Drug Formulary

Avoid High Medication Costs

Ask your doctor to choose a drug from this covered list.

Drug Formulary Alphabetical (pdf)
Special 90-Day Drug Formulary (pdf)

$5

30-day supply of generic drugs

$12

90-day supply of certain generic drugs*

$15

30-day supply of brand-name drugs that are not available generically

*90-day formulations and dosages may vary and are at the discretion of the pharmacy.

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Drug Name Trade Name Brand Name Supply Category Agent Class Keywords
acarbose PRECOSE Generic 30 days Endocrine/Diabetes Non-Insulin Hypoglycemic Agents
acebutolol SECTRAL Generic 30 days Cardiovascular, Hypertension and Lipids Beta Blockers heart
acetaminophen/butalbital/caffeine Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Headache Therapy
acetaminophen/codeine TYLENOL #3, TYLENOL #4 Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Combination Narcotic;Analgesics
acetaminophen/hydrocodone VICODIN, LORTAB, LORCET, LORTAB, NORCO Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Combination Narcotic;Analgesics
acetaminophen/oxycodone PERCOCET, ENDOCET Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Combination Narcotic;Analgesics
acetazolamide DIAMOX Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants;Oral Drugs for Glaucoma
acetic acid/alum otic Generic 30 days Ear, Nose and Throat Medications Miscellaneous Otic Preparations
acetic acid/HC otic ACETASOL HC Generic 30 days Ear, Nose and Throat Medications Miscellaneous Otic Preparations
acyclovir 800mg ZOVIRAX Generic 30 days Anti-Infectives Miscellaneous Antivirals infection; virus
acyclovir 200mg caps, 400mg ZOVIRAX Generic 30 days or 90 days Anti-Infectives Miscellaneous Antivirals infection; virus
acyclovir (susp.) ZOVIRAX Generic 30 days Anti-Infectives Miscellaneous Antivirals infection; virus
ADVAIR (Diskus, HFA) ADVAIR DISKUS, ADVAIR HFA Brand Name 30 days Respiratory, Allergy, Cough and Cold Miscellaneous Pulmonary Agents
AEROCHAMBER or equivalent (spacer) Brand Name 30 days Respiratory, Allergy, Cough and Cold Miscellaneous Agents
ALAMAST ALAMAST Brand Name 30 days Ophthalmology Miscellaneous Opthalmologics
albuterol (inhaler, inhalation solution) PROVENTIL Generic 30 days Respiratory, Allergy, Cough and Cold Inhaled Beta Agonists;Beta Agonists Oral
albuterol (nebul. Sol, syrup, tablet) PROVENTIL Generic 30 days Respiratory, Allergy, Cough and Cold Inhaled Beta Agonists;Beta Agonists Oral Asthma
alclometasone ACLOVATE Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
alendronate FOSAMAX Generic 30 days Musculoskeletal and Rheumatology Osteoporosis Therapy;Miscellaneous Agents
allopurinol (tab) ZYLOPRIM Generic 30 days or 90 days Musculoskeletal and Rheumatology Gout Therapy
ALOCRIL Brand Name 30 days Ophthalmology Miscellaneous Opthalmologics
ALOMIDE Brand Name 30 days Ophthalmology Miscellaneous Opthalmologics
ALPHAGAN-P Brand Name 30 days Ophthalmology Miscellaneous Opthalmologics
alprazolam XANAX, NIRAVAM, XANAX, XANAX XR Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anxiolytics Anxiety, Panic Disorders
ALREX Brand Name 30 days Ophthalmology Steroids
amantadine SYMMETREL Generic 30 days Anti-Infectives;Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antivirals/Antiparkinsonism Drugs
amcinonide CYCLOCORT Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
amiloride MIDAMOR Generic 30 days Cardiovascular, Hypertension and Lipids Thiazide and Related Diuretics heart
amiloride/hctz Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Thiazide and Related Diuretics heart
amiodarone CORDARONE, PACERONE Generic 30 days Cardiovascular, Hypertension and Lipids Antiarrhythmic Agents heart
amitriptyline ELAVIL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Tricyclic Antidepressant Agents
amlodipine NORVASC Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Calcium Channel Blockers (Dihydropyridines)
amoxicillin/clavunate (chewable, suspen., tab, amoxicillin drops, susp) AUGMENTIN Generic 30 days Anti-Infectives Penicillins infection
amphetamine salts ADDERALL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Psychotherapeutic Agents ADHD
amphetamine salts combo-XR (cap) ADDERALL-XR Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Psychotherapeutic Agents
ampicillin PRINCIPEN Generic 30 days Anti-Infectives Penicillins infection
anastrozole ARIMIDEX Generic 30 days Antineoplastic and Immunosuppressant Drugs Antiestrogens
ANORO (inhalation powder) ANORO ELLIPTA Brand Name 30 days Respiratory, Allergy, Cough and Cold Miscellaneous Pulmonary Agents COPD
APHTHASOL Brand Name 30 days Ear, Nose and Throat Medications Miscellaneous Agents
apraclonidine ophth. IOPIDINE Generic 30 days Ophthalmology Sympathomimetics
aripiprazole (tab) [Prior Authorization Required] ABILIFY Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antipsychotics
ARNUITY ARNUITY Brand Name 30 days
ASACOL Brand Name 30 days Gastroenterology Miscellaneous Gastrointestinal Agents
ASMANEX Brand Name 30 days Respiratory, Allergy, Cough and Cold Inhaled Corticosteroids
atenolol TENORMIN Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Beta Blockers Heart, Angina, Hypertension
atenolol/chlorthalidone TENORETIC Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Beta Blockers and Thiazide and Related Diuretics heart
atorvastatin (tab) LIPITOR Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Lipid/Cholesterol Lowering Agents heart, cholesterol
atropine ophth. Generic 30 days Ophthalmology Cycloplegic Mydriatics
ATROVENT HFA Brand Name 30 days Respiratory, Allergy, Cough and Cold Miscellaneous Pulmonary Agents
azathioprine (tab) AZASAN, IMURAN Generic 30 days Antineoplastic and Immunosuppressant Drugs Immunosuppressant Drugs;Miscellaneous Rheumatological Agents
azithromycin (powder, susp, tab) ZITHROMAX, ZPAK Generic 30 days Anti-Infectives Macrolides infection
AZOPT Brand Name 30 days Ophthalmology Other Glaucoma Drugs
bacitracin (ophth.) Generic 30 days Ophthalmology Antibiotics
bacitracin/neomycin /polymyxin/HC ophth. Generic 30 days Ophthalmology Steroid-Antibiotic Combinations
baclofen LIORESAL, GABLOFEN Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology Muscle Relaxants and Antispasmodic Agents
balsalazide disodium Generic 30 days Gastroenterology Miscellaneous Gastrointestinal Agents
balziva 0.04/0.035mg Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents
Bayer Breeze-2 (Glucometer) Brand Name 30 days Diabetes Care Supplies
Bayer Breeze-2 (Glucose test strips – provided at cost) Brand Name 30 days Diabetes Care Supplies
Bayer Contour (Glucometer) Brand Name 30 days Diabetes Care Supplies
Bayer Contour (Glucose test strips – provided at cost) Brand Name 30 days Diabetes Care Supplies
Bayer Contour Next (Glucose test strips – provided at cost) Brand Name 30 days Diabetes Care Supplies
Bayer Contour Next EZ (Glucometer) Brand Name 30 days Diabetes Care Supplies
Bayer MicroLancets (Lancets) Brand Name 30 days Diabetes Care Supplies
benazepril LOTENSIN Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids ACE Inhibitors heart
benzonatate TESSALON Generic 30 days Respiratory, Allergy, Cough and Cold Antitussives
benzoyl peroxide (gel, liq) Generic 30 days Dermatologicals/Topical Therapy Therapy for Acne Skin
benzoyl peroxide w/ erythromycin (gel) BENZAMYCIN, BENZAMYCIN PAK Generic 30 days Dermatologicals/Topical Therapy Therapy for Acne Skin
benztropine COGENTIN Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych Antiparkinsonism Drugs
betamethasone (augmented) (crm, oint) Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
betamethasone (crm, oint) Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
betamethasone/clotrimazole (crm, oint) LOTRISONE Generic 30 days Dermatologicals/Topical Therapy Topical Antifungals Skin
bethanechol URECHOLINE Generic 30 days Urologicals Cholinergic Stimulants
BETIMOL Brand Name 30 days Ophthalmology Beta Blockers
BETOPTIC-S Brand Name 30 days Ophthalmology Beta Blockers
bisoprolol ZEBETA Generic 30 days Cardiovascular, Hypertension and Lipids Beta Blockers heart
bisoprolol/hctz ZIAC Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Other Antihypertensive Combinations heart
BLEPHAMIDE Brand Name 30 days Ophthalmology Steroid-Sulfonamide Combinations
BREO BREO Brand Name 30 days
brimonidine Generic 30 days Ophthalmology Sympathomimetics
bromocriptine PARLODEL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Antiparkinsonism Drugs
budesonide (nebul sol) PULMICORT, RHINOCORT, ENTOCORT EC Generic 30 days Respiratory, Allergy, Cough and Cold Inhaled Corticosteroids Allergies
bumetanide BUMEX Generic 30 days Cardiovascular, Hypertension and Lipids Thiazide and Related Diuretics heart
bupropion WELLBUTRIN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antidepressants
bupropion-SR WELLBUTRIN-SR Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Diagnostics and Miscellaneous Agents Miscellaneous Antidepressants
bupropion-XL WELLBUTRIN-XL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antidepressants
buspirone BUSPAR Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anxiolytics
cabergoline DOSTINEX Generic 30 days Endocrine/Diabetes Miscellaneous Agents
calcipotriene (crm, ointm, soln) CALCITRENE, DOVONEX, SORILUX Generic 30 days Dermatologicals/Topical Therapy Antipsoriatic;Antiseborrheic Skin
calcitonin spray MIACALCIN, FORTICAL Generic 30 days Endocrine/Diabetes Miscellaneous Agents;Osteoporosis Therapy
calcium acetate PHOSLO, ELIPHOS, PHOSLYRA Generic 30 days Vitamins, Hematinics and Electrolytes Other Electrolytes
camila 0.35mg ERRIN, JOLIVETTE, LYZA, NOR-QD, NORA-BE, ORTHO MICRONOR Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents nor-q-d, errin, jolivette, heather
CAMPRAL [Prior Authorization Required] Brand Name 30 days Diagnostics and Miscellaneous Agents Miscellaneous Agents
CANASA (suppository) Brand Name 30 days Gastroenterology Miscellaneous Gastrointestinal Agents
CAPEX 0.01% (shampoo) Brand Name 30 days Dermatologicals/Topical Therapy Miscellaneous Dermatologicals Skin
captopril CAPOTEN Generic 30 days Cardiovascular, Hypertension and Lipids ACE Inhibitors heart
captopril/hctz CAPOZIDE Generic 30 days Cardiovascular, Hypertension and Lipids Other Antihypertensive Combinations heart
carbamazepine TEGRETOL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants
carbamazepine-sr TEGRETOL-XR Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants
carbidopa/levodopa SINEMET, PARCOPA Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Antiparkinsonism Drugs
carbidopa/levodopa-sr SINEMET-CR Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Antiparkinsonism Drugs
carisoprodol SOMA Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Muscle Relaxants and Antispasmodic Agents Muscle Injuries
carisoprodol/aspirin SOMA COMPOUND Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology Muscle Relaxants and Antispasmodic Agents
carteolol ophthalmic OCUPRESS Generic 30 days Ophthalmology Beta Blockers
carvedilol (tablet) COREG Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Beta Blockers Heart, Hypertension, Heart Failure
cefaclor CECLOR, RANICLOR Generic 30 days Anti-Infectives Cephalosporins, Second Generation infection
cefadroxil DURICEF Generic 30 days Anti-Infectives Cephalosporins, First Generation infection
cefdinir OMNICEF Generic 30 days Anti-Infectives Antibiotics infection,
cefpodoxime VANTIN Generic 30 days Anti-Infectives Cephalosporins, Third Generation infection
cefuroxime CEFTIN, KEFUROX, ZINACEF Generic 30 days Anti-Infectives Cephalosporins, Second Generation infection
celecoxib CELEBREX Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology NSAIDS-specific COX II Inhibitors
cephalexin KEFLEX Generic 30 days Anti-Infectives Cephalosporins, First Generation infection
CHANTIX Brand Name 30 days Diagnostics and Miscellaneous Agents Smoking Deterrents
CHEMOTHERAPY (PARENTERAL) AGENTS [Prior Authorization Required] Brand Name 30 days Antineoplastic and Immunosuppressant Drugs Antineoplastic Agents
chlorhexidine gluconate PERIDEX Generic 30 days Ear, Nose and Throat Medications Miscellaneous Agents
chloroquine ARALEN PHOSPHATE Generic 30 days Anti-Infectives Antimalarials infection
chlorpromazine THORAZINE Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Phenothiazines
chlorpropamide DIABINESE Generic 30 days Endocrine/Diabetes Non-Insulin Hypoglycemic Agents
chlorthalidone THALITONE, HYGROTON Generic 30 days Cardiovascular, Hypertension and Lipids Thiazide and Related Diuretics heart
cholestyramine QUESTRAN, PREVALITE Generic 30 days Cardiovascular, Hypertension and Lipids Lipid/Cholesterol Lowering Agents heart
cholestyramine lite QUESTRAN LIGHT Generic 30 days Cardiovascular, Hypertension and Lipids Lipid/Cholesterol Lowering Agents heart
ciclopirox (crm, gel, lotion) PENLAC, LOPROX Generic 30 days Dermatologicals/Topical Therapy Topical Antifungals Skin
cimetidine 300mg, 400mg, 800mg TAGAMET Generic 30 days Gastroenterology H2 Antagonists
ciprofloxacin CIPRO, CIPRO XR, PROQUIN XR, CIPRO I.V., CIPRO CYSTITIS PACK Generic 30 days Anti-Infectives Fluoroquinolones;Antibiotics infection
citalopram 20, 40mg CELEXA Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych Selective Serotonin Reuptake Inhibitors (SSRIs) Depression
clarithromycin (susp, tab) BIAXIN Generic 30 days Anti-Infectives Macrolides infection
CLEOCIN 100mg (vaginal suppos.) Brand Name 30 days Obstetrics and Gynecology Antibiotics
clindamycin (cap, cream, gel, lotion, solution) CLEOCIN Generic 30 days Anti-Infectives Miscellaneous Anti-Infectives;Therapy for Acne infection
clomiphene CLOMID Generic 30 days Obstetrics and Gynecology Ovulatory Stimulants;Drugs to Treat Infertility;IVF Agents
clomipramine ANAFRANIL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Tricyclic Antidepressant Agents
clonazepam KLONOPIN, KLONOPIN WAFER Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants Seizure, Panic Attack
clonidine (patch) CATAPRES Generic 30 days Cardiovascular, Hypertension and Lipids Adrenergic Antagonists and Related Drugs Heart, Hypertension
clonidine (tab) CATAPRES Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Adrenergic Antagonists and Related Drugs Heart, Hypertension
clopidogrel 75mg (tab) PLAVIX Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Antiplatelet heart
clorazepate TRANXENE Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anxiolytics
clotrimazole LOTRIMINE, DESENEX Generic 30 days Dermatologicals/Topical Therapy Antifungal Agents Skin
colestipol COLESTID Generic 30 days Cardiovascular, Hypertension and Lipids Lipid/Cholesterol Lowering Agents heart
COMBIPATCH 0.05, 0.14 Brand Name 30 days Obstetrics and Gynecology Estrogen Combinations
COMBIVENT COMBIVENT, DUONEB Brand Name 30 days Respiratory, Allergy, Cough and Cold Miscellaneous Pulmonary Agents
CREON Brand Name 30 days Gastroenterology Digestive Enzymes
CRINONE (gel) CRINONE, PROMETRIUM, ENDOMETRIN Brand Name 30 days Obstetrics and Gynecology Progestins
cromolyn (nebul soln) INTAL Generic 30 days Respiratory, Allergy, Cough and Cold Miscellaneous Pulmonary Agents
cyclobenzaprine FLEXERIL Generic 30 days or 90 days Musculoskeletal and Rheumatology Muscle Relaxants and Antispasmodic Agents Muscle Pain, Spasms
cyclopentolate ophth. AK-PENTOLATE, CYCLOGYL, CYLATE, OCU-PENTOLATE, PENTOLAIR Generic 30 days Ophthalmology Cycloplegic Mydriatics
cyclosporine (cap) NEORAL, GENGRAF, SANDIMMUNE Generic 30 days Antineoplastic and Immunosuppressant Drugs Immunosuppressant Drugs
cyproheptadine PERIACTIN Generic 30 days Respiratory, Allergy, Cough and Cold Antihistamines
danazol DANOCRINE Generic 30 days Endocrine/Diabetes Androgens
desipramine NORPRAMIN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Tricyclic Antidepressant Agents
desmopressin DDAVP Generic 30 days Endocrine/Diabetes Miscellaneous Agents
desonide DESONATE Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
desoximetasone TOPICORT Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
dexamethasone DECADRON Generic 30 days Endocrine/Diabetes Corticosteroids;Adrenal Hormones
diazepam (tab, gel) VALIUM Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants/Muscle Relaxants and Antispasmodic Agents;Anxiolytics
dibenzyline DIBENZYLINE Generic 30 days Cardiovascular, Hypertension and Lipids Agents for Pheochromocytoma heart
diclofenac (tab) VOLTAREN, ZORVOLEX Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology NSAIDS
dicloxacillin Generic 30 days Anti-Infectives Penicillins infection
dicyclomine 10, 20mg BENTYL Generic 30 days or 90 days Gastroenterology;Urologicals Antispasmodics;Anticholinergics
diflorasone APEXICON, MAXIFLOR, PSORCON Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
diflunisal DOLOBID Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology NSAIDS
digoxin (tab) LANOXIN Generic 30 days Cardiovascular, Hypertension and Lipids Cardiac Glycosides heart
diltiazem 30, 60, 90, 120mg (tab) CARDIZEM Generic 30 days Cardiovascular, Hypertension and Lipids Calcium Channel Blockers (Non-Dihydropyridines)
diltiazem-CD CARDIZEM-CD Generic 30 days Cardiovascular, Hypertension and Lipids Calcium Channel Blockers (Non-Dihydropyridines) heart
dipyridamole PERSANTINE Generic 30 days Cardiovascular, Hypertension and Lipids Antiplatelet Drugs heart
disopyramide NORPACE Generic 30 days Cardiovascular, Hypertension and Lipids Antiarrhythmic Agents heart
divalproex sodium DEPAKOTE Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants
divalproex-ER DEPAKOTE-ER Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants
donepezil (tab) ARICEPT Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Neurological Therapy
dorzolamide TRUSOPT Generic 30 days Ophthalmology Other Glaucoma Drugs
dorzolamide/timolol COSOPT Generic 30 days Ophthalmology Other Glaucoma Drugs
doxazosin CARDURA Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Adrenergic Antagonists and Related Drugs;Benign Prostatic Hyperplasia Therapy heart
doxepin (liquid) SINEQUAN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Tricyclic Antidepressant Agents
doxycycline DORYX, MONODOX, ORACEA Generic 30 days Anti-Infectives Tetracyclines infection
DULERA Brand Name 30 days Respiratory, Allergy, Cough and Cold Miscellaneous Pulmonary Agents
duloxetine CYMBALTA Generic 30 days
emoquette 0.15/0.03mg ORTHO-CEPT
APRI, AZURETTE, CAZIANT, CESIA, CYCLESSA, DESOGEN, EMOQUETTE, KARIVA, MIRCETTE, ORTHO-CEPT, RECLIPSEN, SOLIA, VELIVET, VIORELE
Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related Agents
enalapril VASOTEC Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids ACE Inhibitors heart
enalapril/hctz VASERETIC Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Other Antihypertensive Combinations heart
enpresse-28 TRIPHASIL-28, TRI-LEVLEN-28 Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents triphasic,trivora-28
epinephrine auto-injector EPIPEN Generic 30 days Respiratory, Allergy, Cough and Cold Adrenergics
epinephrine auto-injector jr. EPIPEN-JR Generic 30 days Respiratory, Allergy, Cough and Cold Adrenergics
erythromycin (caps, gel, ophth ointm, susp, tab) E.E.S. GRANULES, E.E.S.-200, E.E.S.-400, E.E.S.-400 FILMTAB, ERY-TAB, ERYC, ERYPED, ERYPED 200, ERYPED 400 Generic 30 days Anti-Infectives;Dermatologicals/Topical Therapy Macrolides;Therapy for Acne;Antibiotics Skin
erythromycin/sulfisoxazole PEDIAZOLE, ERYZOLE, SULFIMYCIN Generic 30 days Anti-Infectives Macrolides infection
escitalopram (tab) LEXAPRO Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Selective Serotonin Reuptake Inhibitors (SSRIs)
estradiol (crm, patch) CLIMARA, VIVELLE, ESTRACE, ESTRADERM, FEMTRACE, GYNODIOL Generic 30 days Obstetrics and Gynecology Osteoporosis Therapy;Estrogens
estradiol (tab) ESTRACE Generic 30 days or 90 days Obstetrics and Gynecology Osteoporosis Therapy;Estrogens
estrogen/methyltestosterone Generic 30 days Obstetrics and Gynecology Androgens
estropipate 0.75, 1.5mg (tab) OGEN 0.625, OGEN 1.25, OGEN 2.5, ORTHO-EST Generic 30 days Musculoskeletal and Rheumatology;Obstetrics and Gynecology Osteoporosis Therapy
ethambutol MYAMBUTOL Generic 30 days Anti-Infectives Antimycobacterials infection
ethosuximide ZARONTIN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants
etodolac LODINE Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology NSAIDS
EURAX (crm, lotion) Brand Name 30 days Dermatologicals/Topical Therapy Topical Scabicides;Pediculicides Skin
EXELDERM (crm, soln) Brand Name 30 days Dermatologicals/Topical Therapy Topical Antifungals Skin
famciclovir FAMVIR Generic 30 days Anti-Infectives Miscellaneous Antivirals infection; virus
famotidine 40mg PEPCID Generic 30 days or 90 days Gastroenterology H2 Antagonists
FEMCON-FE 0.4/0.035mg Brand Name 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents zeosa, zenchent-fe, chewable
fenofibrate (tab) TRICOR, LIPOFEN, FENOGLIDE Generic 30 days Cardiovascular, Hypertension and Lipids Lipid/Cholesterol Lowering Agents Heart, Cholesterol
fentanyl DURAGESIC, FENTORA, ONSOLIS Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Narcotic Analgesics
finasteride PROSCAR, PROPECIA, PROSCAR Generic 30 days or 90 days Urologicals Benign Prostatic Hyperplasia Therapy Benign Prostatic Hyperplasia (BPH)
FLAGYL ER Brand Name 30 days Anti-Infectives Antiparasitics infection
flavoxate URISPAS Generic 30 days Urologicals Anticholinergics and Antispasmodics
flecainide TAMBOCOR Generic 30 days Cardiovascular, Hypertension and Lipids Antiarrhythmic Agents heart
FLOVENT (Diskus, HFA) Brand Name 30 days Respiratory, Allergy, Cough and Cold Inhaled Corticosteroids
fluconazole (oral suspension, tab) DIFLUCAN Generic 30 days Anti-Infectives Antifungal Agents;Vaginal Antifungals infection
fludrocortisone FLORINEF ACETATE Generic 30 days Endocrine/Diabetes Adrenal Hormones
flunisolide (nasal spray) NASAREL Generic 30 days Ear, Nose and Throat Medications Intranasal Steroids
fluocinolone Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
fluoride oral supplements Generic 30 days Vitamins, Hematinics and Electrolytes Vitamins and Hematinics
fluoride oral supplements (chewables, drops) Generic 30 days or 90 days Vitamins, Hematinics and Electrolytes Vitamins and Hematinics
fluorometholone (ophth. ointm & susp.) FML Generic 30 days Ophthalmology Steroids
fluorouracil (crm, top. soln) Generic 30 days Dermatologicals/Topical Therapy Miscellaneous Dermatologicals Skin
fluoxetine (capsule) PROZAC Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych Selective Serotonin Reuptake Inhibitors (SSRIs) Depression
fluphenazine Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Phenothiazines
flurazepam DALMANE Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Hypnotic Agents
flurbiprofen ANSAID Generic 30 days Musculoskeletal and Rheumatology NSAIDS
fluticasone (inhaler, nasal spray, cream, ointment) FLONASE, FLOVENT, CUTIVATE Generic 30 days Dermatologicals/Topical Therapy;Ear, Nose and Throat Medications;Respiratory, Allergy, Cough and Cold Intranasal Steroids Rhinitis, Skin
fluvoxamine LUVOX Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Selective Serotonin Reuptake Inhibitors (SSRIs)
folic acid 1mg FA-8, FOLACIN-800 Generic 30 days or 90 days Vitamins, Hematinics and Electrolytes Vitamins and Hematinics
FOLLISTIM AQ [Prior Authorization Required] Brand Name 30 days Obstetrics and Gynecology Gonadotropins
furosemide LASIX, LASIX, DIAQUA-2, LO-AQUA Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Thiazide and Related Diuretics Heart, Hypertension
gabapentin NEURONTIN Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants Seizures
ganciclovir Generic 30 days Anti-Infectives Miscellaneous Antivirals infection; virus
gemfibrozil LOPID Generic 30 days Cardiovascular, Hypertension and Lipids Lipid/Cholesterol Lowering Agents heart, cholesterol
gentamicin (crm, ophth, oint, soln) GENTAK, GARAMYCIN Generic 30 days Anti-Infectives;Dermatologicals/Topical Therapy;Ophthalmology Antibiotics Eyes, Skin
glimepiride AMARYL Generic 30 days or 90 days Endocrine/Diabetes Non-Insulin Hypoglycemic Agents
glipizide GLIPIZIDE Generic 30 days Endocrine/Diabetes Non-Insulin Hypoglycemic Agents
glipizide-XL GLUCOTROL-XL Generic 30 days or 90 days Endocrine/Diabetes Non-Insulin Hypoglycemic Agents
GLUCAGON KIT Generic 30 days Endocrine/Diabetes Glucose Elevating Agents
glyburide Generic 30 days or 90 days Endocrine/Diabetes Non-Insulin Hypoglycemic Agents
glyburide micronized Generic 30 days or 90 days Endocrine/Diabetes Non-Insulin Hypoglycemic Agents
griseofulvin v (susp, tab) GRIFULVIN Generic 30 days Anti-Infectives Antifungal Agents infection
guaifenesin/codeine Generic 30 days Respiratory, Allergy, Cough and Cold Antitussive Combinations
guanfacine (tab) TENEX Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Cardiovascular, Hypertension and Lipids Miscellaneous Psychotherapeutic Agents;Adrenergic Antagonists and Related Drugs blood pressure; ADHD; hypertension
H.Pylori 14-day Triple Therapy Amox/Clarithomycin/Lansoprazole Generic 30 days Gastroenterology Other Ulcer Therapy
halobetasol ULTRAVATE Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
HALOG (crm, oint) Brand Name 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
haloperidol (tab) HALDOL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Phenothiazines
HARVONI [Prior Authorization Required] HARVONI Brand Name 30 days Anti-Infectives Antiviral Agents hepatitis C infection, virus
heparin Generic 30 days Vitamins, Hematinics and Electrolytes Anticoagulants – Heparin
HIGHLY ACTIVE ANTI-RETROVIRAL THERAPY (HAART) AGENTS [Prior Authorization Required] Brand Name 30 days Anti-Infectives HIV/AIDS Agents infection
homatropine Generic 30 days Ophthalmology Cycloplegic Mydriatics
homatropine/hydrocodone (syr) TUSSIGON Generic 30 days Respiratory, Allergy, Cough and Cold Antitussive Combinations
hydralazine APRESOLINE Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Vasodilators heart
hydrochlorothiazide DIURIL Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Thiazide and Related Diuretics Heart, Hypertension
hydrocortisone 2.5% (lotion) Generic 30 days
hydrocortisone (tab, suppository) Generic 30 days Dermatologicals/Topical Therapy;Respiratory, Allergy, Cough and Cold Topical Corticosteroids;Antipsoriatic;Antiseborrheic;Miscellaneous Gastrointestinal Agents Skin
hydrocortisone/iodoquinol DERMAZENE AND VYTONE Generic 30 days Dermatologicals/Topical Therapy Miscellaneous Dermatologicals Skin
hydrocortisone/pramoxine ANALPRAM, HC PRAMOXINE, NOVACORT, PRAMOSONE, PROCTOFOAM HC, RECTOCORT HC, PRAMCORT Generic 30 days Dermatologicals/Topical Therapy Miscellaneous Gastrointestinal Agents Skin
hydromorphone DILAUDID Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Narcotics
hydroquinone (crm) Generic 30 days Dermatologicals/Topical Therapy Miscellaneous Dermatologicals Skin
hydroxychloroquine PLAQUENIL Generic 30 days Anti-Infectives Antimalarials;Miscellaneous Rheumatological Agents infection
hydroxyurea (cap) DROXIA Generic 30 days
hydroxyzine ATARAX, VISTARIL, HYZINE Generic 30 days Respiratory, Allergy, Cough and Cold Antihistamines
hyoscyamine Generic 30 days Gastroenterology Anticholinergics and Antispasmodics
hyoscyamine-er Generic 30 days Gastroenterology Anticholinergics and Antispasmodics
ibuprofen 400mg, 600mg, 800mg (tab) MOTRIN Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych NSAIDS Inflammation
imipramine TOFRANIL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Tricyclic Antidepressant Agents
imiquimod (Limit: 12 packets/30 days) ALDARA, ZYCLARA Generic 30 days Dermatologicals/Topical Therapy Miscellaneous Dermatologicals Skin Growths
INCRUSE Ellipta (inhalation powder) INCRUSE Brand Name 30 days Respiratory, Allergy, Cough and Cold Miscellaneous Pulmonary Agents COPD
indapamide LOZOL Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Thiazide and Related Diuretics heart
indomethacin, indomethacin-er 25mg, 50mg, 75mg INDOCIN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych NSAIDS
ipratropium (neb. sol) ATROVENT Generic 30 days Respiratory, Allergy, Cough and Cold Miscellaneous Pulmonary Agents
isoniazid NYDRAZID Generic 30 days Anti-Infectives Antimycobacterials infection
ISOPTO CARBACHOL Brand Name 30 days Ophthalmology Miotics
ISOPTO HOMATROPINE Brand Name 30 days Ophthalmology Cycloplegic Mydriatics
ISOPTO HYOSCINE Brand Name 30 days Ophthalmology Cycloplegic Mydriatics
isosorbide dinitrate DILATRATE-SR Generic 30 days Cardiovascular, Hypertension and Lipids Long Acting Nitrates heart
isosorbide mononitrate 30mg, 60mg, 120mg IMDUR Generic 30 days Cardiovascular, Hypertension and Lipids Long Acting Nitrates heart
JANUMET Brand Name 30 days Endocrine/Diabetes Non-Insulin Hypoglycemic Agents
JANUMET-XR Brand Name 30 days Endocrine/Diabetes Non-Insulin Hypoglycemic Agents
JANUVIA Brand Name 30 days Endocrine/Diabetes Non-Insulin Hypoglycemic Agents
jinteli 1/0.005mg Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents
jolivette 0.35mg ORTHO-MICRONOR,
AYGESTIN, CAMILA, ERRI, NOR-QD, NORA-BE, ORTHO MICRONOR
Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents ortho-micronor, nor-q-d, errin, camila, heather
junel 1/0.02mg or 1.5/.03mg LOESTRIN Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents
junel-fe 1.5/0.03mg LOESTRIN-FE Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents
kariva MIRCETTE, APRI, AZURETTE, CAZIANT, CESIA, CYCLESSA, DESOGEN, EMOQUETTE, KARIVA, MIRCETTE, ORTHO-CEPT, RECLIPSEN, SOLIA, VELIVET, VIORELE Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents
kelnor 1/0.035mg DEMULEN 1/35-28, KELNOR, ZOVIA 1/35, ZOVIA 1/50 Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents zovia 1/35
ketoconazole (shampoo only) NIZORAL Generic 30 days Anti-Infectives;Dermatologicals/Topical Therapy Antifungal Agents;Topical Antifungals Skin
ketoprofen ACTRON, ORUDIS Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology NSAIDS
ketorolac TORADOL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology;Ophthalmology NSAIDS Eyes
labetolol Generic 30 days Cardiovascular, Hypertension and Lipids Beta Blockers heart
lactic acid (lotion) AMLACTIN, LAC-HYDRIN Generic 30 days Dermatologicals/Topical Therapy Miscellaneous Dermatologicals Skin
lactulose (syrup) Generic 30 days or 90 days Gastroenterology Miscellaneous Gastrointestinal Agents
lamotrigine LAMICTAL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants Seizures
LANTUS Brand Name 30 days Endocrine/Diabetes Insulin Therapy
latanoprost ophth. XALATAN Generic 30 days or 90 days Ophthalmology Other Glaucoma Drugs glaucoma
LATUDA (tab) [Prior Authorization Required] LATUDA Brand Name 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antipsychotics
leena TRI-NORINYL Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents triphasic
letrozole FEMARA Generic 30 days Antineoplastic and Immunosuppressant Drugs Antiestrogens
leuprolide injection Generic 30 days Antineoplastic and Immunosuppressant Drugs;Obstetrics and Gynecology Drugs to Treat Infertility;IVF Agents
levetiracetam KEPPRA Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants Seizures
levobunolol ophth. BETAGAN Generic 30 days Ophthalmology Beta Blockers
levofloxacin LEVAQUIN Generic 30 days Anti-Infectives Fluoroquinolones;Antibiotics infection
levothyroxine (tablet) Generic 30 days or 90 days
levoxyl SYNTHROID Brand Name 30 days Endocrine/Diabetes Antithyroid Agents
lidocaine (crm, gel, ointm, viscous liq) Generic 30 days Dermatologicals/Topical Therapy Topical Anesthetics;Miscellaneous Agents Skin
lidocaine/prilocaine (top.) EMLA Generic 30 days Dermatologicals/Topical Therapy Topical Anesthetics Skin
LIDODERM (patch) [Prior Authorization Required] Brand Name 30 days Dermatologicals/Topical Therapy Topical Anesthetics Skin
lindane Generic 30 days Dermatologicals/Topical Therapy Topical Scabicides;Pediculicides Skin
liothyronine CYTOMEL, TRIOSTAT Generic 30 days Endocrine/Diabetes Thyroid Hormones
lisinopril PRINIVIL, ZESTRIL Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids ACE Inhibitors
lisinopril/hctz PRINZIDE, ZESTORETIC Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Other Antihypertensive Combinations heart
lithium carbonate LITHOBID Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Psychotherapeutic Agents psychiatry
lorazepam ATIVAN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anxiolytics Anxiety
losartan COZAAR Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Angiotensin II Receptor Blockers and Renin Inhibitors
losartan/hctz HYZAAR Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Angiotensin II Receptor Blockers and Renin Inhibitors heart
LOTEMAX Brand Name 30 days Ophthalmology Steroids
lovastatin MEVACOR, ALTOCOR Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Lipid/Cholesterol Lowering Agents Heart, High Cholesterol
low-ogestrel 0.3/0.03mg LO/OVRAL-21, CRYSELLE 28, LO/OVRAL-28, LOW-OGESTREL, OGESTREL-28 Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents cryselle-28
loxapine LOXITANE, LOXITANE, LOXITANE C, LOXITANE IM Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Psychotherapeutic Agents psychiatry
MAXAIR Brand Name 30 days Respiratory, Allergy, Cough and Cold Inhaled Beta Agonists
mebendazole VERMOX Generic 30 days Anti-Infectives Antiparasitics infection
meclofenamate MECLOMEN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology NSAIDS
medroxyprogesterone (injectable (90-d), tab(30-d)) DEPO-PROVERA, PROVERA Generic 30 days or 90 days Obstetrics and Gynecology Progestins
mefloquine LARIAM Generic 30 days Anti-Infectives Antimalarials infection
megestrol (tab) MEGACE Generic 30 days or 90 days Obstetrics and Gynecology Hormones
meloxicam MOBIC Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology NSAIDS Arthritis
memantine (tab) NAMENDA Generic 30 days
meprobamate EQUANIL, MB-TAB Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology Anxiolytics
MEPRON Brand Name 30 days Anti-Infectives Antiparasitics infection
mesalamine CANASA Generic 30 days Gastroenterology Miscellaneous Gastrointestinal Agents
metaproterenol (syr) ALUPENT, METAPREL Generic 30 days Respiratory, Allergy, Cough and Cold Beta Agonists Oral
metformin FORTAMET, GLUCOPHAGE, GLUCOPHAGE XR, GLUMETZA, RIOMET Generic 30 days or 90 days Endocrine/Diabetes Non-Insulin Hypoglycemic Agents Diabetes
methazolamide GLAUCTABS, MZM, NEPTAZANE Generic 30 days Ophthalmology Oral Drugs for Glaucoma
methimazole NORTHYX, TAPAZOLE Generic 30 days Endocrine/Diabetes Antithyroid Agents
methocarbamol ROBAXIN, ROBAXIN-750, CARBACOT, SKELEX Generic 30 days Musculoskeletal and Rheumatology Muscle Relaxants and Antispasmodic Agents
methotrexate (tab) RHEUMATREX DOSE PACK, TREXALL Generic 30 days Antineoplastic and Immunosuppressant Drugs;Musculoskeletal and Rheumatology Antimetabolites;Miscellaneous Rheumatological Agents
methyldopa ALDOMET Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Adrenergic Antagonists and Related Drugs heart
methylphenidate RITALIN, METADATE, METHYLIN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Psychotherapeutic Agents ADHD
methylphenidate-sr RITALIN-SR Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Psychotherapeutic Agents ADHD
methylprednisolone MEDROL Generic 30 days Endocrine/Diabetes Adrenal Hormones
metipranolol opht. OPTIPRANOLOL Generic 30 days Ophthalmology Beta Blockers
metoclopramide (syr, tab) METOZOLV ODT, REGLAN Generic 30 days or 90 days Gastroenterology Miscellaneous Gastrointestinal Agents
metolazone ZAROXOLYN, MYKROX Generic 30 days Cardiovascular, Hypertension and Lipids Thiazide and Related Diuretics heart
metoprolol LOPRESSOR Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Beta Blockers
metoprolol/hctz LOPRESSOR HCT Generic 30 days Cardiovascular, Hypertension and Lipids Other Antihypertensive Combinations heart
metoprolol-xl TOPROL-XL Generic 30 days Cardiovascular, Hypertension and Lipids Beta Blockers heart
metronidazole (crm, vag. gel, tab) FLAGYL, METROGEL Generic 30 days Anti-Infectives;Dermatologicals/Topical Therapy;Obstetrics and Gynecology Antiparasitics;Therapy for Acne Skin
mexiletine MEXITIL Generic 30 days Ophthalmology Antiarrhythmic Agents
Microchamber MICROCHAMBER 30 days
microgestin 1/0.02mg or 1.5/0.03mg LOESTRIN Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents
microgestin-fe 1/0.02mg or 1.5/0.03mg LOESTRIN-FE Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents
minocycline DYNACIN, MINOCIN, MINOCIN PAC, MYRAC, SOLODYN, VECTRIN Generic 30 days Anti-Infectives Tetracyclines infection
minoxidil LONITEN Generic 30 days Cardiovascular, Hypertension and Lipids Vasodilators heart
mirtazapine (tab) REMERON Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antidepressants
misoprostol CYTOTEC Generic 30 days Gastroenterology;Obstetrics and Gynecology Prostaglandins
mometasone (crm, lotion, ointment) ELOCON Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
montelukast (chew, tab) SINGULAIR Generic 30 days Respiratory, Allergy, Cough and Cold Miscellaneous Pulmonary Agents
morphine MS CONTIN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Narcotics
MULTAQ [Prior Authorization Required] Brand Name 30 days Cardiovascular, Hypertension and Lipids Antiarrhythmic Agents heart
mupirocin (ointment only) BACTROBAN Generic 30 days Dermatologicals/Topical Therapy Topical Antibacterials Skin
MYCOBUTIN Brand Name 30 days Anti-Infectives Antimycobacterials infection
mycophenolate mofetil CELLCEPT Generic 30 days Antineoplastic and Immunosuppressant Drugs Immunosuppressant Drugs
nabumetone RELAFEN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych NSAIDS
nadolol CORGARD Generic 30 days Cardiovascular, Hypertension and Lipids Beta Blockers heart
naltrexone REVIA Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Narcotic Antagonists/Opioid Dependence
naproxen NAPROSYN, ALEVE Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych NSAIDS Inflammation
naproxen-ec EC-NAPROSYN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych NSAIDS
naratriptan AMERGE Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Headache Therapy
neomycin Generic 30 days Anti-Infectives Miscellaneous Anti-Infectives infection
neomycin/polymyxin/ HC ophth. (crm, ointm, susp ) Generic 30 days Ophthalmology Antibiotics
neomycin/polymyxin/gramicidin ophth. Generic 30 days Ophthalmology Antibiotics
nicotine (gum, lozenges, patches) NICODERM, NICORETTE, NICOTROL Generic 30 days Diagnostics and Miscellaneous Agents Smoking Deterrents
nifedipine PROCARDIA, NIFEDICAL Generic 30 days Cardiovascular, Hypertension and Lipids Calcium Channel Blockers (Dihydropyridines)
nitrofurantoin MACROBID, MACRODANTIN Generic 30 days Anti-Infectives Urinary Tract Agents infection
nitroglycerin (ointm, patch, SL, spray) Generic 30 days Cardiovascular, Hypertension and Lipids Rapid/Long Acting Nitrates heart
norethindrone AYGESTIN, CAMILA, ERRIN, JOLIVETTE, NOR-QD, NORA-BE, ORTHO MICRONOR, HEATHER Generic 30 days Obstetrics and Gynecology Progestins
nortrel 7/7/7 (0.5/0.035mg) ORTHO-NOVUM 7/7/7 Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents triphasic
nortriptyline PAMELOR, AVENTYL HCL Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych Tricyclic Antidepressant Agents
NOVOLIN 70/30 Brand Name 30 days Endocrine/Diabetes Insulin Therapy
NOVOLIN N Brand Name 30 days Endocrine/Diabetes Insulin Therapy
NOVOLIN R Brand Name 30 days Endocrine/Diabetes Insulin Therapy
NOVOLOG Brand Name 30 days Endocrine/Diabetes Insulin Therapy
NUVARING Brand Name 30 days Obstetrics and Gynecology Diaphragms and Other Non-Oral Contraceptives
nystatin (crm, ointm, powd, susp) MYCOSTATIN TOPICAL, NYSTOP Generic 30 days Anti-Infectives;Dermatologicals/Topical Therapy Antifungal Agents;Topical Antifungals Skin
ocella 3-0.03mg YASMIN, GIANVI, LORYNA, OCELLA, SYEDA, VESTURA, YASMIN, YAZ, ZARAH Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents syeda, zarah
ofloxacin (ophth, otic) FLOXIN, OCUFLOX Generic 30 days Ear, Nose and Throat Medications;Ophthalmology Fluoroquinolones;Miscellaneous Otic Preparations
orphenadrine NORFLEX, ORPHENATE Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology Muscle Relaxants and Antispasmodic Agents
orphenadrine compound Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology Muscle Relaxants and Antispasmodic Agents
ORTHO EVRA Brand Name 30 days Obstetrics and Gynecology Diaphragms and Other Non-Oral Contraceptives
ORTHO-PREFEST Brand Name 30 days Obstetrics and Gynecology Estrogen Combinations
OXSORALEN-ULTRA Brand Name 30 days Dermatologicals/Topical Therapy;Diagnostics and Miscellaneous Agents Miscellaneous Dermatologicals Skin
oxybutynin DITROPAN Generic 30 days Urologicals Anticholinergics and Antispasmodics
oxybutynin-XL DITROPAN-XL Generic 30 days Urologicals Anticholinergics and Antispasmodics
oxycodone OXYCONTIN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Narcotics
oxycodone/acetaminophen ENDOCET, PERCOCET Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Combination Narcotic;Analgesics
oxycodone-ER Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Narcotics
PANCREAZE Brand Name 30 days Gastroenterology Digestive Enzymes
pantoprazole PROTONIX Generic 30 days or 90 days Gastroenterology Proton Pump Inhibitors GERD
paroxetine PAXIL Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych Selective Serotonin Reuptake Inhibitors (SSRIs) Depression
peg 3350/electrolytes Generic 30 days Gastroenterology Bowel Evacuants
PEGASYS [Prior Authorization Required] Brand Name 30 days Immunology, Vaccines and Biotechnology Interferons
PEG-INTRON [Prior Authorization Required] Brand Name 30 days Immunology, Vaccines and Biotechnology Interferons infection, hepatititis
penicilln vk Generic 30 days Anti-Infectives Penicillins infection
PENTASA Brand Name 30 days Gastroenterology Miscellaneous Gastrointestinal Agents
pentoxifylline-er Generic 30 days Cardiovascular, Hypertension and Lipids;Vitamins, Hematinics and Electrolytes Miscellaneous Coagulation Agents heart
permethrin Generic 30 days Dermatologicals/Topical Therapy Topical Scabicides;Pediculicides Skin
perphenazine TRILAFON Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Phenothiazines
perphenazine/amitriptyline ETRAFON, TRIAVIL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antidepressants
phenazopyridine Generic 30 days Urologicals Urinary Anesthetics
phenobarbital Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants
phenytoin DILANTIN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants
PHISOHEX 0.3% Brand Name 30 days Dermatologicals/Topical Therapy Miscelleneous Anti-Infectives Skin
pilocarpine (ophth.) ISOPTO CARPINE, PILOPINE HS Generic 30 days Ophthalmology Direct Acting Miotics
PILOPINE HS Brand Name 30 days Ophthalmology Direct Acting Miotics
pindolol VISKEN Generic 30 days Cardiovascular, Hypertension and Lipids Beta Blockers heart
piroxicam FELDENE Generic 30 days Autonomic and CNS Drugs;Neurology and Psych NSAIDS
podofilox CONDYLOX Generic 30 days Dermatologicals/Topical Therapy;Diagnostics and Miscellaneous Agents Miscellaneous Dermatologicals Skin
polymyxin-b & trimethoprim Generic 30 days Ophthalmology Antibiotics
portia-28 0.15/0.03mg NORDETTE-28 Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related agents altavera, levora-28
potassium chloride KLOR-CON, K-DUR Generic 30 days or 90 days Vitamins, Hematinics and Electrolytes Miscellaneous Urologicals;Electrolytes
potassium chloride-er Generic 30 days or 90 days Vitamins, Hematinics and Electrolytes Miscellaneous Urologicals;Electrolytes
PRADAXA [Prior Authorization Required] Brand Name 30 days Cardiovascular, Hypertension and Lipids Anticoagulants heart
pramipexole MIRAPEX, MIRAPEX ER Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Antiparkinsonism Drugs
PRANDIN Brand Name 30 days Endocrine/Diabetes Non-Insulin Hypoglycemic Agents
pravastatin PREVACHOL, PRAVACHOL Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Lipid/Cholesterol Lowering Agents Heart, High Cholesterol
prazosin MINIPRESS Generic 30 days Cardiovascular, Hypertension and Lipids Adrenergic Antagonists and Related Drugs heart
prednicarbate DERMATOP Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
prednisolone (oral liquid, ophth. Drop) ORAPRED, PEDIAPRED, PRELONE, PRED FORTE Generic 30 days Endocrine/Diabetes, Ophthalmology Steroids
prednisone (tab) DELTASONE Generic 30 days or 90 days Endocrine/Diabetes Steroids Swelling, Allergic Reactions
PREMARIN (tab, vag crm) Brand Name 30 days Obstetrics and Gynecology Osteoporosis Therapy;Estrogens
PREMPHASE Brand Name 30 days Obstetrics and Gynecology Estrogen Combinations
PREMPRO Brand Name 30 days Obstetrics and Gynecology Estrogen Combinations
prenatal plus vitamins Generic 30 days or 90 days Vitamins, Hematinics and Electrolytes Vitamins and Hematinics
primidone MYSOLINE Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants
probenecid BENEMID Generic 30 days Musculoskeletal and Rheumatology Gout Therapy
procainamide Generic 30 days Cardiovascular, Hypertension and Lipids Antiarrhythmic Agents heart
prochlorperazine COMPAZINE Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych;Gastroenterology Antivertigo and Antiemetic Drugs
progesterone 50mg/ml (injection) PROMETRIUM Generic 30 days Obstetrics and Gynecology Progestins
promethazine (syr, tab) PHENERGAN Generic 30 days Gastroenterology;Respiratory, Allergy, Cough and Cold Antivertigo and Antiemetic Drugs;Antihistamines
promethazine/codeine PHENERGAN W/ CODEINE Generic 30 days Respiratory, Allergy, Cough and Cold Antitussive Combinations
promethazine-dm Generic 30 days Respiratory, Allergy, Cough and Cold Antitussive Combinations
propranolol INDERAL Generic 30 days Cardiovascular, Hypertension and Lipids Beta Blockers heart
propranolol-ER Generic 30 days Cardiovascular, Hypertension and Lipids Beta Blockers heart
propranolol-LA Generic 30 days Cardiovascular, Hypertension and Lipids Beta Blockers heart
propylthiouracil Generic 30 days Endocrine/Diabetes Antithyroid Agents
PROTOPIC Brand Name 30 days Dermatologicals/Topical Therapy Miscellaneous Dermatologicals Skin
PROVENTIL HFA Brand Name 30 days Respiratory, Allergy, Cough and Cold Inhaled Beta Agonists
PULMICORT FLEXHALER Brand Name 30 days Respiratory, Allergy, Cough and Cold Inhaled Corticosteroids
PULMOZYME Brand Name 30 days Respiratory, Allergy, Cough and Cold Miscellaneous Pulmonary Agents
pyrazinamide Generic 30 days Anti-Infectives Antimycobacterials infection
pyridostigmine Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Muscle Relaxants and Antispasmodic Agents
quetiapine fumarate SEROQUEL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antipsychotics psychiatry
quinidine sulfate Generic 30 days Cardiovascular, Hypertension and Lipids Antiarrhythmic Agents heart
quinidine sulfate-er Generic 30 days Cardiovascular, Hypertension and Lipids Antiarrhythmic Agents heart
QVAR Brand Name 30 days Respiratory, Allergy, Cough and Cold Inhaled Corticosteroids
ramipril ALTACE Generic 30 days Cardiovascular, Hypertension and Lipids ACE Inhibitors blood pressure
ranitidine 150, 300mg ZANTAC Generic 30 days or 90 days Gastroenterology H2 Antagonists Ulcers, GERD
REGRANEX Brand Name 30 days Dermatologicals/Topical Therapy Miscellaneous Dermatologicals Skin
RENAGEL Brand Name 30 days Diagnostics and Miscellaneous Agents Miscellaneous Agents
ribavirin (caps, tabs) COPEGUS, REBETOL, RIBAPAK, RIBASPHERE, RIBATAB, VIRAZOLE Generic 30 days Anti-Infectives Miscellaneous Antivirals infection; virus
rifampin RIFADIN, RIMACTANE Generic 30 days Anti-Infectives Antimycobacterials infection
risperidone (tab) RISPERDAL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antipsychotics
rizatriptan MAXALT Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Headach Therapy migraine; headache
ropinirole REQUIP Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Antiparkinsonism Drugs
salsalate 500mg SALFLEX, AMIGESIC Generic 30 days Gastroenterology Salicylates
SANTYL Brand Name 30 days Dermatologicals/Topical Therapy Topical Enzymes Skin
selegiline ELDEPRYL, ZELAPAR Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Antiparkinsonism Drugs
selenium sulfide (lotion) DANDREX, SELSUN BLUE, TERSI FOAM Generic 30 days Dermatologicals/Topical Therapy Antipsoriatic;Antiseborrheic Skin
SEROQUEL-XR [Prior Authorization Required] Brand Name 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antipsychotics psychiatry
sertraline ZOLOFT Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych Selective Serotonin Reuptake Inhibitors (SSRIs)
silver sulfadiazine SILVADENE Generic 30 days Dermatologicals/Topical Therapy Burn Therapy Skin
simvastatin ZOCOR Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Lipid/Cholesterol Lowering Agents Heart, High Cholesterol
sodium citrate/citric acid (liq) BICITRA, CYTRA-2, LIQUI-DUAL CITRA, ORACIT Generic 30 days or 90 days Urologicals Miscellaneous Urologicals
SOLU-CORTEF Brand Name 30 days Endocrine/Diabetes Corticosteroids
sotalol 80mg BETAPACE, SORINE Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Antiarrhythmic Agents heart
SOVALDI [Prior Authorization Required] SOVALDI Brand Name 30 days Anti-Infectives Antiviral Agents hepatitis C infection, virus
spironolactone 25mg ALDACTONE Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Thiazide and Related Diuretics Heart, Hypertension
spironolactone/hctz ALDACTAZIDE Generic 30 days Cardiovascular, Hypertension and Lipids Thiazide and Related Diuretics heart
sprintec 0.25/0.035mg MONONESSA, ORTHO TRI-CYCLEN, ORTHO TRI-CYCLEN LO, ORTHO-CYCLEN, PREVIFEM, SPRINTEC, TRI-LO-SPRINTEC, TRI-PREVIFEM, TRI-SPRINTEC, TRINESSA Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related Agents
sucralfate CARAFATE Generic 30 days Gastroenterology Other Ulcer Therapy
sulfacetamide sodium 10% ophth. Generic 30 days Ophthalmology Antibiotics
sulfacetamide/prednisolone Generic 30 days Ophthalmology Antibiotics
sulfacetamide/sulfur 10%/5% (topical cleanser) Generic 30 days
sulfamethoxazole-trimethoprim Generic 30 days Anti-Infectives Sulfas and Related Agents infection
sulfasalazine AZULFIDINE, SULFAZINE Generic 30 days Gastroenterology Miscellaneous Gastrointestinal Agents;Miscellaneous Rheumatological Agents
sulfasalazine-ec Generic 30 days Gastroenterology Miscellaneous Gastrointestinal Agents;Miscellaneous Rheumatological Agents
sulindac CLINORIL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Musculoskeletal and Rheumatology NSAIDS
sumatriptan IMITREX Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Headache Therapy Migraines
SYNTHROID Brand Name 30 days Endocrine/Diabetes Antithyroid Agents
tacrolimus (cap) PROTOPIC, PROGRAF Generic 30 days Antineoplastic and Immunosuppressant Drugs Immunosuppressant Drugs Transplant Organ Rejection
TAMIFLU Brand Name 30 days Anti-Infectives Miscellaneous Antivirals infection; virus
tamoxifen SOLTAMOX Generic 30 days or 90 days Antineoplastic and Immunosuppressant Drugs Antiestrogens
tamsulosin FLOMAX Generic 30 days or 90 days Urologicals Benign Prostatic Hyperplasia Therapy
temazepam RESTORIL Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Hypnotic Agents Insomnia
teraconazole vaginal Generic 30 days Obstetrics and Gynecology Vaginal Antifungals
terazosin HYTRIN Generic 30 days Cardiovascular, Hypertension and Lipids;Urologicals Adrenergic Antagonists and Related Drugs;Benign Prostatic Hyperplasia Therapy heart
terbinafine (tab) LAMISIL Generic 30 days or 90 days Anti-Infectives Antifungal Agents infection
testosterone depot DEPO-TESTOSTERONE Generic 30 days Endocrine/Diabetes Androgens
tetracycline ALA-TET, PANMYCIN, SUMYCIN Generic 30 days Anti-Infectives Tetracyclines infection
theophylline Generic 30 days Respiratory, Allergy, Cough and Cold Xanthines
thioridazine MELLARIL, MELLARIL-S Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Phenothiazines
thiothixene NAVANE Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antipsychotics psychiatry
ticlopidine TICLID Generic 30 days Cardiovascular, Hypertension and Lipids;Vitamins, Hematinics and Electrolytes Antiplatelet Drugs heart
timolol (sol) BLOCADREN Generic 30 days or 90 days Ophthalmology Beta Blockers
timolol-xe (ophth.) Generic 30 days Ophthalmology Beta Blockers
tobramycin ophth. Generic 30 days Ophthalmology Antibiotics
tobramycin/dexamethasone ophth. 0.3-0.1% TOBRADEX Generic 30 days Ophthalmology Steroid-Antibiotic Combinations
TOBREX (ophth. ointment) Brand Name 30 days Ophthalmology Antibiotics
tolterodine DETROL Generic 30 days Urologicals Anticholinergics and Antispasmodics bladder, urinary incontinence
tolterodine-LA [Prior Authorization Required] DETROL-LA Generic 30 days Urologicals Anticholinergics and Antispasmodics bladder, urinary incontinence
topiramate TOPAMAX Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants Seizures
torsemide DEMADEX Generic 30 days Cardiovascular, Hypertension and Lipids Thiazide and Related Diuretics heart
tramadol ULTRAM Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Analgesics Moderate Pain
TRANSDERM-SCOP Brand Name 30 days Autonomic and CNS Drugs;Neurology and Psych Antivertigo and Antiemetic Drugs
trazodone DESYREL Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antidepressants
triamcinolone (crm) KENALOG Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
triamcinolone (ointm) ARISTOCORT Generic 30 days Dermatologicals/Topical Therapy Topical Corticosteroids Skin
triamcinolone/orabase Generic 30 days Ear, Nose and Throat Medications Miscellaneous Agents
triamterene/hctz DYAZIDE, MAXZIDE Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Thiazide and Related Diuretics heart
triazolam HALCION Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Hypnotic Agents
trifluoperazine STELAZINE Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Phenothiazines
trifluridine ophth. TRIFLURIDINE, VIROPTIC Generic 30 days Ophthalmology Antivirals
trihexyphenidyl ARTANE, TRIHEXANE Generic 30 days or 90 days Autonomic and CNS Drugs;Neurology and Psych Antiparkinsonism Drugs
tri-lo-sprintec ORTHO TRICYCLEN-LO Generic 30 days
trimethobenzamide TIGAN, TICON, BENZACOT Generic 30 days Autonomic and CNS Drugs;Neurology and Psych;Gastroenterology Antivertigo and Antiemetic Drugs
trimethoprim/polymyxin Generic 30 days Ophthalmology Antibiotics
tri-sprintec MONONESSA, ORTHO TRI-CYCLEN, ORTHO TRI-CYCLEN LO, ORTHO-CYCLEN, PREVIFEM, SPRINTEC, TRI-LO-SPRINTEC, TRI-PREVIFEM, TRI-SPRINTEC, TRINESSA Generic 30 days Obstetrics and Gynecology Oral Contraceptives and Related Agents
urea 40% (crm, gel) URAMAXIN GT Generic 30 days Dermatologicals/Topical Therapy Miscellaneous Dermatologicals Skin
ursodiol ACTIGALL, URSO Generic 30 days Gastroenterology Bile Acids
VAGIFEM Brand Name 30 days Obstetrics and Gynecology Bile Acids
valacyclovir VALTREX Generic 30 days Anti-Infectives Miscellaneous Antivirals infection; virus
valproic acid DEPAKENE, STAVZOR, DEPACON Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants
vancomycin injectable Generic 30 days Anti-Infectives Vancomycin infection
VANOXIDE-HC Brand Name 30 days Dermatologicals/Topical Therapy Miscellaneous Dermatologicals Skin
venlafaxine (cap) EFFEXOR Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antidepressants
venlafaxine-ER (cap) EFFEXOR-XR Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Miscellaneous Antidepressants
VENTOLIN HFA VENTOLIN HFA Brand Name 30 days
verapamil CALAN, VERELAN Generic 30 days Cardiovascular, Hypertension and Lipids Calcium Channel Blockers (Non-Dihydropyridines)
verapamil-er CALAN-SR Generic 30 days Cardiovascular, Hypertension and Lipids Calcium Channel Blockers (Non-Dihydropyridines) heart
VIGAMOX [Prior Authorization Required] Brand Name 30 days Ophthalmology Antibiotics
VIREAD Brand Name 30 days Anti-Infectives Miscellaneous Antivirals hepatitis b
warfarin COUMADIN Generic 30 days or 90 days Cardiovascular, Hypertension and Lipids Anticoagulants Heart, Thrombosis
zafirlukast ACCOLATE Generic 30 days Respiratory, Allergy, Cough and Cold Miscellaneous Pulmonary Agents
ZENPEP Brand Name 30 days Gastroenterology Digestive Enzymes
ZEPATIER [Prior Authorization Required] ZEPATIER Brand Name 30 days
zolpidem AMBIEN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Hypnotic Agents sleep, insomnia
zonisamide ZONEGRAN Generic 30 days Autonomic and CNS Drugs;Neurology and Psych Anticonvulsants