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 |
amlodipine/benazepril |
| niacin SR |
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Tier 1 - Generic Drugs on the FormularyCurrent as of 1/10/2010
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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 |
amphetamine salts |
| Apri |
atenolol |
| Aviane |
azathioprine |
| azelastine nasal |
baclofen |
| balsalazide |
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 |
| ciprofloxaxin ophthalmic |
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 |
| fexofenadine/pse |
finasteride |
| flecainide |
fluconazole* |
| fludrocortisone |
fluocinonide topical |
| fluoxetine |
flurazepam |
| fluticasone nasal |
fluticasone topical |
| fluvoxamine |
fosinopril |
| furosemide |
gabapentin |
| ganciclovir |
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 |
| liothyronine |
lisinopril |
| lorazepam |
lovastatin |
| Low-Ogestrel |
lubiprostone |
| medroxyprogesterone oral |
metformin |
| methotrexate |
methyldopa |
| methylprednisolone |
metoclopramide |
| metolazone |
metoprolol |
| metronidazole |
Microgestin |
| minocycline |
mirtazapine |
| misoprostol |
moexipril/hctz |
| mometasone topical |
Mononessa |
| mupirocin oint |
nabumetone |
| nadolol |
naproxen |
| Necon |
nefazodone |
| nicardipine |
nifedipine |
| nisoldipine |
nitrofurantoin |
| nitroglycerin |
nitroglycerin spray |
| norethindrone |
Nortrel |
| nortriptyline |
ofloxacin |
| omeprazole - RX only |
ondansetron |
| oxaprozin |
oxcarbazepine |
| oxybutynin |
pantoprazole* |
| paroxetine |
penicillin |
| perindopril |
phenobarbital |
| phenytoin |
pilocarpine |
| piroxicam |
potassium chloride |
| pramipexole |
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 |
| sumatriptan |
tamoxifen |
| tamsulosin |
temazepam |
| terazosin |
tetracycline |
| theophylline |
thioridazine |
| ticlopidine |
timolol |
| tizanidine |
tobramycin |
| topiramate |
torsemide |
| tramadol |
trandolapril |
| trazodone |
tretinoin topical* |
| Tri-Sprintec |
triamcinolone topical |
| triamterene/hydrochlorothiazide |
Trinessa |
| Trivora |
valacyclovir |
| verapamil |
warfarin |
| zaleplon |
zolpidem |
| zonisamide |
Zovia |
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Tier 2 - Brand Name Drugs on the FormularyCurrent as of 1/10/2010
|
| Abilify |
Accu-Chek |
| Actonel |
Actos |
| Advair |
Aggrenox |
| Aldara |
Alrex |
| Anzemet |
Aricept |
| Asacol |
Asmanex |
| Avandia |
Avandmet |
| Avonex |
Azilect |
| Azopt |
Banzel* |
| Benicar |
Benicar HCT |
| Betaseron |
Betimol |
| Betoptic S |
Byetta |
| Canasa |
Chantix |
| Chemstrip |
CombiPatch |
| Combivent |
Copaxone |
| Covera-HS |
Crestor* |
| Cymbalta* |
Detrol LA |
| Differin* |
Diovan |
| Diovan HCT |
DuoNeb |
| Effexor XR* |
Effient |
| Elidel |
Enbrel* |
| Epipen |
Evista |
| Exelon/patch |
Femara |
| Flovent HFA |
FML Forte |
| Foradil |
Foteo* |
| Fragmin |
Glyset |
| Humalog |
Humira* |
| Humulin |
Increlex* |
| Intuniv ER |
Iplex* |
| Januvia |
Keppra |
| Lantus |
Levemir |
| Lexapro |
Lotemax |
| Lovenox |
Lumigan |
| Lyrica* |
Maxalt |
| Namenda |
Nasonex* |
| Neupro |
Novalog |
| Novolin |
Nuvaring |
| One Touch |
Onglyza |
| Patanase |
Patanol |
| Pentasa |
Plavix |
| Prandin |
Premarin |
| Premphase |
Prempro |
| Prometrium |
Protopic |
| Pulmicort |
Relenza |
| Relistor |
Restasis |
| Serevent |
Seroquel |
| Simcor |
Singulair* |
| Strattera |
Surestep |
| Symbicort |
Symlin |
| Synthroid |
Tamiflu |
| Tazorac* |
Tegretol XR |
| Tekturna |
Tekturna HCT |
| Tilade |
Tobradex |
| TriLipix |
Trusopt |
| Uloric* |
Uroxatral |
| Vectical |
Ventolin HFA |
| Vexol |
Vigamox |
| Vimpat* |
Vytorin* |
| Xalatan |
Xenazine* |
| Zetia |
Zymar |
| Zyprexa |
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Tier 3 - Brand Name Drugs Not on the FormularyCurrent as of 1/10/2010
|
| Accolate* |
Aciphex* |
| Aczone |
Advicor* |
| Aerobid |
Afrezza |
| AllerNaze |
Altabax |
| Altocor* |
Alvesco |
| Ambien CR* |
Amerge |
| Angeliq |
Antara |
| Ascensia |
Astepro |
| Atacand |
Atacand HCT |
| Augmentin XR |
Avalide |
| Avapro |
Avelox |
| Avodart |
Axanum |
| Axert |
Azmacort |
| Beconase AQ |
Besivance |
| Boniva |
Brovana |
| Bystolic |
Caduet* |
| Cardizem LA |
Celebrex |
| Cenestin |
Cesamet |
| Cimzia* |
Clarinex |
| Cozaar |
Daytrana |
| Dipentum |
Duodart |
| Enablex |
Estrogel |
| EvaMist |
Exforge |
| Exforge HCT |
Extavia |
| Exubera |
Fanapt |
| Flector |
Focalin XR |
| Freestyle |
Gelnique |
| Geodon |
Glucometer |
| Glycoset |
Hyzaar |
| Invega |
Kapidex* |
| Lescol* |
Lexxel |
| Lipitor* |
Livalo* |
| Lunesta* |
Lybrel |
| Maxair |
Menest |
| Metadate CD |
Micardis |
| Micardis HCT |
Moxatag |
| Multaq |
Nasacort AQ* |
| Nexium* |
Noroxin |
| Nucynta |
Nuvigil* |
| Omnaris* |
Opana |
| Ortho Evra |
Ortho Prefest |
| Ortho Tri-Cyclen Lo |
Oxytrol |
| PCE |
Perforomist |
| Precision |
Pristiq* |
| Pro-Air HFA |
Promacta* |
| Proventil HFA |
Provigil* |
| QVAR |
Rapaflo |
| Relpax |
Rhinocort Aqua* |
| Rozerem* |
Sabril |
| Samsca |
Sanctura |
| Sancuso |
Saphris |
| Savella* |
Sensipar |
| Simponi* |
Skelid |
| Solzira |
Starlix |
| Stedesa |
Suprax |
| Tarka |
Teveten |
| Teveten HCT |
Tobi |
| Toviaz |
Tricor |
| Valturna |
Vectical |
| Veramyst* |
Veregen |
| Vesicare |
Viviant |
| Voltaren Gel |
Vyvanse |
| Welchol |
Xopenex HFA* |
| Xyzal |
Zenpep |
| Zensana |
Zirgan |
| Zolpimist* |
Zomig |
| Zuplenz |
Zyflo CR* |