The following Preferred Drug List is an abbreviated version of commonly prescribed medications. This list is intended to be a guide and prescribers should still use generics when possible. Drugs listed in CAPS and Italics are Brand Drugs and generic products are listed in lowercase letters. (SP) indicates a specialty medication. A ARISTADA [INJ] (SP) bupropion clonazepam ABSORICA ARNUITY ELLIPTA bupropion ext-release clonidine ACANYA ASMANEX HFA buspirone clopidogrel acetaminophen/codeine ACTEMRA [INJ] (SP) acyclovir ADEMPAS (SP) ADVAIR DISKUS ADVAIR HFA AFSTYLA [INJ] (SP) AIMOVIG [INJ] (SP) AKYNZEO albuterol nebulization solution allopurinol ALPHAGAN P 0.1% alprazolam ALREX amiodarone AMITIZA amitriptyline amlodipine amlodipine/benazepril amlodipine/valsartan amoxicillin amoxicillin/potassium clavulanate anastrozole ANDRODERM ANORO ELLIPTA ASMANEX TWISTHALER atenolol atenolol/chlorthalidone atorvastatin ATRIPLA (SP) AUBAGIO (SP) AVONEX [INJ] (SP) AZASITE azelastine nasal spray azithromycin B baclofen BD AUTOSHIELD DUO NEEDLES BD ULTRAFINE INSULIN SYRINGES BD ULTRAFINE PEN NEEDLES BELBUCA BELSOMRA BELVIQ, BELVIQ XR benazepril benzonatate BEPREVE BERINERT (SP) BETHKIS (SP) BEVESPI AEROSPHERE bisoprolol/hctz butalbital/ acetaminophen/ caffeine BYSTOLIC BYVALSON C CABOMETYX (SP) CANASA CARAC carbidopa/levodopa carvedilol/er cefdinir cefuroxime axetil celecoxib cephalexin CERDELGA (SP) CEREZYME [INJ] (SP) CETROTIDE [INJ] (SP) chlorhexidine gluconate chlorthalidone CIMDUO (SP) CIPRODEX ciprofloxacin citalopram clarithromycin CLENPIQ clindamycin hcl clindamycin phosphate clotrimazole/ betamethasone dipropionate COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COPAXONE 40 MG [INJ] (SP) CORLANOR COSENTYX [INJ] (SP) CREON CRESEMBA CRINONE cyanocobalamin [INJ] cyclobenzaprine D DALIRESP DAYTRANA DESCOVY (SP) desloratadine desonide desvenlafaxine succinate er dexamethasone DEXCOM G4/G5/G6 DEXILANT dexmethylphenidate extrelease apri APRISO ARCAPTA NEOHALER BOSULIF (SP) BREO ELLIPTA BRILINTA clindamycin phosphate/benzoyl peroxide clobetasol propionate dextroamphetamine/ amphetamine dextroamphetamine/ amphetamine ext-release aripiprazole budesonide nebulization suspension clomiphene citrate diazepam 2019 all rights reserved. Effective 1/1/19. CE 1
diclofenac sodium delayed-release dicyclomine digoxin diltiazem ext-release diphenoxylate/atropine divalproex delayed-release divalproex ext-release DIVIGEL donepezil doxazosin doxycycline hyclate doxycycline monohydrate DUAVEE ESBRIET (SP) escitalopram esomeprazole magnesium delayedrelease estradiol estradiol patch ESTRING eszopiclone etodolac EUFLEXXA [INJ] (SP) EXTAVIA (SP) F famotidine FARXIGA G gabapentin gemfibrozil GENVOYA (SP) gildess fe GILENYA (SP) GILOTRIF (SP) glimepiride glipizide glipizide ext-release GLUCAGEN [INJ] glyburide GLYXAMBI GONAL-F (SP) hydroxyzine pamoate HYSINGLA ER I ibandronate IBRANCE (SP) ibuprofen ILEVRO indomethacin INLYTA (SP) irbesartan IRESSA (SP) isosorbide mononitrate extrelease J DULERA fenofibrate GRALISE JANUMET, JANUMET XR duloxetine delayed-release fenofibrate micronized GRANIX [INJ] (SP) JANUVIA DYMISTA E EDARBI EDARBYCLOR ELIDEL ELIGARD (SP) ELIQUIS EMBEDA enalapril ENBREL [INJ] (SP) enoxaparin [INJ] ENSTILAR ENTRESTO EPCLUSA (SP) EPIDUO FORTE EPIPEN, EPIPEN JR [INJ] ergocalciferol ERLEADA (SP) fenofibric acid delayedrelease fentanyl patch FETZIMA FIASP FINACEA finasteride FLECTOR FLOVENT DISKUS FLOVENT HFA fluconazole fluocinonide fluoxetine 60 mg tab folic acid FORTEO [INJ] (SP) FRAGMIN [INJ] (SP) furosemide FYCOMPA GRASTEK guanfacine ext-release H HARVONI (SP) HUMATROPE (SP) HUMIRA [INJ] (SP) HUMULIN R U-500 [INJ] hydralazine hydrochlorothiazide hydrocodone/ acetaminophen hydrocodone/ chlorpheniramine polistirex ext-release hydrocodone/homatropine hydrocortisone topical hydromorphone hydroxychloroquine hydroxyzine hcl JARDIANCE JENTADUETO, JENTADUETO XR JUBLIA junel fe K ketoconazole topical KISQALI (SP) KITABIS PAK (SP) KOVALTRY [INJ] (SP) L labetalol lamotrigine lansoprazole delayedrelease LANTUS [INJ] latanoprost eye solution LATUDA LETAIRIS (SP) erythromycin eye ointment 2019 all rights reserved. Effective 1/1/19. CE 2
LEVEMIR [INJ] methimazole N olanzapine levetiracetam levocetirizine levofloxacin levothyroxine sodium lidocaine patches LINZESS liothyronine LIPOFEN methocarbamol methotrexate methylphenidate methylphenidate extrelease methylprednisolone metoclopramide hcl metoprolol succinate extrelease nabumetone NAMENDA XR NAMZARIC naproxen, naproxen sodium NARCAN NASCOBAL neomycin/polymyxin/ hydrocortisone ear drops NEUPRO PATCHES olmesartan olmesartan/hctz olmesartan/amlodipine/hct olopatadine omeprazole delayedrelease ondansetron ondansetron orally disintegrating tablets lisinopril lisinopril/hctz LIVALO LOKELMA LO LOESTRIN FE lorazepam losartan losartan/hctz LOTEMAX lovastatin LUPRON DEPOT [INJ] (SP) LUZU LYRICA M MAVYRET (SP) meclizine medroxyprogesterone meloxicam mesalamine MESTINON SYRUP metaxalone metformin metformin ext-release metoprolol tartrate metronidazole metronidazole topical metronidazole vaginal gel microgestin fe MINIVELLE minocycline MIRENA (SP) mirtazapine MIRVASO MITIGARE moderiba mometasone mononessa MONOVISC [INJ] (SP) montelukast morphine sulfate extrelease MOVANTIK MOXEZA multivitamins/fluoride mupirocin MUSE MYRBETRIQ NEXIUM PACKETS niacin ext-release nifedipine ext-release nitrofurantoin monohydrate/ macrocrystal NITYR (SP) [INJ] (SP) nortriptyline NOVOEIGHT [INJ] (SP) NOVOFINE AUTOSHIELD NEEDLES NOVOFINE NEEDLES NOVOTWIST NEEDLES NOVOLIN [INJ] NOVOLOG [INJ] NUCYNTA, NUCYNTA ER NUEDEXTA NUVARING NUWIQ [INJ] (SP) nystatin oral suspension nystatin O topical ODACTRA ODEFSEY (SP) OFEV (SP) ONETOUCH TEST STRIPS; ULTRA, VERIO (all other test strips excluded) ONEXTON OPSUMIT (SP) ORACEA ORENITRAM ER (SP) ORTHOVISC [INJ] (SP) OTEZLA (SP) OTREXUP [INJ] (SP) OVIDREL [INJ] (SP) oxcarbazepine OXTELLAR XR oxybutynin ext-release oxycodone oxycodone/ acetaminophen OXYCONTIN OZEMPIC [INJ] P pantoprazole delayedrelease paroxetine PAZEO penicillin v potassium PENTASA 2019 all rights reserved. Effective 1/1/19. CE 3
PERFOROMIST Q SAVELLA tamsulosin ext-release PHOSLYRA QUDEXY SAXENDA TARCEVA (SP) PICATO quetiapine SEREVENT DISKUS TASIGNA (SP) pioglitazone PLEGRIDY [INJ] (SP) polymyxin/trimethoprim eye solution potassium chloride extrelease PRALUENT [INJ] (SP) pramipexole pravastatin prednisolone acetate eye suspension prednisolone sodium phosphate prednisone PREMARIN CREAM PREMARIN TABS PREMPHASE PREMPRO PREPOPIK PROAIR HFA PROAIR RESPICLICK PROCRIT [INJ] (SP) PROCTOFOAM-HC progesterone micronized PROLASTIN C [INJ] (SP) PROLENSA promethazine promethazine/ dextromethorphan QUILLICHEW ER QUILLIVANT XR quinapril QVAR R rabeprazole delayedrelease RAGWITEK raloxifene ramipril RANEXA ranitidine RAPAFLO RASUVO [INJ] (SP) REBIF [INJ] (SP) RECTIV RELISTOR [INJ] (SP) REMICADE [INJ] (SP) REPATHA [INJ] (SP) RESTASIS risperidone rizatriptan ropinirole rosuvastatin RUCONEST [INJ] (SP) RYTARY S sertraline SILENOR simvastatin SOLIQUA [INJ] SOLODYN SOMATULINE DEPOT [INJ] (SP) SOOLANTRA SOVALDI (SP) SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone sprintec SPRYCEL (SP) STELARA [INJ] (SP) STIOLTO RESPIMAT STRIVERDI RESPIMAT SUBOXONE SL FILM sulfamethoxazole/ trimethoprim sumatriptan SUPREP SYMBICORT SYMFI (SP) SYMFI LO (SP) SYMLINPEN [INJ] SYMPROIC TAZORAC (gel and 0.05% cream) TECFIDERA (SP) TEKTURNA TEKTURNA HCT temazepam terazosin terconazole vaginal testosterone cypionate [INJ] timolol maleate eye solution tizanidine TOBI PODHALER (SP) TOBRADEX OINTMENT TOBRADEX ST tobramycin eye solution tobramycin/ dexamethasone eye suspension topiramate TOUJEO SOLOSTAR [INJ] TOVIAZ TRACLEER (SP) TRADJENTA tramadol TRAVATAN Z trazodone TREMFYA [INJ] (SP) propranolol SANCUSO SYNJARDY, SYNJARDY XR TRESIBA [INJ] propranolol ext-release SAPHRIS T triamcinolone topical PULMICORT FLEXHALER TACLONEX SUSPENSION triamterene/hctz PYLERA tamoxifen trinessa 2019 all rights reserved. Effective 1/1/19. CE 4
TRINTELLIX VIMPAT ZOVIRAX CREAM tri-sprintec VIOKACE ZUBSOLV TROKENDI XR VOSEVI (SP) ZYLET TRULICITY [INJ] VYVANSE ZYTIGA TYMLOS [INJ] (SP) W TYSABRI [INJ] (SP) warfarin U X ULORIC XARELTO UPTRAVI (SP) XELJANZ, XELJANZ XR (SP) V XIFAXAN valacyclovir XIGDUO XR valsartan XIIDRA valsartan/hctz XTANDI (SP) VASCEPA XULTOPHY [INJ] VELPHORO (SP) Y VELTASSA YONSA (SP) venlafaxine Z venlafaxine ext-release ZARXIO [INJ] (SP) VENTOLIN HFA ZELAPAR verapamil ext-release ZENPEP VESICARE zolpidem VIBERZI zolpidem ext-release VICTOZA [INJ] ZOMIG NASAL VIIBRYD ZONTIVITY 2019 all rights reserved. Effective 1/1/19. CE 5
Excluded Medications with Covered Preferred Alternatives The following is a list of excluded medications with covered preferred alternatives that are on the formulary. Excluded Medications Covered Preferred Alternative(s) ABSTRAL ACCU-CHEK METERS/ STRIPS ACIPHEX SPRINKLE ACUVAIL AEROSPAN ALOGLIPTIN ALOGLIPTIN/METFORMIN ALVESCO APIDRA ARANESP (SP) ASACOL HD BECONASE AQ BRAVELLE (SP) BREEZE, CONTOUR METERS/STRIPS BYETTA, BYDUREON, BYDUREON BCise CETRAXAL CIALIS CIMZIA (SP) COLCHICINE DELZICOL DIPENTUM DOXYCYCLINE 40 MG CAPSULES ENDOMETRIN EPINEPHRINE AUTO-INJECTOR (by A-S Medications, Impax & Lineage) fentanyl citrate lozenges bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA JANUVIA, TRADJENTA JANUMET/XR, JENTADUETO/XR ARNUITY ELLIPTA, ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA, PULMICORT FLEXHALAR, QVAR NOVOLOG, FIASP PROCRIT balsalazide disodium, mesalamine, sulfasalazine, APRISO, PENTASA budesonide, flunisolide, fluticasone, mometasone GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT TRULICITY, VICTOZA, OZEMPIC ciprofloxacin ear solution, ofloxacin ear solution, CIPRODEX ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR COLCRYS, MITIGARE balsalazide disodium, mesalamine, sulfasalazine, APRISO, PENTASA balsalazide disodium, mesalamine, sulfasalazine, APRISO, PENTASA ORACEA CRINONE 8% GEL EPINEPHRINE AUTO-INJECTOR (by Mylan), EPIPEN, EPIPEN JR. EPOGEN (SP) PROCRIT ESTROGEL DIVIGEL EVZIO naloxone syringe, NARCAN NASAL SPRAY FENTORA fentanyl citrate lozenges FLUOROURACIL 0.5% CREAM (SP) Diclofenac gel, fluorouracil 5% cream, fluorouracil 2% solution, imiquimod 5% cream, CARAC, PICATO FOLLISTIM AQ (SP) GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT FORTESTA ANDROGEL 1.62% FREESYLE, PRECISION METERS/STRIPS GANIRELIX ACETATE (SP) CETROTIDE GEL-ONE (SP) GELSYN-3 (SP) GENOTROPIN (SP) GENVISC 850 (SP) GLUMETZA metformin extended-release HUMALOG/HUMULIN NOVOLOG, FIASP HUMULIN NOVOLIN HYALGAN (SP) HYMOVIS (SP) INCRUSE ELLIPTA SPIRIVA RESPIMAT, SPIRIVA HANDIHALER INVOKAMET, INVOKAMET XR, INVOKANA FARXIGA, XIGDUO, JARDIANCE, SYNJARDY, SYNJARDY XR KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR KINERET (EXCLUDED FOR RA) (SP) ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XR KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR LEVITRA LUMIGAN TRAVATAN Z MIRCERA (SP) PROCRIT NATESTO ANDROGEL 1.62% NESINA JANUVIA, TRADJENTA NEUPOGEN (SP) GRANIX, ZARXIO NEVANAC bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA NUTROPIN AQ OMNARIS budesonide, flunisolide, fluticasone, mometasone OMNITROPE (SP) QNASL fluticasone (nasal), triamcinolone (nasal), mometasone (nasal), DYMISTA ONGLYZA JANUVIA, TRADJENTA ORENCIA (IV & SC (SP) ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XR PANCREAZE CREON, ZENPEP 2019 all rights reserved. Effective 1/1/19. CE 6
PERTZYE CREON, ZENPEP PREVACID SOLUTAB PRILOSEC SUSPENSION PROTONIX SUSPENSION PROVENTIL HFA PROAIR HFA/RESPICLICK, VENTOLIN HFA QSYMIA phentermine, BELVIQ, BELVIQ XR, SAXENDA SAIZEN (SP) SIMPONI (SP) ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR STAXYN STENDRA SUPARTZ FX (SP) SYNVISC, SYNVISC ONE (SP) TALTZ (SP) COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA TANZEUM TRULICITY, VICTOZA, OZEMPIC TESTIM ANDROGEL 1.62% TRULANCE AMITIZA, LINZESS TUDORZA SPIRIVA RESPIMAT, SPIRIVA HANDIHALER TRUETEST, TRUETRACK METERS/STRIPS UNISTRIP METERS/STRIPS VELTIN clindamycin/benzoyl peroxide, clindamycin/tretinoin, ACANYA, ONEXTON VIEKIRA/VIEKIRA XR (SP) EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI VISCO-3 (SP) VOGELXO ANDROGEL 1.62% XOPENEX HFA PROAIR HFA/RESPICLICK, VENTOLIN HFA ZEPATIER (SP) EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI ZETONNA budesonide, flunisolide, fluticasone, mometasone ZIOPTAN bimatoprost, latanoprost, travoprost, TRAVATAN Z ZOMACTON (SP) ZYCLARA Diclofenac gel, fluorouracil 5% cream, fluorouracil 2% solution, imiquimod 5% cream, CARAC, PICATO Nonformulary Tier 3 Medications ACZONE ADDYI ATRALIN AURYXIA BESIVANCE BETIMOL BUNAVAIL CLINDESSE CLOBEX COSOPT PF DIFFERIN DIFICID ELESTRIN EPIDUO FLUOROPLEX FORFIVO XL INTRAROSA KERYDIN LIALDA LORZONE METROGEL MIGRANAL MOVIPREP MULTAQ OSPHENA RAYALDEE RENVELA REXULTI SAVAYSA TACLONEX OINTMENT TAZORAC 0.1% CREAM TIROSINT UCERIS VIVLODEX XIMINO ZORVOLEX ZURAMPIC 2019 all rights reserved. Effective 1/1/19. CE 7