General InformationThe drugs listed below represent the most commonly used medications (names in lower case letters are generic names). The list is not all inclusive nor does it guarantee coverage. Drugs may be subject to quantity, age, or gender limitations.
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| * = Requires Pre-Service Authorization |
ciprofloxaxin ophthalmic |
| trandolapril |
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Tier 1 - Generic Drugs on the FormularyCurrent as of 10/24/2008
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| acarbose |
acetaminophen/codeine |
| acetaminophen/hydrocodone |
acyclovir |
| albuterol HFA inhaler |
alclometasone topical |
| alendronate |
allopurinol |
| alprazolam |
amantadine |
| amiloride/hydrochlorothiazide |
amitriptyline |
| amlodipine |
amoxicillin |
| amoxicillin/clavulanate |
Apri |
| atenolol |
Aviane |
| azathioprine |
baclofen |
| benazepril |
benztropine |
| betamethasone topical |
bisoprolol |
| bromocriptine |
bumetanide |
| bupropion |
buspirone |
| calcipotriene |
calcitonin nasal |
| calcitriol |
captopril |
| carbidopa/levodopa |
carvedilol |
| cefaclor |
cefadroxil |
| cefpodoxime |
cefprozil |
| cefuroxime |
cephalexin |
| ciclopirox topical |
cilostazol |
| ciprofloxacin |
citalopram |
| clarithromycin |
clindamycin |
| clobetasol topical |
clonazepam |
| clonidine |
clopidogrel |
| clotrimazole |
clozapine |
| colchicine |
colestipol |
| Cryselle |
cyclobenzaprine |
| desipramine |
dexamethasone |
| diazepam |
diclofenac |
| diflunisal |
digoxin |
| diltiazem |
dipyridamole |
| divalproex sodium |
doxazosin |
| doxepine |
doxycycline |
| enalapril |
Enpresse |
| eplerenon |
erythromycin |
| erythromycin/sulfisoxazole |
estradiol |
| estropipate |
ethinyl estradiol/drospirenone |
| etodolac |
felodipine |
| fenofibrate |
fexofenadine |
| finasteride |
flecainide |
| fluconazole* |
fludrocortisone |
| fluocinonide topical |
fluoxetine |
| flurazepam |
fluticasone nasal |
| fluticasone topical |
fluvoxamine |
| fosinopril |
furosemide |
| gabapentin |
gemfibrozil |
| glimepiride |
glipizide |
| glyburide |
glyburide/metformin |
| granisetron |
guanfacine |
| haloperidol |
hydralazine |
| hydrochlorothiazide |
hydroxychloroquine |
| hydroxyzine |
imipramine |
| indapamide |
indomethacin |
| ipratropium nasal |
isosorbide |
| itraconazole* |
Kariva |
| ketoconazole |
ketoprofen |
| labetalol |
lamotrigine |
| Lessina |
levobunolol |
| Levora |
levothyroxine |
| lisinopril |
lorazepam |
| lovastatin |
Low-Ogestrel |
| medroxyprogesterone oral |
metformin |
| methotrexate |
methyldopa |
| methylprednisolone |
metoclopramide |
| metolazone |
metoprolol |
| metronidazole |
Microgestin |
| minocycline |
mirtazapine |
| misoprostol |
mometasone topical |
| Mononessa |
mupirocin oint |
| nabumetone |
nadolol |
| naproxen |
Necon |
| nefazodone |
nicardipine |
| nifedipine |
nisoldipine |
| nitrofurantoin |
nitroglycerin |
| norethindrone |
Nortrel |
| nortriptyline |
ofloxacin |
| omeprazole - RX only |
ondansetron |
| oxaprozin |
oxcarbazepine |
| oxybutynin |
pantoprazole* |
| paroxetine |
penicillin |
| phenobarbital |
phenytoin |
| pilocarpine |
piroxicam |
| potassium chloride |
pravastatin |
| prazosin |
prednisolone |
| prednisone |
prenatal vitamins |
| primidone |
probenecid |
| prochlorperazine |
promethazine/codeine |
| propafenone |
propranolol |
| quinapril |
quinidine |
| ramipril |
risperidone |
| ropinirole |
salsalate |
| sertraline |
simvastatin |
| sotalol |
spironolactone |
| Sprintec |
sucralfate |
| sulfamethoxazole/trimethoprim |
sulindac |
| tamoxifen |
temazepam |
| terazosin |
tetracycline |
| theophylline |
thioridazine |
| ticlopidine |
timolol |
| tizanidine |
tobramycin |
| torsemide |
trazodone |
| tretinoin topical* |
Tri-Sprintec |
| triamcinolone topical |
triamterene/hydrochlorothiazide |
| Trinessa |
Trivora |
| verapamil |
warfarin |
| zaleplon |
zolpidem |
| Zovia |
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Tier 2 - Brand Name Drugs on the FormularyCurrent as of 10/24/2008
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| Abilify |
Accu-Chek |
| Actonel |
Actos |
| Adderall XR |
Advair |
| Aggrenox |
Aldara* |
| Alrex |
Anzemet |
| Aricept |
Asacol |
| Asmanex |
Astelin |
| Avandia |
Avandmet |
| Avonex |
Azilect |
| Azopt |
Benicar |
| Benicar HCT |
Betaseron |
| Betimol |
Betoptic S |
| Byetta |
Canasa |
| Chantix |
Chemstrip |
| CombiPatch |
Combivent |
| Concerta |
Copaxone |
| Cosopt |
Covera-HS |
| Crestor* |
Cymbalta* |
| Cytomel |
Detrol LA |
| Differin* |
Diovan |
| Diovan HCT |
DuoNeb |
| Effexor* |
Elidel |
| Enbrel* |
Epipen |
| Evista |
Exelon |
| Famvir |
Femara |
| FemHRT |
Flomax |
| Flovent HFA |
FML Forte |
| Foradil |
Foteo* |
| Fragmin |
Glyset |
| Humalog |
Humira* |
| Humulin |
Imitrex |
| Increlex* |
Iplex* |
| Januvia |
Keppra |
| Lantus |
Levemir |
| Lexapro |
Lotemax |
| Lotrel |
Lovenox |
| Lumigan |
Lyrica* |
| Maxalt |
Metadate CD |
| Namenda |
Nasonex |
| Neupro |
Niaspan |
| Nitrolingual |
Novalog |
| Novolin |
Nuvaring |
| One Touch |
Patanase |
| Patanol |
Pentasa |
| Plavix |
Prandin |
| Premarin |
Premphase |
| Prempro |
Pro-Air HFA |
| Prometrium |
Protopic |
| Pulmicort |
Relenza |
| Relistor |
Restasis |
| Serevent |
Seroquel |
| Simcor |
Singulair* |
| Strattera |
Surestep |
| Symbicort |
Symlin |
| Synthroid |
Tamiflu |
| Tazorac* |
Tegretol XR |
| Tekturna |
Tekturna HCT |
| Tilade |
Tobradex |
| Topamax |
Trusopt |
| Uroxatral |
Vexol |
| Vigamox |
Vytorin* |
| Xalatan |
Xopenex HFA* |
| Zetia |
Zonegran |
| Zymar |
Zyprexa |
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Tier 3 - Brand Name Drugs Not on the FormularyCurrent as of 10/24/2008
|
| Accolate* |
Aciphex* |
| Advicor* |
Aerobid |
| Allegra-D |
Altabax |
| Altocor* |
Alvesco |
| Ambien CR* |
Amerge |
| Amitiza |
Angeliq |
| Antara |
Ascensia |
| Atacand |
Atacand HCT |
| Augmentin XR |
Avalide |
| Avapro |
Avelox |
| Avodart |
Axert |
| Azmacort |
Beconase AQ |
| Boniva |
Brovana |
| Bystolic |
Caduet* |
| Cardizem LA |
Celebrex |
| Cenestin |
Cesamet |
| Cipro XR |
Clarinex |
| Colazal |
Cozaar |
| Daytrana |
Dipentum |
| Dynabac |
Enablex |
| Estrogel |
Estrostep FE |
| EvaMist |
Exforge |
| Exubera |
Flector |
| Focalin XR |
Freestyle |
| Frova |
Gantrisin |
| Glucometer |
Glucovance |
| Hyzaar |
Innopran XL |
| Invega |
Lescol* |
| Lexxel |
Lipitor* |
| Lorabid |
Lunesta* |
| Lybrel |
Maxair |
| Maxaquin |
Menest |
| Micadis HCT |
Micardis |
| Moxatag |
Nasacort AQ |
| Nasalide |
Nexium* |
| Noroxin |
Nuvigil* |
| Omnaris |
Opana |
| Ortho Evra |
Ortho Prefest |
| Ortho Tri-Cyclen Lo |
Oxytrol |
| PCE |
Perforomist |
| Precision |
Prevacid* |
| Pristiq* |
Provigil* |
| Prozac Weekly |
QVAR |
| Relpax |
Rhinocort Aqua |
| Rozerem* |
Sanctura |
| Seasonale |
Sensipar |
| Skelid |
Starlix |
| Suprax |
Tarka |
| Teveten |
Teveten HCT |
| Toviaz |
Tricor |
| Uniretic |
Ventolin HFA |
| Veramyst |
Veregen |
| Verelan PM |
Vesicare |
| Viviant |
Voltaren Gel |
| Vyvanse |
Welchol |
| Xyzal |
Yaz |
| Zomig |
Zyflo CR* |