2007
Mutual of Omaha
Drug Formulary
ANESTHETICS
Topical Anesthetics
Dyclone
lidocaine viscous
ANTIINFECTIVES
Antibacterial Drugs
Amoxil (G)
Augmentin (G)
Avelox
Bactrim (G)
Biaxin (G)
Biaxin XL
Ceftin (G)
Cipro (G)
Cleocin Pediatric
Duricef (G)
E.E.S. (G)
E-Mycin (G)
erythrocin stearate
Floxin (G)
furadantin
Gantrisin Pediatric
Keflex (G)
Ketek
Levaquin
Macrobid (G)
Minocin (G)
Omnicef
PCE
Pediazole (G)
Principen (G)
Vantin (G)
Veetids (G)
Velosef
Vibramycin (G)
Zithromax (G)
Topical Antibacterial Drugs
Bactroban (G)
gentamicin
silver sulfadiazine
Sulfamylon
Oral Antifungal Drugs
Diflucan (QL) (G)
Grifulvin V
Gris-Peg (G)
griseofulvin
Lamisil (PAR)
Mycelex (G)
nystatin
Sporanox (PAR) (G)
Vfend (PAR)
Topical Antifungal Drugs
Loprox (G)
Nixoral (G)
nystatin
Spectazole (G)
Topical AntifungalCorticosteroid
Combinations
nystatin
w/ triamcinolone
Oral Antiviral Drugs
All injectable products
for Hepatitis C and all HIV
medications are on the
formulary.
acyclovir
amantadine
Cytovene (G)
Famvir (QL)
Valcyte
Valtrex (QL)
Topical Antiviral Drugs
Zovirax
Antiinfectives Specialized
Indications
All FDA approved TB
medications, Amebicides,
Antihelminthics and
Plasmodicides are on the
Formulary.
AUTONOMIC AND CNS
MEDICATIONS
Class II Narcotics
Actiq (PAR) (QL) (G)
codeine sulfate
dolophine
Duragesic (G)
hydromorphone
levorphanol tartrate
meperidine
morphine
MS Contin
MS IR (G)
OMS
oxycodone
w/acetaminophen
oxycodone w/aspirin
Oxycontin (QL)
Oxy IR (G)
Percocet (G)
Percodan (G)
RMS-Suppository
Class III Narcotics
codeine w/acetaminophen
codeine w/aspirin
hydrocodone bitartrate w/
acetaminophen
Zydone
Class IV Narcotics
proxyphene combinations
are covered
Talwin NX (G)
Drugs to Prevent and Treat
Headaches
Triptans:
Amerge (QL)
Imitrex (QL)
Zomig (QL)
Ergot-containing Drugs:
Bellergal-S (G)
Cafergot (G)
D.H.E. 45 (G)
Migranal (QL)
phenobarbital/ergotamine/
bell
Wigraine
The Mutual of Omaha Drug Formulary lists preferred medications. The formulary
is developed and updated by the Mutual of Omaha Pharmacy and Therapeutics
(P&T) Committee and is subject to change. Please note that when a generic
equivalent becomes available for a brand name drug on formulary, the brand
name formulary drug becomes non-formulary. Certain drugs require prior
authorization and/or have quantity limit requirements in some circumstances.
All compounded medications, if covered under your plan, are non-formulary. All
drugs listed on the formulary are subject to your specific plan provisions. All drugs may
not be covered under your plan. To obtain the most current formulary listing, please go
to mutualofomaha.com or call the customer service number on your ID card.
Other drugs:
acetaminophen w/
butalbital
butalbital compound w/
codeine
Equagesic (G)
Esgic Plus 500mg cap (G)
Fioricet (G)
Fiorinal w/codeine
No. 3 (G)
Midrin (G)
Stadol NS (G)
Antianxiety and SedativeHypnotic Drugs
Anxiolytics:
alprazolam intensol
Buspar (G)
chlordiazepoxide HCl
lorazepam
oxazepam
Sedative/Hypnotic:
Ambien (QL)
estazolam
flurazepam
hydroxyzine HCl
Restoril (G)
triazolam
Antimania Drugs
lithium citrate
Lithobid (G)
Anticonvulsant Drugs
Celontin
clonazepam
Depakene (G)
Depakote
Dilantin
Dilantin Infatab
ethosuximide
Felbatol
Gabitril
Keppra
Lamictal
Lyrica (PAR)
Mebaral (G)
Mesantoin
Mysoline (G)
Neurontin (G)
Peganone
phenobarbital
Primidone
Tegretol
Tegretol XR
Topamax
Trileptal
Zarontin (G)
Zonegran (G)
Antidepressant Drugs
Amines:
amitriptyline HCl
amoxapine
Anafranil (G)
clomipramine
desipramine HCl
doxepin
imipramine HCl
nortriptyline HCl
protriptyline HCl
Vivactil (G)
Selective Serotonin
Reuptake Inhibitors:
Celexa (10mg & 40mg) (G)
Lexapro (PAR)
Paxil (G)
Paxil CR (PAR)
Prozac (G)
Zoloft (25mg & 100mg) (G)
Other Antidepressants:
amitriptyline w/perphenaz
Cymbalta (PAR)
Effexor (G)
Effexor XR (PAR)
maprotiline
Remeron (G)
trazadone HCl
Wellbutrin (G)
Wellbutrin SR (QL) (G)
Antivertigo and Antiemetic
Drugs
Anzemet
Kytril
Phenergan (G)
prochlorperazine
Torecan
trimethobenzamide HCl
Zofran
Zofran-ODT
Antiparkinson Drugs
Akineton
Apokyn
Comtan
Keppra
Lodosyn
Mirapex
Paracopa
Parlodel 2.5mg tab (G)
Requip
selegiline HCl
Sinemet (G)
Sinemet CR (G)
Stalevo
Tasmar
trihexyphenidyl HCl
Antipsychotic Drugs
Conventional (Typical):
Haldol (G)
Mellaril (G)
Moban
Orap
Thorazine (G)
Novel (Atypical):
Abilify
Clozaril (G)
Geodon
Risperdal (G)
Risperdal consta
Seroquel
Zyprexa
CNS Stimulant/Other CNSAutonomic Drugs
CNS Stimulant Drugs:
Adderall (G)
Concerta
Cylert (G)
Dexedrine (G)
Strattera
Pemoline
Provigil (PAR)
Ritalin (G)
Antidementia Drugs:
Aricept
Exelon
Namenda
Razadyne
CARDIOVASCULAR
MEDICATIONS
Antilipidemic Medications
HMG CoA Reductase
Inhibitors:
Crestor (PAR)
Lipitor (PAR)
lovastatin
Pravachol (G)
Zocor (G)
HMG CoA Combination:
Vytorin (PAR)
Hypolipoproteinemics:
cholestyramine
Colestid (bulk) (G)
Lopid (G)
Niacin
Niaspan
Prevalite
Tricor
Welchol (PAR)
Zetia (PAR)
Cardiac Glycosides
Lanoxin
Diuretics
amiloride HCl w/HCTZ
Bumex (G)
chlorothiazide
chlorthalidone
Demadex (G)
Dyazide (G)
hydrochlorothiazide
Inspra (PAR)
Lasix (G)
spironolactone
spironolactone/HCTZ
Zaroxolyn (G)
Beta-Adrenergic Antagonist
Drugs
Cardioselective:
acebutolol HCL
atenolol
metoprolol
Toprol XL
Non-Cardioselective:
Inderal LA (G)
nadolol
pindolol
propranolol
timolol
Combination Alpha-Beta
Antagonists:
Coreg
labetalol
(G) next to a drug name indicates that a generic is available for at least one or more strengths of the brand medication and the brand name product is
non-formulary; (PAR) stands for Prior Authorization Required; (QL) stands for Quantity Limit and OTC stands for over-the-counter medications.
MUG6319_1006
Drug Formulary
ACE Inhibitors
Altace
captopril
Lotensin (G)
Prinivil (G)
Vasotec (G)
Monopril (G)
ARBs
Cozaar
Diovan
Diovan HCT
Hyzaar
Calcium Antagonists
Cardizem CD (G)
diltiazem
nicardipine
Nimotop
Norvasc
Plendil (G)
Procardia XL (G)
verapamil HCl
Other Antihypertensives
and Combinations:
atenolol w/chlorthalidone
Capozide (G)
Cardura (G)
clonidine HCL
clonidine w/chlorthalidone
Clorpres
Combipress
hydralazine HCl
hydralazine w/HCTZ
Hytrin (G)
Lopressor HCT (G)
Lotensin HCT (G)
Lotrel
methyldopa
methyldopa w/HCTZ
Minoxidil (G)
prazosin HCl
Prinizide (G)
propranolol w/HCTZ
Tenex (G)
Vaseretic (G)
Ziac (G)
Pulmonary Arterial
Hypertension
Revatio (PAR)
Ventavis
Vasodilating Drugs
Nitrates:
BiDil
Imdur (G)
nitroglycerin SR
Nitrol (G)
Nitro-Dur (G)
Nitrostat (G)
Other Vasodilating Drugs:
Persantine (G)
DERMATOLOGICAL
MEDICATIONS
Topical Corticosteroid
Drugs
Group I - Very High Potency:
Diprolene oint (G)
Temovate (G)
Ultravate (G)
Group II - High Potency:
Aristocort 0.1% oint (G)
Diprolene AF cream (G)
Diprosone (G)
Lidex-E (G)
Topicort (G)
Group III - Medium Potency
Aristocort 0.025% cream,
oint, lotion (G)
Aristocort 0.5% cream,
oint (G)
Diprolene (G)
Topicort (G)
Topicort LP (G)
Westcort (G)
Group IV - Low Potency
Desowen (G)
Hytone (G)
Synalar (G)
Tridesilon (G)
Antipruritic Drugs
Oral Antipruritic Drugs:
Atarax (G)
cyproheptadine HCL
Antiacne Drugs
Benzoyl Peroxide Products:
Some prescription noncombination benzoyl
peroxide products are
not covered. Numerous
benzoyl peroxide products
in various forms and
strengths are available
over-the-counter.
Topical Antiacne Drugs:
Azelex (G)
Differin (PAR Age 25) (G)
Emgel (G)
Erycette (G)
Erygel (G)
Metrocream (G)
Metrogel (G)
Metrolotion (G)
Retin-A (G) (PAR Age 25)
Retin-A Micro (PAR Age 25)
T-Stat (G)
Combinations:
Benzamycin (G)
Sulfacet-R (G)
Sulfoxyl
Accutanes:
Accutane (G)
Keratolytic Drugs
Condylox gel
Condylox solution (G)
Antipsoriasis and
Antieczema Drugs
Capitrol Shampoo
Dovonex
Dritho-Scalp
Drithocreme
Drithocreme-HP
methotrexate
selenium sulfide
Soriatane
Tazorac
Topical Immunomodulators
Elidel (PAR)
EAR-NOSE-THROAT
MEDICATIONS
Drugs Affecting the Ear
acetic acid otic
acetic acid
w/hydrocortisone
antipyrine w/benzocaine
Cerumenex
chloromycetin otic
Cipro HC
Floxin (G)
neomycin/polymyxin/HC otic
Drugs Affecting the Nose
Nasal Corticosteroids:
Flonase (QL) (G)
Nasacort (QL)
Nasorex (QL)
ENDOCRINE
MEDICATIONS
Hypoglycemic
Insulin:
Humalog
Humulin
Lantus
Novolin
Novoiog
Oral Hypoglycemic Drugs:
Amaryl
Glucotrol (G)
Glucotrol XL (G)
glyburide micronized
metformin
Prandin
Precose
Starlix
Insulin Sensitizers:
Actos
Avandia
Combination Products:
Avandamet
ActoplusMET (QL)
Adrenal Corticosteroid
Drugs
Glucocorticoid Drugs:
cortisone acetate
dexamethasone
hydrocortisone
methylprednisolone
dosepak
prednisolone
prednisone
Mineralcorticoid Drugs:
Florinef Acetate (G)
Thyroid Drugs
Levothroid
levothyroxine
Levoxyl
Synthroid
Unithroid
Other Endocrine Drugs
Cytadren
DDAVP (G)
Didronel (G)
Stimate
Osteoporosis Drugs
Actonel (QL)
Evista
Fosamax (QL)
Fosamax Plus D (QL)
Miacalcin
GASTROINTESTINAL
MEDICATIONS
Antidiarrheal Drugs
diphenoxylate w/atropine
Antispasmodics/Drugs
Affect GI Motility
Anticholinergic Drugs:
Levsin (G)
Pro-Banthine (G)
Cholinergic Drugs:
urecholine
Other Drugs:
Donnatal Extentab (G)
Lotronex
metoclopramide
Antiulcer Drugs
H2 Antagonists:
cimetidine
famotidine 40mg
Other Antiulcer Drugs:
Cytotec (G)
sulcralfate
Proton Pump Inhibitors:
Nexium (PAR) (QL)
Prilosec 10mg (G) (QL)
Protonix (PAR)
Helicobacter Pylori Drugs:
Prevpac
Other GI Drugs
Actigall (G)
Analpram-HC (G)
Anusol-HC 2.5% cream (G)
Asacol
Azulfidine En-Tab (G)
Colozal
Colyte (G)
Cortenema (G)
Cortifoam
Cotazym
Creon (G)
Entocort-EC
Pentasa
Proctocort cream (G)
Proctocream-HC 1% (G)
Proctofoam-HC (G)
Proctosol HC (G)
Rowasa (G)
Urso
Zelnorm
IMMUNOLOGICALS AND
VACCINES
All immunoglobins,
immune serums, toxoids
and vaccines are included
in the formulary
MUSCULOSKELETAL
MEDICATIONS
Drugs for Inflammatory
Diseases
Salicylates and Related
Drugs:
choline mag trisalicylate
diflunisal
salsalate
Zorprin
Non-Steroidal
Antiinflammatory Agents
First Line Agents:
Anaprox (G)
Anaprox DS (G)
Cataflam (G)
Clinoril (G)
Daypro (G)
EC Naprosyn (G)
Feldene (G)
Indocin (G)
Lodine (G)
meclofenamate
Mobic (G)
Motrin (G)
Naprosyn (G)
Orudis (G)
Relafen (G)
Toradol (G) (QL)
Second Line Agents:
Arthrotec (PAR)
Celebrex (PAR)
Other Drugs for Arthritis
Arava
methotrexate
Plaquenil (G)
Ridaura
Drugs to Prevent and Treat
Gout
Uricosurics:
Anturane (G)
Probenecid (G)
Other Drugs:
allopurinol
colchicine
Skeletal Muscle Relaxants
Direct Muscle Relaxants:
baclofen
CNS Muscle Relaxants:
chlorzoxazone
methocarbamol
orphenadrine
orphengesic
Soma (G)
Other Musculoskeletal
Drugs:
Rilutek
NUTRITION, BLOOD
MODIFIERS,
ELECTROLYTES
Vitamins & Minerals &
Related Products
Multivitamins are NOT
included in the Formulary
as various OTC products are
available.
Multi-Vit w/Flouride
Multi-Vit w/Flouride & Iron
Soluvite chewable
Soluvite drops (G)
Vi-Daylin F ADC (G)
Vi-Daylin F ADC w/Iron (G)
Therapeutic Vitamins &
Minerals
Carnitor (G)
folic acid
Hectorol
Hematron-AF
Pre-Folic tablet
Rocaltrol (G)
Flouride Products
Luride drops (G)
sodium flouride
Potassium Supplements
Sustained-Release Tablets:
K-Dur 10MEQ (G)
K-Dur 20MEQ (G)
Klor-Con (G)
Slow-K (G)
Sustained-Release
Capsules:
Micro-K (G)
Liquids:
Kaon
Kaochlor (G)
Effervescent Tablets:
K-Lyte/CL (25meq) (G)
K-Lyte DS (50meq)
(G) next to a drug name indicates that a generic is available for at least one or more strengths of the brand medication and the brand name product is
non-formulary; (PAR) stands for Prior Authorization Required; (QL) stands for Quantity Limit and OTC stands for over-the-counter medications.
Drug Formulary
Powders:
K-Lor (G)
Klor-Con
Potassium Removing
Resins:
Kayexalate (G)
Drugs and Vitamins
Affecting Coagulation
Oral Anticoagulants,
Vitamin K:
Coumadin
Mephyton
warfarin Sodium
Heparin and Heparin
Antagonists:
Arixtra
Fragmin
Normiflo
Orgaran
Antiplatelet Drugs:
Aggrenox
Persantine (G)
Plavix
Ticlid (G)
Hemostatics:
Amicar tab (G)
Blood Detoxicants:
Chronulac (G)
Enulose
Lactulose
Renagel
OBSTETRICAL &
GYNECOLOGICAL
MEDICATIONS
Prenatal Vitamins
All generic prescription
prenatal vitamins are
included in the formulary.
Specialized OB/GYN Drugs
Brethine (G)
Lupron (PAR)
Profasi HP (G)
Synarel
Bravelle
OB/GYN Topical
Antiinfective Drugs
Cleocin
Metrogel Vaginal
sulfanilamide
Triple sulfa vaginal (G)
Vaginal Antifungals
Nystatin Vaginal
Androgen Drugs
Androgel
Danocrine (G)
fluoxymesterone
methyltestosterone
Estrogen Drugs
Alora
Climara (G)
Estrace (G)
Estratest
Estratest HS
Estring
Gynodiol
Ortho-Est (G)
Premarin
Vagifem
Estrogen/Progestin
Combinations
Combipatch
Femhrt
Lunelle (QL)
Ortho Evra Patch
Prefest
Premphase
Prempro
Selective Estrogen Receptor
Modulator
Evista
Progestin Drugs
Aygestin (G)
medroxyprogesterone
Ovrette
Prometrium
Oral Contraceptives
For patients with coverage,
the following are included
in the formulary:
Alesse (G)
Estrostep FE (G)
Loestrin (G)
Micronor (G)
Nordette 0.15/0.03, -28 (G)
Ortho Tri-Cyclen (G)
Ortho Tri-Cyclen Lo
Ortho-Cept (G)
Ortho-Cyclen (G)
Ortho-Novum 1/35, 1/50,
10/11, 7/7/7 (G)
Ovral (G)
Plan B
OPHTHALMIC
MEDICATIONS
Ophthalmic Antiinfective
Drugs
Ophthalmic Topical
Anitbacterial Drugs:
Ak-Tracin (G)
Bacitracin Ophth oint (G)
Ciloxan (G)
Ilotycin (G)
Polytrim (G)
sodium sulfacetamide
ophthalmic
Tobrex (G)
Vigamox
Ophthalmic Topical
Antiviral Drugs:
Vira-A
Viroptic (G)
Ophthalmic Corticosteroid
Drugs
Decadron (G)
Econopred
Econopred-Plus (G)
Flarex
FML Liquifilm (G)
FML-Forte ophth
HMS Liquifilm
Inflamase (G)
Inflamase-Forte (G)
Lotemax
Pred Mild
prednisolone
Ophthalmic Antiinfective/
Corticosteroids
Blephamide Liquifilm
Cortisporin 1% oint (G)
Cortisporin 1.5% ophth
drops
FML-S (G)
Maxitrol (G)
Tobradex
Vasocidin (G)
Zylet
Antiglaucoma Drugs
Oral:
Diamox (G)
Neptazane (G)
Osmoglyn
Topical Antiglaucoma
Drugs: Cardioselective
Beta-Blockers:
Betoptic (G)
Betoptic S
Topical Antiglaucoma
Drugs: Non-Cardioselective
Beta-Blockers:
Betagan (G)
Betimol (G)
Optipranolol (G)
timolol maleate 0.25% &
0.5% ophth drops
Timoptic-XE (G)
Other Topical Antiglaucoma
Drugs:
Alphagan (G)
Azopt
Cosopt
Iopidine
isopto carbachol
Isopto Carpine (G)
Phospholine Iodide
Pilopine H.S.
Propine ophth (G)
Travatan
Trusopt
Xalatan
Other Ophthalmic Drugs
Acular
Acular PF
Alocril
Alomide
Crolom (G)
Cyclogyl
Isopto Atropine (G)
Isopto Homatropine
Mydriacyl (G)
Neo-Synephrine
Patanol
Restasis (QL)
Zaditor (G)
RESPIRATORY
MEDICATIONS
Bronchodilators and
Related Drugs
Beta-2 Adrenergic Drugs,
Tablets & Syrups:
albuterol
Brethine (G)
Beta-2 Adrenergic Drugs,
Inhalation Solution:
Alupent (QL)
Duoneb (QL)
Pulmicort Respules (QL)
Beta-2 Adrenergic Drugs,
Inhalers:
albuterol (QL)
Maxair (QL)
Maxair Autohaler (QL)
Proventil HFA (QL)
Beta-2 Adrenergic Drugs,
Inhaled Capsules:
Ventolin Rotocap (QL)
Beta-2 Adrenergic Drugs,
Inhaled Powders:
Serevent Diskus (QL)
Methyl Xanthine Drugs
Aminophylline (G)
Cafcit (G)
Slo-Bid 50mg, 75mg, 125mg
Slo-Bid 100, 200, 300mg (G)
Slo-Phyllin
T-Phyl
Uni-Dur
Uniphyl (G)
Other Drugs for Asthma
Advair (QL)
cromolyn (QL)
Intal 20mg/2ml nebs (G) (QL)
Intal oral inh (G) (QL)
Tilade (QL)
Pulmonary
Antiinflammatory Drugs
Flovent (QL)
Pulmicort (QL)
QVAR (QL)
Leukotriene Modifiers (QL)
Singulair (PAR)
Antihistamine and
Decongestant Drugs
Dallergy (G)
Guaifed (G)
Extendryl SR (G)
Histex SR (G)
Poly-Histine -D (G)
Antitussive and Expectorant
Drugs
Narcotic Containing
Products:
Ambenyl (G)
Histussin D (G)
Histussin HC (G)
Hycodan (G)
Hycomine syrup (G)
Hycomine pediatric (G)
Novahistine DH (G)
Phenergan w/codeine (G)
Phenergan VC w/codeine (G)
Poly-Histine CS (G)
Robitussin AC (G)
Tussionex
Non-narcotic Containing
Products:
Entex LA (G)
Phenergan w/DM (G)
Poly-Histine DM (G)
Rondec-DM (G)
SSKI
Other Respiratory Drugs
Ana-Guard
Ana-Kit
Atrovent
Epipen
Mucomyst (G)
Pulmozyme
Spiriva
UROLOGICAL
MEDICATIONS
Drugs to Treat Urinary Tract
Disorders
Anticholinergic
Antispasmodics:
Detrol
Detrol LA)
Levsin (G)
oxybutynin
Urispas (G)
Cholinergic Stimulants:
bethanechol
Urinary Anesthetics:
phenazopyridine HCL
Other Genitourinary
Products
Renacidin
Oracit
Polycitra (G)
Trac 2X
Uri-Septic DS
Urised (G)
Uro-KP-Neutral (G)
Usept
Drugs for BPH
Cardura (G)
Hytrin (G)
Flomax
Proscar (G)
MEDICAL
(MISCELLANEOUS)
SUPPLIES
Diabetic Supplies
Diabetic supplies may
not be included in the
outpatient prescription
drug benefit and will vary
by patient
Meters
Accu-Chek Advantage (QL)
Accu-Chek Complete Care
Kit (QL)
Accu-Chek Easy (QL)
Accu-Chek III (QL)
Chemstrip BG Test Kit (QL)
One Touch Fast Monitoring
System (QL)
One Touch II System Kit (QL)
One Touch Profile System
Kit (QL)
One Touch System Kit (QL)
Test Strips
Accu-Chek Advantage
Accu-Chek Comfort Curve
Accu-Chek Instant - Easy
Chemstrip BG
Chemstrip K
Chemstrip UG
Chemstrip UGK
One Touch Fast-Take Strips
One Touch Test Strips
One Touch Ultra Test Strips
One Touch Sure Step Test
Strips
Tracer BG
This list is subject to
change.
(G) next to a drug name indicates that a generic is available for at least one or more strengths of the brand medication and the brand name product is
non-formulary; (PAR) stands for Prior Authorization Required; (QL) stands for Quantity Limit and OTC stands for over-the-counter medications.
Drug Formulary
Examples of Non-Formulary Medications with Selected Formulary and Over-The-Counter Alternatives
The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of your
pharmacy benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor
to prescribe generic drugs whenever appropriate. Over-the-counter medications are not covered under the pharmacy benefit.
The following is a list of some non-formulary brand medications with examples of selected alternatives that are on the formulary.
Thank you for your compliance.
Non-Formulary
Accuretic
Aceon
Aciphex
Activella
Aerobid M
Allegra, D
Alphagan P
Altocor
Atacand
Atacand HCT
Avalide
Avapro
Avinza
Axert
Azelex
Azmacort
Beconase AQ (QL)
Benicar
Benicar HCT
Cardene SR
Cardizem CD
Catapres-TTS
Ceclor
Cedax
Cenestin
Clarinex
Covera- HS
Dipentum
Dynabac
Dynacirc CR
Estraderm
Focalin
Frova (QL)
Glyset
Helidac
Kadian
Lamisil topical
Lescol, XL
Lorabid
Lumigan
Mavik
Maxalt, MLT (QL)
Maxaquin
Metadate CD, ER
Micardis
Micardis HCT
Monopril HCT
Nasarel (QL)
Formulary Alternative
enalapril/hctz, lisinopril/HCTZ, Lotensin HCT (G)
captopril, enalapril, lisinopril, Altace, Lotensin (G)
omeprazole (10mg) (QL), Nexium (PAR) (QL),
Protonix (PAR), Prilosec OTC
FemHRT, Prempro/Premphase
Flovent (QL), Pulmicort (QL), Qvar (QL)
OTC Alavert, OTC Claritin, OTC loratadine
brimonidine tartrate
lovastatin, Pravachol (G), Zocar (G), Lipitor
Cozaar, Diovan
Diovan HCT, Hyzaar
Diovan HCT, Hyzaar
Cozaar, Diovan
Generics, MS Contin
Amerge (QL), Imitrex (QL), Zomig/ZMT (QL)
Generics, Differin (PAR)
Flovent (QL), Pulmicort (QL), Qvar (QL)
Flonase (QL) (G), Nasacort (QL), Nasonex (QL)
Cozaar, Diovan
Diovan HCT, Hyzaar
nifedipine extended release, Norvasc
diltiazem extended release
clonidine hcl
cefaclor extended release
amox tr/potassium clavulanate, Augmentin ES (G),
Augmentin XR
Premarin
OTC Alavert, OTC Claritin, OTC loratadine
verapamil extended release
Asacol, Pentasa, Rowasa
erythromycin, Biaxin (G), Biaxin XL, Zithromax (G)
nifedipine extended release, Norvasc
Generics, Climara (G)
methylphenidate, Concerta
Amerge (QL), Imitrex (QL), Zomig/ZMT (QL)
Precose
Prevpac
Generics, MS Contin
OTC Lamisil
lovastatin, Pravachol (G), Zocor (G), Lipitor
amox tr/potassium clavulanate, Augmentin ES (G),
Augmentin XR
Travatan, Xalatan
captopril, enalapril, lisinopril, Altace, Lotensin (G)
Amerge (QL), Imitrex (QL), Zomig/ZMT (QL)
Avelox, ciprofloxacin, ofloxacin, Levaquin
methylphenidate
Cozaar, Diovan
Diovan HCT, Hyzaar
enaplapril/hcyz, lisinopril/hctz, Lotensin HCT
Flonase (QL) (G), Nasacort (QL), Nasonex (QL)
Non-Formulary
Optivar
Oxytrol
Penetrex
Pravigard
Prevacid (QL) (PAR)
Protopic
Prozac Weekly (QL)
Quixin
Relenza
Relpax
Rescula
Restoril 7.5MG
Rhinocort AQ
Risperdal M-Tab
Ritalin, LA
Serzone
Skelid
Sonata (QL)
Spectracef
Sular
Suprax
Tarka
Tequin
Testoderm
Testim
Teveten
Teveten HCT
Uniretic
Vancenase AQ (QL)
Vantin
Ventolin (QL)
Vexol
Vivelle-Dot
Zagam
Zyflo
Zyprexa Zydis
Zyrtec
Formulary Alternative
Patanol, Zaditor
Detrol/LA (G)
Avelox, ciprofloxacin, ofloxacin, Levaquin
lovastatin, Pravachol (G), Zocor (G), Lipitor
Omeprazole (10mg) (QL), Nexium (PAR) (QL),
Protonix (PAR), Prilosec OTC
Elidel
fluoxetine (daily), Celexa (10mg and 40mg) (G),
Lexapro (PAR), paroxetine, Paxil CR,
Zoloft (25mg and 100mg) (G)
Ciloxan, Vigamox
rimantadine
Amerge (QL), Imitrex (QL), Zomig/ZMT (QL)
Travatan, Xalatan
temazepam
Flonase (QL) (G), Nasacort (QL), Nasonex (QL)
Risperdal (non M-tabs)
methylphenidate, Concerta, Strattera
(non-stimulant)
bupropion, Effexor (G), Effexor xr, mirtazapine,
Wellbutrin SR (PAR)
Actonel, Didronel (G), Evista, Fosamax
Ambien (QL)
amox tr/potassium clavulanate, Augmentin ES (G)
Omnicef
nifedipine extended release, Norvasc
amox tr/potassium clavulanate,
Augmentin ES (G), Augmentin XR, Omnicef
verapamil+ACE inhibitor, Lotrel
Avelox, ciprofloxacin, ofloxacin, Levaquin
Androderm, Androgel
Androderm, Androgel
Cozaar, Diovan
Diovan HCT, Hyzaar
enalapril/hctz, lisinopril/hctz, Lotensin HCT
Flonase (QL) (G), Nasacort (QL), Nasonex (QL)
amox tr/potassium clavulanate,
Augmentin ES (G) Augmentin XR, Omnicef
albuterol inh (QL), Maxair Auto (QL),
Proventil HFA (QL)
Generic steroids, Lotemax
Generics, Climara (G)
Avelox, ciprofloxacin, ofloxacin, Levaquin
Singulair (PAR)
Zyprexa (non-Zydis)
OTC Alavert, OTC Claritin, OTC loratadine
KEY
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(G) next to a drug name indicates that a generic is available for at least one or more strengths of the brand medication and the brand name product is
non-formulary.
PAR stands for Prior Authorization Required.
QL stands for Quantity Limit.
OTC stands for over-the-counter medications.
For the member: Generic medications contain the same active ingredients as their corresponding brand name medications, although they may look different in
color or shape. They have been FDA-approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substititutions when medically appropriate. Thank You.
Drug Formulary
