chp 2019 formulary (2 test) - geneseehealthplan.org · nitroglycerin sublingual tablet sublingual...

County Health Plan Formulary

lowercase = Generic drugsUPPERCASE = Brand name drugs

Copay100% copay = 100% Brand = $3.00Generic = $3.00Zero Copay = $0.00

NoteQL = Quantity Limit

Drug Name Reference Copay Note

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*

*Stimulants - Misc.***methylphenidate hcl er oral tablet extended release 20 mg

Metadate ER Generic Prior Auth Required

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg

Ritalin Generic Prior Auth Required

*Analgesics - Anti-Inflammatory*

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)***diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg

Generic

etodolac oral capsule 300 mg Generic

etodolac oral tablet 400 mg Lodine Generic

etodolac oral tablet 500 mg Generic

fenoprofen calcium oral tablet 600 mg Nalfon Generic

flurbiprofen oral tablet 100 mg, 50 mg Generic

ibuprofen oral tablet 200 mg Advil Generic OTC

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

IBU Generic

indomethacin er oral capsule extended release 75 mg

Generic

indomethacin oral capsule 25 mg, 50 mg Generic

meclofenamate sodium oral capsule 100 mg, 50 mg

Generic

meloxicam oral tablet 15 mg, 7.5 mg Mobic Generic

nabumetone oral tablet 500 mg, 750 mg Generic

naproxen oral tablet 250 mg, 500 mg Naprosyn Generic

naproxen oral tablet 375 mg Generic

naproxen sodium oral tablet 220 mg Aleve Generic OTC

piroxicam oral capsule 10 mg, 20 mg Feldene Generic

sulindac oral tablet 150 mg, 200 mg Generic

tolmetin sodium oral capsule 400 mg Generic

1

Drug Name Reference Copay Notetolmetin sodium oral tablet 200 mg Generic

*Analgesics - Nonnarcotic*

*Analgesics Other***acetaminophen extra strength oral tablet 500 mg

Healthy Mama Shake That Ache

Generic OTC

acetaminophen oral tablet 325 mg Pharbetol Generic OTC

*Analgesics-Sedatives***butalbital-aspirin-caffeine oral capsule 50-325-40 mg

Fiorinal Generic

*Salicylates***diflunisal oral tablet 500 mg Generic

salsalate oral tablet 500 mg, 750 mg Generic

*Analgesics - Opioid*

*Codeine Combinations***

acetaminophen-codeine #2 oral tablet 300-15 mg

100% copayDiscount applies to only 6 fills per year.; QL (12 tabs per 1 day)


Tylenol with Codeine #3 100% copayDiscount applies to only 6 fills per year.; QL (12 tabs per 1 day)


Tylenol with Codeine #4 100% copayDiscount applies to only 6 fills per year.; QL (12 tabs per 1 day)

acetaminophen-codeine oral solution 120-12 mg/5ml

100% copayDiscount applies to only 6 fills per year.

butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg

Ascomp-Codeine 100% copayDiscount applies to only 6 fills per year.

*Hydrocodone Combinations***hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml

100% copayDiscount applies to only 6 fills per year.

hydrocodone-acetaminophen oral tablet 10-325 mg

Lorcet HD 100% copayDiscount applies to only 6 fills per year.; QL (12 tabs per 1 day)

hydrocodone-acetaminophen oral tablet 5-325 mg

Lorcet 100% copayDiscount applies to only 6 fills per year.; QL (12 tabs per 1 day)

hydrocodone-acetaminophen oral tablet 7.5-325 mg

Lorcet Plus 100% copayDiscount applies to only 6 fills per year.; QL (12 tabs per 1 day)

*Opioid Agonists***

methadone hcl oral tablet 10 mg, 5 mg Dolophine 100% copayDiscount applies to only 6 fills per year.

2

Drug Name Reference Copay Notemorphine sulfate er oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg

MS Contin Generic Prior Auth Required

tramadol hcl oral tablet 50 mg Ultram 100% copayDiscount applies to only 6 fills per year.

*Opioid Combinations***

oxycodone-acetaminophen oral tablet 5-325 mg

Endocet 100% copayDiscount applies to only 6 fills per year.; QL (12 tabs per 1 day)

oxycodone-aspirin oral tablet 4.8355-325 mg

100% copayDiscount applies to only 6 fills per year.; QL (12 EA per 1 day)

*Anorectal Agents*

*Rectal Steroids***hydrocortisone acetate rectal suppository 25 mg

Anusol-HC Generic

*Antianginal Agents*

*Nitrates***NITRO-BID TRANSDERMAL OINTMENT 2 %

Brand

isosorbide dinitrate er oral tablet extended release 40 mg

Generic

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg

Generic

isosorbide dinitrate oral tablet 5 mg Isordil Titradose Generic

isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg

Generic

nitroglycerin er oral capsule extended release 2.5 mg, 6.5 mg, 9 mg

Nitro-Time Generic

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

Nitrostat Generic

*Antianxiety Agents*

*Antianxiety Agents - Misc.***buspirone hcl oral tablet 10 mg, 15 mg, 5 mg

Generic

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg

Generic

hydroxyzine pamoate oral capsule 25 mg, 50 mg

Vistaril Generic

meprobamate oral tablet 200 mg, 400 mg Generic

3


*Benzodiazepines***

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

Xanax 100% copayLimit of 1 fill of any Benzodiazepine per 30 days

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg

100% copayLimit of 1 fill of any Benzodiazepine per 30 days

clorazepate dipotassium oral tablet 15 mg, 3.75 mg


clorazepate dipotassium oral tablet 7.5 mg Tranxene-T 100% copayLimit of 1 fill of any Benzodiazepine per 30 days

diazepam oral tablet 10 mg, 2 mg, 5 mg Valium 100% copayLimit of 1 fill of any Benzodiazepine per 30 days

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg Ativan 100% copayLimit of 1 fill of any Benzodiazepine per 30 days

oxazepam oral capsule 10 mg, 15 mg, 30 mg


*Antiarrhythmics*

*Antiarrhythmics Type I-A***disopyramide phosphate oral capsule 150 mg

Norpace Generic

quinidine gluconate er oral tablet extended release 324 mg

Generic

quinidine sulfate oral tablet 200 mg, 300 mg

Generic

*Antiarrhythmics Type I-B***mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

Generic

*Antiarrhythmics Type Iii***amiodarone hcl oral tablet 200 mg Pacerone Generic

*Antiasthmatic And Bronchodilator Agents*

*Anti-Inflammatory Agents***cromolyn sodium inhalation nebulization solution 20 mg/2ml

Generic

4


*Beta Adrenergics***PROAIR HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT

Brand

PROAIR RESPICLICK AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT INHALATION 108 (90 BASE) MCG/ACT

Brand

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%

Generic

albuterol sulfate oral syrup 2 mg/5ml Generic

albuterol sulfate oral tablet 2 mg, 4 mg Generic

metaproterenol sulfate oral syrup 10 mg/5ml

Generic

metaproterenol sulfate oral tablet 10 mg Generic

*Bronchodilators - Anticholinergics***ipratropium bromide inhalation solution 0.02 %

Generic

*Leukotriene Receptor Antagonists***montelukast sodium oral tablet 10 mg Singulair Generic

*Xanthines***ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML

Brand

theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg

Theochron Generic

*Anticoagulants*

*Coumarin Anticoagulants***COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

Coumadin Brand

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

Coumadin Generic

5


*Anticonvulsants*

*Anticonvulsants - Benzodiazepines***

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg KlonoPIN 100% copayLimit of 1 fill of any Benzodiazepine per 30 days

*Anticonvulsants - Misc.***TEGRETOL ORAL TABLET 200 MG Epitol Brand

carbamazepine oral tablet 200 mg Epitol Generic

carbamazepine oral tablet chewable 100 mg

Generic

gabapentin oral capsule 100 mg, 300 mg, 400 mg

Neurontin Generic

gabapentin oral tablet 600 mg, 800 mg Neurontin Generic

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

LaMICtal Generic

primidone oral tablet 250 mg, 50 mg Mysoline Generic

*Hydantoins***DILANTIN ORAL CAPSULE 100 MG Dilantin Brand

DILANTIN ORAL SUSPENSION 125 MG/5ML

Dilantin Brand

phenytoin oral suspension 125 mg/5ml Dilantin Generic

phenytoin sodium extended oral capsule 100 mg

Dilantin Generic

*Valproic Acid***divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

Depakote Generic

valproic acid oral capsule 250 mg Depakene Generic

*Antidepressants*

*Antidepressants - Misc.***bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg

Wellbutrin SR Generic

bupropion hcl oral tablet 100 mg, 75 mg Generic

maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg

Generic

*Modified Cyclics***trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

Generic

6


*Selective Serotonin Reuptake Inhibitors (Ssris)***citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg

CeleXA Generic

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg

Lexapro Generic

fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg

PROzac Generic

paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg

Paxil Generic

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg

Zoloft Generic

*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)***duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg

Cymbalta Generic

venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg

Effexor XR Generic

venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

Generic

*Tricyclic Agents***amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

Generic

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg

Generic

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg

Anafranil Generic

desipramine hcl oral tablet 10 mg, 25 mg Norpramin Generic

desipramine hcl oral tablet 100 mg, 150 mg, 50 mg, 75 mg

Generic

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

Generic

doxepin hcl oral concentrate 10 mg/ml Generic

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg

Tofranil Generic

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

Pamelor Generic

protriptyline hcl oral tablet 10 mg, 5 mg Generic

*Antidiabetics*

*Biguanides***metformin hcl oral tablet 1000 mg, 500 mg, 850 mg

Glucophage Zero Copay

7


*Human Insulin***BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML

Zero Copay

HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML

Zero Copay

HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML

Zero Copay

HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML

Zero Copay

HUMULIN 70/30 SUSPENSION (70-30) 100 UNIT/ML SUBCUTANEOUS (70-30) 100 UNIT/ML

Zero Copay OTC

HUMULIN N SUSPENSION 100 UNIT/ML SUBCUTANEOUS 100 UNIT/ML

Zero Copay OTC

HUMULIN R SOLUTION 100 UNIT/ML INJECTION 100 UNIT/ML

Zero Copay OTC

LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML

Zero Copay

*Sulfonylureas***chlorpropamide oral tablet 100 mg, 250 mg

Zero Copay

glimepiride oral tablet 1 mg, 2 mg, 4 mg Amaryl Zero Copay

glipizide oral tablet 10 mg, 5 mg Glucotrol Zero Copay

glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

Glucotrol XL Zero Copay

glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg

Glynase Zero Copay

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg

Zero Copay

tolazamide oral tablet 250 mg, 500 mg Zero Copay

tolbutamide oral tablet 500 mg Zero Copay

*Antidiarrheals*

*Antidiarrheal Agents - Misc.***pink bismuth oral suspension 262 mg/15ml

Kao-Tin Generic OTC

*Antiperistaltic Agents***diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml

Generic

8

Drug Name Reference Copay Notediphenoxylate-atropine oral tablet 2.5-0.025 mg

Lomotil Generic

loperamide hcl oral capsule 2 mg Imodium A-D Generic

*Antiemetics*

*5-Ht3 Receptor Antagonists***ondansetron hcl oral tablet 4 mg, 8 mg Zofran Generic

*Antiemetics - Anticholinergic***meclizine hcl oral tablet 12.5 mg Generic

meclizine hcl oral tablet 25 mg Dramamine Less Drowsy Generic

*Antifungals*

*Antifungals***nystatin oral tablet 500000 unit Generic

*Imidazoles***ketoconazole oral tablet 200 mg Generic

*Triazoles***fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg

Diflucan Generic

*Antihistamines*

*Antihistamines - Alkylamines***chlorpheniramine maleate oral tablet 4 mg Chlor-Trimeton Generic OTC

*Antihistamines - Ethanolamines***clemastine fumarate oral tablet 2.68 mg Generic

diphenhydramine hcl oral capsule 25 mg, 50 mg

Banophen Generic

*Antihistamines - Phenothiazines***promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

Generic

*Antihistamines - Piperidines***cyproheptadine hcl oral syrup 2 mg/5ml Generic

cyproheptadine hcl oral tablet 4 mg Generic

*Antihyperlipidemics*

*Bile Acid Sequestrants***cholestyramine light oral powder 4 gm/dose

Prevalite Generic

cholestyramine oral packet 4 gm Questran Generic

9


*Fibric Acid Derivatives***gemfibrozil oral tablet 600 mg Lopid Generic

*Hmg Coa Reductase Inhibitors***atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

Lipitor Generic

pravastatin sodium oral tablet 10 mg Generic

pravastatin sodium oral tablet 20 mg, 40 mg, 80 mg

Pravachol Generic

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg

Zocor Generic

*Antihypertensives*

*Ace Inhibitors***benazepril hcl oral tablet 10 mg, 20 mg, 40 mg

Lotensin Generic

benazepril hcl oral tablet 5 mg Generic

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

Generic

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

Vasotec Generic

lisinopril oral tablet 10 mg, 20 mg, 5 mg Prinivil Generic

lisinopril oral tablet 2.5 mg, 30 mg, 40 mg Zestril Generic

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Accupril Generic

*Adrenolytics-Central & Thiazide/Thiazide-Like Comb***methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 250-25 mg

Generic

*Angiotensin Ii Receptor Antagonists***losartan potassium oral tablet 100 mg, 25 mg, 50 mg

Cozaar Generic

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

Diovan Generic

*Antiadrenergics - Centrally Acting***clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg

Catapres Generic

guanfacine hcl oral tablet 1 mg, 2 mg Generic

methyldopa oral tablet 250 mg, 500 mg Generic

10


*Antiadrenergics - Peripherally Acting***doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg

Cardura Generic

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg

Minipress Generic

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg

Generic

*Beta Blocker & Diuretic Combinations***atenolol-chlorthalidone oral tablet 100-25 mg

Tenoretic 100 Generic

atenolol-chlorthalidone oral tablet 50-25 mg

Tenoretic 50 Generic

*Vasodilators***hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

Generic

minoxidil oral tablet 10 mg, 2.5 mg Generic

*Anti-Infective Agents - Misc.*

*Anti-Infective Agents - Misc.***metronidazole oral capsule 375 mg Flagyl Generic

metronidazole oral tablet 250 mg, 500 mg Flagyl Generic

trimethoprim oral tablet 100 mg Generic

*Anti-Infective Misc. - Combinations***sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml

Sulfatrim Pediatric Generic

sulfamethoxazole-trimethoprim oral tablet 400-80 mg

Bactrim Generic

sulfamethoxazole-trimethoprim oral tablet 800-160 mg

Bactrim DS Generic

*Lincosamides***clindamycin hcl oral capsule 150 mg Cleocin Generic

*Antimalarials*

*Antimalarials***hydroxychloroquine sulfate oral tablet 200 mg

Plaquenil Generic

quinine sulfate oral capsule 324 mg Qualaquin Generic

11


*Antimycobacterial Agents*

*Antimycobacterial Agents***ethambutol hcl oral tablet 100 mg, 400 mg Myambutol Generic

isoniazid oral tablet 100 mg, 300 mg Generic

pyrazinamide oral tablet 500 mg Generic

rifampin oral capsule 150 mg, 300 mg Rifadin Generic

*Antineoplastics And Adjunctive Therapies*

*Antimetabolites***methotrexate oral tablet 2.5 mg Generic

*Folic Acid Antagonists Rescue Agents***leucovorin calcium oral tablet 5 mg Generic

*Progestins-Antineoplastic***megestrol acetate oral tablet 20 mg, 40 mg Generic

*Antiparkinson Agents*

*Antiparkinson Anticholinergics***benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

Generic

trihexyphenidyl hcl oral elixir 0.4 mg/ml Generic

trihexyphenidyl hcl oral tablet 2 mg, 5 mg Generic

*Antiparkinson Dopaminergics***amantadine hcl oral syrup 50 mg/5ml Generic

amantadine hcl oral tablet 100 mg Generic

*Levodopa Combinations***carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

Sinemet Generic

*Antipsychotics/Antimanic Agents*

*Antimanic Agents***lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

Generic

*Benzisoxazoles***risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg

RisperDAL Generic

12


*Butyrophenones***haloperidol lactate oral concentrate 2 mg/ml

Generic

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

Generic

*Dibenzoxazepines***loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

Generic

*Phenothiazines***chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

Generic

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

Generic

prochlorperazine maleate oral tablet 10 mg, 5 mg

Generic

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

Generic

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

Generic

*Quinolinone Derivatives***aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

Abilify Generic

*Thienbenzodiazepines***olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

ZyPREXA Generic

*Thioxanthenes***thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg

Generic

*Antivirals*

*Herpes Agents - Purine Analogues***acyclovir oral capsule 200 mg Zovirax Generic

acyclovir oral tablet 400 mg, 800 mg Zovirax Generic

*Neuraminidase Inhibitors***RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER

Brand

oseltamivir phosphate oral capsule 75 mg Tamiflu Generic

13


*Assorted Classes*

*Purine Analogs***azathioprine oral tablet 50 mg Imuran Generic

*Beta Blockers*

*Alpha-Beta Blockers***carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

Coreg Generic

*Beta Blockers Cardio-Selective***acebutolol hcl oral capsule 200 mg, 400 mg

Generic

atenolol oral tablet 100 mg, 25 mg, 50 mg Tenormin Generic

metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg

Toprol XL Generic

metoprolol tartrate oral tablet 100 mg, 50 mg

Lopressor Generic

metoprolol tartrate oral tablet 25 mg Generic

*Beta Blockers Non-Selective***nadolol oral tablet 20 mg, 40 mg, 80 mg Corgard Generic

pindolol oral tablet 10 mg, 5 mg Generic

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

Inderal LA Generic

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

Generic

timolol maleate oral tablet 10 mg, 20 mg, 5 mg

Generic

*Calcium Channel Blockers*

*Calcium Channel Blockers***amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg

Norvasc Generic

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

Cardizem CD Generic

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

Generic

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg

Cardizem Generic

diltiazem hcl oral tablet 90 mg Generic

nicardipine hcl oral capsule 20 mg, 30 mg Generic

14

Drug Name Reference Copay Notenifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

Adalat CC Generic

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 90 mg

Procardia XL Generic

nifedipine er osmotic release oral tablet extended release 24 hour 60 mg

Nifedical XL Generic

nifedipine oral capsule 10 mg Procardia Generic

nifedipine oral capsule 20 mg Generic

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

Calan SR Generic

verapamil hcl oral tablet 120 mg, 80 mg Calan Generic

verapamil hcl oral tablet 40 mg Generic

*Cardiotonics*

*Cardiac Glycosides***LANOXIN ORAL TABLET 125 MCG, 250 MCG

Digitek Brand

digoxin oral solution 0.05 mg/ml Generic

digoxin oral tablet 125 mcg, 250 mcg Digitek Generic

*Cardiovascular Agents - Misc.*

*Peripheral Vasodilators***isoxsuprine hcl oral tablet 10 mg, 20 mg Generic

*Cephalosporins*

*Cephalosporins - 1St Generation***cefadroxil oral capsule 500 mg Generic

cephalexin oral suspension reconstituted 250 mg/5ml

Generic

cephalexin oral tablet 250 mg, 500 mg Generic

*Cephalosporins - 2Nd Generation***cefaclor oral capsule 250 mg, 500 mg Generic

cefaclor oral suspension reconstituted 250 mg/5ml, 375 mg/5ml

Generic

*Contraceptives*

*Triphasic Contraceptives - Oral***norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg

Ortho Tri-Cyclen (28) Generic Prior Auth Required

15


*Corticosteroids*

*Glucocorticosteroids***dexamethasone oral solution 0.5 mg/5ml Generic

dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg, 6 mg

Decadron Generic

dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg

Generic

methylprednisolone oral tablet therapy pack 4 mg

Medrol Generic

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

Generic

prednisone oral tablet 20 mg Deltasone Generic

*Mineralocorticoids***fludrocortisone acetate oral tablet 0.1 mg Generic

*Cough/Cold/Allergy*

*Antitussive - Nonnarcotic***benzonatate oral capsule 100 mg Tessalon Perles Generic

benzonatate oral capsule 200 mg Generic

*Expectorants***guaifenesin oral syrup 100 mg/5ml Diabetic Tussin EX Generic OTC

guaifenesin oral tablet 200 mg Generic OTC

*Dermatologicals*

*Acne Antibiotics***clindamycin phosphate external solution 1 %

Cleocin-T Generic

erythromycin external gel 2 % Erygel Generic

erythromycin external solution 2 % Generic

*Acne Combinations***sulfacetamide sodium-sulfur external emulsion 10-5 %

Avar Cleanser Generic

*Antibiotics - Topical***gentamicin sulfate external cream 0.1 % Generic

gentamicin sulfate external ointment 0.1 %

Generic

*Antifungals - Topical Combinations***nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

Generic

16

Drug Name Reference Copay Notenystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

Generic

*Antifungals - Topical***nystatin external cream 100000 unit/gm Generic

nystatin external ointment 100000 unit/gm Generic

*Antiseborrheic Products***selenium sulfide external shampoo 2.3 % SelRx Generic

*Burn Products***silver sulfadiazine external cream 1 % Silvadene Generic

*Corticosteroids - Topical***betamethasone dipropionate external cream 0.05 %

Generic

betamethasone dipropionate external lotion 0.05 %

Generic

betamethasone dipropionate external ointment 0.05 %

Generic

betamethasone valerate external cream 0.1 %

Generic

betamethasone valerate external lotion 0.1 %

Generic

betamethasone valerate external ointment 0.1 %

Generic

desonide external cream 0.05 % DesOwen Generic

desoximetasone external cream 0.05 %, 0.25 %

Topicort Generic

desoximetasone external ointment 0.25 % Topicort Generic

fluocinolone acetonide external cream 0.025 %

Synalar Generic

fluocinolone acetonide external ointment 0.025 %

Synalar Generic

fluocinolone acetonide external solution 0.01 %

Synalar Generic

fluocinonide emulsified base external cream 0.05 %

Generic

fluocinonide external cream 0.05 % Generic

fluocinonide external gel 0.05 % Generic

fluocinonide external ointment 0.05 % Generic

fluocinonide external solution 0.05 % Generic

hydrocortisone external cream 1 % Aveeno Anti-Itch Max St Generic

hydrocortisone external cream 2.5 % Generic

17


hydrocortisone external lotion 1 %Anti-Itch Intensive Healing

Generic OTC

hydrocortisone external lotion 2.5 % Generic

hydrocortisone external ointment 1 % Cortizone-10 Generic

hydrocortisone external ointment 2.5 % Generic

triamcinolone acetonide external cream 0.025 %

Generic

triamcinolone acetonide external cream 0.1 %, 0.5 %

Triderm Generic

triamcinolone acetonide external lotion 0.025 %, 0.1 %

Generic

triamcinolone acetonide external ointment 0.1 %

Generic

*Imidazole-Related Antifungals - Topical***ketoconazole external cream 2 % Generic

*Scabicides & Pediculicides***lice treatment external liquid 1 % Nix Creme Rinse Generic OTC

permethrin external cream 5 % Elimite Generic

*Diagnostic Products*

*Diagnostic Tests***FREESTYLE INSULINX TEST STRIP IN VITRO

Zero CopayOTC; QL (100 strips per 30 days)

FREESTYLE LITE TEST STRIP IN VITRO


FREESTYLE PRECISION NEO TEST STRIP IN VITRO


FREESTYLE TEST STRIP IN VITRO Zero CopayOTC; QL (100 strips per 30 days)

PRECISION XTRA BLOOD GLUCOSE STRIP IN VITRO


*Diuretics*

*Carbonic Anhydrase Inhibitors***acetazolamide oral tablet 125 mg, 250 mg Generic

methazolamide oral tablet 25 mg, 50 mg Generic

*Diuretic Combinations***amiloride-hydrochlorothiazide oral tablet 5-50 mg

Generic

spironolactone-hctz oral tablet 25-25 mg Aldactazide Generic

18

Drug Name Reference Copay Notetriamterene-hctz oral capsule 37.5-25 mg Dyazide Generic

triamterene-hctz oral tablet 37.5-25 mg Maxzide-25 Generic

triamterene-hctz oral tablet 75-50 mg Maxzide Generic

*Loop Diuretics***bumetanide oral tablet 0.5 mg, 1 mg, 2 mg Bumex Generic

furosemide oral tablet 20 mg, 40 mg, 80 mg

Lasix Generic

torsemide oral tablet 10 mg, 20 mg Demadex Generic

torsemide oral tablet 100 mg, 5 mg Generic

*Potassium Sparing Diuretics***spironolactone oral tablet 100 mg, 25 mg, 50 mg

Aldactone Generic

*Thiazides And Thiazide-Like Diuretics***chlorothiazide oral tablet 250 mg, 500 mg Generic

chlorthalidone oral tablet 25 mg, 50 mg Generic

hydrochlorothiazide oral capsule 12.5 mg Microzide Generic

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

Generic

indapamide oral tablet 1.25 mg, 2.5 mg Generic

methyclothiazide oral tablet 5 mg Generic

*Endocrine And Metabolic Agents - Misc.*

*Bisphosphonates***alendronate sodium oral tablet 10 mg, 5 mg

Generic

alendronate sodium oral tablet 70 mg Fosamax Generic

*Hyperparathyroid Treatment - Vitamin D Analogs***calcitriol oral capsule 0.25 mcg, 0.5 mcg Rocaltrol Generic

*Estrogens*

*Estrogens***estradiol oral tablet 0.5 mg, 1 mg, 2 mg Estrace Generic

*Fluoroquinolones*

*Fluoroquinolones***ciprofloxacin hcl oral tablet 250 mg, 500 mg

Cipro Generic

ciprofloxacin hcl oral tablet 750 mg Generic

19

Drug Name Reference Copay Notelevofloxacin oral tablet 250 mg, 500 mg, 750 mg

Levaquin Generic

*Gastrointestinal Agents - Misc.*

*Gallstone Solubilizing Agents***ursodiol oral capsule 300 mg Actigall Generic

*Gastrointestinal Stimulants***metoclopramide hcl oral solution 5 mg/5ml

Generic

metoclopramide hcl oral tablet 10 mg, 5 mg

Reglan Generic

*Inflammatory Bowel Agents***AZULFIDINE ORAL TABLET 500 MG Generic

*Genitourinary Agents - Miscellaneous*

*Alpha 1-Adrenoceptor Antagonists***tamsulosin hcl oral capsule 0.4 mg Flomax Generic

*Urinary Analgesics***phenazopyridine hcl oral tablet 100 mg Pyridium Generic

phenazopyridine hcl oral tablet 200 mg Phenazo Generic

*Gout Agents*

*Gout Agent Combinations***colchicine-probenecid oral tablet 0.5-500 mg

Generic

*Gout Agents***allopurinol oral tablet 100 mg, 300 mg Zyloprim Generic

*Uricosurics***probenecid oral tablet 500 mg Generic

*Hematological Agents - Misc.*

*Hematorheologic Agents***pentoxifylline er oral tablet extended release 400 mg

Generic

*Phosphodiesterase Iii Inhibitors***cilostazol oral tablet 100 mg, 50 mg Generic

20


*Platelet Aggregation Inhibitors***dipyridamole oral tablet 25 mg, 50 mg, 75 mg

Generic

*Thienopyridine Derivatives***clopidogrel bisulfate oral tablet 75 mg Plavix Generic

*Hematopoietic Agents*

*Folic Acid/Folates***folic acid oral tablet 1 mg Generic

*Hypnotics*

*Barbiturate Hypnotics***phenobarbital oral tablet 100 mg, 15 mg, 30 mg, 60 mg

Generic

*Benzodiazepine Hypnotics***

flurazepam hcl oral capsule 15 mg, 30 mg 100% copayLimit of 1 fill of any Benzodiazepine per 30 days

temazepam oral capsule 15 mg, 30 mg Restoril 100% copayLimit of 1 fill of any Benzodiazepine per 30 days

*Laxatives*

*Bowel Evacuant Combinations***peg 3350/electrolytes oral solution reconstituted 240 gm

Colyte with Flavor Packs Generic

peg-3350/electrolytes oral solution reconstituted 236 gm

GaviLyte-G Generic

*Laxatives - Miscellaneous***lactulose oral solution 10 gm/15ml Generic

*Laxatives & Dss***stool softener plus laxative oral tablet 8.6-50 mg

Colace 2-IN-1 Generic OTC

*Surfactant Laxatives***docusate sodium oral capsule 100 mg Colace Generic OTC

ra col-rite oral capsule 50 mg Colace Clear Generic OTC

*Macrolides*

*Azithromycin***azithromycin oral tablet 250 mg, 500 mg Zithromax Generic

21


*Erythromycins***erythromycin base oral capsule delayed release particles 250 mg

Generic

erythromycin ethylsuccinate oral tablet 400 mg

E.E.S. 400 Generic

erythromycin stearate oral tablet 250 mg Erythrocin Stearate Generic

*Medical Devices*

*Glucose Monitoring Test Supplies***

lancetsAccu-Chek FastClix Lancets

Zero Copay OTC

lancets 28gAccu-Chek FastClix Lancets

Zero Copay OTC

lancets 30gAccu-Chek FastClix Lancets

Zero Copay OTC

lancets thinAccu-Chek FastClix Lancets

Zero Copay OTC

*Needles & Syringes***BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML

Advocate Insulin Syringe Zero Copay OTC

BD INSULIN SYR ULTRAFINE II 31G X 5/16" 0.5 ML


BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML

Zero Copay OTC

BD INSULIN SYRINGE 27G X 1/2" 1 ML

Zero Copay OTC

BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML

Zero Copay OTC

BD INSULIN SYRINGE MICROFINE 28G X 1/2" 0.5 ML

BD Insulin Syringe MicroFine

Zero Copay OTC

BD INSULIN SYRINGE MICROFINE 28G X 1/2" 1 ML


Zero Copay OTC

BD INSULIN SYRINGE U/F 30G X 1/2" 1 ML

BD Insulin Syringe U/F Zero Copay OTC

BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.3 ML, 29G X 1/2" 1 ML


BD INSULIN SYRINGE ULTRAFINE 29G X 1/2" 0.5 ML


BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 ML


22

Drug Name Reference Copay NoteBD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.3 ML

Zero Copay

BD SAFETYGLIDE INSULIN SYRINGE 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML

Zero Copay OTC

insulin syringe 27g x 1/2" 0.5 mlEasy Touch Insulin Syringe

Zero Copay OTC

insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml


Zero Copay OTC

insulin syringe 29g x 1" 0.3 ml Zero Copay OTC

insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml


insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml

BD Insulin Syringe U/F Zero Copay OTC

insulin syringe-needle u-100 31g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml

UltiCare Insulin Syringe Zero Copay OTC

pen needles 29g x 12mm , 31g x 6 mm , 32g x 5 mm

CareFine Pen Needles Zero Copay OTC

pen needles 3/16" 31g x 5 mmAdvocate Insulin Pen Needles

Zero Copay OTC

pen needles 30g x 5 mmAssure ID Safety Pen Needles

Zero Copay OTC

pen needles 32g x 4 mm BD Pen Needle Nano U/F Zero Copay OTC

pen needles 32g x 6 mmBD Pen Needle Micro U/F

Zero Copay OTC

pen needles 5/16" 30g x 8 mmAssure ID Safety Pen Needles

Zero Copay OTC

pen needles 5/16" 31g x 8 mmAdvocate Insulin Pen Needles

Zero Copay OTC

*Migraine Products*

*Selective Serotonin Agonists 5-Ht(1)***

rizatriptan benzoate oral tablet 10 mg Maxalt Generic QL (9 tabs per 30 days)

rizatriptan benzoate oral tablet 5 mg Generic QL (9 tabs per 30 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg

Maxalt-MLT Generic QL (9 tabs per 30 days)

sumatriptan succinate oral tablet 100 mg Imitrex Generic QL (9 TABS per 30 days)

23

Drug Name Reference Copay Notesumatriptan succinate oral tablet 25 mg, 50 mg

Imitrex Generic QL (9 tabs per 30 days)

*Minerals & Electrolytes*

*Potassium***potassium bicarbonate oral tablet effervescent 25 meq

Effer-K Generic

potassium chloride er oral capsule extended release 10 meq

Klor-Con Sprinkle Generic

potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq

K-Tab Generic

potassium chloride oral solution 40 meq/15ml (20%)

Generic

*Mouth/Throat/Dental Agents*

*Anesthetics Topical Oral***lidocaine viscous mouth/throat solution 2 %

Generic

*Anti-Infectives - Throat***nystatin mouth/throat suspension 100000 unit/ml

Generic

*Antiseptics - Mouth/Throat***chlorhexidine gluconate mouth/throat solution 0.12 %

Paroex Generic

*Steroids - Mouth/Throat***triamcinolone acetonide mouth/throat paste 0.1 %

Oralone Generic

*Multivitamins*

*B-Complex W/ C***b complex-vitamin c oral capsule Generic OTC

*B-Complex W/ Folic Acid***b complex plus oral tablet Generic OTC

*Musculoskeletal Therapy Agents*

*Central Muscle Relaxants***baclofen oral tablet 10 mg, 20 mg Generic

chlorzoxazone oral tablet 500 mg Generic

cyclobenzaprine hcl oral tablet 10 mg Generic

methocarbamol oral tablet 500 mg Robaxin Generic

methocarbamol oral tablet 750 mg Robaxin-750 Generic

tizanidine hcl oral tablet 2 mg Generic

24

Drug Name Reference Copay Notetizanidine hcl oral tablet 4 mg Zanaflex Generic

*Ophthalmic Agents*

*Beta-Blockers - Ophthalmic***levobunolol hcl ophthalmic solution 0.5 % Betagan Generic

timolol maleate ophthalmic solution 0.25 %, 0.5 %

Timoptic Generic

*Cycloplegic Mydriatics***tropicamide ophthalmic solution 1 % Mydriacyl Generic

*Miotics - Direct Acting***pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

Isopto Carpine Generic

*Ophthalmic Antibiotics***GENTAK OPHTHALMIC OINTMENT 0.3 %

Generic

bacitracin ophthalmic ointment 500 unit/gm

Generic

erythromycin ophthalmic ointment 5 mg/gm

Generic

gentamicin sulfate ophthalmic solution 0.3 %

Generic

tobramycin ophthalmic solution 0.3 % Tobrex Generic

*Ophthalmic Anti-Infective Combinations***neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400-10000

Neo-Polycin Generic

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

Neosporin Generic

*Ophthalmic Decongestant Combinations***eye allergy relief ophthalmic solution 0.025-0.3 %

Naphcon-A Generic OTC

*Ophthalmic Steroid Combinations***bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

Neo-Polycin HC Generic

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

Maxitrol Generic

neomycin-polymyxin-dexameth ophthalmic suspension 0.1 %

Maxitrol Generic

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

Generic

25


*Ophthalmic Steroids***dexamethasone sodium phosphate ophthalmic solution 0.1 %

Generic

fluorometholone ophthalmic suspension 0.1 %

FML Liquifilm Generic

prednisolone acetate ophthalmic suspension 1 %

Omnipred Generic

*Ophthalmic Sulfonamides***sulfacetamide sodium ophthalmic ointment 10 %

Generic

sulfacetamide sodium ophthalmic solution 10 %

Bleph-10 Generic

*Otic Agents*

*Otic Agents - Miscellaneous***acetic acid otic solution 2 % Generic

*Otic Steroid-Anti-Infective Combinations***neomycin-polymyxin-hc otic solution 1 % Generic

neomycin-polymyxin-hc otic suspension 3.5-10000-1

Generic

*Otic Steroids***hydrocortisone-acetic acid otic solution 1-2 %

Acetasol HC Generic

*Penicillins*

*Aminopenicillins***amoxicillin oral capsule 250 mg, 500 mg Generic

amoxicillin oral suspension reconstituted 250 mg/5ml

Generic

amoxicillin oral tablet chewable 250 mg Generic

ampicillin oral capsule 500 mg Generic

*Natural Penicillins***penicillin v potassium oral solution reconstituted 250 mg/5ml

Generic

penicillin v potassium oral tablet 250 mg, 500 mg

Generic

*Penicillin Combinations***amoxicillin-pot clavulanate oral tablet 500-125 mg, 875-125 mg

Augmentin Generic

26


*Penicillinase-Resistant Penicillins***dicloxacillin sodium oral capsule 250 mg, 500 mg

Generic

*Progestins*

*Progestins***medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

Provera Generic

*Psychotherapeutic And Neurological Agents - Misc.*

*Benzodiazepines & Tricyclic Agents***chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg

Generic

*Phenothiazines & Tricyclic Agents***perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg

Generic

*Tetracyclines*

*Tetracyclines***doxycycline hyclate oral capsule 100 mg, 50 mg

Morgidox Generic

minocycline hcl oral capsule 100 mg, 50 mg

Minocin Generic

tetracycline hcl oral capsule 250 mg, 500 mg

Generic

*Thyroid Agents*

*Antithyroid Agents***methimazole oral tablet 10 mg, 5 mg Tapazole Generic

propylthiouracil oral tablet 50 mg Generic

*Thyroid Hormones***SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

Levo-T Brand

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

Levo-T Generic

27

Drug Name Reference Copay Notelevothyroxine-liothyronine oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg

Armour Thyroid Generic

*Ulcer Drugs*

*Anticholinergic Combinations***chlordiazepoxide-clidinium oral capsule 5-2.5 mg

Librax Generic

*Antispasmodics***dicyclomine hcl oral capsule 10 mg Generic

dicyclomine hcl oral tablet 20 mg Generic

*Belladonna Alkaloids***hyoscyamine sulfate er oral tablet extended release 12 hour 0.375 mg

Levbid Generic

hyoscyamine sulfate sl sublingual tablet sublingual 0.125 mg

Levsin/SL Generic

*H-2 Antagonists***cimetidine oral tablet 300 mg, 400 mg, 800 mg

Generic

ranitidine hcl oral tablet 150 mgWal-Zan 150 Maximum Strength

Generic

ranitidine hcl oral tablet 300 mg Zantac Generic

*Misc. Anti-Ulcer***sucralfate oral tablet 1 gm Carafate Generic

*Proton Pump Inhibitors***omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg

Generic

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg

Protonix Generic

*Urinary Anti-Infectives*

*Urinary Anti-Infectives***nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg

Macrodantin Generic

nitrofurantoin monohyd macro oral capsule 100 mg

Macrobid Generic

*Urinary Antispasmodics*

*Urinary Antispasmodic - Antimuscarinics (Antichol)***(New)oxybutynin chloride oral tablet 5 mg Generic

28


*Urinary Antispasmodics - Cholinergic Agonists*** (New)bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

Urecholine Generic

*Vaccines*

*Bacterial Vaccines***PNEUMOVAX 23 INJECTION INJECTABLE 25 MCG/0.5ML

Brand

PREVNAR 13 INTRAMUSCULAR SUSPENSION

Brand

*Viral Vaccines***AFLURIA INTRAMUSCULAR SUSPENSION

Brand

AFLURIA PRESERVATIVE FREE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

Brand

FLUZONE HIGH-DOSE INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

Brand

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION , 0.5 ML

Brand

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 0.5 ML

Brand

SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML

Brand

*Vaginal Products*

*Imidazole-Related Antifungals***clotrimazole-7 vaginal cream 1 % Gyne-Lotrimin Generic OTC

miconazole 3 vaginal suppository 200 mg Generic

miconazole 7 vaginal cream 2 % Monistat 7 Simply Cure Generic OTC

*Vasopressors*

*Anaphylaxis Therapy Agents***EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML

Auvi-Q Brand

epinephrine injection solution auto-injector 0.3 mg/0.3ml

Auvi-Q Generic

29


*Vitamins*

*Vitamin D***vitamin d (ergocalciferol) oral capsule 50000 unit

Drisdol Generic

30

chp 2019 formulary (2 test) - geneseehealthplan.org · nitroglycerin sublingual tablet sublingual...

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