Download 2014 NationalEnvisionFormularyAlpha 1-1-2014.xlsx - Akron-AAUP

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Preferred Drug List
INTRODUCTION
The Envision Preferred Drug List (PDL) is a list of commonly prescribed drugs eligible for
coverage under your prescription drug benefit program. This list is reviewed from time to time
as new drugs and new prescribing information becomes available.
The Envision Pharmacy and Therapeutics Committee is responsible for the development and
maintenance of the Preferred Drug List. The Committee is comprised of independent, practicing
physicians and pharmacists from a wide variety of medical specialties. The Preferred Drug List
is reviewed and updated from time to time as new drugs or new prescribing information becomes
available. Factors which affect decisions regarding the Preferred Drug List include safe use,
clinical efficacy, and therapeutic need. Only after those factors are assessed is cost considered.
Decisions are reached by a committee’s simple majority vote. Committee members are required
to remain free from conflict of interest in all committee votes. They attest to that fact at every
committee meeting. Compliance with the Preferred Drug List is important for improving quality
of care and restraining health care costs.
You may be able to obtain a drug not included on the Preferred Drug List for reasons of medical
necessity or if formulary alternatives are inappropriate. Drugs used for cosmetic purposes may
not be covered under your prescription drug plan.
STRUCTURE
Co-payment Tiers may vary with individual plans, but generally follow these guidelines:
Tier 1: Most Generic Drugs
Tier 2: Preferred Branded Drugs
Tier 3: Non-Preferred Branded Drugs
Tier 4: Preferred Specialty Drugs - not all plans cover specialty drugs (for 3 tier benefits,
these would be considered preferred brand)
Tier 5: Non-Preferred Specialty Drugs - not all plans cover specialty drugs (for 3 tier
benefits, these would be considered non-preferred brand)
Prior Authorizations and Quantity Limits may be in place for certain medications and will vary
by plan. Check with member services to see if your plan has these limitations in place.
i
IMPORTANT
The ability to obtain medications listed on this formulary may be limited by other state or
regulatory limitations on prescriptions such as expiration dates or limitations on the number of
refills. If you have any questions regarding the coverage of any particular drug under your
benefit program, please call the member services number located on the back of your
prescription drug identification card (800-361-4542), refer to your plan-specific documents or
contact your plan administrator for further information.
SPECIALTY MEDICATIONS
Specialty medications are medications for chronic diseases such as rheumatoid arthritis, multiple
sclerosis, or Hepatitis C. These diseases typically require special care and the medications may
be given by injection or infusion. These medications are very expensive and may require special
handling (i.e. must be kept refrigerated). Often additional education and support is required
from a health care professional in order to access these medications. If your plan covers specialty
medications, they may only be available through a preferred specialty pharmacy provider. In the
case of an emergency or a first time fill, you may be able to fill these at your local retail
pharmacy.
ii
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
A
abacavir (ZIAGEN)
ABILIFY (all forms)
ACANYA
acarbose (PRECOSE)
ACCOLATE
ACCU-CHEK
ACCU-CHEK STRIPS
acebutolol (SECTRAL)
acetaminiphen/caffeine/bultalb (ESGIC/PLUS, FIORCET)
acetaminophen/butalbital (PHRENLIN/FORTE)
acetazolamide (DIAMOX/SEQUELS)
acetic acid (VOSOL)
acetic acid/aluminum acetate (DOMEBORO OTIC)
acetic acid/hydrocortisone (VOSOL HC)
acetylcysteine (MUCOMYST)
ACIPHEX
ACLOVATE
ACTONEL
ACTONEL WITH CALCIUM
ACTOPLUS MET
ACTOPLUS MET XR
ACTOS
ACUVAIL
acyclovir ointment (ZOVIRAX OIN)
adapalene (DIFFERIN)
ADDERALL XR
ADVAIR DISKUS/HFA
ADVATE
ADVICOR
AFINITOR
AGGRENOX
AKINETON
AKNE-MYCIN, STATICIN
ALAMAST
ALBENZA
albuterol neb soln (ACCUNEB)
alendronate (FOSAMAX)
alfuzosin HCl ER
ALINIA
ALKERAN INJ
ALKERAN TABS
1
2
2
1
3
3
3
3
3
Multiple generic topical steroids
3
3
3
2
1
1
Age limit may apply
3
2
5
3
4
2
2
2
2
2
1
1
1
2
5
2
FREE Freestyle or Precision meter available. Call 1-866-224-8892
for more information.
FREE Contour or Breeze meter available. Call 1-877-229-3777 for
more information.
2
2
1
1
3
Alamast preferred
3
CLIMARA, VIVELLE DOT, MENOSTAR, ESTRADERM
2
ALORA
Effective 1/1/2014
Omeprazole, Pantoprazole
2
2
ALL BAYER PRODUCTS (includes CONTOUR/BREEZE)
ALPHAGAN P 0.1%
ALPHAGAN P 0.15%
ALPHANATE
ALPHANINE S
alprazolam/xr (XANAX/XR)
ALREX
aluminum chloride hexahydrate (DRYSOL)
amantadine (SYMMETREL)
amcinonide (CYCLOCORT)
Amethia (SEASONIQUE)
Freestyle/Precision/Contour/Breeze products preferred
1
1
1
1
1
1
1
1
ALL ABBOTT PRODUCTS (includes FREESTYLE/PRECISION)
All Generic Prenatal Vitamins
allopurinol
ALOCRIL
ALOMIDE
Freestyle/Precision/Contour/Breeze products preferred
2
2
3
5
1
3
1
1
1
1
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2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
Amethia Lo (LOSEASONIQUE)
amethyst (LYBREL)
amiloride/hctz (MODURETIC)
aminocaproic acid (AMICAR)
aminophylline
amiodarone (CORDARONE)
AMITIZA
amitriptyline (ELAVIL)
amitriptyline hcl/perphenazine (TRIAVIL)
amitriptyline/chlordiazepixide (LIMBITROL)
amlodipine/atorvastatin (CADUET)
amlodipine besylate (NORVASC)
amlodipine besylate-benazepril (LOTREL)
amoxapine (ASENDIN)
amoxicillin (AMOXIL)
amoxicillin/clavulanate (AUGMENTIN)
amoxicillin/clavulanate ex (AUGMENTIN ES)
amoxicillin/clavulanate ex susp (AUGMENTIN ES SUSP)
amoxicillin/clavulanic acid (AUGMENTIN XR)
amphetamine/dextroamphetamine (ADDERALL)
AMTURNIDE
anagrelide (AGRYLIN)
ANA-KITS
ANALPRAM (all forms including kit)
anastrozole (ARIMIDEX)
ANDRODERM
ANDROGEL
ANDROID
ANTABUSE
ANTARA
anthralin cream (DRITHOCREME HP)
antipyrine/benzocaine (AURALGAN)
ANZEMET
apap/isometheptene/dichlphen (MIDRIN)
APIDRA
APIDRA SOLOSTAR
apraclonidine ophth (IOPIDINE)
apri (DESOGEN)
APRISO
ARANESP
ARICEPT/ARICEPT ODT (23MG)
ARICEPT/ARICEPT ODT (5MG and 10MG)
ARIXTRA
ARMOUR THYROID
AROMASIN
ASACOL HD
ASMANEX
aspirin/caffeine/butalbital (FIORINAL)
ASTEPRO
ATELVIA
atenolol (TENORMIN)
atenolol/hctz (TENORETIC)
atorvastatin (LIPITOR)
ATRALIN
ATRIPLA
atropine sulfate (ISOPTO ATROPINE)
ATROVENT HFA INHALER
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
2
3
1
3
2
3
3
3
1
1
4
1
2
2
1
1
2
5
3
3
3
3
3
2
1
2
2
1
1
1
2
2
Age limit may apply
1
3
SPIRIVA preferred
5
Effective 1/1/2014
PROCRIT preferred
2
AUBAGIO
AUGMENTIN XR
Preferred Alternatives/Comments
3
Requires prior failure of AVONEX or COPAXONE or TECFIDERA
OR a statement of medical necessity from your doctor
Amoxicillin & K Clavulanate Preferred
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2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
AVANDAMET
2
The US FDA has significantly restricted the use of Avandia to patient
who cannot control their diabetes on other medications.
AVANDARYL
2
The US FDA has significantly restricted the use of Avandia to patient
who cannot control their diabetes on other medications.
AVANDIA
2
The US FDA has significantly restricted the use of Avandia to patient
who cannot control their diabetes on other medications.
AVC
AVELOX
AVINZA
AVODART
AVONEX
AXERT
AXIRON
azatadine (OPTIMINE)
azathioprine (IMURAN)
azelastine (ASTELIN)
azelastine (OPTIVAR)
AZELEX, FINACEA
AZILECT
azithromycin (ZITHROMAX)
AZOPT
AZOR
2
2
2
2
4
3
3
sumatriptan, rizatriptan, RELPAX
1
1
1
1
2
2
1
2
2
B
bacitracin
bacitracin (AK-TRACIN)
baclofen (LIORESAL)
BACTROBAN
balsalazide (COLAZAL)
BANZEL
BARACLUDE
BEBULIN
BECONASE/AQ
belladonna alkaloids (DONNATAL)
benazepril (LOTENSIN)
benazepril/hctz (LOTENSIN HCT)
BENEFIX
BENICAR
BENICAR HCT
BENZACLIN (all forms)
benzonatate (TESSALON PERLES)
benzoyl peroxide - erythromycin gel (BENZAMYCIN)
benzoyl peroxide (BENZAC AC, BENZAGEL, DESQUAM)
benzoyl peroxide cloth (TRIAZ PADS)
benzoyl peroxide gel, lot (BREVOXYL)
benztropine (COGENTIN)
betameth/propylene glycol (DIPROLENE AF)
betameth/propylene glycol (DIPROLENE)
betamethasone dipropionate (DIPROSONE)
betamethasone valerate (VALISONE)
1
1
1
3
1
3
4
5
3
5
2
2
2
1
1
1
1
1
1
1
1
1
1
Some strengths available as generic
BETASERON
betaxolol (KERLONE)
bethanechol (URECHOLINE)
BETIMOL
BETOPTIC-S
BEYAZ
bicalutamide (CASODEX)
BILTRICIDE
bisoprolol (ZEBETA)
bisoprolol/hctz (ZIAC)
Effective 1/1/2014
Fluticasone, NASONEX
1
1
1
5
Requires prior failure of AVONEX or COPAXONE or TECFIDERA
OR a statement of medical necessity from your doctor
1
1
2
2
2
1
2
1
1
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2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
BREO ELLIPTA
BRETHINE INHALER
BRILINTA
brimonidine tartrate (ALPHAGAN P 0.1% )
bromocriptine mesylate (PARLODEL)
BRONCOMAR
budesonide (PULMICORT RESPULES)
budesonide ec (ENTOCORT EC)
bumetanide (BUMEX)
buprenorphine/naloxone tabs (SUBOXONE TABS)
bupropion (WELLBUTRIN)
bupropion sr (WELLBUTRIN SR)
bupropion sr 24hr (WELLBUTRIN XL)
buspirone (BUSPAR)
butorphanol (STADOL)
BUTRANS
BYDUREON
BYETTA
BYSTOLIC
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
2
2
2
1
1
2
1
1
1
1
1
1
1
1
1
2
3
3
2
C
CADUET
calcipotriene (DOVONEX)
calcitonin nasal soln ( MIACALCIN)
calcitriol (ROCALTROL)
calcium acetate (PHOSLO)
Camrese (SEASONIQUE)
Camrese Lo (LOSEASONIQUE)
CANTIL
CAPEX
CAPITROL SHAMPOO
captopril (CAPOTEN)
captopril/hctz (CAPOZIDE)
CARAFATE SUSPENSION
carbachol (ISOPTO CARBACHOL)
carbamazepine (TEGRETOL)
carbamazepine er (CARBATROL)
carbamazepine sr (TEGRETOL XR)
CARBATROL
carbidopa/levodopa (SINEMET/CR)
carbidopa/levodopa/entacapone (STALEVO)
3
1
1
1
1
1
1
2
2
2
1
1
2
1
1
1
1
Some strengths available as generic
3
1
1
CARDENE SR
CARDIZEM LA
carisoprodol & aspirin (SOMA CMPD)
carisoprodol (SOMA)
carteolol (OCUPRESS)
carvedilol (COREG)
CAVERJECT
CEDAX
CEENU
cefaclor (CECLOR)
cefadroxil (DURICEF)
cefdinir (OMNICEF)
cefpodoxime proxetil tabs (VANTIN)
cefprozil (CEFZIL)
cefprozil susp (CEFZIL SUSP)
cefuroxime axetil susp (CEFTIN susp)
cefuroxime axetil tabs (CEFTIN)
CELEBREX
CELONTIN
CENESTIN
Effective 1/1/2014
3
Generic Diltiazem extended release, generic Verapamil extended
release, Amlodipine
3
Generic Diltiazem extended release
3
3
3
Generic Keflex
3
PREMARIN/ESTRACE preferred
1
1
1
1
1
1
1
1
1
1
1
1
2
2
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2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
cephalexin (KEFLEX)
CERUMENEX
cevimeline HCl (EVOXAC)
CHANTIX
CHEMSTRIP
CHEMSTRIP TEST STRIPS
chloral hydrate (AQUACHLORAL)
chloramphenicol (CHLOROMYCETIN)
chlordiazepoxide hcl (LIBRIUM)
chlorhexidine (PERIDEX, PERIOGARD)
chloroquine phosphate (ARALEN)
chlorothiazide (DIURIL)
chlorpheniramine/methscopolamine (ALLERX DF)
chlorpheniramine-hydrocodone (TUSSIONEX)
chlorpromazine (THORAZINE)
chlorthalidone (HYGROTON)
chlorzoxazone (PARADON FORTE)
cholestyramine (PREVALITE/QUESTRAN)
choline/magnesium salicylate (TRILISATE)
choline fenofibrate (TRILIPIX)
chorionic gonadotropin (PREGNYL)
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
1
2
1
2
3
3
Freestyle/Precision/Contour/Breeze products preferred
3
Requires prior failure of a finasteride AND tamsulosin or alfuzosin for
approval for BPH
Freestyle/Precision/Contour/Breeze products preferred
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
CIALIS (all forms)
ciclopirox cream and susp (LOPROX)
ciclopirox soln (PENLAC)
cilostazol (PLETAL)
cimetidine (TAGAMET)
1
1
1
1
CIMZIA
5
CIPRO HC
CIPRODEX
ciprofloxacin (CILOXAN)
ciprofloxacin (CIPRO)
ciprofloxacin sr 24hr (CIPRO XR)
citalopram (CELEXA)
citric acid/k-na citrates (CYTRA-3)
citric acid/potassium citrate (POLYCITRA-K, CYTRA-K)
CLARINEX
clarithromycin (BIAXIN/BIAXIN XL)
clidinium/chlordiazepoxide (LIBRAX)
CLIMARA PRO
clindamycin hcl (CLEOCIN)
clindamycin palmitate (CLEOCIN PEDIATRIC)
clindamycin phosphate (CLEOCIN T)
clindamycin phosphate (CLEOCIN VAG)
clindamycin phosphate-benzoyl peroxide gel ( BENZACLIN)
clobetasol propionate (CLOBEX, OLUX, TEMOVATE/E)
CLODERM
clomipramine (ANAFRANIL)
clonazepam (KLONOPIN)
clonidine (CATAPRES)
clonidine transdermal (CATAPRES TTS)
clopidogrel (PLAVIX)
clorazepate (TRANXENE)
clotrimazole (MYCELEX)
clotrimazole troche (MYCELEX)
clotrimazole/betamethasone dipropionate (LOTRISONE)
clozapine (CLOZARIL)
cod/pro (PHENERGAN w/CODEINE)
codeine phosphate/apap (TYLENOL W/CODEINE)
codeine phosphate/aspirin
codeine sulfate
Effective 1/1/2014
Preferred Alternatives/Comments
Requires prior failure of ENBREL and HUMIRA OR a statement of
clinical necessity from your doctor
2
2
1
1
1
1
1
1
3
Generic loratadine, fexofenadine
3
Multiple generic topical steroids
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
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2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
codeine/apap/caffeine/butalb (FIORICET w/CODEINE)
codeine/asa/caffeine/butalb (FIORINAL w/CODEINE)
colchicine
colchicine & probenecid
COLCRYS
colestipol (COLESTID)
COMBIGAN
COMBIPATCH
COMBIVENT RESPIMAT
COMBIVIR
COMTAN
CONCERTA
COPAXONE
CORDRAN
COREG CR
CORTIFOAM
COSOPT
COUMADIN
CREON
CRESTOR
CRINONE
CRIXIVAN
cromolyn (CROLOM)
cromolyn (INTAL neb)
CUTIVATE
cyclobenzaprine (FLEXERIL)
cyclopentolate soln (CYCLOGYL)
cyclophosphamide (CYTOXAN)
cyclosporine (NEORAL, SANDIMMUNE)
CYKLOKAPRON
cyproheptadine
CYSTADANE
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
1
1
1
1
2
1
2
2
2
3
3
3
4
3
Multiple generic topical steroids
2
2
Generic ANUSOL-HC
3
3
2
2
4
2
1
1
3
1
1
1
1
Multiple generic topical steroids
Some strengths available as generic
3
1
2
D
DALIRESP
DANAZOL
dantrolene (DANTRIUM)
DAPSONE
DARAPRIM
DENAVIR
DEPEN TITRATABS
DERMA-SMOOTHE/FS
desipramine (NORPRAMIN)
desmopressin acetate (DDAVP)
desonide (DESOWEN, TRIDESILON)
desoximetasone (TOPICORT/LP)
dexamethasone (DECADRON)
dexamethasone sod phosphate (DECADRON)
dexchlorpheniramine maleate (POLARAMINE)
DEXILANT
dextroamphetamine (DEXEDRINE, DEXTROSTAT)
DHT, HYTAKEROL
DIASTAT
diazepam (VALIUM)
diazepam rectal gel (DIASTAT)
DIBENZYLINE
diclofenac (VOLTAREN OPHTH DROPS)
diclofenac ophth (VOLTAREN)
diclofenac sodium (VOLTAREN/XR)
dicloxacillin
dicyclomine (BENTYL)
Effective 1/1/2014
2
3
1
2
2
2
2
3
1
1
1
1
1
1
1
2
1
2
3
1
1
2
1
1
1
1
1
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2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
didanosine delayed rel cap (VIDEX EC)
diflorasone (PSORCON/E)
diflorasone diacetate cr (FLORONE/E)
digoxin (LANOXIN)
dihydrocodeine/aspirin/caffeine (SYNALGOS DC)
dihydroergotamine nasal spray (MIGRANAL)
diltiazem (CARDIZEM, DILACOR)
diltiazem (TIAZAC)
DIOVAN
DIPENTUM
dipyridamole (PERSANTINE)
disopyramide cr (NORPACE/CR)
disphenoxylate/atropine sulfate (LOMOTIL)
disulfiram (ANTABUSE)
divalproex (DEPAKOTE/ER)
divalproex sr (DEPAKOTE ER)
donepezil 5mg and 10mg (ARICEPT/ARICEPT ODT (5MG and 10MG))
DORYX
dorzolamide HCl/timolol m
DOVONEX
doxazosin (CARDURA)
doxazosin mesylate (CARDURA)
doxepin (SINEQUAN)
doxycycline hyclate (PERIOSTAT)
doxycycline hyclate (VIBRATABS)
DRITHO-SCALP
DUAC
DUETACT
DULERA
DYMISTA
dyphylline (LUFYLLIN)
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
1
1
1
1
1
1
1
1
2
3
1
1
1
1
1
1
1
3
1
3
1
1
1
1
1
2
3
3
3
3
1
E
EASIVENT
econazole nitrate (SPECTAZOLE)
EDEX
EFFIENT
electrolyte sol'n/peg's (COLYTE, GOLYTELY)
ELIDEL
ELMIRON
EMADINE
EMBEDA
EMCYT
EMEND
ENABLEX
enalapril (VASOTEC)
enalapril/hctz (VASERETIC)
ENBREL
enoxaparin (LOVENOX)
entacapone (COMTAN)
ENTOCORT EC
ENZYMAX
ephedrine sulfate
EPIFOAM
EPIFRIN
EPINAL
EPIPEN/EPIPEN Jr.
EPIVIR
EPOGEN
ERCAF
ergocalciferol (DRISDOL)
Effective 1/1/2014
2
1
3
2
1
2
2
3
2
4
3
2
1
1
4
preferred
4
PROCRIT preferred
1
1
3
2
1
2
2
2
2
3
2
1
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2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
ERGOMAR
Ergotamine w/ Caffeine Suppos (CAFERGOT)
erythromycin base - generic
erythromycin base (A/T/S, EMGEL, ERYGEL, T-STAT)
erythromycin base (E-MYCIN)
erythromycin base/benzoyl peroxide (BENZAMYCIN)
erythromycin ethylsuccinate (E.E.S.)
erythromycin ethylsuccinate (ERYPED)
erythromycin stearate
erythromycin/sulfisoxazole (PEDIAZOLE)
escitalopram oxalate
estazolam (PROSOM)
ESTRACE VAGINAL CREAM
ESTRADERM
estradiol & norethindrone acetate (ACTIVELLA)
estradiol (ESTRACE)
estradiol transdermal (CLIMARA)
ESTRING
estropipate (OGEN, ORTHO-EST)
ESTROSTEP/FE
ethambutol (MYAMBUTOL)
ethinyl estradiol-desogestrel (MIRCETTE)
ethinyl estradiol-ethynodiol diacetate (DEMULEN)
ethinyl estradiol-levonorgestrel (ALESSE)
ethinyl estradiol-levonorgestrel (NORDETTE)
ethinyl estradiol-levonorgestrel (TRIPHASIL)
ethinyl estradiol-norgestrel (LO-OVRAL)
ethinyl estradiol-norgestrel (OVRAL)
ETHMOZINE
ethosuximide (ZARONTIN)
etidronate (DIDRONEL)
etodolac (LODINE/XL)
etoposide (VEPESID)
EURAX
EVISTA
EVOXAC
EXALGO
EXELDERM
EXELON patches
exemestane (AROMASIN)
EXFORGE
EXFORGE HCT
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
2
1
1
1
1
1
1
1
1
1
1
1
Some strengths available as generic
3
2
1
1
1
0.05MG and 0.1MG patches are available as a generic
2
1
3
1
1
1
1
1
1
1
1
2
1
1
1
1
2
2
3
2
3
2
1
2
2
F
famciclovir (FAMVIR)
famotidine (PEPCID)
FARESTON
FAST TAKE
FEIBA VH
felbamate (FELBATOL)
FELBATOL
1
1
felodipine (PLENDIL)
1
FEMARA
FEMHRT
FEMRING
fenofibrate (ANTARA,TRICOR)
FENOGLIDE
fentanyl (ACTIQ)
fentanyl (DURAGESIC)
FETZIMA
fexofenadine (ALLEGRA)
Effective 1/1/2014
2
3
Freestyle/Precision/Contour/Breeze products preferred
5
1
3
Generic Diltiazem extended release, generic Verapamil extended
release, Amlodipine
3
3
3
PREMPRO, PREMPHASE preferred
1
3
1
1
2
1
8 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
fexofenadine/PSE (ALLEGRA-D)
finasteride (PROSCAR)
flavoxate (URISPAS)
flecainide (TAMBOCOR)
FLECTOR
FLOVENT (including ROTADISK and HFA)
fluconazole (DIFLUCAN)
fluconazole susp (DIFLUCAN SUSP)
fludrocortisone (FLORINEF)
fluocinolone acetonide (DERMA-SMOOTHE/FS, SYNALAR)
fluocinonide (LIDEX/E)
fluorometholone (FML)
FLUOROPLEX
fluorouracil cr (EFUDEX)
fluoxetine (PROZAC)
fluoxetine (SARAFEM)
fluoxetine/olanzapine (SYMBYAX)
fluoxymesterone (HALOTESTIN)
fluphenazine hcl (PROLIXIN)
flurazepam (DALMANE)
flurbiprofen (ANSAID)
flutamide (EULEXIN)
fluticasone propionate (FLONASE)
fluvoxamine (LUVOX)
FML FORTE, S.O.P.
FML-S
FOCALIN (all forms)
folic acid
FOLLISTIM/AQ
fondaparinux (ARIXTRA)
FORADIL
FORTAMET
FORTEO
FORTESTA
FORTOVASE
fosinopril (MONOPRIL)
fosinopril/hctz (MONOPRIL HCT)
FOSRENOL
FRAGMIN
FROVA
FURADANTIN
furosemide (LASIX)
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
1
1
1
1
2
2
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
2
2
3
1
4
1
2
3
5
3
2
1
1
2
2
3
3
sumatriptan, rizatriptan, RELPAX
1
G
gabapentin solution (NEURONTIN)
GABITRIL
ganciclovir (CYTOVENE)
GANIRELIX
GELNIQUE
gemfibrozil (LOPID)
GENOTROPIN
gentamicin (GARAMYCIN)
gentamicin (GARAMYCIN, GENOPTIC)
GEODON
gianvi/loryna/vestura (YAZ)
1
3
1
4
3
1
4
1
1
3
1
GILENYA
5
GLEEVEC
glimepiride (AMARYL)
glipizide & metformin (METAGLIP)
glipizide (GLUCOTROL XL)
Effective 1/1/2014
Requires prior failure of AVONEX or COPAXONE or TECFIDERA
OR a statement of medical necessity from your doctor
5
1
1
1
9 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
glipizide (GLUCOTROL)
GLUCAGEN
GLUCAGON
glyburide & metformin (GLUCOVANCE)
glyburide (DIABETA, GLYNASE, MICRONASE)
glycopyrrolate (ROBINUL/FORTE)
GLYSET
granisetron (KYTRIL)
GRIS-PEG
griseofulvin (GRIFULVIN V, GRIS-PEG)
gua/hym (DILAUDID COUGH)
gua/pse (DECONSAL II, ENTEX PSE)
gua/pse (GUAIFED/PD)
guanabenz (WYTENSIN)
guanfacine (TENEX)
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
1
2
2
1
1
1
3
1
3
1
1
1
1
1
1
H
HALFAN
HALFLYTELY
halobetasol propionate (ULTRAVATE)
HALOG
haloperidol (HALDOL)
HBV
hctz/triamterene (DYAZIDE, MAXZIDE)
HECTOROL
HELIDAC
HELIXATE FS
HEPSERA
HEXALEN
HMS LIQUIFILM
homatropine hbr (ISOPTO HOMATROPINE)
HUMALOG PRODUCTS
HUMATE-P
HUMATROPE
HUMIRA
HUMULIN PRODUCTS
hyd/ht (HYCODAN)
hydralazine (APRESOLINE)
hydrochlorothiazide (ESIDRIX, HYDRODIURIL)
hydrocodone bitartrate/apap (LORTAB TAB)
hydrocodone bitartrate/apap (VICODIN/VICODIN ES)
hydrocodone bitartrate/ibuprofen (VICOPROFEN)
hydrocortisone (CORTEF)
hydrocortisone (HYTONE, NUTRACORT, PENECORT)
hydrocortisone (PROCTOCORT HC, CORTENEMA)
hydrocortisone / pramoxine rectal Cr (ANALPRAM HC)
hydrocortisone acetate (ANUSOL-HC)
hydrocortisone acetate/urea (CARMOL HC)
hydrocortisone butyrate (LOCOID OINT/SOLN/CREAM)
hydrocortisone valerate (WESTCORT)
hydromorphone (DILAUDID)
hydroxychloroquine (PLAQUENIL)
hydroxyurea (HYDREA)
hyoscyamine (ANASPAZ, LEVSIN/SL, LEVSINEX)
hyoscyamine sulfate/phenobarb (LEVSIN/PB)
2
3
1
3
Multiple generic topical steroids
3
3
Zemplar preferred
1
2
1
Generic Bismuth, Metronidazole, Tetracycline
5
4
4
2
1
3
3
5
4
preferred
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
I
ibuprofen (MOTRIN)
imipramine hcl (TOFRANIL)
imipramine pamoate (TOFRANIL PM)
imiquimod cream (ALDARA)
IMITREX
Effective 1/1/2014
1
1
1
1
3
sumatriptan, rizatriptan, RELPAX
10 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
INCIVEK
indapamide (LOZOL)
INDERAL LA
indomethacin (INDOCIN/SR)
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
4
1
3
1
INFERGEN
INNOHEP
INNOPRAN XL
5
Requires prior failure of PEGASYS or PEG-INTRON OR a
statement of clinical necessity from your doctor
5
Requires prior failure of PEGASYS or PEG-INTRON OR a
statement of clinical necessity from your doctor
5
Requires prior failure of ENBREL and HUMIRA OR a statement of
clinical necessity from your doctor
2
3
INTRON A
INTUNIV
INVIRASE
INVOKANA
IODINE STRONG
iodoquinol/hydrocortisone (VYTONE)
ipratropium (ATROVENT NASAL SPRAY)
Ipratropium/Albuterol Nebu Soln (DUONEB)
IQUIX
isoniazid & rifampin (RIFAMATE)
isoniazid (ISONIAZID)
isosorbide dinitrate (ISORDIL, SORBITRATE)
isosorbide mononitrate (IMDUR)
isotretinoin (ACCUTANE)
itraconazole (SPORANOX)
Preferred Alternatives/Comments
2
2
2
2
1
1
1
2
1
1
1
1
1
3
J
JALYN
JANUMET
JANUMET XR
JANUVIA
JUVISYNC
2
2
2
2
2
K
KADIAN 10MG, 40MG, 70MG, 130MG, 150MG, 200MG
KALETRA
KAZANO
KEMADRIN
KETEK
ketoconazole
ketoconazole (NIZORAL)
ketoprofen (ORUDIS)
ketorolac (TORADOL)
ketorolac tromethamine (ACULAR LS)
ketotifen fumarate opth sol (ZADITOR)
2
2
3
2
3
1
1
1
1
1
1
KINERET
K-LYTE DS
KOATE DVI
KOGENATE-FS
KOMBIGLYZE
K-PHOS
K-PHOS NEUTRAL
KRISTALOSE
KRONOFED-A
KRONOFED-A JR
2
5
5
2
3
3
2
2
2
L
labetalol (NORMODYNE, TRANDATE)
lactulose (CHRONULAC, ENULOSE, DUPHALAC)
LAMICTAL (ODT)
LAMICTAL (XR)
lamivudine (EPIVIR)
lamivudine/zidovudine (COMBIVIR)
lamotrigine (LAMICTAL XR)
lansoprazole (PREVACID)
Effective 1/1/2014
1
1
2
3
1
1
1
1
11 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
LANTUS
LANTUS SOLOSTAR
LARODOPA
latanoprost (XALATAN)
leflunomide (ARAVA)
LESCOL/XL
LETAIRIS
letrozole (FEMARA)
LEUCOVORIN
LEUKERAN
LEUKINE
levalbuterol neb soln (XOPENEX SOL)
LEVAQUIN
LEVEMIR
LEVEMIR FLEXPEN
levetiracetam (KEPPRA)
LEVITRA
levobunolol (BETAGAN)
levofloxacin (LEVAQUIN)
levofloxacin (QUIXIN)
Levonorgestrel & Ethinyl Estradiol (SEASONALE)
levonorgestrel & ethinyl estradiol tab (LEVLEN)
levonorgestrel & ethinyl estradiol tab (LEVLITE )
levonorgestrel (PLAN B)
levonorgestrel-ethin estradiol (TRI-LEVLEN)
levorphanol
levothyroxine (ARMOUR THYROID)
levothyroxine (LEVOTHROID)
levothyroxine (SYNTHROID)
levothyroxine (UNITHROID)
LEVOXYL
LEXAPRO
LIALDA
lidocaine (XYLOCAINE)
lidocaine cream (LMX)
LIDODERM
LIFESCAN
LINDANE
LINZESS
liothyronine
LIPITOR
LIPOFEN
lisinopril (PRINIVIL)
lisinopril (ZESTRIL)
lisinopril/hctz (PRINZIDE)
lisinopril/hctz (ZESTORETIC)
lithium carbonate (LITHOBID, ESKALITH/CR)
lithium citrate
LIVALO
LMX
LOCOID LIPOCREAM
LOCOID OINT/SOLN
LODOSYN
LOFIBRA
lomustine (CEENU)
loperamide
LOPROX Shampoo and Gel
LORATADINE OTC
lorazepam (ATIVAN)
LORTAB
Effective 1/1/2014
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
2
2
2
1
1
3
4
1
4
2
5
1
3
2
2
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
2
3
2
1
1
2
3
Freestyle/Precision/Contour/Breeze products preferred
2
2
1
3
2
1
1
1
1
1
1
2
3
2
Multiple generic topical steroids
3
Multiple generic topical steroids
2
3
1
1
3
1
1
3
12 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
losartan (COZAAR)
losartan/hctz (HYZAAR)
LOSEASONIQUE
LOTEMAX
LOTRONEX
lovastatin (MEVACOR)
LOVAZA
LOVENOX
loxapine succinate (LOXITANE)
LUMIGAN
LUNESTA
LUPRON-DEPOT/PED
LYBREL
LYRICA
LYSODREN
LYSTEDA
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
1
1
3
3
2
1
2
3
1
2
2
4
3
2
2
3
M
mafenide acetate packet for topical (SULFAMYLON)
malathion (OVIDE)
maprotilie (LUDIOMIL)
MATULANE
MAXAIR
MAXALT
MAXIDEX
mebendazole (VERMOX)
meclizine hcl (ANTIVERT)
meclofenamate
medroxyprogesterone (PROVERA)
medroxyprogesterone inj (DEPO-PROVERA)
mefloquine (LARIAM)
MEGACE ES SUSP
megestrol (MEGACE)
meloxicam
melphalan inj (ALKERAN INJ)
MENEST
MENOSTAR
MENTAX
meperidine (DEMEROL)
MEPHYTON
MEPRON
mercaptopurine (PURINETHOL)
mesna inj (MESNEX)
METADATE CD
metaproterenol (ALUPENT)
metaxolone (SKELAXIN)
metformin (GLUCOPHAGE)
metformin (GLUCOPHAGE/XR
metformin ER 24hr (FORTAMET)
meth/me blue/ba/salol/atp/hyos (URISED)
methadone (DOLOPHINE)
methamphetamine (DESOXYN)
methazolamide (NEPTAZANE)
METHERGINE
methimazole (TAPAZOLE)
methocarbamol (ROBAXIN)
methotrexate (RHEUMATREX)
methscopolamine (PAMINE/FORTE)
methyclothiazide (AQUATENSEN, ENDURON)
methyldopa (ALDOMET)
methyldopa/hctz (ALDORIL)
Effective 1/1/2014
1
1
1
4
3
3
PROAIR HFA or VENTOLIN HFA preferred
sumatriptan, rizatriptan, RELPAX
2
1
1
1
1
1
1
2
1
1
4
2
2
2
1
2
2
1
1
3
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
Some strengths available as generic
13 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
methylergonovine (METHERGINE)
methylphenidate er (ADDERALL XR, CONCERTA, METADATE ER)
methylphenidate/er (RITALIN LA/SR)
methylprednisolone (MEDROL)
metipranolol (OPTIPRANOLOL)
metoclopramide (REGLAN)
metolazone (ZAROXYLN)
metoprolol succinate er (TOPROL XL)
metoprolol tartrate (LOPRESSOR)
metronidazole (FLAGYL ER)
metronidazole (FLAGYL)
metronidazole (METROCREAM, METROGEL, METROLOTION)
metronidazole (METROGEL VAG)
mexiletine (MEXITIL)
MICARDIS
MICARDIS HCT
miconazole nitrate (MONISTAT-DERM)
MIGRANAL
minocycline (DYNACIN, MINOCIN)
minoxidil (LONITEN)
MINTEZOL
mirtazapine (REMERON SOLTAB)
mirtazapine (REMERON/ODT)
misoprostol (CYTOTEC)
MOBAN
moexipril (UNIVASC)
moexipril-hctz (UNIRETIC)
mometasone furoate (ELOCON)
MONOCLATE-P
MONONINE
montelukast (SINGULAIR)
morphine (KADIAN, MS CONTIN, MS IR, ROXANOL)
MOVIPREP
MULTAQ
multivitamins w/flouride
multivitamins w/fluor & iron
mupirocin oint/cre (BACTROBAN OINTMENT)
MUSE
MYCOBUTIN
mycophenolate mofetil ( CELLCEPT)
MYLERAN
MYRBETRIQ
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Some strengths available as generic
2
2
1
3
1
1
2
1
1
1
2
1
1
1
Some strengths available as generic
5
5
1
1
2
2
1
1
1
3
2
4
2
2
N
nabumetone (RELAFEN)
nadolol (CORGARD)
NAMENDA/XR
NAPRELAN
naproxen (NAPROSYN, EC-NAPROSYN)
naproxen sodium (ANAPROX/DS)
naratriptan (AMERGE)
NARDIL
NASACORT AQ
NASCOBAL
NASONEX
NATAZIA
nateglinide (STARLIX)
NEBUPENT
nefazodone (SERZONE)
neloxicam (MOBIC)
neomycin suf/polymy/buffers/hc (PEDIOTIC)
Effective 1/1/2014
1
1
2
3
Generic NSAIDs
1
1
1
3
3
2
2
2
1
2
1
1
1
14 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
neomycin sulfate/hc
neomycin sulfate/polymyxin/hc (CORTISPORIN)
neomycin/bacitracin/poly/hc (CORTISPORIN)
neomycin/bacitracin/polymyxin (NEOSPORIN)
neomycin/polymyxin/dexameth (DEXACIDIN, MAXITROL)
neostigmine bromide (PROSTIGMIN)
NESINA
NEULASTA
NEUMEGA
NEUPOGEN
NEURONTIN SOLUTION
NEVANAC
nevirapine (VIRAMUNE)
NEXAVAR
NEXIUM
NIASPAN
NIAZID-B6
nicardipine (CARDENE)
nifedipine (PROCARDIA)
nifedipine extended-release (ADALAT CC)
nifedipine extended-release (PROCARDIA XL)
NILANDRON
nimodipine (NIMOTOP)
nisoldipine (SULAR)
nitrofurantoin macrocrystal (MACRODANTIN)
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
1
1
1
1
1
1
3
4
5
4
3
2
1
5
2
2
2
1
1
1
1
4
1
1
Not recommended for use in patients with a creatinine clearance of
<60mg/dL
Not recommended for use in patients with a creatinine clearance of
<60mg/dL
1
nitrofurantoin/nitrofuran mac (MACROBID)
1
nitroglycerin (NITROSTAT, NITRO-BID, NITRO-DUR)
NITROLINGUAL SPRAY
nizatidine (AXID)
NORDITROPIN
noreth a-et estra/fe fumarate (LOESTRIN FE)
norethindrone (NOR QD)
norethindrone (ORTHO MICRONOR)
norethindrone acetate (AYGESTIN)
norethindrone-ethin estradiol (MODICON)
norethindrone-mestranol (ORTHO NOVUM)
norgestimate-ethinyl estradiol (ORTHO CYCLEN)
norgestimate-ethinyl estradiol (ORTHO TRI-CYCLEN)
norgestimate-ethinyl estradiol-fe (ESTROSTEP FE)
NOROXIN
nortriptyline (PAMELOR)
1
2
1
4
1
1
1
1
1
1
1
1
1
3
Ciprofloxacin
1
NORVIR
2
NOVOFINE
NOVOLIN
NOVOLIN MIX
NOVOLIN N
2
2
2
2
NOVOLIN R
2
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX
NOVOLOG MIX FLEXPEN
NOVOSEVEN
NOVOTWIST
NUCYNTA
NUCYNTA ER
NUTROPIN AQ
NUTROPIN
NUVARING
nystatin (MYCOSTATIN)
2
2
2
2
Effective 1/1/2014
Preferred Alternatives/Comments
3
2
2
2
5
5
2
1
15 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
nystatin (MYCOSTATIN)
nystatin/triamcinolone (MYCOLOG)
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
1
1
O
Ocella, Zarah, Syeda (YASMIN)
ofloxacin (FLOXIN)
ofloxacin (OCUFLOX)
ofloxacin otic soln (FLOXIN OTIC)
olanzapine (ZYPREXA ZYDIS)
olanzapine (ZYPREXA)
OLUX
omeprazole (PRILOSEC)
ondansetron ODT (ZOFRAN)
ondansetron soln (ZOFRAN soln)
ONE TOUCH
ONE TOUCH TEST STRIPS
ONGLYZA
OPANA
OPANA ER
opium/belladonna alkaloids (B&O)
ORAP
1
1
1
1
1
1
2
1
1
1
3
3
Freestyle/Precision/Contour/Breeze products preferred
Freestyle/Precision/Contour/Breeze products preferred
2
3
2
1
2
ORENCIA
5
orphenadrine (NORFLEX)
orphenadrine/aspirin/caffeine (NORGESIC)
ORTHO-EVRA
OSENI
OVCON
OVIDE
OXANDRIN, ANADROL
oxaprozin (DAYPRO)
oxazepam (SERAX)
oxcarbazepine (TRILEPTAL)
OXISTAT
OXSORALEN-ULTRA, 8-MOP
oxybutynin/SR (DITROPAN/XL)
oxycodone ir (OXY IR)
oxycodone/acetaminophen
oxycodone/aspirin
OXYCONTIN
oxymorphone (OPANA)
Requires prior failure of ENBREL and HUMIRA OR a statement of
clinical necessity from your doctor
1
1
2
3
3
3
3
1
1
1
3
2
1
1
1
1
2
1
P
PANDEL
pantoprazole (PROTONIX)
paromomycin (HUMATIN)
paroxetine (PAXIL)
paroxetine cr (PAXIL CR)
paroxetine susp (PAXIL SUSP)
PASER
PATADAY
PATANOL
PBZ-SR
PCE
pe/cod/pro (PHENERGAN VC/CODEINE)
pe/cpm/scop (EXTENDRYL/SR/JR/CHEW)
peg 3350-kcl-sod bicarb-nacl (NULYTELY)
PEG INTRON
PEGANONE
PEGASYS
pemoline (CYLERT)
penicillin
Effective 1/1/2014
3
Multiple generic topical steroids
3
Pataday Preferred
1
1
1
1
1
2
2
2
3
1
1
1
Generic COLYTE, generic GOLYTELY
4
preferred
4
preferred
2
1
1
16 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
PENNSAID
pentazocine/naloxone (TALWIN NX)
pentoxifylline (TRENTAL)
perindopril (ACEON)
permethrin (ELIMITE)
perphenazine (TRILAFON)
phenazopyridine (PYRIDIUM)
phenelzine (NARDIL)
phenobarbital
PHENURONE
phenylephrine hcl (NEO-SYNEPHRINE)
phenytoin (DILANTIN)
phenytoin extended (PHENYTEK)
PHOSLO
PHOSPHOLINE IODIDE
phosphorus (K-PHOS NEUTRAL)
PICATO
pilocarpine (SALAGEN)
pilocarpine hcl (PILOCAR)
pilocarpine hcl/epinephrine (E-PILO)
PILOPINE H.S.
pindolol (VISKEN)
pioglitazone (ACTOS)
pioglitazone/metformin (ACTOPLUS MET)
piroxicam (FELDENE)
PLAN B
PLAVIX
Podofilox Soln (CONDYLOX)
polymyxin b sulfate/tmp (POLYTRIM)
POLY-PRED
PONSTEL
pot bicarb/pot chloride/ca (K-LYTE)
potassium bicarb/ca (KLOR-CON)
potassium chloride (K-DUR, K-TAB, MICRO K)
potassium citrate er (UROCIT-K)
potassium gluconate
PRADAXA
pramipexole (MIRAPEX)
PRAMOSONE CREAM
PRAMOSONE LOTION/OINT
pramoxine (PROCTOFOAM AER NS)
pramoxine rectal foam (PROCTOCREAM-HC)
pramoxine/hydrocortisone (PRAMOSONE CREAM)
pramoxine-hc-chloroxylenol (CORTANE B)
pramoxine-hc-chloroxylenol aq (CORTANE B AQ)
pramoxine-hc-chloroxylenol lot (CORTANE B)
PRANDIMET
PRANDIN
pravastatin (PRAVACHOL)
prazosin (MINIPRESS)
PRED-G
prednicarbate cr (DERMATOP)
prednisolone (ECONOPRED, PRED MILD)
prednisolone (PRELONE)
prednisolone acetate (ECONOPRED PLUS, PRED FORTE)
prednisolone sod phosphate (INFLAMASE/FORTE)
prednisolone sod phosphate (ORAPRED)
prednisolone sod phosphate (PEDIAPRED)
prednisone (DELTASONE)
PREGNYL
PREMARIN
Effective 1/1/2014
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
2
1
1
1
1
1
1
1
1
2
1
1
1
3
2
1
3
1
1
1
2
1
1
1
1
3
3
1
1
2
3
Generic NSAIDs
1
1
1
1
1
2
1
3
2
1
1
1
1
1
1
2
2
1
1
2
1
1
1
1
1
1
1
1
3
2
17 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
PREMARIN LOW DOSE
PREMARIN VAGINAL CREAM
PREMPHASE
PREMPRO
PREMPRO LOW DOSE
PRENATE DHA
PRENATE ELITE
PRENATE ESSENTIAL
PREVACID (all forms)
PREVPAC
PRIFTIN
primaquine
primidone (MYSOLINE)
PRISTIQ
PROAIR HFA
PRO-BANTHINE
probenecid
prochlorperazine edisylate (COMPAZINE)
PROCRIT
PROCTOFOAM AER HC
PROCTOFOAM AER NS
PROFILNINE
progesterone (PROMETRIUM)
promethazine
PROMETRIUM
propafenone (RYTHMOL)
propranolol (INDERAL)
propranolol/hctz (INDERIDE)
propylthiouracil
PROTOPIC
protriptyline hcl (VIVACTIL)
PROVENTIL HFA
PROVIGIL
PROZAC ONCE WEEKLY
pse/bpm (BROMFED/PD)
pse/dbm
pse/tri
PULMICORT FLEXHALER
PULMICORT RESPULES
PULMOZYME
pyrazinamide
pyridostigmine (MESTINON)
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
2
2
2
2
2
2
2
2
3
2
2
1
1
2
2
2
1
1
4
2
3
5
1
1
3
1
1
1
1
2
1
3
3
3
PROAIR HFA or VENTOLIN HFA preferred
Generic Fluoxetine, generic Paroxetine
1
1
1
2
3
5
1
1
Some strengths available as generic
Q
QNASL
QUARZAN
quetiapine (SEROQUEL)
quinapril (ACCUPRIL)
quinapril/hctz (ACCURETIC)
quinine sulfate (QUALAQUIN)
QUIXIN
QVAR
2
2
1
1
1
1
3
2
R
ramipril (ALTACE)
RANEXA
ranitidine (ZANTAC)
RAPAFLO
RAPAMUNE
RAZADYNE
REBIF
1
2
1
2
2
3
5
Effective 1/1/2014
Requires prior failure of AVONEX or COPAXONE or TECFIDERA
OR a statement of medical necessity from your doctor
18 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
RECOMBINATE
REGRANEX
RELENZA
RELPAX
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
5
2
3
2
REMICADE
5
RENACIDIN
RENAGEL
RENVELA
REQUIP/XL
RESCRIPTOR
RESCULA
RESTASIS
RETIN-A MICRO (Age Limit May Apply)
REVATIO
REVLIMID
REYATAZ
RHINOCORT AQUA
ribavirin (COPEGUS, REBETOL, REBETRON)
RIDAURA
rifampin (RIFADIN)
RIFATER
RILUTEK
riluzole (RILUTEK)
rimantadine (FLUMADINE)
RISPERDAL M-TAB
risperidone (RISPERDAL)
RITALIN LA/SR
rivastigmine (EXELON)
rizatriptan (MAXALT)
ROBINUL FORTE
ROBINUL TABLET
ropinirole/er (REQUIP/XL)
ROWASA
Preferred Alternatives/Comments
Requires prior failure of ENBREL and HUMIRA OR a statement of
clinical necessity from your doctor
2
2
2
3
2
3
2
2
Age limit may apply
5
5
2
3
Fluticasone, NASONEX
4
2
1
2
3
1
1
3
1
3
1
1
3
3
1
3
APRISO preferred
S
SAFYRAL
SAIZEN
salsalate (DISALCID)
SAPHRIS
SAVELLA
SEASONIQUE
selegiline (ELDERPRYL)
selenium sulfide (EXSEL, SELSUN)
SENSIPAR
SEREVENT DISKUS
SEROMYCIN
SEROQUEL
SEROQUEL XR
sertraline (ZOLOFT)
sildenafil citrate (REVATIO)
silver sulfadiazine (SILVADENE)
SIMCOR
2
5
1
3
2
3
1
1
4
2
2
3
2
1
1
1
3
SIMPONI
5
simvastatin (ZOCOR)
SINGULAIR
SKELID
sodium citrate & citric acid solution (BICITRA)
sodium citrate/citric acid (BICITRA)
sodium fluoride (LURIDE)
sodium polystyrene sulfonate (KAYEXELATE)
SOLODYN
Effective 1/1/2014
Requires prior failure of ENBREL and HUMIRA OR a statement of
clinical necessity from your doctor
1
3
3
ACTONEL preferred
1
1
1
1
3
19 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
SORIATANE
sotalol (BETAPACE/AF)
SPIRIVA
spironolactone (ALDACTONE)
spironolactone/hctz (ALDACTAZIDE)
SPRYCEL
STALEVO
stavudine (ZERIT)
STIMATE
STRATTERA
STROMECTOL
SUBOXONE TABS
SUBOXONE FILM
SUCRAID
sucralfate tabs (CARAFATE)
SULAR
sulfacetamide lot (KLARON, SEBIZON)
sulfacetamide sodium (BLEPH-10)
sulfacetamide/prednis sp (VASOCIDIN)
sulfacetamide/prednisolone ac (BLEPHAMIDE)
sulfacetamide/sulfur, sublimed (NOVACET, PLEXION, SULFACET-R, VANOCIN)
sulfamethoxazole/trimethoprim (SEPTRA DS/BACTRIM DS)
SULFAMYLON
sulfasalazine (AZULFIDINE)
SULFOXYL/STRONG
sulindac (CLINORIL)
sumatriptan (IMITREX)
SUPRAX
SURE STEP
SUSTIVA
SUTENT
SYMBICORT
SYMBYAX
SYMLIN
SYNALGOS DC
SYNAREL
SYNTHROID
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
2
1
2
1
1
5
3
1
3
3
2
3
2
2
1
3
1
1
1
1
1
1
3
1
2
1
1
3
3
Generic Keflex
Freestyle/Precision/Contour/Breeze products preferred
2
5
2
3
3
3
2
2
T
tacrolimus (PROGRAF)
TAMIFLU
tamoxifen (NOLVADEX)
tamsulosin (FLOMAX)
TARCEVA
TARGRETIN
TARKA
TASMAR
TAZORAC
TECFIDERA
TEKAMLO
TEKTURNA
TEKTURNA HCT
temazepam (RESTORIL)
TEMODAR
terazosin (HYTRIN)
terbinafine (LAMISIL)
terbutaline sulfate (BRETHINE)
TESTIM
TESTRED
tetracycline (ACHROMYCIN)
TEV-TROPIN
Effective 1/1/2014
1
2
1
1
5
5
2
2
2
PA
4
2
2
2
1
5
1
1
1
2
3
1
5
20 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
THALOMID
THEO-24
theophylline (SLO-BID, THEO-DUR, UNI-DUR, QUIBRON T/SR)
theophylline sr (UNIPHYL)
thioguanine
thioridazine (MELLARIL, MELLARIL S)
thiothixene (NAVANE)
tiagabine HCl (GABITRIL)
ticlopidine (TICLID)
TIKOSYN
TILADE
timolol (BLOCADREN)
timolol (TIMOPTIC/XE)
tizanidine (ZANAFLEX)
TOBI
tobramycin (TOBREX)
tobramycin-dexamethasone ophth (TOBRADEX)
tolmetin (TOLECTIN/DS)
tolterodine/SR (DETROL/LA)
TONOCARD
topiramate (TOPAMAX)
topiramate sprinkle (TOPAMAX SPRINKLE)
TORECAN
torsemide (DEMADEX)
TRACER
TRACER TEST STRIPS
TRACLEER
tramadol (ULTRAM)
tramadol/acetaminophen (ULTRACET)
trandolapril (MAVIK)
tranexamic acid (LYSTEDA)
tranexamic acid inj (CYKLOKAPRON)
TRANXENE SD
tranylcypromine sulfate (PARNATE)
TRAVATAN
TRAVATAN Z
travoprost
trazodone (DESYREL)
TRECATOR-SC
tretinoin (AVITA)
tretinoin (RETIN A)
tretinoin (VESANOID)
TREXALL
TREXIMET
triacinolone acetonide (KENALOG, ARISTOCORT)
triamcinolone acetonide (KENALOG IN ORABASE)
triamcinolone nasal (NASACORT AQ)
triazolam (HALCION)
TRIBENZOR
TRICOR
trifluoperazine (STELAZINE)
trifluridine (VIROPTIC)
TRIGLIDE
trihexyphenidyl (ARTANE)
TRI-K
TRILIPIX
trimethobenzamide (TIGAN)
trimethoprim (TRIMPEX)
trimipramine maleate (SURMONTIL)
TRI-NORINYL
Effective 1/1/2014
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
5
2
1
1
1
1
1
1
1
2
2
1
1
1
5
1
1
1
1
2
1
1
2
1
3
3
Freestyle/Precision/Contour/Breeze products preferred
Freestyle/Precision/Contour/Breeze products preferred
4
1
1
1
1
1
2
1
2
2
Travatan Z preferred
1
1
2
1
1
1
Age limit may apply
Age limit may apply
2
2
1
1
1
1
2
3
1
1
3
1
2
3
1
1
1
3
21 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
TRINSICON
TRIPLE SULFA CREAM
triple vitamins w/fluoride
triple vits w/fluor & iron
TRIZIVIR
tropicamide (MYDRIACYL)
TRUETEST
TRUETEST TEST STRIPS
TRUSOPT
TUSSIONEX
TWINJECT
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
2
2
1
1
2
1
3
3
3
3
Freestyle/Precision/Contour/Breeze products preferred
Freestyle/Precision/Contour/Breeze products preferred
2
U
ULESFIA
ULORIC
ULTICARE LANCETS
ULTICARE PEN NEEDLES
ULTICARE SYRINGES
URO-KP-NEUTRAL
UROXATRAL
ursodiol (ACTIGALL)
ursodiol (URSO/FORTE)
2
2
2
2
2
2
3
1
1
V
VAGIFEM
valacyclovir (VALTREX)
valproic acid (DEPAKENE)
valsartan hctz
VALTURNA
VANCOCIN
VASCEPA
velivet (CYCLESSA)
venlafaxine (EFFEXOR)
venlafaxine ER (EFFEXOR XR)
VENTOLIN HFA
VERAMYST
verapamil (CALAN SR)
VERELAN-PM
VESICARE
VEXOL
VFEND
VIAGRA
VICON FORTE
VICTOZA
VICTRELIS
VIDEX
VIGAMOX
VIIBRYD
VIRACEPT
VIRAMUNE
VIRAMUNE XR
VIREAD
VISICOL
VIVELLE DOT
VOLTAREN GEL
voriconazole (VFEND)
VYTORIN
VYVANSE
2
1
1
1
2
3
2
1
1
1
2
2
1
3
2
2
3
2
2
2
4
2
2
2
2
3
2
2
2
2
3
1
3
2
W
warfarin sodium (COUMADIN)
WELCHOL
1
2
X
Effective 1/1/2014
22 of 23
2014 National Prescription Drug List
Drug Name
(If the product is available generically, the brand name is listed after the generic name for
reference)
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5
Generics
XALATAN
XARELTO
XELODA
XOLAIR
XYLOCAINE
XYREM
XYZAL
Preferred Alternatives/Comments
Non
Non
Preferred
Preferred
Preferred
Preferred
Specialty
Brand
Specialty
Brand
3
generic now available
2
4
5
3
4
3
Y
YASMIN
YAZ
YODOXIN
3
3
2
Z
zafirlukast (ACCOLATE)
zaleplon (SONATA)
ZEGERID
ZEMPLAR
ZENPEP
ZETIA
1
1
3
Omeprazole, Pantoprazole
2
2
2
ZIAGEN
3
zidovudine (RETROVIR)
1
ziprasidone (GEODON)
ZMAX SUS 2GM
zolmitriptan (ZOMIG/ZOMIG ZMT)
zolpidem (AMBIEN)
zolpidem CR (AMBIEN CR)
ZOMIG/ZOMIG ZMT
zonisamide (ZONEGRAN)
ZOVIRAX CRE
ZOVIRAX OIN
ZYCLARA
ZYFLO
ZYLET
ZYMAR
ZYMAXID
ZYPREXA
ZYPREXA ZYDIS
ZYVOX
1
Effective 1/1/2014
2
1
1
1
3
sumatriptan, rizatriptan, RELPAX
3
3
3
3
3
CILOXAN, VIGAMOX
1
2
2
3
3
3
23 of 23