Microsoft word - phc025_web 4-07.doc

PREFERRED CHOICE 3-TIER FORMULARY DRUG LIST
April 2007 Edition
To avoid the higher copayment associated with non-formulary drugs, please ask your prescriber to refer to this
formulary drug list when prescribing medications for you and your dependents. Please note that you will pay a
higher copayment for drugs listed in the Non-Formulary Drug column than for those drugs listed in the
Formulary Alternative(s) column.
It is also important to keep in mind that newly FDA-approved medications will also be subject to the non-formulary copayment pending a review by the Pharmacy and Therapeutics Committee. Please note that this listing does not imply a guarantee of coverage, as covered products and/or categories are subject to individual plan restrictions and/or limitations. Substitution of generic products is encouraged when available and appropriate. The drugs listed in Italics
represent generic medications. Please note that a generic product in the Formulary Alternative(s) column may
not necessarily be the generic equivalent of the non-formulary brand. It does however represent a generic
alternative in the same class of drugs. Any brand name drug for which a generic product becomes
available may be designated as a non-formulary product.
Periodic updates to the formulary may occur. For the most current formulary information, please call PharmaCare at the toll-free number printed on your member I.D. card, or visit PharmaCare at www.pharmacare.com/members.
NON-FORMULARY
FORMULARY
NON-FORMULARY
FORMULARY
ALTERNATIVE(S)
ALTERNATIVE(S)
Accolate Singulair
Aldactone
Spironolactone
Accupril Altace,
Benazepril, Captopril, Enalapril,
Aviane, Lessina, Ortho Tri-Cyclen Lo,
Lisinopril, Quinapril
Yasmin, YAZ
Accuretic
Benazepril/HCTZ, Captopril/HCTZ,
Metronidazole
Enalapril/HCTZ, Lisinopril/HCTZ,
Fexofenadine
Quinaretic
Ketotifen, Optivar, Patanol
Accutane
Amnesteem, Claravis, Isotretinoin, Sotret
Cromolyn, Ketotifen, Optivar, Patanol
Aceon Altace,
Benazepril, Captopril, Enalapril,
Lisinopril, Quinapril
Ondansetron/ODT
Aciphex Nexium,
Omeprazole, Prevacid
Altoprev
Advicor, Crestor, Lipitor, Lovastatin,
Pravastatin, Simvastatin, Vytorin
Morphine Sulfate, Oxycodone
Glimepiride
APAP W/Codeine
Imitrex, Maxalt/MLT, Zomig/ZMT
Adalat CC
Nifedipine CC
Amevive Dovonex,
Adderall
Amphetamine/Dextroamphetamine
Lactulose, PEG 3350/Electolytes
Adoxa/PAK
Doxycycline
Anamantle HC/
Lidocaine/HC
Advance Diabetic
Accu-Chek Products, One Touch Products
Supplies
Anaprox/DS
Etodolac, Flurbiprofen, Nabumetone,
Aerobid/M
Asmanex, Azmacort, Flovent/HFA,
Naproxen, Oxaprozin
Pulmicort, Qvar
Hyoscyamine
Cromolyn, Ketotifen, Optivar, Patanol
Android Androderm,
AndroGel
Naphazoline
Prempro, Premphase, Prefest
Alcortin
Hydrocortisone Valerate
Etodolac, Flurbiprofen, Nabumetone,
Aldactazide 25/25mg Spironolactone/HCTZ
Naproxen, Oxaprozin
NON-FORMULARY
FORMULARY
NON-FORMULARY
FORMULARY
ALTERNATIVE(S)
ALTERNATIVE(S)
Fenofibrate, Gemfibrozil, Tricor
Cardene/SR Cardizem
Felodipine ER, Lotrel,
Nifedipine ER, Norvasc, Sular
Ondansetron/ODT
Cardizem/CD/SR Cardizem
Diltiazem CD, Felodipine ER,
Aranesp* Procrit
Lotrel, Norvasc, Sular
Arthrotec
Diclofenac, Misoprostol, Nabumetone,
Cardura/XL
Doxazosin
Naproxen, Oxaprozin
Cataflam
Diclofenac Potassium, Etodolac,
Ascensia
Accu-Chek Products, One Touch Products
Nabumetone, Oxaprozin
Atacand/HCT Cozaar,
Diovan/HCT,
Catapres
Clonidine
Atopiclair
Alclometasone, Ammonium Lactate
Cefadroxil, Cefpodoxime, Cefprozil,
Atrovent Nasal
Ipratropium Nasal Spray
Cefuroxime, Cephalexin, Cephradine,
Augmentin/ES
Amoxicillin/K Clavulanate
Cefadroxil, Cefpodoxime, Cefprozil,
Diovan HCT, Hyzaar
Cefuroxime, Cephalexin, Cephradine,
Omnicef
Avapro Cozaar,
Ceftin Tabs
Cefuroxime, Omnicef
Differin, Retin-A Micro, Sulfacetamide
Cefprozil, Omnicef
Sodium/Sulfur, Tazorac, Tretinoin
Nortriptyline
Citalopram
Cenogen Ultra
Prenate Elite
Hydrocodone/APAP, Hydromorphone,
Kadian, Morphine Sulfate CR,
Cesamet Emend,
Ondansetron/ODT
Oxycodone/APAP
Chromagen/FA/
Ferotrinsic, Foltrin
Avonex* Copaxone,
Imitrex, Maxalt/MLT, Zomig/ZMT
Ciprofloxacin, Vigamox
Aygestin
Norethindrone Acetate
Cipro/XR
Ciprofloxacin
Azelex BenzaClin,
Clindamycin, Differin,
Cipro HC Otic
Acetic Acid/HC Otic, Ciprodex, Floxin Otic,
Erythromycin, Retin-A Micro, Tazorac,
Neomycin/Polymyxin/HC Otic
Tretinoin
Clarinex/D Allegra-D,
Fexofenadine, Zyrtec/D
Baraclude
Epivir HBV, Hepsera
Cleocin Caps 150mg, Clindamycin
Beconase AQ
Fluticasone,
Nasacort AQ, Nasonex, Rhinocort/AQUA
Cleocin-T
Clindamycin Phosphate, MetroGel,
Benicar/HCT Cozaar,
Diovan/HCT,
Metronidazole, Sodium Sulfacetamide/Sulfur
Benzamycin/PAK BenzaClin,
Erythromycin-Benzoyl Peroxide
Estradiol Patch
Benzoyl Peroxide, Sulfacetamide/Sulfur
Clindagel
Clindamycin Phosphate, MetroGel,
Betagan Cosopt,
Levobunolol, Lumigan, Timolol/XE,
Metronidazole, Sodium Sulfacetamide/Sulfur
Travatan, Trusopt, Xalatan
Clindesse
Clindamycin Phosphate Vaginal Cream,
Betapace/AF
Clindamax
Sotalol/AF
Betaseron* Copaxone,
Clindets
Clindamycin Phosphate, MetroGel,
Metronidazole, Sodium Sulfacetamide/Sulfur
Biaxin/XL
Clarithromycin/ER
Clobetasol Propionate
Bio-Throid
Levoxyl
Clomiphene
Bleph-10
Sodium Sulfacetamide
Codeine Phosphate, APAP/Codeine, Hydrocodone/APAP,
Boniva Actonel,
Codeine Sulfate
Oxycodone/APAP
Bravelle* Gonal-F/RFF
Aricept, Exelon, Namenda, Razadyne/ER
Brevicon
Necon, Nortrel,Ortho Tri-Cyclen Lo,
Colazal Asacol,
Mesalamine, Pentasa, Sulfasalazine
Yasmin, YAZ
Coly-Mycin M
Tobramycin
Buspirone
Coly-Mycin S
Acetic Acid/HC Otic, Ciprodex, Floxin Otic,
Byetta Actos,
Avandia,
Glipizide/ER, Glyburide,
Neomycin/Polymyxin/HC Otic
Januvia, Metformin/ER
Colyte/Flavored
PEG 3350/Electrolytes
Calan/SR
Verapamil/SR
Combunox
Oxycodone/APAP, Oxycodone/ASA
Dicyclomine, Glycopyrrolate, Hyoscyamine,
Concerta
Adderall XR, Metadate CD, Metadate ER,
Propantheline
Methylin ER, Methylphenidate ER,
Capital W-Codeine
APAP W/Codeine
Ritalin LA
NON-FORMULARY
FORMULARY
NON-FORMULARY
FORMULARY
ALTERNATIVE(S)
ALTERNATIVE(S)
Cortane-B-Otic
Acetic Acid/HC Otic, Ciprodex, Floxin Otic,
Doral Ambien/CR,
Flurazepam, Temazepam
Neomycin/Polymyxin/HC Otic
Dostinex
Cabergoline
Cortisporin Oint.
Bacitracin/Polymyxin/Neomycin/HC
Duragesic
Fentanyl, Hydrocodone/APAP,
Cortisporin/TC Otic Acetic Acid/HC Otic, Ciprodex, Floxin Otic,
Hydromorphone, Methadone, Oxycodone CR
Neomycin/Polymyxin/HC Otic
Duratuss/A/AC/DM/ Guaifenesin/Pseudoephedrine,
Covera-HS Cardizem
Diltiazem CD, Felodipine ER,
Guaifenesin/Phenylephrine
Lotrel, Norvasc, Sular
Cefadroxil, Cefprozil, Cefuroxime,
Cutivate
Fluticasone Propionate
Cephalexin, Omnicef
Cyclessa
Velivet
Azithromycin, Clarithromycin/ER,
Erythromycin, ZMAX
Cystospaz/M
Hyoscyamine/TR, Propantheline
Minocycline
Misoprostol
DynaCirc/CR Cardizem
Felodipine ER,
D.H.E. 45
Dihydroergotamine
Nifedipine/ER, Norvasc, Sular
Darvocet A500,
Propoxyphene/APAP,
EC-Naprosyn
Etodolac, Nabumetone, Naproxen, Oxaprozin
Darvocet-N 100
Propoxyphene-N/Acetaminophen
Econopred Plus
Prednisolone Acetate
Darvon/N,
APAP/Codeine, Hydrocodone/APAP,
Darvon Compound
Oxycodone/APAP, Propoxyphene/APAP
Bumetanide, Torsemide
Oxaprozin
Venlafaxine
Daytrana
Adderall XR, Metadate CD,
Eldepryl Azilect,
Selegiline
Methylphenidate ER, Ritalin LA
Ketotifen, Optivar, Patanol
Delatestryl Androderm,
AndroGel,
Testosterone
Mometasone
Enanthate
Ketotifen, Optivar, Patanol
Deltasone
Prednisone
Emcin Clear
Erythromycin
Torsemide
Selegiline
Ortho Tri-Cyclen Lo, Yasmin, YAZ, Zovia
Enablex Detrol/LA,
Oxybutynin/ER, Oxytrol
Depo-Provera
Medroxyprogesterone
Entex/ER/LA/PSE
Guaifenesin/ Pseudoephedrine
Depo-Subq Provera Medroxyprogesterone Acetate
Entocort EC
Prednisone, Prednisolone
Depo-Testosterone Androderm,
AndroGel,
Testosterone
Cypionate
Epogen* Procrit
Dermotic
Acetic Acid/HC Otic
Carbamazepine, Carbatrol, Tegretol XR
Apri, Ortho Tri-Cyclen Lo, Solia, Yasmin,
Ciclopirox, Econazole, Ketoconazole, Oxistat
Erythromycin
Desonide
Erycette
Erythromycin
Trazodone
Erythromycin
Dexacidin
Neomycin/Polymyxin/Dexamethasone
Esgic/Plus
Butalbital/APAP/Caffeine
Didronel Actonel,
Cenestin, Enjuvia, Menest, Premarin
Diflucan
Fluconazole
Estrace Tabs
Cenestin, Enjuvia, Estradiol, Menest,
Dilacor XR
Diltiazem XR
Premarin
Dilaudid/HP
Hydrocodone/APAP, Hydromorphone,
Estrasorb Alora,
Estraderm,
Estradiol, Vivelle/DOT
Morphine Sulfate, Oxycodone CR
EstroGel Alora,
Estraderm,
Estradiol, Vivelle/DOT
Dipentum Asacol,
Mesalamine, Pentasa, Sulfasalazine
Estrostep Fe
Aranelle, Tri-Previfem, Tri-Sprintec, Trinessa
Diprosone
Betamethasone Dipropionate
Clindamycin, Erythromycin
Dispermox
Amox/K Clavulanate, Amoxicillin,
Exactech/RSG
Accu-Chek Products, One Touch Products
Ampicillin, Augmentin XR, Dicloxacillin
Exubera Humalog,
Ditropan/XL Detrol/LA,
Oxybutynin/ER, Oxytrol
Factive Avelox,
Ciprofloxacin, Levaquin
Chlorothiazide
Acyclovir, Valtrex
Dolophine
Hydrocodone/APAP, Hydromorphone,
Methadone, Morphine Sulfate,
Etodolac, Nabumetone, Oxaprozin,
Oxycodone CR
Piroxicam
Domeboro
Acetic Acid/HC Otic, Ciprodex, Floxin Otic,
Femcon Fe
Ortho Tri-Cyclen Lo, Trivora, Yasmin, YAZ
Neomycin/Polymyxin/HC Otic
NON-FORMULARY
FORMULARY
NON-FORMULARY
FORMULARY
ALTERNATIVE(S)
ALTERNATIVE(S)
V-C Forte
Halflytely
PEG 3350/Electrolytes
Femtrace
Estradiol
V-C Forte
Fentanyl OT LOZ
Morphine Sulfate, Oxycodone
Humibid DM
Amibid DM, Mintab DM, Tussi-Bid
Fentanyl, Hydrocodone/APAP,
Hydrocodone/APAP
Hydromorphone, Morphine Sulfate
Hydrocodone/Homatropine
Fertinex* Gonal-F/RFF
Hydroxyurea
Fioricet,
Butalbital/APAP/Caffeine,
Terazosin
Fioricet W/Codeine
Butalbital/APAP/Caffeine/Codeine
Icar Prenatal,
M-Vit, Natafort, NatalCare, Nestabs CBF,
Fiorinal,
ASA/Caffeine/Butalbital,
Icar-C Plus SR
Obstetrix-100
Fiorinal W/Codeine Butal/ASA/CAFF/COD
Inflamase Forte
Prednisolone Phosphate
First-Progesterone
Crinone, Prochieve, Prometrium
Innohep Arixtra,
First-Testosterone
Androderm, AndroGel
Benzoyl Peroxide
Intal Solution
Cromolyn
Metronidazole
Invega Abilify,
Clozapine, Fazaclo, Risperdal,
Flextra-650
Hyflex-650
Seroquel, Zyprexa/Zydis
Fluticasone,
Iopidine Alphagan
Nasacort AQ, Nasonex, Rhinocort AQUA
Isoptin SR
Cardizem LA, Felodipine ER,
Florinef
Fludrocortisone
Nifedipine/ER, Norvasc, Sular,
Verapamil SR
Diflorasone Diacetate
Isosorbide
Floxin Oral
Avelox, Ciprofloxacin, Levaquin, Ofloxacin
Timolol
FML Liquifilm
Alrex, Fluorometholone, Lotemax
K-Tabs 10
Potassium Chloride
Focalin/XR Adderall
Amphetamine/Dextroamphetamine,
Triamcinolone
Metadate CD, Metadate ER, Methylin ER,
Salicylic Acid
Methylphenidate ER, Ritalin LA
Ketek/PAK
Azithromycin, Clarithromycin/ER,
Follistim AQ*
Gonal-F/RFF
Erythromycin, ZMAX
Folpace Rx
Nu-Iron-V
Klonopin/Wafers
Clonazepam/ODT
Folic Acid/B6/B12
Ku-Zyme/HP
Creon, Pancrease/MT, Ultrase, Viokase
Fortamet
Metformin ER
Creon, Pancrease/MT, Ultrase, Viokase
Fragmin Arixtra,
Ondansetron/ODT
Freestyle
Accu-Chek Products, One Touch Products
Lac-Hydrin
Ammonium Lactate
Imitrex, Maxalt/MLT, Zomig/ZMT
Lamisil Spray
Nystatin
Gabarone
Gabapentin
Furosemide
Genotropin* Humatrope,
Norditropin, Tev-Tropin
Lescol/XL
Advicor, Crestor, Lipitor, Lovastatin,
Geodon Abilify,
Clozapine, Fazaclo, Risperdal,
Pravastatin, Simvastatin, Vytorin
Seroquel, Zyprexa/Zydis
Hyoscyamine, Propantheline
Glucometer/Dex/
Accu-Chek Products, One Touch Products
Levitra Cialis,
Elite/Encore
Levora, Ortho Tri-Cyclen Lo, Portia,
Glucophage/XR
Metformin/ER
Yasmin, YAZ
Glucosource Lancets One Touch, Softclix, Soft Touch
Aviane, Lessina, Ortho Tri-Cyclen Lo,
Glucotrol/XL
Glipizide/ER
Yasmin, YAZ
Glucovance
Glyburide/Metformin
Levo-Dromoran
Levorphanol
Glumetza
Metformin ER
Levsin/SL
Hyoscyamine, Propantheline
Glynase/PresTab
Glipizide/ER, Glyburide,
Levsinex
Hyoscyamine, Propantheline
Glyburide/Micronized, Metformin/ER
Lexxel Lotrel
Golytely
PEG 3350/Electrolytes
Fluocinonide
Grifulvin V
Fluconazole, Griseofulvin
Lo/Ovral
Cryselle, Low-Ogestrel,
Microsize/Ultramicrosize, Itraconazole,
Ortho Tri-Cyclen Lo, Yasmin, YAZ
NON-FORMULARY
FORMULARY
NON-FORMULARY
FORMULARY
ALTERNATIVE(S)
ALTERNATIVE(S)
Lodine/XL
Etodolac, Nabumetone, Oxaprozin
Doxycycline, Minocycline, Tetracycline
Loestrin/Fe
Junel Fe, Microgestin Fe, Ortho Tri-Cyclen
PEG 3350/Electrolytes
Lo, Yasmin, YAZ
Mircette
Kariva, Ortho Tri-Cyclen Lo, Yasmin, YAZ
Fenofibrate, Gemfibrozil, Tricor
Etodolac, Meloxicam, Nabumetone,
Diphenoxylate/Atropine
Naproxen, Oxaprozin
Lopressor/HCT
Metoprolol, Metoprolol/HCTZ
Necon, Nortrel, Ortho Tri-Cyclen Lo,
Yasmin, YAZ
Cefadroxil, Cefpodoxime, Cefprozil,
Cefuroxime, Cephalexin, Cephradine,
Monistat-Derm
Nystatin
Monopril/HCT Altace,
Benazepril, Benazepril/HCTZ,
Lorcet/HD/Plus
Hydrocodone/APAP
Captopril, Captopril/HCTZ, Enalapril,
Enalapril/HCTZ, Lisinopril,
Hydrocodone/ Acetaminophen
Lisinopril/HCTZ, Quinapril, Quinaretic
Lotensin/HCT
Benazepril/HCTZ
Etodolac, Ibuprofen, Nabumetone, Naproxen,
Lotrisone
Clotrimazole/Betamethasone
Oxaprozin
Lotronex
Diphenoxylate/Atropine, Loperamide
MS Contin
Morphine Sulfate
Indapamide
Morphine Sulfate
Lunesta Ambien/CR,
Temazepam
Muse Cialis,
Lustra/AF/Ultra
Hydroquinone
Mycostatin
Nystatin
Oxycodone/Acetaminophen
Myfortic Cellcept
Mar-Spas
Hyoscyamine
Minocycline
Mavik Altace,
Benazepril, Captopril, Enalapril,
Etodolac, Fenoprofen, Nabumetone,
Lisinopril, Quinapril
Oxaprozin
Maxair Autohaler
ProAir HFA, Proventil HFA, Ventolin HFA
Naprelan
Etodolac, Nabumetone, Naproxen, Oxaprozin
Maxidone
Hydrocodone/APAP
Naprosyn
Etodolac, Nabumetone, Naproxen, Oxaprozin
Maxiflor
Diflorasone Diacetate
Fluticasone, Nasacort AQ, Nasonex,
Maxinate
Rhinocort/AQUA
Mynate 90 Plus, NatalCare PIC/Forte,
Poly-Iron PN/Forte, Prenate Elite, Vinate 90
Nascobal Nasal
Cyanocobalamin
Maxitrol
Neomycin/Polymyxin/Dexamethasone
Natelle/EZ/Prefer
NatalCare Plus, Prenatal Formula
Triamterene/HCTZ
Prenate Elite
Megestrol Acetate
Navane 2mg, 5mg,
Thiothixene
Menopur* Gonal-F/RFF
Menostar Alora, Estraderm, Estradiol, Vivelle/DOT
Tobramycin
Mestinon 60mg
Pyridostigmine
Necon 10/11
Kariva, Ortho Tri-Cyclen Lo, Yasmin, YAZ
Metaglip
Glipizide/ER, Glipizide-Metformin,
Neptazane
Methazolamide
Metformin/ER
Neurontin
Gabapentin
Methitest Androderm,
AndroGel
Nevanac Acular
Flurbiprofen,
MetroCream
Metronidazole Cream
Voltaren Ophth.
MetroGel Vag Gel
Metronidazole Vag Gel
Nexgen Diabetic
Accu-Chek Products, One Touch Products
MetroLotion 0.75% Metronidazole 0.75%
Supplies
Advicor, Crestor, Lipitor, Lovastatin,
Niferex/150/150
Ferotrinsic, Foltrin
Pravastatin Simvastatin, Vytorin
Mexiletine
Alprazolam
Micardis/HCT Cozaar,
Diovan/HCT,
Nitro-Bid
Nitroglycerin
Micronase
Glipizide/ER, Glyburide, Metformin/ER
Nitrostat
Nitroglycerin
Microzide
Hydrochlorothiazide
Ketoconazole
Isometheptene/APAP/ Dichloralphenazone
Nolvadex
Tamoxifen
Ammonium Lactate
Hydrocodone/ Acetaminophen
Minipress
Prazosin
Nordette
Levora, Ortho Tri-Cyclen Lo, Portia,
Yasmin, YAZ
NON-FORMULARY
FORMULARY
NON-FORMULARY
FORMULARY
ALTERNATIVE(S)
ALTERNATIVE(S)
Baclofen, Cyclobenzaprine HCl,
Etodolac, Ketoprofen, Nabumetone,
Methocarbamol, Orphenadrine, Skelaxin,
Oxaprozin
Tizanidine
Osmoprep
PEG 3350/Electrolytes
Norgesic/Forte
Baclofen, Cyclobenzaprine HCl,
A/B Otic
Methocarbamol, Orphenadrine, Skelaxin,
Tizanidine
Betamethasone, Hydrocortisone, Selenium
Sulfide Shampoo, Triamcinolone
Necon, Nortrel, Ortho Tri-Cyclen Lo,
Yasmin, YAZ
Ovcon/Fe
Necon, Nortrel, Ortho Tri-Cyclen Lo,
Yasmin, YAZ
Normodyne
Labetalol
Camila, Errin, Nora-Be
Noroxin Avelox,
Ciprofloxacin, Levaquin
Oxycontin
Oxycodone CR
Norpramin
Desipramine
Oxycodone
Novacort
Hydrocortisone Valerate
Pamine/Forte
Methscopolamine Bromide
Novanatal
Carenate, NatalCare, Precare, Prenate Elite
Panixine
Cephalexin
Chorionic Gonadotropin
Panlor DC/SS
APAP/Codeine, Hydrocodone/APAP,
Choline Magnesium Trisalicylate, Diflunisal,
Oxycodone/APAP
Salsalate
Parafon Forte DSC
Baclofen, Chlorzoxazone, Cyclobenzaprine
Novastart Prenate
HCl , Methocarbamol, Orphenadrine,
Hyoscyamine, Propantheline
Skelaxin, Tizanidine
Nulytely/ Flavor
PEG 3350/Electrolytes
Carbidopa/Levodopa
Numoisyn Evoxac
Paroxetine
Numorphan
Fentanyl, Hydrocodone/APAP,
Azithromycin, Clarithromycin/ER,
Hydromorphone, Methadone, Oxycodone CR
Erythromycin, ZMAX
Nutropin/AQ/
Humatrope, Norditropin, Tev-Tropin
Pediapred
Prednisolone
Pediatex/D/HC Allegra-D,Clemastine Fumarate,
Ofloxacin, Vigamox
Dexchlorpheniramine, Diphenhydramine,
Fexofenadine, Promethazine VC/Codeine,
Ogen Cenestin,
Enjuvia,
Estropipate, Menest,
Zyrtec/D
Premarin
Pediazole
Erythromycin ES/Sulfisoxazole
Ogestrel
Mononessa, Ortho Tri-Cyclen Lo, Previfem,
Sprintec, Yasmin, YAZ
Pediotic
Acetic Acid/HC Otic, Ciprodex, Floxin Otic,
Neomycin/Polymyxin/HC Otic
Omnitrope* Humatrope,
Norditropin, Tev-Tropin
Fluconazole, Gris-PEG, Griseofulvin
Opana/ER
Fentanyl, Hydrocodone/APAP,
Ultramicrosize, Itraconazole, Ketoconazole,
Hydromorphone, Methadone, Oxycodone CR
Lamisil
OptiPranolol
Betaxolol, Betoptic-S, Levobunolol,
Pepcid/RPD
Cimetidine, Famotidine, Ranitidine
Metipranolol, Timolol/XE
Percocet
Oxycodone/ Acetaminophen
Oramorph SR
Morphine Sulfate
Percodan
Oxycodone/ASA
Orapred/ODT
Prednisolone Sod. Phos.
Pergolide
Orencia Enbrel,
Persantine
Dipyridamole
Ortho-Cept
Apri, Ortho Tri-Cyclen Lo, Solia, Yasmin,
YAZ
Paroxetine, Paxil CR
Ortho-Cyclen
Mononessa, Ortho Tri-Cyclen Lo, Previfem,
Phenergan
Promethazine /Codeine
Sprintec, Yasmin, YAZ
w/Codeine
Ortho Micronor
Camila, Errin, Jolivette, Nora-Be
Plaquenil
Hydroxychloroquine
Ortho-Novum
Necon, Nortrel, Ortho Tri-Cyclen Lo,
Plenaxis Casodex,
Flutamide, Nilandron
Yasmin, YAZ
Plendil Cardizem
Felodipine ER,
Ortho Evra
Apri, Ortho Tri-Cyclen Lo, Quasense,
Nifedipine/ER, Norvasc, Sular
Trinessa, Yasmin, YaZ
Cilostazol
Ortho Tri-Cyclen
Ortho Tri-Cyclen Lo, Tri-Previfem,
Plexion/SCT/TS BenzaClin,
Clindamycin, Differin,
Tri-Sprintec, Trinessa, Yasmin, YAZ
Erythromycin, Retin-A Micro, Sodium
Etodolac, Ketoprofen, Nabumetone,
Sulfacetamide/Sulfur, Tazorac, Tretinoin
Oxaprozin
Polysporin
Bacitracin/Polymyxin-B, Vigamox
Polytrim
Polymyxin-B/Trimethoprim, Vigamox
NON-FORMULARY
FORMULARY
NON-FORMULARY
FORMULARY
ALTERNATIVE(S)
ALTERNATIVE(S)
Etodolac, Nabumetone, Oxaprozin
Rifampin
Pravachol
Advicor, Crestor, Lipitor, Lovastatin,
Risperdal Consta,
Abilify, Clozapine, Fazaclo, Risperdal,
Pravastatin, Simvastatin, Vytorin
Risperdal M-Tab
Seroquel, Zyprexa/Zydis
Precision/QID/
Accu-Chek Products, One Touch Products
Ritalin/SR
Metadate CD, Metadate ER, Methylin ER,
Methylphenidate/ER, Ritalin LA
Pred Forte
Prednisolone Acetate
RMS-Suppository
Morphine Sulfate
Chorionic Gonadotropin
Robinul/Forte
Glycopyrrolate, Propantheline
Prednisolone
Rondec/DM
Cardec/DM, Rondamine/DM
Prestige
Accu-Chek Products, One Touch Products
Mesalamine Enema
Prevident
Sodium Fluoride
Roxicodone
Oxycodone
Prilosec Nexium,
Omeprazole, Prevacid
Rozerem Ambien/CR,
Temazepam
Primacare
Maternity 90, Prenatal 1+1, Prenate Elite
Rozex MetroGel,
Metronidazole Lotion
Prinivil Altace,
Benazepril, Captopril, Enalapril,
Propafenone, Rythmol SR
Lisinopril, Quinapril
Humatrope, Norditropin, Tev-Tropin
Prinzide
Benazepril/HCTZ, Captopril/HCTZ,
Sanctura Detrol/LA,
Oxybutynin/ER, Oxytrol
Enalapril/HCTZ, Lisinopril/HCTZ,
Quinaretic
Citalopram, Fluoxetine, Lexapro,
Mirtazapine, Paroxetine, Paxil CR, Sertraline
Procardia/XL Cardizem
Diltiazem CD, Felodipine ER,
Nifedipine, Norvasc, Sular, Verapamil
Seasonale
Quasense
Profasi/HP
Chorionic Gonadotropin
Seasonique
Ortho Tri-Cyclen Lo, Quasense, Yasmin,
YAZ
Dipivefrin
Seb-Prev
Sodium Sulfacetamide/Sulfur
Proquin XR
Avelox, Ciprofloxacin, Levaquin
Selenium Sulfide Shampoo
Finasteride
Selsun RX
Selenium Sulfide Shampoo
Prosed EC
Methenamine
Serophene
Clomiphene
Protonix Nexium,
Omeprazole, Prevacid
Serostim*
Humatrope, Norditropin, Tev-Tropin
Proventil
ProAir HFA, Proventil HFA, Ventolin HFA
Silvadene
Silver Sulfadiazine
Medroxyprogesterone
Sinemet/CR
Carbidopa/Levodopa/CR
Citalopram, Fluoxetine, Lexapro,
Prozac Weekly
Mirtazapine, Paroxetine, Paxil CR, Sertraline
Sinequan
Doxepin
Psorcon/E
Diflorasone Diacetate
Skelid Actonel,
Psoriatec Dovonex,
Dritho-Scalp, Tazorac
Slo-Bid Theo-24,
Theophylline ER
Dicyclomine, Glycopyrrolate, Hyoscyamine,
Solaraze Carac, Fluoroplex
Propantheline
Soma/Compound/
Carisoprodol/Aspirin/Codeine
Questran/Light
Cholestyramine/Light, WelChol
Quibron-T/SR Theo-24,
Theophylline ER
Sonata Ambien/CR,
Temazepam
Klor-Con, Potassium Chloride
Spectazole
Econazole
Ofloxacin, Vigamox
Spectracef
Cefpodoxime, Omnicef
Raniclor
Cefaclor, Cefprozil, Cefuroxime
Strattera Adderall
Amphetamine/Dextroamphetamine,
Rapiflux
Fluoxetine
Metadate CD,Metadate ER, Methylin ER,
Nabumetone
Methylphenidate ER, Ritalin LA
Relion Insulin
Humulin Insulin, Novolin Insulin
Striant Androderm,
AndroGel
Imitrex, Maxalt/MLT, Zomig/ZMT
Suboxone
Methadone
Remeron/SolTab
Mirtazapine
Methadone
Reprexain
APAP/Hydrocodone
Sulfacet-R
Sodium Sulfacetamide/Sulfur
Repronex* Gonal-F/RFF
Sulfacetamide/Sulfur
Restoril Ambien/CR,
Temazepam
Symax Duotab
Hyoscyamine, Propantheline
Retrovir
Zidovudine
Fluoxetine, Zyprexa/Zydis
Revatio Tracleer
Symlin Humulin,
Humalog, Novolin, Novolog
NON-FORMULARY
FORMULARY
NON-FORMULARY
FORMULARY
ALTERNATIVE(S)
ALTERNATIVE(S)
Symmetrel
Amantadine
Oxycodone/APAP
Fluocinolone
Tysabri* Copaxone,
Synalgos DC
APAP/Codeine, Hydrocodone/APAP,
Epivir HBV, Hepsera
Oxycodone/APAP
Udamin/SP
Ferocon, Ferotrinsic, Foltrin, Nu-Iron-V
Lidocaine
Ultima Diabetic
Accu-Chek Products, One Touch Products
Taladine
Cimetidine, Ranitidine
Supplies
Tambocor
Flecainide
Ultracet
Tramadol/APAP
Tapazole
Methimazole
Ultram/ER
Tramadol HCl
Tarka Lotrel
Uniretic
Benazepril/HCTZ, Captopril/HCTZ,
Enalapril/HCTZ, Lisinopril/HCTZ,
Tasmar COMTan
Quinaretic
Temovate/E
Clobetasol Propionate
Unistik 3
Accu-Chek Products, One Touch Products
Tequin Avelox,
Ciprofloxacin, Levaquin
Univasc Altace,
Benazepril, Captopril, Enalapril,
Terconazole
Lisinopril, Quinapril
Testim Androderm,
AndroGel
Flavoxate
Testopel Pellets
Androderm, AndroGel
Phenazopyridine
Testred Androderm,
AndroGel
Phenazopyridine
Teveten/HCT Cozaar,
Diovan/HCT,
Potassium Citrate
Tiazac Cardizem
Diltiazem/SR,
Uroxatral Avodart,
Doxazosin, Finasteride, Flomax,
Felodipine ER, Nifedipine/SR, Norvasc,
Terazosin
Sular, Verapamil/SR
Fluocinonide
Ticlopidine
Buspirone
Timoptic/XE
Betaxolol, Betoptic-S, Cosopt, Levobunolol,
Leuprolide,Lupron Depot
Timolol
Cefpodoxime, Omnicef
Tindamax
Metronidazole
Vaseretic
Benazepril/HCTZ, Captopril/HCTZ,
Tolectin DS
Etodolac, Nabumetone, Oxaprozin,
Enalapril/HCTZ, Lisinopril/HCTZ,
Tolmetin Sodium
Quinaretic
Etodolac, Ketorolac, Nabumetone, Oxaprozin
Vasocidin
Sulfacetamide/Prednisolone
Tranxene T-Tab
Clorazepate
Altace, Benazepril, Captopril, Enalapril,
Trecator
Ethambutol, Isoniazid, Mycobutin, Rifampin,
Lisinopril, Quinapril
Cefadroxil Monohydrate, Cephalexin,
Pentoxifylline
Cephradine
Tretin-X
Differin, Retin-A Micro, Tazorac, Tretinoin
Ventavis Tracleer
Tridesilon
Desonide
Ventolin
ProAir HFA, Proventil HFA, Ventolin HFA
Triglide
Fenofibrate, Gemfibrozil, Tricor
Verelan/PM Cardizem
Diltiazem CD, Felodipine ER,
Tri-Levlen
Enpresse, Ortho Tri-Cyclen Lo, Trivora,
Lotrel, Norvasc, Sular, Verapamil/ER/SR
Yasmin, YAZ
Vesicare Detrol
Oxybutynin/ER, Oxytrol
Tri-Luma
Fluocinolone, Hydroquinone, Tretinoin
Vibramycin Caps
Doxycycline Hyclate
Tri-Norinyl
Aranelle, Leena, Ortho Tri-Cyclen Lo,
Vicodin/ES/HP
Hydrocodone/Acetaminophen
Yasmin, YAZ
Vicoprofen
Hydrocodone/Ibuprofen
PEG 3350/Electrolytes
PEG 3350/Electrolytes
Triphasil
Enpresse, Ortho Tri-Cyclen Lo, Trivora,
Vistaril
Hydroxyzine Pamoate
Yasmin, YAZ
Voltaren/XR
Diclofenac Sodium, Etodolac, Nabumetone,
True Care Diabetic
Accu-Chek Products, One Touch Products
Oxaprozin
Supplies
APAP W/Codeine
TrueTrack Diabetic Accu-Chek Products, One Touch Products
Supplies
Wellbutrin/SR/XL
Bupropion/SR/XL, Wellbutrin XL 150mg
Propoxyphene/APAP
Westcort
Hydrocortisone Valerate
Twinject Epipen/Jr
Xanax/XR
Alprazolam/ER
Tylenol W/Codeine
Acetaminophen/Codeine
NON-FORMULARY
FORMULARY
ALTERNATIVE(S)
Xibrom Acular
Flurbiprofen,
Voltaren Ophth.
SMZ-TMP DS
Hydrocodone/APAP
Asmanex, Azmacort, Flovent/HFA,
Pulmicort, Qvar
Ketoconazole
Xopenex/HFA
Albuterol, ProAir HFA, Proventil HFA,
Ventolin HFA
Z-Clinz BenzaClin
Erythromycin/Benzoyl Peroxide
Ketotifen
Zanaflex
Tizanidine
Zegerid Nexium,
Omeprazole, Prevacid
Zelapar Azilect,
Selegiline
Dicyclomine, Hyoscyamine, Lactulose, PEG
3350/Electolytes
Zemplar Capsule
Calcitriol, Hectorol
Zestoretic
Benazepril/HCTZ, Captopril/HCTZ,
Enalapril/HCTZ, Lisinopril/HCTZ,
Quinaretic
Zestril Altace,
Benazepril, Captopril, Enalapril,
Lisinopril, Quinapril
Sodium Sulfacetamide/Sulfur
Bisoprolol/HCTZ
Benzoyl Peroxide, Clindamycin, Tretinoin
Zithromax/Z-Pak
Azithromycin, ZMAX
Advicor, Crestor, Lipitor, Lovastatin,
Pravastatin, Simvastatin, Vytorin
Zoderm BenzaClin,
Benzoyl Peroxide,
Erythromycin-Benzoyl Peroxide
Sertraline
Actonel, Evista, Forteo, Fortical, Fosamax,
Miacalcin
Zorbtive* Humatrope,
Norditropin, Tev-Tropin
Acetic Acid/HC Otic, Ciprodex, Floxin Otic,
Neomycin/Polymyxin/HC Otic
Zovirax Oral
Acyclovir, Valtrex
APAP/Codeine, Hydrocodone/APAP,
Oxycodone/APAP
Zyflo Singulair
Zyloprim
Allopurinol
Ofloxacin, Vigamox
Zymine/D/HC Allegra-D,
Chlorpheniramine,
Dexchlorpheniramine, Fexofenadine,
Zyrtec-D
*Trial of Formulary Alternative medication may be required.

Source: http://www.iape1096.org/info/documents/FormularyNonFormulary.pdf