McAllen Independent School District Preferred Drug List The American Health Care powered by MaxorPlus preferred drug list or PDL names the most commonly prescribed medications for your pharmacy benefit plan. This list is not all-inclusive, does not guarantee coverage, and is subject to change. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. Most generics can be obtained at the lowest copayment. For specific questions about your coverage, please call Member Service at (800) 872-8276. Effective July 1, 2019 This list is subject to change. A ABSORICA acetaminophen/codeine ACTEMRA [INJ] acyclovir ADEMPAS ADVAIR HFA AIMOVIG [INJ] AJOVY [INJ] 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 ANDROGEL 1.62% ANORO ELLIPTA apri APRISO ARCAPTA NEOHALER aripiprazole ARNUITY ELLIPTA ASMANEX HFA ASMANEX TWISTHALER atenolol atenolol/chlorthalidone atorvastatin AUBAGIO AUSTEDO AVONEX [INJ] 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 BETHKIS BEVESPI AEROSPHERE bisoprolol/hctz BOSULIF BREO ELLIPTA BRILINTA budesonide nebulization suspension bupropion bupropion ext-release buspirone butalbital/acetaminophen/caffeine BYSTOLIC BYVALSON C CABOMETYX CARAC carbidopa/levodopa carvedilol/er cefdinir cefuroxime axetil celecoxib cephalexin CERDELGA chlorhexidine gluconate chlorthalidone CIMDUO CIPRODEX ciprofloxacin citalopram clarithromycin CLENPIQ clindamycin hcl clindamycin phosphate clindamycin phosphate/benzoyl peroxide clobetasol propionate clonazepam clonidine clopidogrel clotrimazole/betamethasone dipropionate COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COPAXONE 40 MG [INJ] CORLANOR COSENTYX [INJ] CREON cyanocobalamin [INJ] cyclobenzaprine D DALIRESP DAYTRANA DESCOVY desloratadine desonide desvenlafaxine succinate er dexamethasone dexmethylphenidate ext-release dextroamphetamine/ amphetamine dextroamphetamine/amphetamine ext-release diazepam 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 DULERA duloxetine delayed-release DUPIXENT [INJ] DYMISTA E ELIDEL ELIQUIS ELZONRIS EMBEDA enalapril ENBREL [INJ] 3850 Atherton Road, Rocklin, CA 95765 Office 1-800-872-8276 www.americanhealthcare.com 1 P a g e
enoxaparin [INJ] ENSTILAR ENTRESTO EPCLUSA EPIDUO FORTE EPIPEN, EPIPEN JR [INJ] ergocalciferol ERLEADA erythromycin eye ointment ESBRIET escitalopram esomeprazole magnesium delayedrelease estradiol estradiol patch ESTRING eszopiclone etodolac EUCRISA EVEKEO F famotidine FARXIGA fenofibrate fenofibrate micronized fenofibric acid delayed-release fentanyl patch FETZIMA FIASP FINACEA finasteride FIRDAPSE FLOVENT DISKUS FLOVENT HFA fluconazole fluocinonide fluoxetine 60 mg tab fluticasone nasal spray FOCALIN XR 25 MG, 35 MG folic acid FORTEO [INJ] FRAGMIN [INJ] furosemide FYCOMPA G gabapentin gemfibrozil GENVOYA gildess fe GILENYA GILOTRIF glimepiride glipizide glipizide ext-release GLUCAGEN [INJ] GLUCAGON [INJ] glyburide GLYXAMBI GRALISE GRANIX [INJ] GRASTEK guanfacine ext-release H HUMIRA [INJ] HUMULIN R U-500 [INJ] hydralazine hydrochlorothiazide hydrocodone/acetaminophen hydrocodone/chlorpheniramine polistirex ext-release hydrocodone/homatropine hydrocortisone topical hydromorphone hydroxychloroquine hydroxyzine hcl hydroxyzine pamoate HYSINGLA ER I ibandronate IBRANCE ibuprofen ILEVRO indomethacin INLYTA INVELTYS irbesartan IRESSA isosorbide mononitrate ext-release J JANUMET, JANUMET XR JANUVIA JARDIANCE JENTADUETO, JENTADUETO XR JUBLIA JULUCA junel fe K ketoconazole topical KISQALI KITABIS PAK L labetalol lamotrigine lansoprazole delayed-release LANTUS [INJ] latanoprost eye solution LATUDA LETAIRIS LEVEMIR [INJ] levetiracetam levocetirizine levofloxacin levothyroxine sodium lidocaine patches LINZESS liothyronine LIPOFEN lisinopril lisinopril/hctz LIVALO LOKELMA LO LOESTRIN FE lorazepam LORBRENA losartan losartan/hctz LOTEMAX/SM lovastatin LUZU LYRICA M meclizine medroxyprogesterone meloxicam MEPHYTON mesalamine MESTINON SYRUP metaxalone metformin metformin ext-release methimazole methocarbamol methotrexate methylphenidate methylphenidate ext-release methylprednisolone metoclopramide hcl metoprolol succinate ext-release metoprolol tartrate metronidazole metronidazole topical metronidazole vaginal gel microgestin fe minocycline mirtazapine MIRVASO moderiba mometasone mononessa montelukast morphine sulfate ext-release MOVANTIK MOXEZA mupirocin MYDAYIS MYRBETRIQ N nabumetone NAMZARIC naproxen, naproxen sodium NARCAN NASCOBAL neomycin/polymyxin/ hydrocortisone ear drops NEXIUM PACKETS niacin ext-release nifedipine ext-release nitrofurantoin monohydrate/ macrocrystal NITYR [INJ] nortriptyline NOVOEIGHT [INJ] NOVOFINE AUTOSHIELD NEEDLES NOVOFINE NEEDLES NOVOTWIST NEEDLES NOVOLIN [INJ] NOVOLOG [INJ] NUCYNTA, NUCYNTA ER NUEDEXTA nystatin oral suspension nystatin topical O ODACTRA ODEFSEY OFEV olanzapine olmesartan olmesartan/hctz olmesartan/amlodipine/hct olopatadine omeprazole delayed-release ondansetron ondansetron orally disintegrating tablets ONETOUCH TEST STRIPS; ULTRA, VERIO (other test strips excluded) ONEXTON OPSUMIT 3850 Atherton Road, Rocklin, CA 95765 Office 1-800-872-8276 www.americanhealthcare.com 2 P a g e
ORACEA ORENITRAM ER ORILISSA OTEZLA OTREXUP [INJ] oxcarbazepine OXERVATE OXTELLAR XR oxybutynin ext-release oxycodone oxycodone/ acetaminophen OXYCONTIN OZEMPIC [INJ] P pantoprazole delayed-release paroxetine PAZEO penicillin v potassium PENTASA PERFOROMIST PHOSLYRA PICATO pioglitazone PLEGRIDY [INJ] polymyxin/trimethoprim eye solution potassium chloride ext-release PRALUENT [INJ] pramipexole pravastatin prednisolone acetate eye suspension prednisolone sodium phosphate prednisone PREMARIN CREAM PREMARIN TABS PREMPHASE PREMPRO PREPOPIK PROAIR HFA PROAIR RESPICLICK [INJ] PROCTOFOAM-HC progesterone micronized PROLENSA PROMACTA promethazine promethazine/ dextromethorphan propranolol propranolol ext-release PULMICORT FLEXHALER PYLERA Q QBREXZA QUDEXY quetiapine QUILLICHEW ER QUILLIVANT XR quinapril QVAR R rabeprazole delayed-release RAGWITEK raloxifene ramipril ranitidine RASUVO [INJ] REBIF [INJ] RECTIV RENVELA Tablets REPATHA [INJ] RESTASIS risperidone rizatriptan ropinirole rosuvastatin RYTARY S SANCUSO SAPHRIS SAVELLA SAXENDA SEREVENT DISKUS sertraline sildenafil SILENOR simvastatin SOLIQUA [INJ] SOOLANTRA SOVALDI SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone sprintec SPRYCEL STELARA [INJ] STRIVERDI RESPIMAT SUBOXONE SL FILM sulfamethoxazole/ trimethoprim sumatriptan SUPREP SYMBICORT SYMFI SYMFI LO SYMLINPEN [INJ] SYMPROIC SYNJARDY, SYNJARDY XR T TACLONEX SUSPENSION TALZENNA tamoxifen tamsulosin ext-release TARCEVA TASIGNA TAZORAC (gel and 0.05% cream) TECFIDERA TEKTURNA TEKTURNA HCT temazepam terazosin terconazole vaginal testosterone cypionate [INJ] timolol maleate eye solution tizanidine TOBI PODHALER TOBRADEX OINTMENT TOBRADEX ST tobramycin eye solution tobramycin/ dexamethasone eye suspension topiramate TOUJEO SOLOSTAR [INJ] TOUJEO MAX SOLOSTAR [INJ] TOVIAZ TRACLEER TRADJENTA tramadol TRAVATAN Z trazodone TREMFYA [INJ] TRESIBA [INJ] triamcinolone topical triamterene/hctz trinessa TRINTELLIX tri-sprintec TRIUMEQ TROKENDI XR TRULANCE TRULICITY [INJ] TYMLOS [INJ] U UCERIS RECTAL FOAM ULORIC UPTRAVI V valacyclovir valsartan valsartan/hctz VASCEPA VELPHORO venlafaxine venlafaxine ext-release VENTOLIN HFA verapamil ext-release VESICARE VIBERZI VICTOZA [INJ] VIIBRYD VIMPAT VIOKACE VITRAKVI VIZIMPRO VOSEVI VYVANSE W warfarin X XARELTO XELJANZ, XELJANZ XR XIFAXAN XIGDUO XR XIIDRA XOSPATA XTANDI XULTOPHY [INJ] Y YONSA YUPELRI Z ZARXIO [INJ] ZELAPAR ZENPEP zolpidem zolpidem ext-release ZOMIG NASAL ZONTIVITY ZOVIRAX CREAM ZUBSOLV ZYLET 3850 Atherton Road, Rocklin, CA 95765 Office 1-800-872-8276 www.americanhealthcare.com 3 P a g e
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 albuterol sulfate HFA alogliptin alogliptin/metformin alogliptin/pioglitazone ALTOPREV ALVESCO APIDRA ARANESP ASACOL HD ATRIPLA BECONASE AQ BREEZE, CONTOUR METERS/STRIPS BROVANA BYETTA, BYDUREON, BYDUREON BCise CETRAXAL CIMZIA CINQAIR COLCHICINE COMPLERA DAKLINZA DELZICOL DIPENTUM DOXYCYCLINE 40 MG CAPSULES EPINEPHRINE AUTO-INJECTOR (by A-S Medications, Impax & Lineage) EPOGEN ESTROGEL EXTAVIA EVZIO FENTORA FLUOROURACIL 0.5% CREAM fluticasone/salmeterol (generic ) fentanyl citrate lozenges bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA JANUMET/XR, JENTADUETO/XR pioglitazone plus JANUVIA or TRADJENTA atorvastatin, lovastatin, rosuvastatin, simvastatin, LIVALO ARNUITY ELLIPTA, ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA, PULMICORT FLEXHALAR, QVAR BIKTARVY, GENVOYA, ODEFSEY, STRIBILD, SYMFI, SYMFI LO, TRIUMEQ PERFOROMIST TRULICITY, VICTOZA, OZEMPIC ciprofloxacin ear solution, ofloxacin ear solution, CIPRODEX ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR FASENRA, NUCALA, DUPIXENT COLCRYS, ULORIC ODEFSEY ORACEA EPINEPHRINE AUTO-INJECTOR (by Mylan), EPIPEN, EPIPEN JR. DIVIGEL AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, PLEGRIDY, REBIF, REBIF REBIDOSE naloxone syringe, NARCAN NASAL SPRAY fentanyl citrate lozenges diclofenac gel, fluorouracil 5% cream, fluorouracil 2% solution, imiquimod 5% cream, CARAC, PICATO FORTESTA ANDROGEL 1.62% FREESYLE, PRECISION METERS/STRIPS GENOTROPIN GLUMETZA HUMALOG HUMATROPE HUMULIN INCRUSE ELLIPTA INGREZZA INSULIN LISPRO INVOKAMET/XR INVOKANA KAZANO KINERET (EXCLUDED FOR RA) KOMBIGLYZE XR ledipasvir-sofosbuvir LUMIGAN MAVYRET metformin extended-release NOVOLIN SPIRIVA RESPIMAT, SPIRIVA HANDIHALER tetrabenazine, AUSTEDO XIGDUO XR, SYNJARDY, SYNJARDY XR FARXIGA, JARDIANCE JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR TRAVATAN Z 3850 Atherton Road, Rocklin, CA 95765 Office 1-800-872-8276 www.americanhealthcare.com 4 P a g e
MIRCERA NATESTO ANDROGEL 1.62% NESINA NEUPOGEN GRANIX, ZARXIO NEUPRO PATCHES pramipexole tablets, pramipexole ER tablets, ropinirole tablets NEVANAC bromfenac, diclofenac, ketorolac, ILEVRO, PROLENSA NUTROPIN AQ OLYSIO OMNARIS OMNITROPE QNASL fluticasone (nasal), triamcinolone (nasal), mometasone (nasal), DYMISTA ONGLYZA ORENCIA (IV & SC) ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XR PANCREAZE PERTZYE PRADAXA ELIQUIS, XARELTO PREVACID SOLUTAB PREZCOBIX atazanavir, ritonavir, KALETRA TABLETS, PREZISTA PRILOSEC SUSPENSION PROTONIX SUSPENSION PROVENTIL HFA QSYMIA phentermine, BELVIQ, BELVIQ XR, SAXENDA RECOMBINATE ADVATE, ADYNOVATE, AFSTYLA, HELIXATE FS, KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ SAIZEN SAVAYSA ELIQUIS, XARELTO SEGLUROMET XIGDUO XR, SYNJARDY, SYNJARDY XR SIMPONI ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR sofosbuvir-velpatasvir STEGLATRO FARXIGA, JARDIANCE STENDRA tadalafil, sildenafil STIOLTO RESPIMAT ANORO ELLIPTA, BEVESPI AEROSPHERE STRIBILD BIKTARVY, GENVOYA TALTZ COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA TECHNIVIE topiramate er topiramate tablets, QUDEXY XR TRULANCE AMITIZA, LINZESS TUDORZA SPIRIVA RESPIMAT, SPIRIVA HANDIHALER TRUETEST, TRUETRACK METERS/STRIPS ULTRESA UNISTRIP METERS/STRIPS VELTASSA LOKELMA VELTIN clindamycin/benzoyl peroxide, clindamycin/tretinoin, ONEXTON VIEKIRA/VIEKIRA XR EPCLUSA, HARVONI, SOVALDI, VOSEVI WIXELA INHUB XOPENEX HFA XYNTHA/XYNTHA SOLOFUSE ADVATE, ADYNOVATE, AFSTYLA, HELIXATE FS, KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ ZEPATIER EPCLUSA, HARVONI, SOVALDI, VOSEVI ZETONNA ZIOPTAN bimatoprost, latanoprost, travoprost, TRAVATAN Z ZOMACTON ZORVOLEX diclofenac, etodolac, ibuprofen, meloxicam, nabumetone, naproxen, piroxicam ZYCLARA diclofenac gel, fluorouracil 5% cream, fluorouracil 2% solution, imiquimod 5% cream, CARAC, PICATO 3850 Atherton Road, Rocklin, CA 95765 Office 1-800-872-8276 www.americanhealthcare.com 5 P a g e