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1199SEIU Funds Preferred Drug List (PDL)
1199SEIU Preferred Drug List (PDL) Please take this guide with you the next time you visit your doctor. © 2016 Express Scripts Holding Company. All Rights Reserved. If you have questions about your prescription drug benefit, visit Express-Scripts.com or call Express Scripts Member Services at (800) 818-6720. For questions about your 1199SEIU benefits, call the 1199SEIU Benefit Funds’ Member Services representatives at (646) 473-9200. * M G 4 6 7 7 9 G* MG46779G (Ed. 08/16) Express Scripts manages your prescription benefit for the 1199SEIU Benefit Funds. Section II provides a listing of nonpreferred brands and their possible preferred alternatives. SAFETY CONSIDERATION SYMBOLS Here is a quick guide that explains our safety symbols. These symbols appear next to certain medications. Weigh the risk of birth defects or other adverse outcomes. Do not use during pregnancy. PRESCRIPTION PROGRAM CONSIDERATION SYMBOLS For more information, please call Express Scripts: (800) 753-2851. [PA]This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program. [ST]This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program. [QD]This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program. OTHER SYMBOLS: [AC]This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo. Please call Accredo: (800) 803-2523. [CVS]This symbol indicates that this medication is only available through CVS Health. Please call: (800) 818-6720 for dispensing guidelines. [PICA]This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage. Shaded areas indicate the most recent additions to the Preferred Drug List. Drugs Not Covered by the 1199SEIU Benefit Funds Cosmetic Drugs Non-Sedating Antihistamines Fertility Drugs O ver-the-counter Drugs (except for diabetic supplies) or as mandated by PPACA legislation Investigational/Experimental Drugs Select Cough & Cold Drugs Erectile Dysfunction Drugs Please refer to your Summary Plan Description for a complete list of excluded drugs. Information was in effect at the time of printing and may be subject to change. For the most up-to-date 1199SEIU Benefit Funds Preferred Drug List go to www.1199SEIUBenefits.org. 1 Section I: Therapeutic Drug Categories Adrenal Hormones (Effective 3-1-11) Gmethylprednisolone Gprednisolone prednisolone sodium phosphate G Gprednisone G cortisone acetate Gdexamethasone G fludrocortisone acetate Ghydrocortisone Alzheimer’s Agents G G Grivastigmine P Exelon Solution P Namenda Dose Pak Anticonvulsants G P nilutamide [PICA] Xtandi [AC/PA/QD/PICA] P Zytiga [AC/PA/QD/PICA] (Effective 7-1-10) G carbamazepine G carbamazepine XR G clonazepam G diazepam kit G divalproex sodium G divalproex sodium ER G divalproex sodium sprinkles G ethosuximide Gfelbamate Ggabapentin Glamotrigine G lamotrigine ODT G lamotrigine XR Glevetiracetam G levetiracetam XR Goxcarbazepine G phenobarbital G phenytoin chewable tablet G phenytoin extended-release G phenytoin suspension G primidone Gtiagabine topiramate [PA] G G valproic acid Gzonisamide P Banzel Tablet P Celontin P Diastat P Dilantin 30mg P Gabitril 12mg, 16mg PLyrica [ST/QD] P Peganone PVimpat G G G Gclarithromycin, c larithromycin ER Gerythromycin base Gerythromycin ethylsuccinate Gerythromycin ethylsuccinate/ sulfisoxazole acetyl Gerythromycin stearate PDificid Eryped Suspension P (Antibiotics) Oral Penicillins Gamoxicillin trihydrate Gamoxicillin trihydrate/ potassium clavulanate, ER Gamoxicillin trihydrate/ potassium clavulanate chewable Gamoxicillin trihydrate/ potassium clavulanate suspension Gampicillin trihydrate Gdicloxacillin sodium Gpenicillin v potassium PAugmentin Suspension 125 - 31.25mg/5ml Oral Tetracyclines G G G G P Namenda XR PNamzaric (Effective 3-1-11) bicalutamide [PICA] flutamide [PICA] Anti-Infectives Celestone Solution Medrol Tablet 2mg (Effective 1-1-16) Gdonepezil Ggalantamine Gmemantine Antiandrogens P P demeclocycline HCl doxycycline hyclate capsule doxycycline hyclate enteric coated tablet doxycycline hyclate tablet Antiparkinsonism Agents Gamantadine Gbenztropine Gbromocriptine Gcarbidopa Gcarbidopa/levadopa Key: G =Preferred generic medication. P =Preferred brand-name medication. = Weigh the risk of birth defects or other adverse outcomes. =Do not use during pregnancy. doxycycline monohydrate minocycline HCl, XR tetracycline HCl Oral Cephalosporins Gcefaclor, ER Gcefadroxil hydrate Gcefdinir Gcefditoren pivoxil Gcefixime suspension Gcefpodoxime proxetil Gcefprozil Gceftibuten Gcefuroxime axetil Gcephalexin monohydrate PCeftin Suspension Oral Erythromycins and other Macrolides Oral Quinolones Gciprofloxacin ER Gciprofloxacin HCl tablet Gciprofloxacin suspension Glevofloxacin Gmoxifloxacin Gofloxacin P Avelox ABC Pack Gazithromycin (Effective 1-1-10) G carbidopa/levadopa ER Gcarbidopa/levadopa/entacapone Gentacapone Gpramipexole Di-HCl Gpramipexole ER Gropinirole Gselegiline Gtolcapone Gtrihexylphenidyl PApokyn [AC] [pa]This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program. [st]This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program. [qd]This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program. [ac]This symbol indicates that this specialty medication must be obtained through Accredo. Please call: (800) 803-2523. [cvs]This symbol indicates that this medication is only available through CVS Health. Please call: (800) 818-6720 for dispensing guidelines. [pica]This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage. 2 Antivertigo & Antiemetic Drugs G G ondansetron HCl [QD/PICA] ondansetron ODT [QD/PICA] (Effective 4-1-10) G granisetron HCl [QD/PICA] PEmend [QD/PICA] Anti-Psoriatic/Anti-Seborrheic Anti-Psoriatic/Anti-Seborrheic Topical Agents (Effective 3-1-11) G calcitriol ointment G Drithocreme HP Ghydrocortisone acetate/ pramoxine G selenium sulfide Gcalcipotriene Gcalcipotriene/betamethasone G P P sodium sulfacetamide Pramosone Pramosone E Benign Prostate Hyperplasia (BPH) Therapy G alfuzosin HCl ER Gdoxazosin G dutasteride G G G dutasteride-tamsulosin finasteride tamsulosin HCl Gterazosin Biotechnology Drugs Erythroid Stimulants Hereditary Angioedema - Plasma derived C1 Esterase Inhibitors (Effective 3-1-14) PAranesp [AC/PA/PICA] PProcrit [AC/PA/PICA] Cardiovascular (Effective 6-1-15) PBerinert [PA/AC] (Blood Pressure/Heart/Cholesterol) Beta Blockers Gacebutolol HCl atenolol G Gbetaxolol HCl Gbisoprolol fumarate Gcarvedilol Glabetalol HCl Gmetoprolol succinate XL Gmetoprolol tartrate Gnadolol Gpindolol Gpropranolol HCl Gpropranolol HCl capsule, sustained action 24 hr Gtimolol maleate PHemangeol Calcium Channel Blockers Gdiltiazem HCl Gdiltiazem HCl capsule, sustained release 12 hr Gdiltiazem HCl capsule, sustained release 24 hr Gnimodipine G verapamil ER G verapamil ER PM G verapamil HCl G verapamil HCl capsule, 24 hr sustained release pellets Dihydropyridines Gamlodipine besylate Gfelodipine Gisradipine Key: G =Preferred generic medication. P =Preferred brand-name medication. = Weigh the risk of birth defects or other adverse outcomes. =Do not use during pregnancy. Gnicardipine Gnifedipine tablet, sustained action Gnifedipine tablet, sustained release osmotic push Gnisoldipine ACE Inhibitors G G G G lovastatin [QD] pravastatin [QD] rosuvastatin [QD] simvastatin [QD] Other Antilipidemics Gcolestipol HCl Gcholestyramine/aspartame Gcholestyramine/sucrose Gfenofibrate Gfenofibrate, micronized Gfenofibrate, nanocrystal G fenofibric acid Ggemfibrozil G niacin ER G omega-3 acid ethyl esters [PA] PColestid PJuxtapid PWelchol PZetia G G G G G G G G G G benazepril HCl captopril enalapril maleate fosinopril sodium lisinopril moexipril HCl perindopril erbumine quinapril ramipril capsules trandolapril G G G G G G G G G G G c andesartan c andesartan/hydrochlorothiazide Select Combination eprosartan mesylate 600mg G G G amlodipine/atorvastatin [QD] atorvastatin calcium [QD] fluvastatin, ER [QD] Angiotensin II Blockers irbesartan irbesartan/hydrochlorothiazide losartan/hydrochlorothiazide losartan potassium telmisartan telmisartan/HCTZ valsartan valsartan/hydrochlorothiazide Antilipidemics - Statin Drugs Antihypertensives G G G G G G G G G G a mlodipine besylate/benazepril a mlodipine/valsartan amlodipine/valsartan/HCTZ atenolol/chlorthalidone benazepril HCl/HCTZ bisoprolol fumarate/ hydrochlorothiazide captopril/hydrochlorothiazide enalapril maleate/HCTZ fosinopril/hydrochlorothiazide lisinopril/hydrochlorothiazide [pa]This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program. [st]This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program. [qd]This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program. [ac]This symbol indicates that this specialty medication must be obtained through Accredo. Please call: (800) 803-2523. [cvs]This symbol indicates that this medication is only available through CVS Health. Please call: (800) 818-6720 for dispensing guidelines. [pica]This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage. 3 Cardiovascular (Blood Pressure/Heart/Cholesterol), continued Gmethyldopa/hydrochlorothiazide Gmetoprolol/hydrochlorothiazide G moexipril/hydrochlorothiazide G propranolol/hydrochlorothiazide G nadolol/bendroflumethiazide G quinapril/hydrochlorothiazide G telmisartan/amlodipine G trandolapril/verapamil Long-Acting Nitrates (Topical) (Effective 7-1-10) Gnitroglycerin patches, ointment Drugs to Endocrine Gcilostazol G clopidogrel bisulfate Gdipyridamole Gaspirin/dipyridamole PBrilinta PEffient PZontivity PCSK9 Inhibitors (Effective 1-1-16) P P P P G G P Repatha Syringe [PA/AC] Anticoagulants (oral) (Eff. 7-1-14) Gwarfarin PEliquis PPradaxa PSavaysa PXarelto Antidotes (Effective 1-1-16) PPraxbind Praluent Pen [PA/AC] Praluent Syringe [PA/AC] Repatha Pushtronex [PA/AC] Repatha Sureclick [PA/AC] (Updated 3-1-14) tolterodine tartrate, ER trospium chloride, ER PMyrbetriq PVesicare (Diabetes/Hormones/Contraceptives) Insulin Therapy (Updated 7-1-16) Rapid Acting PAfrezza PHumalog Short Acting Humulin R Humulin R Kwikpen Intermediate Acting P Humulin N, Humulin Kwikpen PHumulin 70/30, Humulin 70/30 Kwikpen P Humalog Mix 75-25 P Humalog Mix 50-50 Long Acting P P (Effective 7-1-10) Treat Overactive Bladder Gdarifenacin hydrobromide Gflavoxate Goxybutynin chloride, ER P P Antiplatelet Agents (oral) Lantus, Lantus Solostar Toujeo Solostar Oral Hypoglycemic Agents (Revised – Effective 4-1-10) Gacarbose Gglimepiride G glipizide, glipizide ER G glipizide/metformin HCl [QD] Gglyburide Gglyburide/metformin G glyburide micronized Gmetformin HCl, metformin HCl ER Gmiglitol Gnateglinide G pioglitazone HCl [QD] G pioglitazone/glimepiride [QD] G pioglitazone/metformin [QD] Grepaglinide G repaglinide/metformin [QD] Gtolazamide Gtolbutamide Key: G =Preferred generic medication. P =Preferred brand-name medication. = Weigh the risk of birth defects or other adverse outcomes. =Do not use during pregnancy. P P P Avandamet [QD] Avandaryl [QD] Avandia [QD] Blood Glucose Monitoring Devices (Updated 7-1-16) SGLT2/DPP4 Inhibitor Combinations (Effective 1-1-16) P P P P P P P P P P P Injectable Hypoglycemic Agents (Effective 10-1-09) SGLT2 - Sodium Glucose Co-transporter Agents (Updated 7-1-16) PInvokamet [QD] PInvokana [QD] PJardiance [QD] P Synjardy [QD] ACCU-CHEK Aviva Plus ACCU-CHEK Compact Plus ACCU-CHEK Nano SmartView Contour Next EZ Monitor Contour Next Meter Contour Next Monitor Contour Next USB Meter Contour Next USB Monitor Contour USB Meter True Metrix Blood Glucose Meter True Metrix Air Glucose Meter PGlyxambi Contraceptive Agents (GLP-1 receptor agonist) (Updated 7-1-16) G G G G G G G G G G G G G G G G G G G G G G G P P Bydureon [PA/QD], Bydureon Pen [PA/QD] PByetta [PA/QD] PTrulicity [PA/QD] DPP-4 Inhibitors (Updated 7-1-16) P Janumet, Janumet XR PJanuvia PJentadueto [QD] PJentadueto XR [QD] P Tradjenta [QD] Blood Glucose Test Strips (Updated 7-1-16) PACCU-CHEK Aviva Plus Test Strips PACCU-CHEK Compact Plus Test Strips P ACCU-CHEK SmartView Test Strip PBreeze 2 P Contour Next Test Strips P Contour Test Strips P True Metrix Glucose Test Strips Amethia, Amethia Lo Cryselle Gianvi Gildess FE Gildess 24 FE Junel FE Lomedia 24 FE Loryna Microgestin, Microgestin FE Mononessa Necon Next Choice Next Choice One Dose norgestimate-ethinyl estradiol norethindrone-e.estriadol-iron Orsythia Previfem Syeda Trinessa, Trinessa Lo Tri-Previfem Wymzya FE Xulane Zenchent FE Ella [pa]This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program. [st]This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program. [qd]This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program. [ac]This symbol indicates that this specialty medication must be obtained through Accredo. Please call: (800) 803-2523. [cvs]This symbol indicates that this medication is only available through CVS Health. Please call: (800) 818-6720 for dispensing guidelines. [pica]This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage. 4 Endocrine (Diabetes/Hormones/Contraceptives) continued Intrauterine Devices/Subdermal Implants (Effective 1-1-16) P P P P P P P P P Liletta [AC] Mirena [CVS] Nexplanon [AC] Skyla [CVS] Oral/Transdermal Testosterone Replacement Agents Estrogen Agents (oral/vaginal) (Updated 7-1-16) (Updated 1-1-13) G G Cenestin Enjuvia Estring Osphena Vagifem Vaginal Tablets G testosterone gel pump 1.25gm (1%) [PA] P Androderm Patch [PA] P Androgel pump 20.25/1.25 [PA] P Axiron [PA] P Methitest Estrogen Patches (Effective 7-1-09) G estradiol G methyltestosterone capsule G testosterone gel in packet 25mg (1%), 50mg (1%) [PA] estradiol tabs estropipate Gastrointestinal H-Pylori Agents (Effective 1-1-13) Grabeprazole [QD] Granitidine HCl P Nexium OTC [QD] PNexium Rx Suspension [QD] Glansoprazole/amoxicillin/ clarithromycin PPylera Pancreatic Enzymes Ulcer Drugs (Effective 1-1-13) Gcimetidine tablet Gesomeprazole capsule [QD] Gfamotidine, f amotidine suspension G lansoprazole [QD] G misoprostol Gnizatidine Gomeprazole [QD] Gomeprazole/sodium bicarbonate capsule, packet [QD] G pantoprazole [QD] PCreon PZenpep Bowel Evacuants (Effective 6-1-15) Growth Hormones PEpi Pen [PICA] P Epi Pen Jr. [PICA] G probenecid w/colchicine PColcrys PKrystexxa [AC/PA] PUloric [ST/QD] (Effective 3-1-14) PLinzess (Effective 3-1-14) (Revised – Effective 7-1-10) Egrifta [PA] Norditropin Flexpro [PA/AC/PICA] P Norditropin Nordiflex [PA/AC/PICA] PZomacton [PA/AC/PICA] Immunoglobulin Agents (injectables) P P Phosphate Binders (Effective 6-1-15) (Effective 3-1-11) Gallopurinol Gprobenecid P P G balsalazide disodium G mesalamine enema Gsulfasalazine PApriso PCanasa PLialda calcium acetate sevelamer carbonate PEG 3350 bowel preparation Irritable Bowel Syndrome epinephrine autoinjector [PICA] Gout Therapy (Updated 7-1-16) G G G Epinephrine Autoinjectors G Ulcerative Colitis Agents Carimune NF Nanofiltered [PA/AC] Flebogamma DIF [PA/AC] Immunotherapy (Oral) PGrastek [PA] Key: G =Preferred generic medication. P =Preferred brand-name medication. = Weigh the risk of birth defects or other adverse outcomes. =Do not use during pregnancy. PZorbtive [PA/AC/PICA] (Effective 5-1-09) PGamunex [PA/AC] PGamunex-C [PA/AC] PHizentra [PA/AC] (Effective 10-1-14) POralair [PA/AC] PRagwitek [PA] [pa]This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program. [st]This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program. [qd]This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program. [ac]This symbol indicates that this specialty medication must be obtained through Accredo. Please call: (800) 803-2523. [cvs]This symbol indicates that this medication is only available through CVS Health. Please call: (800) 818-6720 for dispensing guidelines. [pica]This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage. 5 Hepatitis C Antivirals (Direct-Acting/Protease Inhibitors) Genotype 1 P P Genotype 3 (Effective 1-1-16) Harvoni [PA/AC/QD] Sovaldi [PA/AC/QD] P P Multiple Sclerosis Injectables PAvonex [PA/AC/PICA] P Copaxone 40mg [PA/AC/PICA] Select Biologic PActemra [PA/AC/PICA] PEnbrel [PA/AC/PICA] PHumira [PA/AC/QD/PICA] POrencia [ST/PA/AC/PICA] Muscle Relaxants Harvoni [PA/AC/QD] Agents PPlegridy [PA/AC/PICA] P Rebif, Rebif Rebidose [PA/AC/PICA] (Effective 7-1-10) PRemicade [ST/PA/AC] PRituxan [PA/AC] Crohn’s Disease Agents (Injectables) Plaque Psoriasis Agents (Injectables) PCosentyx [PA/AC/PICA] PEnbrel [PA/AC/PICA] PHumira [PA/AC/QD/PICA] G G acetaminophen/butalbital acetaminophen/caffeine/ butalbital G aspirin/caffeine/butalbital G aspirin/caffeine/dihydrocodeine G buprenorphine HCl SL tablets [PA/QD] G c odeine/APAP/caffeine/butalbital G codeine/aspirin/caffeine/ butalbital G codeine phosphate/acetaminophen Gcodeine sulfate tablet Non-Narcotic Analgesics NSAIDs diclofenac/misoprostol diclofenac potassium diclofenac sodium diclofenac sodium topical drops, gel etodolac etodolac tablet, sustained release 24 hr fenoprofen calcium 600mg flurbiprofen ibuprofen indomethacin [QD] indomethacin capsule, sustained action [QD] ketoprofen Key: G =Preferred generic medication. P =Preferred brand-name medication. = Weigh the risk of birth defects or other adverse outcomes. =Do not use during pregnancy. G dantrolene sodium G meprobamate Gmetaxalone Gmethocarbamol G orphenadrine citrate G orphenadrine cmpd orphenadrine cmpd forte G Gtizanidine (Pain Relievers) Narcotics G P (Effective 10-1-09) Narcotic Analgesics G G G G G PExtavia [PA/AC/PICA] P Glatiramer Acetate [PA/AC/PICA] PHumira [PA/AC/QD/PICA] P Humira Pediatric [PA/AC/QD/PICA] Gbaclofen G carisoprodol cmpd/codeine Gchlorzoxazone G cyclobenzaprine, XR G G Genotype 4, 5, & 6 (Effective 1-1-16) (Effective 3-1-11) and Immunologic Rheumatoid Arthritis Agents (Injectables) G G G G Daklinza [PA/AC/QD] Sovaldi [PA/AC/QD] (Effective 4-1-15) Gdihydrocodeine/APAP/caffeine G fentanyl citrate lozenges [QD] G fentanyl patch [PA] Ghydrocodone bit/acetaminophen Ghydrocodone/ibuprofen Ghydromorphone G hydromorphone ER [QD] G levorphanol tartrate G meperidine tabs, solution Gmethadone Gmorphine sulfate G morphine sulfate, sustained action [QD] Goxycodone/acetaminophen G oxycodone/aspirin Goxycodone HCl [QD] Goxycodone/ibuprofen Goxymorphone Goxymorphone ER [QD] POxycontin [QD] Miscellaneous Analgesic Therapy (Effective 1-1-09) G G G tramadol [QD] tramadol ER tablets [QD] tramadol/acetaminophen [QD] (Pain Relievers) G G G G G G G G G G G G k etoprofen capsule, 24 hr sustained release pellets ketorolac tablets meclofenamate sodium mefenamic acid meloxicam [QD] nabumetone naproxen naproxen sodium, ER oxaprozin piroxicam sulindac tolmetin sodium NSAID COX-2 Inhibitors Gcelecoxib Migraine/Headache Therapy (Effective 1-1-09) G almotriptan malate [QD] G frovatriptan succinate [QD] Gnaratriptan [QD] G rizatriptan (tabs, disintegrating tabs) [QD] Gsumatriptan (tabs, nasal spray) [QD] Gsumatriptan injection [QD/PICA] Gzolmitriptan [QD] Gzolmitriptan ODT [QD] PRelpax [QD] Osteoarthritis Agents (Injectable) (Updated 7-1-16) PEuflexxa [AC/PA/QD] PMonovisc [AC/PA] POrthovisc [AC/PA] [pa]This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program. [st]This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program. [qd]This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program. [ac]This symbol indicates that this specialty medication must be obtained through Accredo. Please call: (800) 803-2523. [cvs]This symbol indicates that this medication is only available through CVS Health. Please call: (800) 818-6720 for dispensing guidelines. [pica]This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage. 6 Ophthalmics (Eye Preparations) Ophthalmic Combination Carbonic Anhydrase Inhibitors/Beta Antagonists (Effective 7-1-13) Gdorzolamide/timolol Glatanoprost Gtravoprost Ophthalmic Carbonic Anhydrase Inhibitors (Effective 1-1-10) Gdorzolamide Ophthalmic Beta-Blockers Ophthalmics-Steroids (Effective 1-1-10) (Effective 1-1-10) Gdexamethasone Gfluorometholone G prednisolone acetate G prednisolone sodium phosphate P FML S.O.P. Miscellaneous OphthalmicsAntihistamine & Mast-Cell Stabilizers (Effective 3-1-11) Gazelastine Gcromolyn G epinastine HCl olopatadine HCl G PPataday Ophthalmic ProstaglandinAnalogues (Effective 5-1-09) Gbimatoprost G betaxolol HCL Gcarteolol Glevobunolol Gmetipranolol timolol maleate G Antibiotic-Ophthalmics (Effective 1-1-09) Gbacitracin G bacitracin/polymyxin B G ciprofloxacin drops G erythromycin base ointment Ggatifloxacin Ggentamicin sulfate ointment, drops Glevofloxacin Gneomycin sulfate/bacitracin/ polymyxin B ointment Gneomycin sulfate/gramicidin D/ polymyxin B drops Gofloxacin drops Gpolymyxin B/trimethoprim drops Gtobramycin sulfate drops P Ciloxan Oph Ointment PTobrex Oph Ointment PVigamox Ophthalmic Anti-Inflammatory Agents (NSAIDs) (Effective 3-1-11) G G G G bromfenac sodium diclofenac sodium flurbiprofen sodium ketorolac tromethamine Ophthalmic Steroid-Antibiotic Combinations (Effective 3-1-11) Gneomycin/bacitracin/ polymyxin B/HC Gneomycin/polymyxin B/ dexamethasone G neomycin/polymyxin B/HC Gtobramycin-dexamethasone suspension P TobraDex Oint Osteoporosis/Paget’s Disease Galendronate solution [QD] Galendronate tab [QD] Galendronate weekly [QD] calcitonin-salmon nasal spray G Otics G ibandronate [QD] G raloxifene HCl G risedronate sodium DR [QD] Grisedronate sodium tablet [QD] PMiacalcin Injection (Ear Preparations) (Effective 4-1-10) Gneomycin/polymyxin/HC Psychotherapeutics Gofloxacin (Anxiety/Depression) Oral Hypnotic Agents G estazolam [QD] Geszopiclone [QD] G flurazepam HCl [QD] G temazepam [QD] G triazolam [QD] Gzaleplon [QD] Gzolpidem [QD], zolpidem ER [QD] G zolpidem SL tablet [QD] Miscellaneous Antidepressants Gamitriptyline-chlordiazepoxide amitriptyline HCl G Gamitriptyline-perphenazine Gamoxapine Gbupropion HCl tablet [QD] bupropion HCl tablet, sust. action [QD] G Key: G =Preferred generic medication. P =Preferred brand-name medication. = Weigh the risk of birth defects or other adverse outcomes. =Do not use during pregnancy. G clomipramine HCl G desipramine HCl doxepin HCl G duloxetine HCl [QD] G imipramine HCl G imipramine pamoate G G maprotiline HCl G mirtazapine tablet G mirtazapine tablet, rapid dissolve G nortriptyline HCl G phenylzine sulfate G protriptyline HCl G tranylcypromine sulfate Gtrazodone HCl G trimipramine maleate G venlafaxine HCl, ER [QD] PMarplan P Nuplazid [AC] Anxiolytics G alprazolam, alprazolam ER, ODT Gbuspirone HCl chlordiazepoxide HCl G clorazepate dipotassium G diazepam G lorazepam G oxazepam G SSRI Antidepressants G citalopram HBr [QD] Gescitalopram oxalate [QD] G fluoxetine DR 90mg [QD] fluoxetine HCl capsules 10mg, 20mg, 40mg [QD] G G fluoxetine HCl oral solution [QD] fluoxetine HCl tablet 10mg, 20mg [QD] G G fluvoxamine maleate, ER [QD] paroxetine HCl [QD] G [pa]This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program. [st]This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program. [qd]This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program. [ac]This symbol indicates that this specialty medication must be obtained through Accredo. Please call: (800) 803-2523. [cvs]This symbol indicates that this medication is only available through CVS Health. Please call: (800) 818-6720 for dispensing guidelines. [pica]This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage. 7 Psychotherapeutics G (Anxiety/Depression) sertraline HCl [QD] Antipsychotics (Updated 7-1-16) Garipiprazole [QD] G aripiprazole ODT [QD] G chlorpromazine injection [PICA] G chlorpromazine tablet G clozapine, clozapine ODT Gfluphenazine Ghaloperidol G haloperidol decanoate injection [PICA] G haloperidol lactate concentrate Gloxapine Gmolindone Respiratory Attention Deficit Hyperactivity Disorder (Effective 5-1-09) Inhaled Corticosteroid Therapy Anticholinergic/Muscarinic Agents (Updated 7-1-13) (Updated 6-1-15) Short-Acting Agents Gamphetamine and dextroamphetamine salts [PA] Gamphetamine and dextroamphetamine salts ER [PA] G clonidine ER [PA] G D-amphetamine tablet, ER [PA] G dexmethylphenidate, ER [PA] G guanfacine ER [PA] Gmethylphenidate solution Gmethylphenidate tablet, chewable [PA] G methylphenidate CD, ER [PA] PStrattera [PA] PVyvanse [PA] (Allergy/Asthma/COPD) Beta Agonist Agents (Updated 1-1-13) Short-Acting Beta Agonist (inhalers) P P G olanzapine [QD], olanzapine ODT [QD] Golanzapine-fluoxetine [QD] Gpaliperidone [QD] Gperphenazine Gpimozide Gquetiapine fumarate G risperidone tab, ODT [QD] Gthioridazine Gthiothixene Gtrifluoperazine HCl G ziprasidone HCl [QD] PAristada PFazaclo PRisperdal Consta PSeroquel XR [QD] ProAir HFA ProAir Respiclick Short-Acting Beta Agonist (nebulized solutions) Galbuterol sulfate inhalant solution Glevalbuterol inhalation solution Long-Acting Beta Agonist (inhalers) P Arcapta Neohaler PSerevent Diskus [QD] Nasal Corticosteroids Gbudesonide Gflunisolide Gfluticasone propionate G mometasone furoate G triamcinolone acetonide Gbudesonide soln [QD] P Alvesco [QD] P Asmanex [QD], Asmanex HFA [QD] P Pulmicort Flexhaler [QD] P QVAR [QD] Miscellaneous Pulmonary Agents (Updated 3-1-14) PCombivent P Combivent Respimat P Dulera [QD] P Symbicort [QD] Pulmonary Arterial Hypertension (PAH) Agents Gipratropium inhalant soln P Atrovent HFA Inhaler Long-Acting Agents (LAMA) P P P Spiriva Inhaler [QD] Spiriva Respimat [QD] Tudorza Pressair [QD] Long-Acting Muscarinic/ Beta 2 combination Agents (Effective 1-1-16) P Stiolto Respimat [QD] (Endothelial Receptor Antagonist) (Effective 6-1-12) POpsumit [ST/AC/PA] PTracleer [ST/AC/PA] Topical Actinic Keratosis Agents (Effective 1-1-13) Gfluorouracil cream 5% Gfluorouracil solution 2%, 5% G imiquimod 5% PPicato Gel 0.015%, 0.05% Topical Acne Therapy (Effective 1-1-09) Gadapalene Gbenzoyl peroxide Gbenzoyl peroxide microspheres Gclindamycin/benzoyl peroxide Gclindamycin phosphate G clindamycin phosphate/tretinoin [PA] Gerythromycin base/benzoyl peroxide Key: G =Preferred generic medication. P =Preferred brand-name medication. = Weigh the risk of birth defects or other adverse outcomes. =Do not use during pregnancy. Gerythromycin base/ethyl alcohol Gerythromycin base/ethyl alcohol gel Gerythromycin base/ ethyl alcohol swabs Gmetronidazole cream, gel, lotion G Neuac Gel Gsulfacetamide sodium/sulfur Gsulfacetamide sodium/sulfur/urea Gtretinoin [PA] Gtretinoin microspheres [PA] PAzelex PFinacea [pa]This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program. [st]This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program. [qd]This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program. [ac]This symbol indicates that this specialty medication must be obtained through Accredo. Please call: (800) 803-2523. [cvs]This symbol indicates that this medication is only available through CVS Health. Please call: (800) 818-6720 for dispensing guidelines. [pica]This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage. 8 Topical Antifungals Gciclopirox Gciclopirox solution Gclotrimazole Gclotrimazole/betamethasone Geconazole nitrate Gketoconazole G naftifine cream 2% Gnystatin Gnystatin w/triamcinolone Goxiconazole nitrate 1% cream Topical Antiviral Therapy (Effective 1-1-09) G acyclovir ointment PDenavir Cream Topical Corticosteroids (Topical Skin Products) Low Potency Galclometasone (cream, ointment) Gdesonide 0.05% (cream, lotion, ointment) Gfluocinolone (cream, ointment) Ghydrocortisone (cream, ointment) P Capex Shampoo 0.01% Medium Potency Gbetamethasone valerate (cream lotion, foam) Gdesoximetasone 0.05% (cream, ointment) Gfluocinolone 0.025% (cream, ointment) G flurandrenolide 0.05% (cream) Gfluticasone (cream, ointment, lotion) Ghydrocortisone butyrate (cream, ointment, solution) Ghydrocortisone butyrate/emollient (cream) Ghydrocortisone valerate (cream) Gmometasone 0.1% (cream, ointment, solution) Gprednicarbate 0.1% (cream, ointment) Gtriamcinolone 0.025%, 0.1% (cream, ointment, lotion, aerosol) PCordran Tape High Potency Gamcinonide (cream, ointment, lotion) Gapexicon E (cream) Gbetamethasone dipropionate (cream, gel, lotion, ointment) Gbetamethasone DP augmented (cream, lotion) Gbetamethasone valerate 0.1% (ointment) Gdesoximetasone (cream, ointment 0.25%, gel 0.05%) Gdiflorasone diacetate 0.05% (cream) Gfluocinonide (gel, cream, ointment, solution) Gfluocinonide-E (cream) Gtriamcinolone acetonide 0.5% (cream, ointment) Very High Potency Gbetamethasone augmented (ointment) Gclobetasol E (cream) Gclobetasol propionate (cream, ointment, lotion, solution, spray, foam, gel, shampoo) Gdiflorasone diacetate (ointment) Ghalobetasol propionate (cream, ointment) Topical Miscellaneous Anesthetic Preparations (Effective 6-1-15) Glidocaine (cream, oint, gel, patch) [PA/QD] Vitamins — All generics are preferred (Most commonly used listed below) (Effective 1-1-09) G G G Prenatal Vitamin Therapy G Prenatal Plus GPNV-DHA GZatean-PN G Zatean-PN DHA G Zatean-PN Plus Multivitamin Therapy GCorvita G V-C Forte Iron Supplement Therapy G G G G G GFolbee G Folbee Plus P =Preferred brand-name medication. = Weigh the risk of birth defects or other adverse outcomes. =Do not use during pregnancy. Vitamin D Analog Agents Gcalcitriol Gdoxercalciferol Gparicalcitol (Effective 1-1-16) benzphetamine HCL [PA] diethylpropion HCL, ER [PA] phendimetrazine tartrate [PA] Key: G =Preferred generic medication. GFolbic Renal Caps G GTriphrocaps (Effective 1-1-13) Vitamin B Therapy Ferrex 28 Ferrex 150 Forte Weight Loss Agents Ferrex 150 Forte Plus Multigen Plus Poly-Iron 150 Forte G P P phentermine HCL [PA] Contrave [PA] Qsymia [PA] P P Saxenda [PA] Xenical [PA] [pa]This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program. [st]This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program. [qd]This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program. [ac]This symbol indicates that this specialty medication must be obtained through Accredo. Please call: (800) 803-2523. [cvs]This symbol indicates that this medication is only available through CVS Health. Please call: (800) 818-6720 for dispensing guidelines. [pica]This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage. 9 If your prescribed drug is in the “nonpreferred” column, ask your doctor if she or he can prescribe one of the alternatives listed. Section II: Nonpreferred Drugs and Their Possible Preferred Alternatives* Nonpreferred ProductPossible Preferred Alternatives Nonpreferred ProductPossible Preferred Alternatives Abilify Maintena®olanzapine (generic), Risperdal Consta® (Janssen) Abilify vial® olanzepine (generic) fentanyl citrate lozenge (generic) Abstral® Acanya®clindamycin (generic) + benzoyl peroxide (generic) Aciphex Sprinkle®Nexium OTC (AstraZeneca), esomeprazole (generic), lansoprazole (generic), omeprazole (generic), omeprazole/ sodium bicarbonate (generic), pantoprazole (generic), rabeprazole (generic) doxycycline hyclate tablet (generic) Acticlate® pioglitazone/metformin (generic) Actoplus Met XR® Acuvail®bromfenac (generic), diclofenac (generic), flurbiprofen (generic), ketorolac (generic) Aczone®benzoyl peroxide (generic), clindamycin phosphate (generic), erythromycin (generic) Adasuve Inhaler®loxapine (generic) epinephrine (generic), Epi Pen® (Mylan), Epi Pen Jr® (Mylan) Adrenaclick® ® Advair Diskus Dulera® (Merck), Symbicort® (AstraZeneca) Advair HFA®Dulera® (Merck), Symbicort® (AstraZeneca) Advicor® atorvastatin (generic), fluvastatin (generic), lovastatin (generic), pravastatin (generic), rosuvastatin (generic), simvastatin (generic), niacin ER (generic) Adzenys® XR-ODTdextroamphetamine/amphetamine ER (generic) Aerospan®Alvesco® (Sunovion Pharmaceuticals), Asmanex® (Merck), Asmanex® HFA (Merck), Pulmicort Flexhaler® (AstraZeneca), Qvar® (IVAX) Akne-Mycin®erythromycin (generic) Akynzeo®granisetron (generic), ondansetron (generic), Emend (Merck) acetaminophen/butalbital (generic) Allzital® Alocril®azelastine (generic), cromolyn (generic), epinastine (generic), olopatadine (generic), Pataday® (Alcon) Alodox®erythromycin (generic), gentamicin (generic), tobramycin (generic) alogliptin (Perrigo)Januvia (Merck & Co.), Tradjenta (Boehringer Ingelheim) alogliptin-metformin (Perrigo)Janumet (Merck & Co.), Janumet XR (Merck & Co.), Jentadueto (Boehringer Ingelheim) alogliptin-pioglitazone (Perrigo)Januvia (Merck & Co.), Tradjenta (Boehringer Ingelheim), pioglitazone (generic) Alomide®azelastine (generic), cromolyn (generic), epinastine (generic), olopatadine (generic), Pataday® (Alcon) Alora®estradiol patch (generic) Alrex®fluorometholone (generic), prednisolone (generic) Altoprev®atorvastatin (generic), fluvastatin (generic), lovastatin (generic), pravastatin (generic), rosuvastatin (generic), simvastatin (generic) Amitiza®Linzess® (Actavis/Ironwood) amoxicillin ER amoxicillin (generic) Amrix®cyclobenzaprine (generic) Amturnide®candesartan/HCTZ (generic) + amlodipine (generic), irbesartan/HCTZ (generic) + amlodipine (generic), losartan/ HCTZ (generic) + amlodipine (generic), telmisartan/HCTZ (generic) + amlodipine (generic), valsartan/HCTZ (generic) + amlodipine (generic) Androgel® Packettestosterone gel in packet (generic), testosterone gel pump 1.25gm (1%) (generic), Androderm (Watson), Androgel pump 20.25/1.25 (Unimed), Axiron (Eli Lilly) Anoro Ellipta®Stiolto Respimat® (Boehringer Ingelheim) fenofibrate (generic) Antara® 30mg, 90mg Anzemet®ondansetron (generic), granisetron (generic), Emend® (Merck) APOP®adapalene (generic). clindamycin phosphate (generic), erythromycin (generic), sulfacetamide sodium/sulfur (generic) Apidra®Humalog® (Eli Lilly) Apidra Solostar®Humalog® (Eli Lilly) bupropion (generic), bupropion SR (generic) Aplenzin® methylphenidate ER (generic) Aptensio XR® Aptiom®carbamazepine (generic), lamotrigine (generic), levetiracetam (generic), gabapentin (generic), topiramate (generic) Arnuity Ellipta® Alvesco® (Sunovion Pharmaceuticals), Asmanex® (Merck), Asmanex® HFA (Merck), Pulmicort Flexhaler® (AstraZeneca), Qvar® (IVAX) ® Asacol HD balsalazide disodium (generic), mesalamine enema (generic), sulfasalazine (generic), Apriso (Salix), Canasa (Aptalis), Lialda (Shire US) Asmalpred®, Asmalpred Plus® prednisolone sodium phosphate (generic) epinephrine (generic), Epi Pen® (Mylan), Epi Pen Jr® (Mylan) Auvi-Q® Avar® (foam, pads), Avar-E®, Avar LS®sulfacetamide sodium/sulfur (generic) Azasite®ciprofloxacin (generic), erythromycin ointment (generic), gentamicin (generic), levofloxacin (generic), ofloxacin (generic), tobramycin (generic),Vigamox® (Alkon) ® Azilect selegiline (generic) Azopt® dorzolamide (generic) Azor®amlodipine/benazepril (generic) Bacmin®Corvita (generic),V-C Forte (generic) Banzel® SuspensionBanzel® Tablets (Eisai Inc.) Beconase AQ®budesonide (generic), flunisolide (generic), fluticasone propionate (generic), mometasone furoate (generic), triamcinolone acetonide (generic) Belbuca® buprenorphine SL (generic) Belsomra®estazolam (generic), eszopiclone (generic), flurazepam (generic), temazepam (generic), zaleplon (generic), zolpidem (generic) Belviq®Contrave ER (Takeda), Qysmia (Vivus, Inc.), Saxenda (Novo Nordisk), Xenical (Genentech) Benicar®candesartan (generic), eprosartan mesylate (generic), irbesartan (generic), losartan (generic), telmisartan (generic), valsartan (generic) Benicar HCT®candesartan/HCTZ (generic), irbesartan/HCTZ (generic), losartan/HCTZ (generic), telmisartan/HCTZ (generic), valsartan/HCTZ (generic) Benzamycin® Pakerythromycin/benzoyl peroxide (generic) BenzEFoam®/BenzEFoam® Ultrabenzoyl peroxide (generic) Bepreve®azelastine (generic), cromolyn (generic), epinastine (generic), olopatadine (generic) , Pataday® (Alcon) Besivance®ciprofloxacin (generic), erythromycin ointment (generic), gentamicin (generic), levofloxacin (generic), ofloxacin (generic), tobramycin (generic),Vigamox® (Alkon) Betaseron®glaterimer acetate (generic), Avonex® (Biogen), Copaxone® 40 mg (Teva), Extavia® (Novartis), Rebif® (Pfizer) Betimol®betaxolol (generic), carteolol (generic), levobunolol (generic), metipranolol (generic), timolol maleate (generic) Betoptic S®betaxolol (generic), carteolol (generic), levobunolol (generic), metipranolol (generic), timolol maleate (generic) Bevespi Aerosphere®Stiolto Respimat (Boehringer Ingelheim) Beyaz®Folic Acid + Gianvi (generic) Bifera Rx®Ferrex 28 (generic), Ferrex 150 Forte (generic), Ferrex 150 Forte Plus (generic), Multigen Plus (generic), Poly-Iron 150 Forte (generic) Binosto®alendronate (generic) Bivigam®Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF ® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG) Breo Ellipta®Dulera® (Merck), Symbicort® (AstraZeneca) Brisdelle®paroxetine (generic), fluoxetine (generic), venlafaxine (generic) Briviact®levetiracetam (generic), gabapentin (generic), topiramate (generic), lamotrigine (generic) Brovana® Solutionalbuterol inhalant solution (generic), levalbuterol inhalant solution (generic) Butisol®temazepam (generic), triazolam (generic) Butrans® buprenorphine (generic) *This is a partial list of nonpreferred drugs. Please be sure that your drug is listed in Section I. 10 Nonpreferred ProductPossible Preferred Alternatives Nonpreferred ProductPossible Preferred Alternatives Bystolic®acebutolol HCl (generic), atenolol HCl (generic), metoprolol tartrate (generic), metoprolol succinate (generic), propranolol HCl (generic) Byvalson® metoprolol tartrate (generic) + valsartan (generic) Cambia® diclofenac potassium (generic) Capital® w/codeine acetaminophen/codeine (generic) Carac®fluorouracil (generic), imiquimod (generic), Picato® Gel (Leo Pharma Inc.) Cardene SR®amlodipine besylate (generic), nicardipine HCl (generic), nifedipine ER (generic) dilitazem ER (generic) Cardizem® LA 120mg Cimzia® (Crohn’s indication only) Humira® (Abbott) Enbrel® (Amgen), Humira® (Abbott) Cimzia® (Plaque Psoriasis indication only) Enbrel® (Amgen), Humira® (Abbott) Cimzia® (RA indication only) Cinryze®Berinert® (CSL Behring) Ciprodex®neomycin/polymyxin/HC (generic), ofloxacin (generic) Cipro HC®neomycin/polymyxin/HC (generic), ofloxacin (generic) Citranatal Rx®PNV-DHA (generic), Zatean-PN Plus (generic), Zatean-PN DHA (generic), Zatean-PN (generic), Prenatal Plus (generic) clindamycin (generic) Clindacin ETZ®, Clindacin PAC® Clindagel®clindamycin phosphate (generic) Clodan®clobetasol propionate (generic) Cloderm®betamethasone valerate cream (generic), desoximetasone cream (generic), fluocinolone acetonide cream (generic), hydrocortisone valerate cream (generic), triamcinolone acetonide cream (generic) clozapine ODT 150mg, 200mgclozapine ODT (generic), Fazaclo (Jazz) codeine solution codeine sulfate tablets (generic) colchicine tablet, capsule Colcrys® (Takeda) Coly-Mycin S®neomycin/polymyxin/HC (generic), ofloxacin (generic) Colyte® 227.1-21.5PEG3350-electrolyte (generic) dorzolamide/timolol (generic) Combigan® Conzip®tramadol ER (generic) Cordran® ointment, lotionbetamethasone valerate (generic), desoximetasone (generic), fluocinolone acetonide (generic), flurandrenolide cream (generic), hydrocortisone valerate (generic), triamcinolone acetonide (generic) Coreg CR®carvedilol (generic) Cortisporin-TC®neomycin/polymyxin/HC (generic), ofloxacin (generic) Corvite®Corvita (generic),V-C Forte (generic) Corvite FE®Ferrex 28 (generic), Ferrex 150 Forte (generic), Ferrex 150 Forte Plus (generic), Multigen Plus (generic), Poly-Iron 150 Forte (generic) dorzolamide/timolol (generic) Cosopt PF® Cycloset®metformin HCl (generic), Byetta® (Amylin Pharmaceuticals), Janumet® (Merck & Co.), Januvia® (Merck & Co.) Daytrana® dextroamphetamine-amphetamine (generic), methylphenidate ER (generic) Delzicol®balsalazide disodium (generic), mesalamine enema (generic), sulfasalazine (generic), Apriso (Salix), Canasa (Aptalis), Lialda (Shire US) Desonate® Geldesonide (generic), alclometasone (generic), hydrocortisone (generic) desvenlafaxine ERduloxetine (generic), venlafaxine HCl ER (generic) Dexilant®Nexium OTC (AstraZeneca), esomeprazole (generic), lansoprazole (generic), omeprazole (generic), omeprazole/ sodium bicarbonate (generic), pantoprazole (generic), rabeprazole (generic) DexPak® dexamethasone (generic) Diclegis®ondansetron (generic), granisetron (generic), Emend® (Merck) Differin® Lotionadapalene cream (generic) Dipentum®balsalazide disodium (generic), mesalamine enema (generic), sulfasalazine (generic), Apriso (Salix), Canasa (Aptalis), Lialda (Shire US) Divigel®estradiol patch (generic) Dolgic Plus® butalbital/APAP/caffeine (generic) Doral®estazolam (generic), eszopiclone (generic), flurazepam (generic), temazepam (generic), zaleplon (generic), zolpidem (generic) doxycycline IR-DR doxycycline monohydrate (generic), minocycline (generic) Duexis®ibuprofen (generic), famotidine (generic) Durezol®prednisolone (generic) Durlaza®cilostazol (generic), clopidogrel (generic), dipyridamole (generic), aspirin/dipyridamole (generic), Brilinta (AstraZeneca), Effient (Eli Lilly), Zontivity (Merck&Co) Dutoprol®metoprolol succinate (generic), hydrochlorothiazide (generic) Dyanavel XR®dextroamphetamine/amphetamine ER (generic) fluticasone propionate + azelastine nasal spray (generic) Dymista® E.E.S. suspension®Eryped suspension (Southwood Pharm) Ecoza®econazole nitrate (generic) Edarbi®candesartan (generic), eprosartan mesylate (generic), irbesartan (generic), losartan (generic), telmisartan (generic), valsartan (generic) Edarbyclor®candesartan/HCTZ (generic), irbesartan/HCTZ (generic), losartan/HCTZ (generic), telmisartan/HCTZ (generic), valsartan/HCTZ (generic) zolpidem (generic) Edluar® lidocaine cream, ointment, patch (generic) Elenza Patch® estradiol patch (generic) Elestrin® Emadine®azelastine (generic), cromolyn (generic), epinastine (generic), olopatadine (generic), Pataday® (Alcon) ® morphine sulfate ER (generic) Embeda phenylzine sulfate (generic) Emsam® Enstilar® calcipotriene/betamethasone (generic) Epaned®enalapril maleate (generic) Epclusa®Harvoni (Gilead), Daklinza (Bristol Meyers Squibb), Sovaldi (Gilead) Epiduo®, Epiduo Forte®adapalene (generic) + benzoyl peroxide (generic) hydrocortisone acetate/pramoxine (generic) Epifoam® Epogen®Aranesp® (Amgen), Procrit® (Janssen) Equetro®carbamazepine (generic), divalproex (generic) Ertaczo® econazole nitrate (generic), ketoconazole (generic), nystatin (generic) Ery-Tab® 500mgerythromycin base (generic) esomeprazole strontiumNexium OTC (AstraZeneca), esomeprazole magnesium (generic), lansoprazole (generic), omeprazole (generic), omeprazole/sodium bicarbonate (generic), pantoprazole (generic), rabeprazole (generic) Estrace® Vaginal CreamVagifem® (Novo Nordisk), Osphena® (Shionogi) Estrasorb®estradiol patch (generic) Estrogel®estradiol patch (generic) Evamist®estradiol patch (generic) Evekeo® dexmethylphenidate (generic), dextroamphetamine (generic), methylphenidate (generic), amphetamine/dextroamphetamine (generic) Exelderm® econazole nitrate (generic), ketoconazole (generic), nystatin (generic) Fabior®tretinoin (generic), Azelex® (Allergan), Finacea® (Bayer) Factive®ciprofloxacin (generic), levofloxacin (generic), moxifloxacin (generic), ofloxacin (generic) Fanapt®aripiprazole (generic), clozapine (generic), olanzapine (generic), paliperidone (generic), quetiapine fumarate (generic), risperidone (generic), ziprasidone HCl (generic) Farxiga®Invokana (Janssen), Invokamet (Janssen), Jardiance (Boehringer Ingelheim), Synjardy (Eli Lilly) Femring®Estring® (Pfizer) fenoprofen calcium capsulefenoprofen calcium tablet (generic) Fenortho®fenoprofen calcium tablet (generic) fentanyl patch 37.5mcg/hr, fentanyl patch 25mcg/hr, 50mcg/hr, 75mcg/hr (generic) 62.5mcg/hr, 87.5mcg/hr Fentora® fentanyl lozenge (generic) Ferralet 90®Ferrex 28 (generic), Ferrex 150 Forte (generic), Ferrex 150 Forte Plus (generic), Multigen Plus (generic), Poly-Iron 150 Forte (generic) Fetzima®duloxetine (generic), venlafaxine HCl (generic) First-Lansoprazole®Nexium® Rx Suspension (AstraZeneca) First-Omeprazole®Nexium® Rx Suspension (AstraZeneca) *This is a partial list of nonpreferred drugs. Please be sure that your drug is listed in Section I. 11 Nonpreferred ProductPossible Preferred Alternatives Nonpreferred ProductPossible Preferred Alternatives First-Testosterone®testosterone gel in packet (generic), testosterone gel pump 1.25gm (1%) (generic), Androderm (Watson), Androgel pump 20.25/1.25 (Unimed), Axiron (Eli Lilly) fluorometholone (generic) Flarex® Flector® Patchdiclofenac sodium drops (generic), diclofenac sodium gel (generic) Flo-Pred®prednisolone sodium phosphate (generic) Flovent Diskus®Alvesco® (Sunovion Pharmaceuticals), Asmanex® (Merck), Asmanex® HFA (Merck), Pulmicort Flexhaler® (AstraZeneca), Qvar® (IVAX) ® Flovent HFA Alvesco® (Sunovion Pharmaceuticals), Asmanex® (Merck), Asmanex® HFA (Merck), Pulmicort Flexhaler® (AstraZeneca), Qvar® (IVAX) Fluoroplex®fluorouracil (generic), imiquimod (generic), Picato® Gel (Leo Pharma Inc.) fluoxetine 60mg tablet fluoxetine capsule 10mg, 20mg, 40mg (generic), (Edgemont Pharmaceuticals)fluoxetine tablet 10mg, 20mg (generic) FML-Forte® fluorometholone (generic) Focalin XR® 25mg/35mg dimethylphenidate ER (generic) Foradil®Arcapta Neohaler® (Novartis), Serevent Diskus® (GSK) Forfivo XL®bupropion XL (generic) Fortesta®testosterone gel in packet (generic), testosterone gel pump 1.25gm (1%) (generic), Androderm (Watson), Androgel pump 20.25/1.25 (Unimed), Axiron (Eli Lilly) Fosamax D®alendronate (generic), ibandronate (generic), risedronate (generic) Fosrenol® sevelamer carbonate (generic), calcium acetate (generic) Freestyle®ACCU-CHEK (Roche), Breeze 2 (Ascensia Diabetes Care), Contour (Ascensia Diabetes Care), True Metrix (Trividia Health) Fycompa®carbamazepine (generic), lamotrigine (generic), levetiracetam (generic), gabapentin (generic), topiramate (generic) Gamastan S-D®Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF ® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG) Gammagard® Liquid Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF ® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG) Gammagard S-D® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF ® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG) Gammaked® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF ® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG) Gammaplex®Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF ® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG) Gelnique® Metered Dose Geloxybutynin (generic), oxybutynin ER (generic), Myrbetriq (Astellis),Vesicare® (GlaxoSmithKline) Gelnique® 10% Packetsoxybutynin (generic), oxybutynin ER (generic), Myrbetriq (Astellis),Vesicare® (GlaxoSmithKline) Gel-One®Euflexxa (Ferring B.V), Monovisc (Depuy Mitek), Orthovisc (Depuy Mitek) Gelsyn-3®Euflexxa (Ferring B.V.), Monovisc (Depuy Mitek), Orthovisc (Depuy Mitek) Genotropin®Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex® (Novo Nordisk), Zomacton® (Ferring Pharmaceuticals) Genvisc-850®Euflexxa (Ferring B.V), Monovisc (Depuy Mitek), Orthovisc (Depuy Mitek) Geodon® vialolanzepine (generic) Gialax®PEG 3350 bowel prep (generic) Giazo® balsalazide sodium (generic) Golytely® 227.1-21.5 PEG3350-electrolyte (generic) Gralise® gabapentin (generic) Halog®desoximetasone cream (generic), fluocinonide cream (generic) Helidac®lansoprazole/amoxicillin/clarithromycin (generic), Pylera® (Aptalis Pharma) Hetlioz®eszopiclone (generic), temazepam (generic), triazolam (generic), zaleplon (generic), zolpidem (generic) Humatrope®Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex® (Novo Nordisk), Zomacton® (Ferring Pharmaceuticals) Hyalgan®Euflexxa (Ferring B.V), Monovisc (Depuy Mitek), Orthovisc (Depuy Mitek) Hymovis®Euflexxa (Ferring B.V.), Monovisc (Depuy Mitek), Orthovisc (Depuy Mitek) HyQvia® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF ® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG) morphine sulfate ER (generic), hydromorphone ER (generic) Hysingla ER® Ilevro®bromfenac (generic), diclofenac (generic), flurbiprofen (generic), ketorolac (generic) Incruse Ellipta®Spiriva® (Boehringer Ingelheim), Spiriva® Respimat (Boehringer Ingelheim), Tudorza™ Pressair™ (Forest Pharmaceuticals) Inderal XR® propranolol LA (generic) indomethacin capsule (generic), naproxen tablet (generic) Indocin® Suspension Innopran XL® propranolol LA (generic) Invega Sustenna®Aristada (Alkermes, Inc.), Risperdal Consta (Janssen) Invega Trinza®Aristada (Alkermes, Inc.), Risperdal Consta (Janssen) fentanyl patch (generic) Ionsys® Istalol®betaxolol (generic), carteolol (generic), levobunolol (generic), metipranolol (generic), timolol maleate (generic) Jublia® ciclopirox solution (generic) Juvisync®Januvia® (Merck & Co.), simvastatin (generic) morphine sulfate ER (generic) Kadian® Kazano®Janumet (Merck & Co.), Janumet XR (Merck & Co.), Jentadueto (Boehringer Ingelheim) ciclopirox nail kit (generic) Kerydin® Khedezla®duloxetine (generic), venlafaxine HCl ER (generic) Kineret®Enbrel® (Amgen), Humira® (Abbott) Kombiglyze® XRJanumet (Merck & Co.), Janumet XR (Merck & Co.), Jentadueto (Boehringer Ingelheim) Juxtapid (Aegerion) Kynamro® Lamictal® Dosepak lamotrigine (generic) Lamictal® XR Dosepak lamotrigine XR (generic) Lastacaft®azelastine (generic), cromolyn sodium (generic), epinastine (generic), olopatadine (generic), Pataday® (Alcon) ® Latuda aripiprazole (generic), clozapine (generic), olanzapine (generic), paliperidone (generic), quetiapine fumarate (generic), risperidone (generic), ziprasidone HCl (generic) fentanyl lozenge (generic), fentanyl patch (generic) Lazanda® Letairis®Opsumit® (Actelion), Tracleer® (Actelion) Levatol®acebutolol HCl (generic), atenolol (generic), metoprolol tartrate (generic) Levemir®Lantus (Sanofi-Aventis), Lantus Solostar (Sanofi-Aventis), Toujeo Solostar (Sanofi-Aventis) Levemir Flextouch®Lantus (Sanofi-Aventis), Lantus Solostar (Sanofi-Aventis), Toujeo Solostar (Sanofi-Aventis) acyclovir ointment (generic), lidocaine gel (generic) Lidovir® fenofibrate (generic) Lipofen® Liptruzet®atorvastatin (generic), Zetia® (Merck-Schering Plough) Livalo®atorvastatin (generic), fluvastatin (generic), lovastatin (generic), pravastatin (generic), rosuvastatin (generic), simvastatin (generic) Lo-Loestrin FE®Gildess FE® (Dynamic Pharma), Junel FE® (Barr Pharmaceuticals), Microgestin FE® (Watson Pharmaceuticals) ® Lo-Minastrin FE Gildess FE® (Dynamic Pharma), Junel FE® (Barr Pharmaceuticals), Microgestin FE® (Watson Pharmaceuticals) Lorzone®chlorzoxazone (generic) Lotemax®fluorometholone (generic), prednisolone (generic) Lumigan® 0.01%bimatoprost (generic), latanoprost (generic), travaprost (generic) Luzu® econazole nitrate (generic), ketoconazole (generic), nystatin (generic) Magnacet®oxycodone w/APAP (generic) Maxair Autohaler®ProAir HFA® (Teva), ProAir Respiclick® (Teva) *This is a partial list of nonpreferred drugs. Please be sure that your drug is listed in Section I. 12 Nonpreferred ProductPossible Preferred Alternatives Nonpreferred ProductPossible Preferred Alternatives Maxidex®fluorometholone (generic), prednisolone (generic) Menest®estradiol (generic), estropipate (generic), Cenestin® (Barr/ Duramed), Enjuvia® (Barr/Duramed) ® Menostar estradiol patch (generic) Mentax® econazole nitrate (generic), ketoconazole (generic), nystatin (generic) Metanx® Capsule Folbee (generic), Folbee Plus (generic), Folbic (generic), Renal Caps (generic), Triphrocaps (generic) Millipred® Solution prednisolone sodium phosphate (generic) Minastrin 24 FE®Junel FE® (Barr Pharmaceuticals), Microgestin FE® (Watson Pharmaceuticals) Minitran Patch® nitroglycerin patch (generic) Minivelle®estradiol patch (generic) Mircera® Aranesp® (Amgen), Procrit® (Janssen) Mirvaso® metronidazole topical (generic), Finacea® (Bayer) Mitigare® Colcrys® (Takeda) Moderiba® ribavirin (generic), Ribasphere (generic) Momexin®mometasone furoate (generic) Morgidox®doxycycline hyclate capsules (generic) Morphine® sulfate oral syringe morphine sulfate (generic) MoviPrep® PEG 3350 bowel prep (generic) Moxatag® amoxicillin trihydrate (generic) Moxeza®ciprofloxacin (generic), erythromycin ointment (generic), gentamicin (generic), levofloxacin (generic), ofloxacin (generic), tobramycin (generic),Vigamox® (Alkon) Naftin® econazole nitrate (generic), ketoconazole (generic), nystatin (generic) Nalfon®etodolac (generic), ibuprofen (generic), indomethacin (generic), naproxen (generic), sulindac (generic) Naprelan® 750mgnaproxen sodium ER (generic) Natacyn®ciprofloxacin (generic), erythromycin ointment (generic), gentamicin (generic), levofloxacin (generic), ofloxacin (generic), tobramycin (generic),Vigamox® (Alkon) Natazia® Necon (generic) Natesto®testosterone gel in packet (generic), testosterone gel pump 1.25gm (1%) (generic), Androderm (Watson), Androgel pump 20.25/1.25 (Unimed), Axiron (Eli Lilly) Nesina®Januvia (Merck & Co.), Tradjenta (Boehringer Ingelheim) Neuac® Kitclindamycin phosphate/benzoyl peroxide (generic), Neuac® Gel (Medimetriks Pharmaceuticals) Neupro Patch®pramipexole Di-HCl (generic), pramipexole ER (generic), ropinirole (generic), Apokyn® (U.S. World Meds) Nevanac®bromfenac (generic), diclofenac (generic), flurbiprofen (generic), ketorolac (generic) Nitro-Dur Patch® nitroglycerin patch (generic) Noritate®metronidazole cream (generic) Noroxin®ciprofloxacin (generic), levofloxacin (generic), moxifloxacin (generic), ofloxacin (generic) Novolin®Humulin® (Eli Lilly) Novolog®Humalog® (Eli Lilly) Novolog Mix® Humalog Mix® (Eli Lilly) Nucort®hydrocortisone acetate gel (generic) Nucynta®, Nucynta ER® tramadol (generic) Nuox®benzoyl peroxide (generic), sulfacetamide sodium/sulfur (generic) Nutropin®Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex® (Novo Nordisk), Zomacton® (Ferring Pharmaceuticals) Nutropin AQ®Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex® (Novo Nordisk), Zomacton® (Ferring Pharmaceuticals) Nutropin AQ Nuspin®Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex® (Novo Nordisk), Zomacton® (Ferring Pharmaceuticals) Nuvaring®Aviane® (Barr), Lessina® (Barr) Nyata®nystatin (generic) Nymalize® nimodipine (generic) OB Complete One ®PNV-DHA (generic), Zatean-PN Plus (generic), Zatean-PN DHA (generic), Zatean-PN (generic), Prenatal Plus (generic) Octagam® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF ® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG) trazodone HCl (generic) Oleptro ER® Olysio®Solvaldi® (Gilead) Omeclamox-Pak®lansoprazole/amoxicillin/clarithromycin (generic), Pylera® (Aptalis Pharma) Omeprazole® + SyrSpend® SF AlkaNexium® Rx Suspension (AstraZeneca) Omnaris®budesonide (generic), flunisolide (generic), fluticasone propionate (generic), mometasone furoate (generic), triamcinolone acetonide (generic) Omnitrope®Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex® (Novo Nordisk), Zomacton® (Ferring Pharmaceuticals) Omontys® Aranesp® (Amgen), Procrit® (Janssen) One Touch®ACCU-CHEK (Roche), Breeze 2 (Ascensia Diabetes Care), Contour (Ascensia Diabetes Care), True Metrix (Trividia Health) Onexton®clindamycin/benzoyl peroxide (generic) Onfi® felbamate (generic), lamotrigine (generic), topiramate (generic), Banzel® Tablet (Eisai Inc.) Onglyza®Januvia (Merck & Co.), Tradjenta (Boehringer Ingelheim) fentanyl lozenge (generic) Onsolis® Onzetra Xsail®sumatriptan nasal spray (generic) morphine sulfate ER (generic), Oxycontin® (Purdue Pharma) Opana ER® Oracea®doxycycline monohydrate (generic), minocycline (generic) butalbital/acetaminophen (generic) Orbivan CF® Orencia SC®Enbrel® (Amgen), Humira® (Abbott) Osensi®Januvia (Merck & Co.), Tradjenta (Boehringer Ingelheim), pioglitazone (generic) OsmoPrep® PEG 3350 bowel prep (generic) Otovel®neomycin/polymyxin/HC (generic) Otrexup®methotrexate (generic) sulfacetamide sodium (generic) Ovace® 9.8% Plus Lotion sulfacetamide sodium (generic) Ovace® 10% Plus Cleanser sulfacetamide sodium (generic) Ovace® 10% Plus Cream sulfacetamide sodium (generic) Ovace® Plus Foam sulfacetamide sodium (generic) Ovace® 10% Plus Shampoo Oxaydo®oxycodone (generic), Oxycontin (Purdue Pharma) Oxecta®oxycodone (generic), morphine sulfate (generic), oxymorphone (generic), Oxycontin® (Purdue Pharma) Oxistat® lotioneconazole nitrate (generic), ketoconazole (generic), nystatin (generic) Oxtellar XR® oxcarbazepine (generic) oxycodone HCl ER oxycodone IR (generic), Oxycontin® (Purdue Pharma) Oxytrol®flavoxate (generic), oxybutynin (generic), oxybutynin ER (generic), tolterodine tartrate (generic), trospium (generic), Myrbetriq (Astellis),Vesicare® (GlaxoSmithKline) benzoyl peroxide (generic) Pacnex® MX, HP, LP Pancreaze®Creon® (Abbott), Zenpep® (Aptalis Pharma) Pandel®betamethasone valerate cream (generic), desoximetasone cream (generic), fluocinolone acetonide cream (generic), hydrocortisone valerate cream (generic), triamcinolone acetonide cream (generic) Paxil® Suspensionfluoxetine solution (generic) Pazeo®azelastine (generic), cromolyn (generic), epinastine (generic), olopatadine (generic), Pataday® (Alcon) PCE®erythromycin base (generic) Pediapak®ciclopirox (generic) Pennsaid Solution®diclofenac sodium drops (generic), diclofenac sodium gel (generic) Pentasa®balsalazide disodium (generic), mesalamine enema (generic), sulfasalazine (generic), Apriso (Salix), Canasa (Aptalis), Lialda (Shire US) Perforomist®albuterol sulfate (generic), levalbuterol HCl (generic) Pertzye®Creon® (Abbott), Zenpep® (Aptalis Pharma) Pexeva®paroxetine HCl (generic) sevelamer carbonate (generic), calcium acetate (generic) Phoslyra® butalbital/acetaminophen (generic) Phrenilin Forte® *This is a partial list of nonpreferred drugs. Please be sure that your drug is listed in Section I. 13 Nonpreferred ProductPossible Preferred Alternatives Nonpreferred ProductPossible Preferred Alternatives Plexion®sulfacetamide/sulfur (generic) Potaba® Folbee (generic), Folbee Plus (generic), Folbic (generic), Renal Caps (generic), Triphrocaps (generic) Potiga® carbamazepine (generic), levetiracetam (generic), topiramate (generic), Banzel® tablet (Eisai Inc.) Precision®ACCU-CHEK (Roche), Breeze 2 (Ascensia Diabetes Care), Contour (Ascensia Diabetes Care), True Metrix (Trividia Health) Pred-G®tobramycin-dexamethasone (generic), neomycin/ bacitracin/polymyxin B/HC (generic), neomycin/ polymyxin B/dexamethasone (generic), neomycin/ polymyxin B/HC (generic), TobraDex® Oint (Alcon) ® Pred Mild prednisolone acetate (generic) Prefera-OB One®PNV-DHA (generic), Zatean-PN Plus (generic), Zatean-PN DHA (generic), Zatean-PN (generic), Prenatal Plus (generic) Premarin® Tabsestradiol (generic), Cenestin® (Barr/Duramed), Enjuvia® (Barr/ Duramed) Premarin® Vaginal CreamVagifem® (Novo Nordisk), Osphena® (Shionogi) Prenate Essential®PNV-DHA (generic), Zatean-PN Plus (generic), Zatean-PN DHA (generic), Zatean-PN (generic), Prenatal Plus (generic) Prepopik® PEG 3350 bowel prep (generic) Prevacid® Rx disintegrating tab Nexium® Rx Suspension (AstraZeneca) Prilosec® SuspensionNexium® Rx Suspension (AstraZeneca) Primlev®oxycodone w/APAP (generic) Pristiq ER®venlafaxine HCl (generic), citalopram HBR (generic), duloxetine (generic), fluoxetine HCl (generic), paroxetine HCl (generic), sertraline HCl (generic) Privigen®Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF ® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG) Prolensa®bromfenac sodium (generic), diclofenac (generic), flurbiprofen (generic), ketorolac (generic) Promiseb Complete®calcipotriene (generic), selenium sulfide (generic), sodium sulfacetamide (generic) Protonix® granulesNexium® Rx Suspension (AstraZeneca) Proventil HFA®ProAir HFA® (Teva), ProAir Respiclick® (Teva) Qbrelis® lisinopril (generic) Quarette® Amethia (generic), Amethia Lo (generic) Quillichew ER®methylphenidate ER (generic) Quillivant XR® methylphenidate ER (generic) Qnasl®budesonide (generic), flunisolide (generic), fluticasone propionate (generic), mometasone furoate (generic), triamcinolone acetonide (generic) Qroxin® lidocaine cream, ointment, patch (generic) Qudexy XR®topiramate IR sprinkle caps (generic) Rapaflo®alfuzosin HCl ER (generic), dutasteride (generic), dutasteridetamsulosin (generic), doxazosin (generic), finasteride (generic), tamsulosin (generic), terazosin (generic) Rayos® prednisone (generic) Reciphexamine® lidocaine cream, ointment, patch (generic) Regimex®benzphetamine (generic), Contrave ER (Takeda), Qsymia (Vivustro), Saxenda (Novo Nordisk), Xenical (Genentech) Relyyks® lidocaine cream, ointment, patch (generic) Relyyt® lidocaine cream, ointment, patch (generic) Renagel® sevelamer carbonate (generic), calcium acetate (generic) Renovo® lidocaine cream, ointment, patch (generic) Rexulti®aripiprazole (generic), clozapine (generic), olanzapine (generic), paliperidone (generic), quetiapine fumarate (generic), risperidone (generic), ziprasidone HCl (generic) Riomet® Solution metformin (generic) Ritalin LA® 10mg, 60mg methylphenidate ER (generic) Rosadan® metronidazole cream (generic) Rosula® Cleanser sulfacetamide sodium/sulfur cleanser (generic) Roxicet® oral solution oxycodone solution (generic) Rozerem®eszopiclone (generic), temazepam (generic), triazolam (generic), zaleplon (generic), zolpidem (generic) Ruconest®Berinert® (CSL Behring) Rybix ODT®tramadol (generic) Rytary®carbidopa/levodopa ER (generic) Sabril®divalproex (generic), lamotrigine (generic), levetiracetam (generic) Gianvi (generic) Safyral® Saizen®Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex® (Novo Nordisk), Zomacton® (Ferring Pharmaceuticals) Sancuso®ondansetron (generic), granisetron (generic), Emend® (Merck) Saphris®aripiprazole (generic), clozapine (generic), olanzapine (generic), paliperidone (generic), quetiapine fumarate (generic), risperidone (generic), ziprasidone HCl (generic) Sarafem®fluoxetine HCl (generic) Seebri Neohaler®Stiolto Respimat (Boehringer Ingelheim) selenium sulfide (generic) SelRx® Sernivo®betamethasone dipropionate (generic) Serostim®Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex® (Novo Nordisk), Zomacton® (Ferring Pharmaceuticals) Silenor®eszopiclone (generic), temazepam (generic), triazolam (generic), zaleplon (generic), zolpidem (generic) dorzolamide/timolol (generic) Simbrinza® simvastatin (generic) + niacin ER (generic) Simcor® Enbrel® (Amgen), Humira® (Abbott) Simponi®, Simponi® Aria (RA Indication Only) lidocaine cream, ointment, patch (generic) Sinelee® minocycline (generic) Solodyn® Sorilux®calcipotriene (generic) cefaclor (generic), cefuroxime axetil (generic) Spectracef® Spritam®levetiracetam solution (generic), levetiracetam tablet (generic), gabapentin (generic), topiramate (generic) Sprix®etodolac (generic), ibuprofen (generic), naproxen (generic) valproic acid (generic), divalproex (generic) Stavzor® Striant®testosterone gel in packet (generic), testosterone gel pump 1.25gm (1%) (generic), Androderm (Watson), Androgel packet 1.62%, Androgel pump 20.25/1.25 (Unimed) Striverdi Respimat®Arcapta Neohaler® (Novartis), Serevent Diskus® (GSK) Strovite One®Corvita (generic), V-C Forte (generic) fentanyl citrate lozenges (generic) Subsys® Suclear® PEG 3350 bowel prep (generic) sumatriptan (generic) Sumavel® DosePro® sulfacetamide/sulfur (generic) Sumaxin TS® Supartz®Euflexxa (Ferring B.V), Monovisc (Depuy Mitek), Orthovisc (Depuy Mitek) Supartz Fx®Euflexxa (Ferring B.V), Monovisc (Depuy Mitek), Orthovisc (Depuy Mitek) Suprax®cefuroxime (generic), Cefdinir Suprenza ODT®phentermine (generic), Contrave ER (Takeda), Qsymia (Vivustro), Saxenda (Novo Nordisk), Xenical (Genentech) Suprep® PEG 3350 bowel prep (generic) Surestep®ACCU-CHEK (Roche), Breeze 2 (Ascensia Diabetes Care), Contour (Ascensia Diabetes Care), True Metrix (Trividia Health) fluocinolone acetonide (generic) Synalar TS®, Synalar® hydrocodone/APAP (generic) Synalgos-DC® tramadol HCl (generic) Synapryn® lidocaine cream, ointment, patch (generic) Synvexia® Synvisc®Euflexxa (Ferring B.V), Monovisc (Depuy Mitek), Orthovisc (Depuy Mitek) Synvisc-One®Euflexxa (Ferring B.V), Monovisc (Depuy Mitek), Orthovisc (Depuy Mitek) Taclonex® Suspensioncalcipotriene-betamethasone ointment (generic), selenium sulfide (generic) Tanzeum®Bydureon (Amylin Pharmaceuticals), Bydureon Pen (Amylin Pharmaceuticals), Byetta (Amylin Pharmaceuticals), Trulicity (Eli-Lilly) Tazorac® (Acne use only)tretinoin (generic), Azelex® (Allergan), Finacea® (Bayer) Technivie®Harvoni® (Gilead), Sovaldi® (Gilead) *This is a partial list of nonpreferred drugs. Please be sure that your drug is listed in Section I. 14 Nonpreferred ProductPossible Preferred Alternatives Nonpreferred ProductPossible Preferred Alternatives Tekamlo®candesartan (generic) + amlodipine (generic), eprosartan (generic) + amlodipine (generic) irbesartan (generic) + amlodipine (generic), losartan (generic) + amlodipine (generic), telmisartan (generic) + amlodipine (generic), valsartan (generic) + amlodipine (generic) Tekturna®candesartan (generic), eprosartan mesylate (generic), irbesartan (generic), losartan potassium (generic), telmisartan (generic), valsartan (generic) Tekturna/HCT®candesartan/HCTZ (generic), irbesartan/HCTZ (generic), losartan/HCTZ (generic), telmisartan/HCTZ (generic), valsartan/HCTZ (generic) Tersi® Foam selenium sulfide (generic) Testim®testosterone gel in packet (generic), testosterone gel pump 1.25gm (1%) (generic), Androderm (Watson), Androgel pump 20.25/1.25 (Unimed), Axiron (Eli Lilly) testosterone gel in packet (generic), testosterone gel pump testosterone gel 2% (Qualitest Pharm)1.25gm (1%) (generic), Androderm (Watson), Androgel pump 20.25/1.25 (Unimed), Axiron (Eli Lilly) Teveten® 400mgcandesartan (generic), eprosartan (generic), irbesartan (generic), losartan (generic), telmisartan (generic), valsartan (generic) Teveten HCT®candesartan/HCTZ (generic), irbesartan/HCTZ (generic), losartan/HCTZ (generic), telmisartan/HCTZ (generic), valsartan/HCTZ (generic), Texacort® fluocinolone acetonide solution, non oral (generic) Ticanase®budesonide (generic), flunisolide (generic), fluticasone propionate (generic), mometasone furoate (generic), triamcinolone acetonide (generic) Timoptic PF®betaxolol (generic), carteolol (generic), timolol maleate (generic), levobunolol (generic), metipranolol (generic) Tivorbex® indomethacin (generic) TobraDex® STtobramycin-dexamethasone (generic), neomycin/ bacitracin/polymyxin B/HC (generic), neomycin/ polymyxin B/dexamethasone (generic), neomycin/ polymyxin B/HC (generic), TobraDex® Oint (Alcon) Tolak®fluorouracil (generic), imiquimod (generic), Picato gel (Leo Pharma Inc.) Topiramate ER® topiramate (generic) Topicort® spraydesoximetasone spray (generic) Toviaz®flavoxate (generic), oxybutynin (generic), oxybutynin ER (generic), tolterodine tartrate (generic), trospium (generic), Myrbetriq® (Astellas),Vesicare® (GlaxoSmithKline) Tramadol ER® Capsules tramadol ER tablets (generic) Travatan Z®bimatoprost (generic), latanoprost (generic), travaprost (generic) Tresiba Flextouch®Lantus (Sanofi-Aventis), Lantus Solostar (Sanofi-Aventis), Toujeo Solostar (Sanofi-Aventis) Tretin-X® Cream, Kit tretinoin (generic) Treximet®sumatriptan (generic), naproxen (generic) Tribenzor®telmisartan-amlodipine (generic) + hydrochlorothiazide (generic) Triglide®fenofibrate (generic) Trintellix®paroxetine (generic), citalopram (generic), escitalopram (generic), fluvoxamine (generic) Trokendi XR® topiramate (generic) Ultravate Lotion®clobetasol propionate lotion (generic), halobetasol propionate cream (generic) Ultresa®pancrelipase (generic), Creon® (Abbott), Zenpep® (Aptalis Pharma) Utibron Neohaler®Stiolto Respimat (Boehringer Ingelheim) Vanoxide HC® benzoyl peroxide, hydrocortisone cream (generic) Varubi®ondansetron (generic), granisetron (generic), Emend® (Merck) Vascepa®fenofibrate (generic), niacin ER (generic) Velphoro® sevelamer carbonate (generic), calcium acetate (generic) Veltin®clindamycin phosphate/tretinoin (generic) Ventolin HFA®ProAir HFA® (Teva), ProAir Respiclick® (Teva) Veramyst®budesonide (generic), flunisolide (generic), fluticasone propionate (generic), mometasone furoate (generic), triamcinolone acetonide (generic) Verdeso® desonide (generic) Versacloz® clozapine ODT (generic) Vexol® fluorometholone (generic) Vibramycin® Syrup doxycycline monohydrate suspension (generic) Victoza®Bydureon (Amylin Pharmaceuticals), Bydureon Pen (Amylin Pharmaceuticals), Byetta (Amylin Pharmaceuticals), Trulicity (Eli-Lilly) Viekira Pak®Harvoni® (Gilead) Viekira XR®Harvoni (Gilead) Viibryd®citalopram (generic), fluoxetine HCl (generic), paroxetine HCl (generic), sertraline HCl (generic) Vimovo® naproxen (generic) + esomeprazole magnesium (generic) Viokace®Creon® (Abbott), Zenpep® (Aptalis Pharma) Vitafol-OB + DHA®PNV-DHA (generic), Zatean-PN Plus (generic), Zatean-PN DHA (generic), Zatean-PN (generic), Prenatal Plus (generic) Vitafol-One®PNV-DHA (generic), Zatean-PN Plus (generic), Zatean-PN DHA (generic), Zatean-PN (generic), Prenatal Plus (generic) Vital-D Rx® Folbee (generic), Folbee Plus (generic), Folbic (generic), Renal Caps (generic), Triphrocaps (generic) Vivlodex®meloxicam (generic) Vogelxo®testosterone gel in packet (generic), testosterone gel pump 1.25gm (1%) (generic), Androderm (Watson), Androgel pump 20.25/1.25 (Unimed), Axiron (Eli Lilly) Vraylar®aripiprazole (generic), clozapine (generic), olanzapine (generic), paliperidone (generic), quetiapine fumarate (generic), risperidone (generic), ziprasidone HCL (generic) Vytorin®atorvastatin (generic), simvastatin (generic), Zetia® (Merck-Schering Plough) Xartemis XR® oxycodone/APAP (generic), hydrocodone/APAP (generic) Xerese®acyclovir ointment (generic) + hydrocortisone (generic) Xigduo XR®Invokana (Janssen), Invokamet (Janssen), Jardiance (Boehringer Ingelheim), Synjardy (Eli Lilly) Xolegel® econazole nitrate (generic), ketoconazole (generic), nystatin (generic) Xopenex HFA®ProAir HFA® (Teva), ProAir Respiclick® (Teva) Xtampza ER®oxycodone HCL (generic), Oxycontin (Purdue Pharma) Zantac Rx® effervescent cimetidine liquid (generic), ranitidine syrup (generic) Zecuity® sumatriptan succinate (generic) Zelapar® selegiline (generic) Zembrace Symtouch®sumatriptan succinate injection (generic) Zenzedi® dextroamphetamine sulfate (generic) Zepatier®Harvoni (Gilead) Zetonna®budesonide (generic), flunisolide (generic), fluticasone propionate (generic), mometasone furoate (generic), triamcinolone acetonide (generic) Zioptan®bimatoprost (generic), latanoprost (generic), travoprost (generic) Zipsor®diclofenac sodium (generic), ibuprofen(generic), naproxen (generic), nabumetone (generic) Zithranol® , Zithranol-RR®Drithocreme® HP (Summers Labs) Zmax® azithromycin (generic) Zohydro ER® morphine sulfate ER (generic), oxymorphone ER (generic), Oxycontin® (Purdue Pharma) Zolpimist® zolpidem tartrate (generic), zaleplon (generic) Zolvit®hydrocodone w/APAP solution (generic) Zomig® Nasal Spraysumatriptan nasal spray (generic) Zorvolex®diclofenac (generic), etodolac (generic), ibuprofen (generic), ketoprofen (generic) Zovirax® CreamDenavir® Cream (Novartis) Zuplenz® ondansetron ODT (generic) Zyclara®fluorouracil (generic), imiquimod (generic), Picato® Gel (Leo Pharma Inc.) Zydone®hydrocodone w/acetaminophen (generic) Zylet® tobramycin-dexamethasone (generic), neomycin/ bacitracin/polymyxin B/HC (generic), neomycin/ polymyxin B/dexamethasone (generic), neomycin/ polymyxin B/HC (generic), TobraDex® Oint (Alcon) ® Zyprexa Relprevv Aristada (Alkermes, Inc.), Risperdal Consta (Janssen) *This is a partial list of nonpreferred drugs. Please be sure that your drug is listed in Section I. 15
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