol Maxi-Tuss DM Maxi-Tuss HC Maxi-Tuss HCG Maxi-Tuss HCX Maxzide Maxzide-25mg Mc Cough Mc Jr Cough Mebaral Medent DM Medent LD Medent-PE Medrol Mefenamic Acid Mefoxin Megace Megace ES Melanex Mellaril M-End Menostar Mentax Meperidine HCL Mescolor Mestinon Metadate CD Metaglip Methadose Metro IV Metrocream Metrogel-Vaginal Metrolotion Mevacor Mexitil Micardis Micardis HCT Micro-K 10 Micronase Microzide Midamor Migralam Miltown Miltuss-EX Mimyx Minipress Minirin Minitran Minocin Miralax Mobic Moduretic Monistat-Derm Monodox Monoket Monopril Monopril HCT Monteflu HC Monte-G HC Montephen Morphine Sulfate IN Dextrose Motrin Ms Contin Msir Muco-Fen DM Mucomyst Mucomyst-10 Myambutol Mycelex Myci Bron-G Myci Chlorped Myci Chlorped D Myci Chlor-TAN Mycolog II Mycostatin Mydfrin Mydriacyl Mynatal Myophen Mysoline Mytrex Nalex DH Nalex-A Naprelan Naprosyn 7 Narcan Narcan Multiple Dose Nariz Nariz HC Nasacort AQ Nasarel Nascobal Nasop Nasop 12 Natachew Navane Nd-Gesic Nebcin Neo Dm Neobenz Micro SD Neoral Neosporin Neosporin G.U. Irrigant Neo-Synephrine Neotuss-D Nephplex Rx Nephrocaps Nephro-Vite Rx Nervidox 6 Nestabs CBF Nestabs FA Nestabs Rx Neuro B12 Forte Neurontin Nevanac Nexium Nexium I.V. Niferex-PN Niferex-PN Forte Niravam Nitro-DUR Nitrostat Nizoral Norco Norditropin Norel EX Norel LA Norel SR Norflex Norgesic Norgesic Forte Noritate Normodyne Noroxin Norpace Norpace CR Norpramin Notuss Notuss PD Novacort Novahistine DH Novanatal Novasal Novastart Novasus Novocain Noxafil Nubain Nucofed Nulev Nulytely Nulytely With Flavor Packs Numobid Numobid DX Numonyl Numonyl DX Numonyl Pediatric Numonyl SR Nutracort Nutropin Nuzon Nydamax Obtrex Ocufen Ocuflox Ocupress Ogen Omacor Omnihist II LA Opana Opana ER Optipranolol Optivar Oracea Orapred Oratuss Organidin NR Ortho-EST Oruvail Osmitrol Oticin HC Otocain Otogesic Ovace Oxandrin Oxycontin Oxyfast Oxyir Pacerone Palgic D Palgic DS Palladone Pamelor Pamine Pamine Forte Panafil Panatuss Panatuss DX Panatuss DXP Pancof Pancof EXP Pancof HC Pancof XP Pandel Panixine Panlor SS Panmist LA Pannaz Pannaz S Panoxyl 5 Panoxyl AQ 2.5 Panoxyl AQ 5 Parafon Forte DSC Parcopa Paregoric Parlodel Parnate Paxil Paxil CR 8 Pce Pediaflor Pediapred Pediatan D Pediatann-CT Pediatex Pediatex 12 D Pediatex 12 DM Pediatex 12D Pediatex 12dM Pediatex DM Pediatex HC Pediatex-CT Pediatex-D Pediazole Pediotic Pediox Pediox-S Peganone Penlac Pepcid Pepcid RPD P-Epd HCL/Guaifenesin Percocet Percodan Percolone Peridex Periostat Permax Persantine Pexeva Phanasin Phanatuss HC Phenabid Phena-HC Phena-Plus Phena-S Phena-S 12 Phenergan Phenydex Phenylephrine HCL Phos-Flur Phrenilin Pilocar Pirosal Plaquenil Plendil Pletal Plexion Plexion SCT Plexion TS Pneumotussin Poly Hist DM Poly Hist Forte Poly Hist HC Poly Hist PD Poly Tan Poly Tan D Poly Tan DM Polycitra Polycitra-K Polycitra-LC Poly-Histine Polysporin Polytrim Poly-Tussin Poly-Tussin DM Poly-Tussin XP Poly-Vent Poly-Vi-Flor Poly-Vi-Flor W/Iron Pontocaine Pramosone Pramotic Pravachol Pravigard PAC Precare Pred Forte Prehist Prelone Prenate Advance Prenate GT Prevacid Prevacid IV Prevacid Naprapac Prevident Prevident 5000 Plus Prevpac Prilosec Prinivil Prinzide Proamatine Procardia Procardia XL Pro-Clear Proctocort Profen Forte Profen Forte DM Profen II Profen II DM Prohist Prohist DM Prolex D Prolex DH Prolex DM Prolex PD Prolixin Prolixin Decanoate Proloprim Promethazine VC Promethazine VCCodeine Pronestyl Pronestyl-SR Propine Proquin XR Pro-Red Proscar Prosed EC Prosed/DS Prosom Protid Protopic Protuss Proventil Proventil HFA Provera Prozac Prozac Weekly PseudoephedrineGuaifenesin Psorcon Psorcon E Psoriatec Pulmophylline 9 Purinethol P-V-Tussin Pyridium Pyridium Plus Qdall Quadtann Qual-Tussin Questran Questran Light Quibron-T/SR Quixin Radiagel Ranexa Rapiflux Raptiva Rebetol Rebif Reglan Relafen Relagard Relagesic Relenza Remeron Remular-S Reprexain Rescon Rescon-Jr Rescon-Mx Rescula Respa A.R. Respa-1st Respa-Dm Respaire-60 Respa-PE Respi-Tann Respi-Tann G Respi-Tann PD Restasis Restoril Retin-A Retrovir Revia Rheumatrex Rhinaclear Ribatab Ricobid Ricotuss Rifadin Rifadin IV Rifamate Rimso-50 Riomet Ritalin Ritalin LA Ritalin-SR Robaxin Robaxin-750 Robinul Robinul Forte Rocaltrol Romazicon Rondec Rondec-DM Rondec-TR Rosac Rosanil Rowasa Roxicet Roxicodone Roxicodone Intensol Ru-Tuss 800 DM Ru-Tuss A Ru-Tuss Dm Ryna-12 Ryna-12 S Ryna-12x Rynatan Rynatan Pediatric Rynatuss Rythmol Salagen Salex Salflex Sanctura Sandimmune Santuss Sarafem Sebizon Sectral Selseb Selsun Rx Semprex-D Septra Septra DS Serax Serostim Serzone Silvadene Sina-12X Sinadex 12 Sinemet CR Sinemet-10/100 Sinemet-25/100 Sinemet-25/250 Sinequan Sitrex Sitrex PD Slofed 60 Solaquin Forte Solu-Cortef Soma Soma Compound Soma Compound W/Codeine Sonata Sorbutuss Spacol Spectazole Spectracef Sporanox S-T Forte 2 Sta-D Stadol Stadol NS Staflex Stagesic-10 Stahist Starlix Sterapred Sterapred DS Striant Strovite Strovite Forte Strovite Plus Stuartnatal Plus 3 10 Sudal Sudal 12 Sudal DM Sudal SR Sudal-12 Sudex Sulf-10 Supervite Suphera Support-500 Surmontil Symbyax Symlin Symmetrel Symtan Symtan A Synalar Synalgos-DC Taclonex Tagamet Talacen Taladine Talwin NX Tambocor Tamiflu Tanafed Dmx Tanafed DP Tandur DM Tannate-12 Tapazole Tarka Tasmar Temodar Temovate Temovate E Temovate Emollient Tenex Tenoretic 100 Tenoretic 50 Tenormin Tequin Terak Terazol 3 Terazol 7 Terramycin Terramycin IM Tessalon Tessalon Perle Tetravisc Teveten Teveten HCT Texacort Theocap Theochron Theracodophen-325 Theracodophen-650 Theracodophen-Low-90 Therafeldamine Thera-Flur-N Theraprofen-60 Theraprofen-90 Theraproxen Theraproxen-90 Theratramadol-60 Theratramadol-90 Thiocyl Thrombin-JMI Tiazac Tibamine LA Ticlid Tidafen DM Tidafen LA Tigan Tigan Thera-Ject Time-Hist QD Timoptic Timoptic-XE Tisseel VH Tobrex Tofranil Tofranil-PM Tolectin 600 Tolectin DS Tolinase Topicort Topicort LP Toprol XL Toradol Touro Allergy Touro CC Touro CC-LD Touro DM Touro HC Touro LA Touro LA-LD Trandate Tranxene SD Tranxene T-Tab Trental Trepadone Triant-HC Triaz Tricare Tricor Tridesilon Triglide Trikof-D Trilyte With Flavor Packets Trimpex Trinsicon Trionate Trispec DMX Trispec PSE Trispec SFX Trispec-DM Trispec-PE Trispec-SF Trituss Trituss-A Trituss-ER Tri-Vi-Flor Trycet T-Stat Tusnel Tusnel Ped-C Tusnel Pediatric Tusnel-DM Tusnel-HC Tussafed Tussafed EX Tussafed-HC Tussafed-HCG Tussall Tussall-ER 11 Tuss-DA Tuss-DA NR Tussend Tussi-12 Tussi-12 S Tussi-12D Tussi-12D S Tussidex Tussilan N.F. Tussinal 12 Tussinate Tussionex Tussi-Organidin Dm NR Tussi-Organidin Dm-S NR Tussi-Organidin NR Tussi-Organidin-S NR Tussi-Pres Tussi-Pres Pediatric Tusso-DF Tusso-DM Tusso-HC Tusso-XR Tylenol W/Codeine No.3 Tylenol W/Codeine No.4 Tylox Tyzeka Ultane Ultracet Ultram Ultravate Uniretic Uni-Tann CS Univasc Urecholine Uretron D/S Urimax Urised Urispas Uro Blue Urocit-K Uro-Kp-Neutral Uroxatral Valium Vanex HD Vanos Vanspar Vantin Varidin Vaseretic Vasocidin Vasotec Vazol-D Vazotan Vazotuss HC Velosef Ventolin HFA Vepesid Verdeso Verelan Verelan PM Vermox Versed Versiclear Vertin-32 Vesicare Vfend Vfend IV VG Vibramycin Vibra-Tabs Vic-Forte Vicodin Vicodin ES Vicodin HP Vicon Forte Vicoprofen Vi-Daylin F ADC Vi-Daylin/F Vi-Daylin/F + Iron Vi-Daylin/F Adc Plus Iron Videx Videx EC Viravan DM Viravan-S Viravan-T Viroptic Vistaril Vitafol Vitafol-OB Vitafol-PN Vita-Numonyl Vita-Numonyl DM Vita-Numonyl EX Voltaren Voltaren-XR Vusion Vytorin Wellbutrin Wellbutrin SR Wellbutrin XL Westcort Xanax Xanax XR Xenaderm Xibrom Xirahist Xirahistdm Xiratuss Xodol 10/300 Xodol 5/300 Xodol 7.5/300 Xopenex Xopenex HFA Xpect-AT Xpect-HC Xylocaine Xylocaine Viscous Xyrem Yocon Yodefan-NF Zaclir Zaditor Zanaflex Zantac Zarontin Zaroxolyn Z-Cof 12DM Z-Cof DM Z-Cof DMX Z-Cof HC Z-Cof HCX 12 Z-Cof LA Z-Cof LAX Zebeta Zegerid Zelapar Zephrex Zephrex-LA Zestoretic Zestril Zetacet Ziac Ziana Zinacef Zinx Zithromax Zithromax Tri-Pak Zmax Zocor Zoderm Zofran Zoloft Zomig Zomig ZMT Zonalon Zonegran Zorbtive Zorprin Zotex Zotex Dmx Zotex GPX Zotex LAX Zotex-DM Zotex-G Zotex-GP Zotex-LA Zoto-HC Zovirax Ztuss Ztuss ZT Zycose Zydone Zylet Zyloprim Zymar Zymine HC Zymine-D Zyrtec Zyrtec-D Zyvox 13