Preferred Drug List. (List of Covered Drugs) This document includes Passport Health Plan s complete 2015 formulary.

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Preferred Drug List

(List of Covered Drugs)

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The formulary is not a complete list of covered drugs by Passport. Some drugs not listed may be covered, if medically necessary.

These drugs may or may not need prior-authorization.

How do I ﬁnd my drug on the formulary?

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Are there any limits to the drugs you have been prescribed?

Some covered drugs may have limits on them. This could include:

**UÊ Prior-Authorization:Ê-iÊi`ViÃÊÕÃÌÊLiÊ>««ÀÛi`ÊLÞÊ>ÃÃ«ÀÌÊLivÀiÊ>ÃÃ«ÀÌÊÜÊVÛiÀÊÀÊ«>ÞÊvÀÊÌi°Ê/ÃÊi>ÃÊ** ÞÕÀÊ«ÀÛ`iÀÊÜÊii`ÊÌÊ}iÌÊ>««ÀÛ>ÊLivÀiÊÞÕÊV>Ê>ÛiÊÞÕÀÊ«ÀiÃVÀ«ÌÃÊwi`°ÊvÊÞÕÊ`ÊÌÊ}iÌÊ>««ÀÛ>]Ê*>ÃÃ«ÀÌÊ>ÞÊ not cover the drug.

**UÊ Quantity Limits:ÊÀÊÃiÊ`ÀÕ}Ã]ÊÌiÀiÊ>ÀiÊÌÃÊÊÌiÊ>ÕÌÊ*>ÃÃ«ÀÌÊÜÊVÛiÀ°Ê/ÃÊi>ÃÊÞÕÊ>ÞÊÌÊ}iÌÊÌiÊ** standard one month supply.

UÊ Step Therapy:Ê-iÌiÃÊ>ÃÃ«ÀÌÊÀiµÕÀiÃÊÞÕÊÌÊÌÀÞÊViÀÌ>Ê`ÀÕ}ÃÊwÀÃÌÊÌÊÌÀi>ÌÊÞÕÀÊi`V>ÊV`ÌÊLivÀiÊÜiÊÜÊ VÛiÀÊ>ÌiÀÊ`ÀÕ}ÊvÀÊÌ>ÌÊV`Ì°ÊÀÊiÝ>«i]ÊvÊÀÕ}ÊÊ>`ÊÀÕ}Ê ÊLÌÊÌÀi>ÌÊÞÕÀÊi`V>ÊV`Ì]Ê>ÃÃ«ÀÌÊ>ÞÊÌÊ VÛiÀÊ`ÀÕ}Ê ÊÕiÃÃÊÞÕÊÌÀÞÊÀÕ}ÊÊwÀÃÌ°ÊvÊÀÕ}ÊÊ`iÃÊÌÊÜÀÊvÀÊÞÕ]Ê*>ÃÃ«ÀÌÊÜÊÌiÊVÛiÀÊÀÕ}Ê °

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What if my drug is not on the formulary?

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Can the formulary change?

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What are generic drugs?

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How much are my copays?

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Table of Contents ... 1

ANTI-INFECTIVES ... 6

PENICILLINS... 6

TETRACYCLINES ... 6

FIRST GENERATION CEPHALOSPOSINS ... 7

SECOND GENERATION CEPHALOSPORINS ... 8

THIRD GENERATION CEPHALOSPORINS ... 8

ERYTHROMYCINS & OTHER MACROLIDES ... 9

FLUOROQUINOLONES ... 10

SULFAS & RELATED AGENTS ... 11

URINARY TRACT AGENTS ... 11

MISCELLANEOUS ANTIVIRALS... 12

HIV/AIDS THERAPY ... 14

ANTIFUNGAL AGENTS ... 17

VANCOMYCIN ... 19

MISCELLANEOUS ANTIINFECTIVES ... 19

ANTIPARASITICS ... 20

ANTIMALARIALS ... 20

ANTIMYCOBACTERIALS ... 21

ANTINEOPLASTIC & IMMUNOSUPPRESANT DRUGS ... 22

ALKYLATING AGENTS ... 22

ANTIMETABOLITES ... 22

HORMONES ... 23

ANTIESTROGENS ... 23

ANTIANDROGENS ... 23

IMMUNOSUPPRESSANT DRUGS ... 24

MISCELLANEOUS ANTINEOPLASTIC DRUGS ... 25

ADJUNCTIVE AGENTS ... 27

AUTONOMIC & CNS DRUGS, NEUROLOGY, & PSYCH ... 27

NARCOTIC ANALGESICS ... 27

NARCOTICS ... 27

COMBINATION NARCOTIC /ANALGESICS ... 30

NON-NARCOTIC ANALGESICS ... 33

NSAIDS ... 33

NSAIDS- SPECIFIC COX-II INHIBITORS ... 36

03030200 SALICYLATES ... 36

MISCELLANEOUS ANALGESICS ... 37

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NARCOTIC ANTAGONISTS ... 38

MIGRAINE & CLUSTER HEADACHE THERAPY ... 38

HEADACHE THERAPY ... 38

ANTIPARKINSONISM AGENTS ... 40

ANTICONVULSANTS ... 41

MISCELLANEOUS NEUROLOGICAL THERAPY ... 46

MUSCLE RELAXANTS & ANTISPASMODIC AGENTS ... 47

MYASTHENIA GRAVIS ... 48

HYPNOTIC AGENTS ... 48

TRICYCLICS ... 50

MISCELLANEOUS ANTIDEPRESSANTS ... 51

MAO INHIBITORS ... 52

SELECTIVE SEROTONIN REUPTAKE INHIBITORS... 52

PHENOTHIAZINES ... 54

BUTYROPHENONES ... 55

MISCELLANEOUS ANTIPSYCHOTICS ... 55

MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS ... 56

ANXIOLYTICS ... 59

CARDIOVASCULAR, HYPERTENSION, & LIPIDS ... 60

ANTIARRHYTHMIC AGENTS ... 60

CARDIAC GLYCOSIDES ... 61

NITRATES ... 62

RAPID ACTING NITRATES ... 62

LONG ACTING NITRATES ... 62

COAGULATION THERAPY ... 63

ANTICOAGULANTS ... 63

ANTIPLATELET DRUGS ... 63

HEPARIN ... 63

VITAMIN K ... 64

HEMOSTATICS ... 64

MISCELLANEOUS COAGULATION AGENTS ... 64

ANTIHYPERTENSIVE THERAPY ... 65

THIAZIDE & RELATED DIURETICS ... 65

BETA BLOCKERS ... 66

CALCIUM CHANNEL BLOCKERS/NON-DIHYDROPYRIDINES ... 68

CALCIUM CHANNEL BLOCKERS/DIHYDROPYRIDINES ... 70

ACE INHIBITORS ... 71

ADRENERGIC ANTAGONISTS & RELATED DRUGS ... 72

AGENTS FOR PHEOCHROMOCYTOMA ... 73

VASODILATORS ... 73

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3 LIPID/CHOLESTEROL LOWERING AGENTS ... 78

DERMATOLOGICAL/TOPICAL THERAPY ... 80

TOPICAL CORTICOSTEROIDS ... 80

TOPICAL CORTICOSTEROIDS VERY HIGH POTENCY ... 80

TOPICAL CORTICOSTEROIDS HIGH POTENCY ... 83

TOPICAL CORTICOSTEROIDS MEDIUM POTENCY ... 85

TOPICAL CORTICOSTEROIDS LOW POTENCY ... 88

TOPICAL ANESTHETICS ... 90

THERAPY FOR ACNE ... 91

TOPICAL ANTIBACTERIALS ... 98

TOPICAL ANTIFUNGALS ... 99

TOPICAL ANTIVIRALS ... 101

BURN THERAPY ... 101

TOPICAL ENZYMES ... 101

KERATOLYTICS ... 101

ANTIPSORIATIC / ANTISEBORRHEIC ... 102

TOPICAL SCABICIDES / PEDICULICIDES ... 104

MISCELLANEOUS DERMATOLOGICALS ... 105

DIAGNOSTICS & MISCELLANEOUS AGENTS ... 111

MISCELLANEOUS AGENTS ... 111

SMOKING DETERRENTS ... 113

ANOREXIANTS ... 113

EAR, NOSE, & THROAT MEDICATIONS ... 113

MISCELLANEOUS OTIC PREPARATIONS ... 113

OTIC STEROID / ANTIBIOTIC ... 115

MISCELLANEOUS AGENTS ... 116

ENDOCRINE/DIABETES ... 117

ANTITHYROID AGENTS ... 117

THYROID HORMONES ... 117

ADRENAL HORMONES ... 118

ANDROGENS ... 120

MISCELLANEOUS AGENTS ... 121

DIABETES THERAPY ... 122

INSULIN THERAPY ... 122

NON-INSULIN HYPOGLYCEMIC AGENTS ... 123

GLUCOSE ELEVATING AGENTS ... 125

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INSULIN BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES ... 126

INSULIN SYRINGES/MISCELLANEOUS ... 126

GASTROENTEROLOGY ... 127

H2 ANTAGONISTS ... 127

PROSTAGLANDINS ... 127

OTHER ULCER THERAPY ... 127

PROTON PUMP INHIBITORS ... 128

ANTIDIARRHEALS ... 129

ANTISPASMODICS ... 129

COMBINATION ANTICHOLINERGICS ... 131

BILE ACIDS ... 131

DIGESTIVE ENZYMES ... 131

MISCELLANEOUS GASTROINTESTINAL AGENTS ... 132

ANTIVERTIGO & ANTIEMETIC AGENTS ... 135

BOWEL EVACUANTS ... 136

IMMUNOLOGY, VACCINES, & BIOTECHNOLOGY ... 136

ERYTHROID STIMULANTS ... 136

INTERFERONS ... 136

GROWTH HORMONES ... 137

INTERLEUKINS ... 138

VACCINES & MISCELLANEOUS IMMUNOLOGICALS... 138

MUSCULOSKELETAL & RHEUMATOLOGY ... 139

GOUT THERAPY ... 139

MISCELLANEOUS RHEUMATOLOGICAL AGENTS ... 140

OSTEOPOROSIS THERAPY ... 141

OBSTETRICS & GYNECOLOGY ... 141

MONOPHASIC /BIPHASIC /TRIPHASIC AGENTS ... 141

OXYTOCICS ... 148

ESTROGENS & PROGESTINS ... 148

PROGESTINS ... 148

ESTROGENS ... 149

ESTROGEN COMBINATIONS ... 149

MISCELLANEOUS OB/GYN ... 149

VAGINAL CLEANSER /ANTIINFECTIVE ... 149

VAGINAL ANTIFUNGALS ... 150

SPECIALIZED OB/GYN DRUGS ... 150

OPHTHALMOLOGY ... 150

BETA-BLOCKERS ... 150

CHOLINESTERASE INHIBITOR MIOTICS ... 151

DIRECT ACTING MIOTICS ... 151

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5 CYCLOPLEGIC MYDRIATICS ... 152

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ... 152

VASOCONSTRICTOR DECONGESTANTS ... 153

ANTIBIOTICS ... 153

SULFONAMIDES ... 155

STEROIDS ... 155

STEROID-ANTIBIOTIC COMBINATIONS ... 156

SYMPATHOMIMETICS ... 157

MISCELLANEOUS OPHTHALMOLOGICS ... 157

ANTIVIRALS ... 158

RESPIRATORY, ALLERGY, COUGH, & COLD ... 158

ANTIHISTAMINES & ANTIALLERGENIC AGENTS ... 158

ANTIHISTAMINES ... 158

ADRENERGICS ... 162

COUGH & COLD THERAPY... 162

ANTITUSSIVE COMBINATIONS ... 162

EXPECTORANT COMBINATIONS ... 170

DECONGESTANT / ANTIHISTAMINES... 171

XANTHINES ... 175

BETA AGONISTS ORAL ... 176

BETA AGONISTS INHALERS ... 176

INHALED CORTICOSTEROIDS ... 177

INTRANASAL STEROIDS ... 177

MISCELLANEOUS PULMONARY AGENTS ... 177

MISCELLANEOUS EQUIPMENT ... 179

PEAK FLOW METERS ... 179

SPACERS ... 180

UROLOGICALS ... 181

CHOLINERGIC STIMULANTS ... 181

ANTICHOLINERGICS & ANTISPASMODICS ... 181

URINARY ANESTHETICS ... 182

MISCELLANEOUS UROLOGICALS ... 182

BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY ... 184

VITAMINS, HEMATINICS, & ELECTROLYTES ... 184

VITAMINS & HEMATINICS... 184

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BRAND/

GENERIC FORMULARY

STATUS TRADE NAME GENERIC NAME DOSE DESCRIPTION PA ST QL/SP COMMENTS

ANTI-INFECTIVES PENICILLINS

Generic Preferred Amox Tr/Potassium

Clavulanate Amoxicillin/

Potassium Clav

Suspension;

Reconstituted;

Oral (Ml)

Potassium Clav Tablet

Potassium Clav Tablet; Chewable

Generic Preferred Amoxicillin Amoxicillin Capsule

Generic Preferred Amoxicillin Amoxicillin Suspension;

Reconstituted;

Oral (Ml)

Generic Preferred Amoxicillin Amoxicillin Tablet

Generic Preferred Amoxicillin Amoxicillin Tablet; Chewable Generic Preferred Amoxicillin-

Clavulanate Er Amoxicillin/

Potassium Clav Tablet; Extended

Release 12 Hr Generic Preferred Ampicillin Trihydrate Ampicillin

Trihydrate

Suspension;

Reconstituted;

Oral (Ml)

Generic Preferred Ampicillin Trihydrate Ampicillin

Trihydrate Capsule

BRAND GENERIC

AVAILABLE AUGMENTIN AMOXICILLIN/

POTASSIUM CLAV TABLET

BRAND GENERIC

AVAILABLE AUGMENTIN AMOXICILLIN/

POTASSIUM CLAV

SUSPENSION;

RECONSTITUTED

; ORAL (ML) BRAND GENERIC

AVAILABLE AUGMENTIN ES AMOXICILLIN/

POTASSIUM CLAV

SUSPENSION;

RECONSTITUTED

AVAILABLE AUGMENTIN XR AMOXICILLIN/

POTASSIUM CLAV

TABLET;

EXTENDED

RELEASE 12 HR Generic Preferred Dicloxacillin Sodium Dicloxacillin

Sodium Capsule

Generic Preferred Penicillin G Procaine Penicillin G

Procaine Syringe (Ml)

Generic Preferred Penicillin V Potassium Penicillin V Potassium

Solution;

Reconstituted;

Oral

Generic Preferred Penicillin V Potassium Penicillin V

Potassium Tablet

TETRACYCLINES

BRAND GENERIC

AVAILABLE ADOXA DOXYCYCLINE

MONOHYDRATE CAPSULE

Generic Preferred Avidoxy Doxycycline

Monohydrate Tablet

Generic Preferred Demeclocycline Hcl Demeclocycline

Hcl Tablet

BRAND GENERIC

AVAILABLE DORYX DOXYCYCLINE

HYCLATE TABLET;

ENTERIC

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COATED Generic Preferred Doxycycline Hyclate Doxycycline

Hyclate Tablet; Enteric

Coated

Generic Preferred Doxycycline Hyclate Doxycycline

Hyclate Tablet

Generic Preferred Doxycycline Hyclate Doxycycline

Hyclate Capsule

Generic Preferred Doxycycline

Monohydrate Doxycycline

Monohydrate Tablet

Monohydrate Doxycycline Monohydrate

Suspension;

Reconstituted;

Oral (Ml)

Monohydrate Doxycycline

Monohydrate Capsule

BRAND GENERIC

AVAILABLE DYNACIN MINOCYCLINE HCL TABLET

BRAND GENERIC

AVAILABLE MINOCIN MINOCYCLINE HCL CAPSULE

Generic Preferred Minocycline Hcl Minocycline Hcl Capsule Generic Preferred Minocycline Hcl Minocycline Hcl Tablet Generic Preferred Minocycline Hcl Minocycline Hcl Tablet; Extended

Release 24 Hr BRAND GENERIC

AVAILABLE MONODOX DOXYCYCLINE

MONOHYDRATE CAPSULE

Generic Preferred Morgidox Doxycycline

Hyclate Capsule

Generic Preferred Ocudox Doxy/Eyelid Clns

#3/Eye Eml #1 Kit

BRAND GENERIC

AVAILABLE PERIOSTAT DOXYCYCLINE

HYCLATE TABLET

BRAND GENERIC

AVAILABLE SOLODYN MINOCYCLINE HCL TABLET;

EXTENDED

RELEASE 24 HR Generic Preferred Tetracycline Hcl Tetracycline Hcl Capsule BRAND GENERIC

AVAILABLE VIBRAMYCIN DOXYCYCLINE MONOHYDRATE

SUSPENSION;

RECONSTITUTED

AVAILABLE VIBRAMYCIN DOXYCYCLINE

HYCLATE CAPSULE

FIRST GENERATION CEPHALOSPOSINS

Generic Preferred Cefadroxil Cefadroxil Hydrate Suspension;

Reconstituted

Oral (Ml)

Generic Preferred Cefadroxil Cefadroxil Hydrate Tablet

Generic Preferred Cefadroxil Cefadroxil Hydrate Capsule

Generic Preferred Cephalexin Cephalexin Capsule

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BRAND/

STATUS TRADE NAME GENERIC NAME DOSE DESCRIPTION PA ST QL/SP COMMENTS Generic Preferred Cephalexin Cephalexin Suspension;

Reconstitutedoral

(Ml)

Generic Preferred Cephalexin Cephalexin Tablet

BRAND GENERIC

AVAILABLE KEFLEX CEPHALEXIN CAPSULE

SECOND GENERATION CEPHALOSPORINS

Generic Preferred Cefaclor Cefaclor Capsule

Generic Preferred Cefaclor Cefaclor Suspension;

Reconstituted;

Oral (Ml)

Generic Preferred Cefaclor Er Cefaclor Tablet; Extended

Release 12 Hr Generic Preferred Cefpodoxime Proxetil Cefpodoxime

Proxetil

Suspension;

Reconstitutedoral

(Ml)

Generic Preferred Cefpodoxime Proxetil Cefpodoxime

Proxetil Tablet

Generic Preferred Cefprozil Cefprozil Tablet

Generic Preferred Cefprozil Cefprozil Suspension;

Reconstitutedoral

(Ml)

BRAND GENERIC

AVAILABLE CEFTIN CEFUROXIME

AXETIL TABLET

Generic Preferred Cefuroxime Axetil Cefuroxime Axetil Suspension;

Reconstitutedoral

(Ml)

Generic Preferred Cefuroxime Axetil Cefuroxime Axetil Tablet

THIRD GENERATION CEPHALOSPORINS

BRAND GENERIC

AVAILABLE CEDAX CEFTIBUTEN

DIHYDRATE CAPSULE

BRAND GENERIC

AVAILABLE CEDAX CEFTIBUTEN

DIHYDRATE

SUSPENSION;

RECONSTITUTED

ORAL (ML)

Generic Preferred Cefdinir Cefdinir Suspension;

Reconstituted

Oral (Ml)

Generic Preferred Cefdinir Cefdinir Capsule

Generic Preferred Cefditoren Pivoxil Cefditoren Pivoxil Tablet

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Generic Preferred Ceftibuten Ceftibuten Dihydrate

Suspension;

Reconstitutedoral

(Ml)

Generic Preferred Ceftibuten Ceftibuten

Dihydrate Capsule

BRAND GENERIC

AVAILABLE SPECTRACEF CEFDITOREN

PIVOXIL TABLET

ERYTHROMYCINS & OTHER MACROLIDES

Generic Preferred Azithromycin Azithromycin Tablet tabs:

500mg:1/day 250mg:1/day Generic Preferred Azithromycin Azithromycin Suspension;

Reconstituted;

Oral (Ml)

Generic Preferred Azithromycin Azithromycin Packet (Ea)

BRAND GENERIC

AVAILABLE BIAXIN CLARITHROMYCIN SUSPENSION;

RECONSTITUTED

; ORAL (ML) 150ml/Rx BRAND GENERIC

AVAILABLE BIAXIN CLARITHROMYCIN TABLET 2/day

BRAND GENERIC

AVAILABLE BIAXIN XL CLARITHROMYCIN TABLET;

EXTENDED

RELEASE 24 HR 2/day Generic Preferred Clarithromycin Clarithromycin Tablet 250mg, 500mg

tabs 20 qty/10 days

Generic Preferred Clarithromycin Clarithromycin Suspension;

Reconstituted;

Oral (Ml) 150ml/rx Generic Preferred Clarithromycin Er Clarithromycin Tablet; Extended

Release 24 Hr

BRAND PREFERRED E.E.S. ERYTHROMYCIN

ETHYLSUCCINATE

SUSPENSION;

RECONSTITUTED

; ORAL (ML)

Generic Preferred E.E.S. Erythromycin

Ethylsuccinate Tablet

BRAND PREFERRED ERYPED ERYTHROMYCIN

ETHYLSUCCINATE

SUSPENSION;

RECONSTITUTED

; ORAL (ML) Generic Preferred Ery-Tab Erythromycin Base Tablet; Enteric Coated

BRAND PREFERRED ERY-TAB ERYTHROMYCIN

BASE

TABLET;

ENTERIC

COATED

Generic Preferred Erythrocin Stearate Erythromycin

Stearate Tablet

Generic Preferred Erythromycin Erythromycin Base Tablet

(13)

BRAND/

STATUS TRADE NAME GENERIC NAME DOSE DESCRIPTION PA ST QL/SP COMMENTS Generic Preferred Erythromycin Erythromycin Base Capsule;Delayed

Release (Enteric

Coated)

BRAND PREFERRED ERYTHROMYCIN ERYTHROMYCIN BASE

TABLET;

ENTERIC

COATED

Generic Preferred Erythromycin

Ethylsuccinate Erythromycin Ethylsuccinate

Suspension;

Reconstituted;

Oral (Ml)

Ethylsuccinate Erythromycin

Ethylsuccinate Tablet

Generic Preferred Erythromycin Stearate Erythromycin Stearate Tablet

W/Sulfisoxazole Ery E-

Succ/Sulfisoxazole

Suspension;

Reconstituted;

Oral (Ml)

BRAND GENERIC

AVAILABLE ZITHROMAX AZITHROMYCIN TABLET tabs: 250mg:

6/30 days; 500mg 5/30 days BRAND GENERIC

AVAILABLE ZITHROMAX AZITHROMYCIN PACKET (EA) tabs: 250mg:

6/30 days; 500mg 5/30 days BRAND GENERIC

AVAILABLE ZITHROMAX AZITHROMYCIN SUSPENSION;

RECONSTITUTED

; ORAL (ML)

FLUOROQUINOLONES

BRAND GENERIC

AVAILABLE AVELOX MOXIFLOXACIN

HCL TABLET 1/day

BRAND PREFERRED CIPRO CIPROFLOXACIN SUSPENSION;

MICROCAPSULE

RECONSTITUTED 10mL/day BRAND GENERIC

AVAILABLE CIPRO CIPROFLOXACIN

HCL TABLET 2 tabs/day

BRAND GENERIC

AVAILABLE CIPRO XR CIPROFLOXACIN/C

IPROFLOXA HCL

TABLET;EXTEND ED RELEASE MULTIPHASE 24 HR

2 tabs/day

Generic Preferred Ciprofloxacin Er Ciprofloxacin/

Ciprofloxa Hcl

Tablet;Extended Release

Multiphase 24 Hr 2 tabs/day Generic Preferred Ciprofloxacin Hcl Ciprofloxacin Hcl Tablet 2 tabs/day

BRAND GENERIC

AVAILABLE LEVAQUIN LEVOFLOXACIN TABLET 5 tabs/30 days

BRAND GENERIC

AVAILABLE LEVAQUIN LEVOFLOXACIN SOLUTION; ORAL 480ml/Rx Generic Preferred Levofloxacin

Hemihydrate Levofloxacin Solution; Oral 480ml/rx

(14)

Generic Preferred Levofloxacin

Hemihydrate Levofloxacin Tablet 5 tabs/30 days

Generic Preferred Moxifloxacin Hcl Moxifloxacin Hcl Tablet 1/day

SULFAS & RELATED AGENTS

BRAND GENERIC

AVAILABLE BACTRIM SULFAMETHOXAZ

OLE/TRIMETHOPR

IM TABLET

BRAND GENERIC

AVAILABLE BACTRIM DS SULFAMETHOXAZ

OLE/TRIMETHOPR

IM TABLET

BRAND GENERIC

AVAILABLE SEPTRA SULFAMETHOXAZ

OLE/TRIMETHOPR

IM TABLET

BRAND GENERIC

AVAILABLE SEPTRA DS SULFAMETHOXAZ

OLE/TRIMETHOPR

IM TABLET

Generic Preferred Smz-Tmp Ds Sulfamethoxazole/

Trimethoprim Tablet

Generic Preferred Sulfadiazine Sulfadiazine Tablet

Generic Preferred Sulfamethoxazole/Tri

methoprim Sulfamethoxazole/

Trimethoprim Tablet

Generic Preferred Sulfamethoxazole/Tri

methoprim Sulfamethoxazole/

Trimethoprim Suspension; Oral

(Final Dose Form) BRAND GENERIC

AVAILABLE SULFATRIM SULFAMETHOXAZ

OLE/TRIMETHOPR IM

SUSPENSION;

ORAL (FINAL

DOSE FORM)

URINARY TRACT AGENTS

BRAND GENERIC

AVAILABLE FURADANTIN NITROFURANTOIN SUSPENSION;

ORAL (FINAL

DOSE FORM)

BRAND GENERIC

AVAILABLE HIPREX METHENAMINE

HIPPURATE TABLET

BRAND GENERIC

AVAILABLE MACROBID NITROFURANTOIN

MONOHYD/M-

CRYST CAPSULE

BRAND GENERIC

AVAILABLE MACRODANTIN NITROFURANTOIN

MACROCRYSTAL CAPSULE

Generic Preferred Methenamine

Hippurate Methenamine

Hippurate Tablet

Generic Preferred Methenamine

Mandelate Methenamine

Mandelate Tablet

Generic Preferred Methylene Blue Methylene Blue

(Antidotes) Ampul (Ml)

(15)

BRAND/

STATUS TRADE NAME GENERIC NAME DOSE DESCRIPTION PA ST QL/SP COMMENTS Generic Preferred Nitrofurantoin Nitrofurantoin Suspension; Oral

(Final Dose Form) Generic Preferred Nitrofurantoin Nitrofurantoin

Macrocrystal Capsule

Generic Preferred Nitrofurantoin

Macrocrystal Nitrofurantoin

Monohyd/M-Cryst Capsule

Generic Preferred Trimethoprim Trimethoprim Tablet

BRAND GENERIC

AVAILABLE UREX METHENAMINE

HIPPURATE TABLET

MISCELLANEOUS ANTIVIRALS

Generic Preferred Acyclovir Acyclovir Suspension; Oral

(Final Dose Form)

Generic Preferred Acyclovir Acyclovir Capsule

Generic Preferred Acyclovir Acyclovir Tablet

Generic Preferred Adefovir Dipivoxil Adefovir Dipivoxil Tablet PA SP

Generic Preferred Amantadine Hcl Amantadine Hcl Tablet

Generic Preferred Amantadine Hcl Amantadine Hcl Syrup

Generic Preferred Amantadine Hcl Amantadine Hcl Capsule

BRAND PREFERRED BARACLUDE ENTECAVIR TABLET PA SP

BRAND PREFERRED BARACLUDE ENTECAVIR SOLUTION; ORAL PA SP

BRAND GENERIC

AVAILABLE COPEGUS RIBAVIRIN TABLET PA SP

BRAND GENERIC

AVAILABLE EPIVIR HBV LAMIVUDINE TABLET

BRAND PREFERRED EPIVIR HBV LAMIVUDINE SOLUTION; ORAL

Generic Preferred Famciclovir Famciclovir Tablet

BRAND GENERIC

AVAILABLE FAMVIR FAMCICLOVIR TABLET

BRAND GENERIC

AVAILABLE FLUMADINE RIMANTADINE

HCL TABLET

(16)

Generic Preferred Ganciclovir Ganciclovir Capsule

BRAND GENERIC

AVAILABLE HEPSERA ADEFOVIR

DIPIVOXIL TABLET PA SP

BRAND PREFERRED INCIVEK TELAPREVIR TABLET PA SP

Generic Preferred Lamivudine Lamivudine Tablet

Generic Preferred Moderiba Ribavirin Tablet; Dose Pack SP

Generic Preferred Moderiba Ribavirin Tablet SP

BRAND PREFERRED OLYSIO SIMEPREVIR

SODIUM CAPSULE PA

SP;1 tablet per day for a total duration of 12 weeks BRAND GENERIC

AVAILABLE REBETOL RIBAVIRIN CAPSULE PA SP

BRAND PREFERRED RELENZA ZANAMIVIR DISK; WITH

INHALATION

DEVICE 20/10days; 10

days' supply

Generic Preferred Ribapak Ribavirin Tablet; Dose Pack SP

Generic Preferred Ribasphere Ribavirin Tablet SP

Generic Preferred Ribasphere Ribavirin Capsule SP

BRAND GENERIC

AVAILABLE RIBATAB RIBAVIRIN TABLET; DOSE

PACK PA SP

Generic Preferred Ribavirin Ribavirin Tablet SP

Generic Preferred Ribavirin Ribavirin Capsule SP

Generic Preferred Rimantadine Hcl Rimantadine Hcl Tablet

BRAND PREFERRED SOVALDI SOFOSBUVIR TABLET PA SP;28/28 days

BRAND PREFERRED SYNAGIS PALIVIZUMAB VIAL (ML) PA SP

BRAND PREFERRED TAMIFLU OSELTAMIVIR

PHOSPHATE

SUSPENSION;

RECONSTITUTED

; ORAL (ML) 25 mL/day

(17)

BRAND/

BRAND PREFERRED TAMIFLU OSELTAMIVIR

PHOSPHATE CAPSULE

BRAND PREFERRED TYZEKA TELBIVUDINE TABLET SP

Generic Preferred Valacyclovir Valacyclovir Hcl Tablet

BRAND PREFERRED VALCYTE VALGANCICLOVIR

HCL

SOLUTION;

RECONSTITUTED

; ORAL

BRAND PREFERRED VALCYTE VALGANCICLOVIR

HCL TABLET

BRAND GENERIC

AVAILABLE VALTREX VALACYCLOVIR

HCL TABLET

BRAND PREFERRED VICTRELIS BOCEPREVIR CAPSULE PA SP

BRAND GENERIC

AVAILABLE ZOVIRAX ACYCLOVIR TABLET

BRAND GENERIC

AVAILABLE ZOVIRAX ACYCLOVIR SUSPENSION;

ORAL (FINAL

DOSE FORM)

BRAND GENERIC

AVAILABLE ZOVIRAX ACYCLOVIR CAPSULE

HIV/AIDS THERAPY

Generic Preferred Abacavir Abacavir Sulfate Tablet

Generic Preferred Abacavir-Lamivudine- Zidovudine

Abacavir/

Lamivudine/

Zidovudine Tablet

BRAND PREFERRED APTIVUS TIPRANAVIR CAPSULE

BRAND PREFERRED APTIVUS TIPRANAVIR/

VITAMIN E TPGS SOLUTION; ORAL

BRAND PREFERRED ATRIPLA EFAVIRENZ/

EMTRICITAB/

TENOFOVIR TABLET

BRAND GENERIC

AVAILABLE COMBIVIR LAMIVUDINE/ZID

OVUDINE TABLET

BRAND PREFERRED COMPLERA EMTRICITAB/RILP

IVIRINE/TENOFOV TABLET

BRAND PREFERRED CRIXIVAN INDINAVIR

SULFATE CAPSULE

Generic Preferred Didanosine Didanosine Capsule;Delayed Release (Enteric

Coated)

(18)

BRAND PREFERRED EDURANT RILPIVIRINE HCL TABLET

BRAND PREFERRED EMTRIVA EMTRICITABINE SOLUTION; ORAL

BRAND PREFERRED EMTRIVA EMTRICITABINE CAPSULE

BRAND PREFERRED EPIVIR LAMIVUDINE SOLUTION; ORAL

BRAND GENERIC

AVAILABLE EPIVIR LAMIVUDINE TABLET

BRAND PREFERRED EPZICOM ABACAVIR

SULFATE/LAMIVU

DINE TABLET

BRAND PREFERRED FUZEON ENFUVIRTIDE KIT PA SP

BRAND PREFERRED INTELENCE ETRAVIRINE TABLET

BRAND PREFERRED INVIRASE SAQUINAVIR

MESYLATE TABLET

BRAND PREFERRED INVIRASE SAQUINAVIR

MESYLATE CAPSULE

BRAND PREFERRED ISENTRESS RALTEGRAVIR

POTASSIUM TABLET PA SP

BRAND PREFERRED ISENTRESS RALTEGRAVIR

POTASSIUM TABLET;

CHEWABLE PA SP

BRAND PREFERRED KALETRA LOPINAVIR/RITON

AVIR SOLUTION; ORAL

BRAND PREFERRED KALETRA LOPINAVIR/RITON

AVIR TABLET

Generic Preferred Lamivudine Lamivudine Tablet

Generic Preferred Lamivudine-

Zidovudine Lamivudine/

Zidovudine Tablet

BRAND PREFERRED LEXIVA FOSAMPRENAVIR

CALCIUM

SUSPENSION;

ORAL (FINAL

DOSE FORM)

BRAND PREFERRED LEXIVA FOSAMPRENAVIR

CALCIUM TABLET

Generic Preferred Nevirapine Nevirapine Suspension; Oral

(Final Dose Form)

Generic Preferred Nevirapine Nevirapine Tablet

(19)

BRAND/

Generic Preferred Nevirapine ER 400mg Nevirapine ER Tablet

BRAND PREFERRED NORVIR RITONAVIR CAPSULE

BRAND PREFERRED NORVIR RITONAVIR SOLUTION; ORAL

BRAND PREFERRED NORVIR RITONAVIR TABLET

BRAND PREFERRED PREZISTA DARUNAVIR

ETHANOLATE TABLET

BRAND PREFERRED PREZISTA DARUNAVIR

ETHANOLATE

SUSPENSION;

ORAL (FINAL

DOSE FORM)

BRAND PREFERRED RESCRIPTOR DELAVIRDINE

MESYLATE TABLET

BRAND PREFERRED RESCRIPTOR DELAVIRDINE

MESYLATE TABLET;

DISPERSIBLE BRAND GENERIC

AVAILABLE RETROVIR ZIDOVUDINE CAPSULE

BRAND GENERIC

AVAILABLE RETROVIR ZIDOVUDINE TABLET

BRAND GENERIC

AVAILABLE RETROVIR ZIDOVUDINE SYRUP

BRAND PREFERRED REYATAZ ATAZANAVIR

SULFATE CAPSULE

BRAND PREFERRED SELZENTRY MARAVIROC TABLET PA

Generic Preferred Stavudine Stavudine Capsule

Generic Preferred Stavudine Stavudine Solution;

Reconstituted;

Oral

BRAND PREFERRED STRIBILD ELVITEGR/

COBICIST/

EMTRIC/TENOF TABLET

BRAND PREFERRED SUSTIVA EFAVIRENZ CAPSULE

BRAND PREFERRED SUSTIVA EFAVIRENZ TABLET

BRAND PREFERRED TIVICAY DOLUTEGRAVIR

SODIUM TABLET SP

BRAND GENERIC

AVAILABLE TRIZIVIR ABACAVIR/

LAMIVUDINE/

ZIDOVUDINE TABLET

(20)

BRAND PREFERRED TRUVADA EMTRICITABINE/

TENOFOVIR TABLET

BRAND PREFERRED VIDEX DIDANOSINE SOLUTION;

RECONSTITUTED

; ORAL

BRAND GENERIC

AVAILABLE VIDEX EC DIDANOSINE

CAPSULE;DELAY ED RELEASE (ENTERIC COATED)

BRAND PREFERRED VIRACEPT NELFINAVIR

MESYLATE TABLET

BRAND GENERIC

AVAILABLE VIRAMUNE NEVIRAPINE SUSPENSION;

ORAL (FINAL

DOSE FORM)

BRAND GENERIC

AVAILABLE VIRAMUNE NEVIRAPINE TABLET

BRAND PREFERRED VIRAMUNE XR NEVIRAPINE TABLET;

EXTENDED

RELEASE 24 HR BRAND GENERIC

AVAILABLE VIRAMUNE XR 400MG NEVIRAPINE TABLET;

EXTENDED

RELEASE 24 HR

BRAND PREFERRED VIREAD TENOFOVIR

DISOPROXIL

FUMARATE TABLET

BRAND GENERIC

AVAILABLE ZERIT STAVUDINE SOLUTION;

RECONSTITUTED

; ORAL

BRAND GENERIC

AVAILABLE ZERIT STAVUDINE CAPSULE

BRAND GENERIC

AVAILABLE ZIAGEN ABACAVIR

SULFATE TABLET

BRAND PREFERRED ZIAGEN ABACAVIR

SULFATE SOLUTION; ORAL

Generic Preferred Zidovudine Zidovudine Capsule

Generic Preferred Zidovudine Zidovudine Syrup

Generic Preferred Zidovudine Zidovudine Tablet

ANTIFUNGAL AGENTS

BRAND GENERIC

AVAILABLE ANCOBON FLUCYTOSINE CAPSULE

Generic Preferred Clotrimazole Clotrimazole Troche

BRAND GENERIC DIFLUCAN FLUCONAZOLE SUSPENSION;

(21)

BRAND/

AVAILABLE RECONSTITUTED

; ORAL (ML)

BRAND GENERIC

AVAILABLE DIFLUCAN FLUCONAZOLE TABLET 150mg: 2 EA/7

days

Generic Preferred Fluconazole Fluconazole Tablet 150mg: 2 ea/7

days Generic Preferred Fluconazole Fluconazole Suspension;

Reconstituted;

Oral (Ml)

Generic Preferred Flucytosine Flucytosine Capsule

BRAND GENERIC

AVAILABLE GRIFULVIN V GRISEOFULVIN;

MICROSIZE TABLET

Generic Preferred Griseofulvin Griseofulvin;

Microsize Tablet

Generic Preferred Griseofulvin Griseofulvin;

Microsize Suspension; Oral

(Final Dose Form) Generic Preferred Griseofulvin

Ultramicrosize Griseofulvin

Ultramicrosize Tablet

BRAND GENERIC

AVAILABLE GRIS-PEG GRISEOFULVIN

ULTRAMICROSIZE TABLET

Generic Preferred Itraconazole Itraconazole Capsule

Generic Preferred Ketoconazole Ketoconazole Tablet PA

BRAND GENERIC

AVAILABLE LAMISIL TERBINAFINE HCL TABLET

250mg: 1 tab/day;84 days of therapy per 365 days

BRAND PREFERRED LAMISIL TERBINAFINE HCL GRANULES IN PACKET (EA)

BRAND PREFERRED NOXAFIL POSACONAZOLE SUSPENSION;

ORAL (FINAL

DOSE FORM)

BRAND PREFERRED NOXAFIL POSACONAZOLE TABLET;

ENTERIC

COATED

Generic Preferred Nystatin Nystatin Suspension; Oral

(Final Dose Form)

Generic Preferred Nystatin Nystatin Tablet

BRAND GENERIC

AVAILABLE SPORANOX ITRACONAZOLE CAPSULE

(22)

BRAND PREFERRED SPORANOX ITRACONAZOLE SOLUTION; ORAL

Generic Preferred Terbinafine Terbinafine Hcl Tablet

250mg: 1 tab/day;84 days of therapy per 365 days BRAND GENERIC

AVAILABLE VFEND VORICONAZOLE SUSPENSION;

RECONSTITUTED

AVAILABLE VFEND VORICONAZOLE TABLET

Generic Preferred Voriconazole Voriconazole Suspension;

Reconstituted;

Oral (Ml)

Generic Preferred Voriconazole Voriconazole Tablet

VANCOMYCIN

BRAND GENERIC

AVAILABLE VANCOCIN HCL VANCOMYCIN HCL CAPSULE

Generic Preferred Vancomycin Hcl Vancomycin Hcl Capsule

MISCELLANEOUS ANTIINFECTIVES

Generic Preferred Amikacin Sulfate Amikacin Sulfate Syringe (Ml)

BRAND PREFERRED CAYSTON AZTREONAM

LYSINE VIAL; NEBULIZER

(ML) PA SP; 3 vials per day

BRAND GENERIC

AVAILABLE CLEOCIN HCL CLINDAMYCIN

HCL CAPSULE

BRAND GENERIC

AVAILABLE CLEOCIN PALMITATE CLINDAMYCIN PALMITATE HCL

SOLUTION;

RECONSTITUTED

; ORAL

Generic Preferred Clindamycin Hcl Clindamycin Hcl Capsule

Generic Preferred Clindamycin Palmitate

Hcl Clindamycin

Palmitate Hcl

Solution;

Reconstituted;

Oral

Generic Preferred Clindamycin Pediatric Clindamycin Palmitate Hcl

Solution;

Reconstituted;

Oral

BRAND PREFERRED DAPSONE DAPSONE TABLET

Generic Preferred Neomycin Sulfate Neomycin Sulfate Tablet

(23)

BRAND/

STATUS TRADE NAME GENERIC NAME DOSE DESCRIPTION PA ST QL/SP COMMENTS BRAND GENERIC

AVAILABLE TOBI TOBRAMYCIN IN

0.225% NACL

AMPUL FOR NEBULIZATION

(ML) PA

BRAND PREFERRED TOBI PODHALER TOBRAMYCIN CAPSULE; WITH INHALATION

DEVICE PA SP

Generic Preferred Tobramycin Sulfate Tobramycin In

0.225% Nacl Ampul For

Nebulization (Ml) PA

BRAND PREFERRED XIFAXAN RIFAXIMIN TABLET

BRAND PREFERRED ZYVOX LINEZOLID SUSPENSION;

RECONSTITUTED

; ORAL (ML) PA

BRAND PREFERRED ZYVOX LINEZOLID TABLET PA

ANTIPARASITICS

BRAND PREFERRED ALBENZA ALBENDAZOLE TABLET

BRAND PREFERRED ALINIA NITAZOXANIDE SUSPENSION;

RECONSTITUTED

; ORAL (ML)

BRAND PREFERRED ALINIA NITAZOXANIDE TABLET

Generic Preferred Atovaquone Atovaquone Suspension; Oral (Final Dose Form)

BRAND NON-

PREFERRED BILTRICIDE PRAZIQUANTEL TABLET PA

Allow to bypass denial if provider inserts ICD-9 diagnosis code of 120.9

BRAND GENERIC

AVAILABLE FLAGYL METRONIDAZOLE CAPSULE

BRAND GENERIC

AVAILABLE FLAGYL METRONIDAZOLE TABLET

generic preferred mebendazole mebendazole tablet; chewable BRAND GENERIC

AVAILABLE MEPRON ATOVAQUONE SUSPENSION;

ORAL (FINAL

DOSE FORM)

Generic Preferred Metronidazole Metronidazole Capsule

Generic Preferred Metronidazole Metronidazole Tablet

Generic Preferred Paromomycin Sulfate Paromomycin

Sulfate Capsule

BRAND PREFERRED STROMECTOL IVERMECTIN TABLET

BRAND GENERIC

AVAILABLE TINDAMAX TINIDAZOLE TABLET

Generic Preferred Tinidazole Tinidazole Tablet

ANTIMALARIALS

BRAND GENERIC

AVAILABLE ARALEN PHOSPHATE CHLOROQUINE

PHOSPHATE TABLET

Generic Preferred Atovaquone-Proguanil

Hcl Atovaquone/Progu

anil Hcl Tablet

(24)

Generic Preferred Chloroquine

Phosphate Chloroquine

Phosphate Tablet

BRAND PREFERRED COARTEM ARTEMETHER/LU

MEFANTRINE TABLET

BRAND PREFERRED DARAPRIM PYRIMETHAMINE TABLET

Generic Preferred Hydroxychloroquine

Sulfate Hydroxychloroquine

Sulfate Tablet

BRAND GENERIC

AVAILABLE MALARONE ATOVAQUONE/PR

OGUANIL HCL TABLET

Generic Preferred Mefloquine Hcl Mefloquine Hcl Tablet BRAND GENERIC

AVAILABLE PLAQUENIL HYDROXYCHLORO

QUINE SULFATE TABLET

BRAND GENERIC

AVAILABLE QUALAQUIN QUININE SULFATE CAPSULE

Generic Preferred Quinine Sulfate Quinine Sulfate Capsule

ANTIMYCOBACTERIALS

Generic Preferred Ethambutol Hcl Ethambutol Hcl Tablet

Generic Preferred Isonarif Rifampin/Isoniazid Capsule

Generic Preferred Isoniazid Isoniazid Tablet

Generic Preferred Isoniazid Isoniazid Solution; Oral

BRAND GENERIC

AVAILABLE MYAMBUTOL ETHAMBUTOL

HCL TABLET

BRAND PREFERRED MYCOBUTIN RIFABUTIN CAPSULE

BRAND PREFERRED PRIFTIN RIFAPENTINE TABLET

Generic Preferred Pyrazinamide Pyrazinamide Tablet

BRAND GENERIC

AVAILABLE RIFADIN RIFAMPIN CAPSULE

BRAND GENERIC

AVAILABLE RIFAMATE RIFAMPIN/ISONIA

ZID CAPSULE

Generic Preferred Rifampin Rifampin Capsule

BRAND PREFERRED SIRTURO BEDAQUILINE

FUMARATE TABLET

(25)

BRAND/

ANTINEOPLASTIC & IMMUNOSUPPRESANT DRUGS ALKYLATING AGENTS

BRAND PREFERRED ALKERAN MELPHALAN TABLET SP

BRAND PREFERRED CEENU LOMUSTINE CAPSULE SP

Generic Preferred Cyclophosphamide Cyclophosphamide Tablet

BRAND PREFERRED LEUKERAN CHLORAMBUCIL TABLET SP

BRAND PREFERRED LOMUSTINE LOMUSTINE CAPSULE

BRAND PREFERRED MYLERAN BUSULFAN TABLET SP

BRAND GENERIC

AVAILABLE TEMODAR TEMOZOLOMIDE CAPSULE SP

Generic Preferred Temozolomide Temozolomide Capsule SP

ANTIMETABOLITES

Generic Preferred Capecitabine Capecitabine Tablet PA SP

Generic Preferred Mercaptopurine Mercaptopurine Tablet

Generic Preferred Methotrexate Methotrexate

Sodium Tablet

Generic Preferred Methotrexate Methotrexate

Sodium Tablet; Dose Pack Generic Preferred Methotrexate Sodium Methotrexate

Sodium Tablet

BRAND PREFERRED OFORTA FLUDARABINE

PHOSPHATE TABLET

BRAND GENERIC

AVAILABLE PURINETHOL MERCAPTOPURINE TABLET

BRAND PREFERRED TABLOID THIOGUANINE TABLET SP

BRAND PREFERRED TREXALL METHOTREXATE

SODIUM TABLET

BRAND GENERIC

AVAILABLE XELODA CAPECITABINE TABLET PA SP

(26)

HORMONES

BRAND GENERIC

AVAILABLE MEGACE MEGESTROL

ACETATE

SUSPENSION;

ORAL (FINAL

DOSE FORM)

Generic Preferred Megestrol Acetate Megestrol Acetate Suspension; Oral

(Final Dose Form) Generic Preferred Megestrol Acetate Megestrol Acetate Tablet

ANTIESTROGENS

Generic Preferred Anastrozole Anastrozole Tablet

BRAND GENERIC

AVAILABLE ARIMIDEX ANASTROZOLE TABLET

BRAND GENERIC

AVAILABLE AROMASIN EXEMESTANE TABLET SP

Generic Preferred Exemestane Exemestane Tablet SP

BRAND PREFERRED FARESTON TOREMIFENE

CITRATE TABLET SP

BRAND GENERIC

AVAILABLE FEMARA LETROZOLE TABLET

Generic Preferred Letrozole Letrozole Tablet

Generic Preferred Tamoxifen Citrate Tamoxifen Citrate Tablet

ANTIANDROGENS

Generic Preferred Bicalutamide Bicalutamide Tablet

BRAND GENERIC

AVAILABLE CASODEX BICALUTAMIDE TABLET

Generic Preferred Flutamide Flutamide Capsule

BRAND PREFERRED NILANDRON NILUTAMIDE TABLET SP

BRAND PREFERRED XTANDI ENZALUTAMIDE CAPSULE SP

BRAND PREFERRED ZYTIGA ABIRATERONE

ACETATE TABLET SP

(27)

BRAND/

IMMUNOSUPPRESSANT DRUGS

BRAND PREFERRED AZASAN AZATHIOPRINE TABLET

Generic Preferred Azathioprine Azathioprine Tablet

BRAND PREFERRED CELLCEPT MYCOPHENOLATE

MOFETIL

SUSPENSION;

RECONSTITUTED

AVAILABLE CELLCEPT MYCOPHENOLATE

MOFETIL TABLET

BRAND GENERIC

AVAILABLE CELLCEPT MYCOPHENOLATE

MOFETIL CAPSULE

Generic Preferred Cyclosporine Cyclosporine Capsule

Generic Preferred Cyclosporine Cyclosporine Solution; Oral

Generic Preferred Cyclosporine Cyclosporine;

Modified Capsule

Generic Preferred Cyclosporine Cyclosporine;

Modified Solution; Oral Generic Preferred Gengraf Cyclosporine;

Modified Capsule

Generic Preferred Hecoria Tacrolimus Capsule

BRAND GENERIC

AVAILABLE IMURAN AZATHIOPRINE TABLET

Generic Preferred Mycophenolate

Mofetil Mycophenolate

Mofetil Tablet

Generic Preferred Mycophenolate

Mofetil Mycophenolate

Mofetil Capsule

Generic Preferred Mycophenolic Acid Mycophenolate

Sodium Tablet; Enteric

Coated

BRAND GENERIC

AVAILABLE MYFORTIC MYCOPHENOLATE

SODIUM

TABLET;

ENTERIC

COATED

BRAND GENERIC

AVAILABLE PROGRAF TACROLIMUS CAPSULE

BRAND PREFERRED RAPAMUNE SIROLIMUS SOLUTION; ORAL SP

BRAND PREFERRED RAPAMUNE SIROLIMUS TABLET SP

(28)

Generic Preferred Sirolimus Sirolimus Tablet

Generic Preferred Tacrolimus Tacrolimus Capsule

BRAND PREFERRED ZORTRESS EVEROLIMUS TABLET SP

MISCELLANEOUS ANTINEOPLASTIC DRUGS

BRAND PREFERRED AFINITOR EVEROLIMUS TABLET SP

BRAND PREFERRED AFINITOR DISPERZ EVEROLIMUS TABLET FOR

SUSPENSION SP

BRAND PREFERRED BOSULIF BOSUTINIB TABLET SP

BRAND PREFERRED CAPRELSA VANDETANIB TABLET SP

BRAND PREFERRED DROXIA HYDROXYUREA CAPSULE

BRAND PREFERRED EMCYT ESTRAMUSTINE

PHOSPHATE

SODIUM CAPSULE SP

BRAND PREFERRED ERIVEDGE VISMODEGIB CAPSULE SP

Generic Preferred Etoposide Etoposide Capsule

BRAND PREFERRED GILOTRIF AFATINIB

DIMALEATE TABLET SP

BRAND PREFERRED GLEEVEC IMATINIB

MESYLATE TABLET SP

BRAND PREFERRED HEXALEN ALTRETAMINE CAPSULE SP

BRAND PREFERRED HYCAMTIN TOPOTECAN HCL CAPSULE SP

BRAND GENERIC

AVAILABLE HYDREA HYDROXYUREA CAPSULE

Generic Preferred Hydroxyurea Hydroxyurea Capsule

BRAND PREFERRED IMBRUVICA IBRUTINIB CAPSULE PA SP

BRAND PREFERRED INLYTA AXITINIB TABLET SP

(29)

BRAND/

BRAND PREFERRED IRESSA GEFITINIB TABLET SP

BRAND PREFERRED JAKAFI RUXOLITINIB

PHOSPHATE TABLET SP

BRAND PREFERRED LYSODREN MITOTANE TABLET SP

BRAND PREFERRED MATULANE PROCARBAZINE

HCL CAPSULE SP

BRAND PREFERRED MEKINIST TRAMETINIB

DIMETHYL

SULFOXIDE TABLET SP

BRAND PREFERRED NEXAVAR SORAFENIB

TOSYLATE TABLET SP

BRAND PREFERRED POMALYST POMALIDOMIDE CAPSULE SP

BRAND PREFERRED REVLIMID LENALIDOMIDE CAPSULE SP

BRAND PREFERRED SIGNIFOR PASIREOTIDE

DIASPARTATE AMPUL (ML) SP

BRAND PREFERRED SPRYCEL DASATINIB TABLET SP

BRAND PREFERRED STIVARGA REGORAFENIB TABLET SP

BRAND PREFERRED SUTENT SUNITINIB

MALATE CAPSULE SP

BRAND PREFERRED TAFINLAR DABRAFENIB

MESYLATE CAPSULE SP

BRAND PREFERRED TARCEVA ERLOTINIB HCL TABLET SP

BRAND PREFERRED TARGRETIN BEXAROTENE CAPSULE SP

BRAND PREFERRED TARGRETIN BEXAROTENE GEL (GRAM) SP

BRAND PREFERRED TASIGNA NILOTINIB HCL CAPSULE SP

BRAND PREFERRED THALOMID THALIDOMIDE CAPSULE SP

Generic Preferred Tretinoin Tretinoin Capsule SP

BRAND PREFERRED TYKERB LAPATINIB

DITOSYLATE TABLET PA SP

(30)

BRAND PREFERRED VANDETANIB VANDETANIB TABLET

BRAND PREFERRED VOTRIENT PAZOPANIB HCL TABLET SP

BRAND PREFERRED XALKORI CRIZOTINIB CAPSULE SP

BRAND PREFERRED ZELBORAF VEMURAFENIB TABLET SP

BRAND PREFERRED ZOLINZA VORINOSTAT CAPSULE SP

BRAND PREFERRED ZYKADIA CERITINIB TABLET

SP; 140 capsules per 28 days (5 capsules per day)

ADJUNCTIVE AGENTS

Generic Preferred Leucovorin Calcium Leucovorin

Calcium Tablet

BRAND PREFERRED MESNEX MESNA TABLET SP

AUTONOMIC & CNS DRUGS, NEUROLOGY, & PSYCH NARCOTIC ANALGESICS

NARCOTICS

BRAND GENERIC

AVAILABLE ACTIQ FENTANYL

CITRATE LOZENGE ON A

HANDLE

BRAND GENERIC

AVAILABLE AVINZA MORPHINE

SULFATE

CAPSULE;

EXTENDED RELEASE MULTIPHASE 24HR

1/day

Generic Preferred Buprenorphine

Hydrochloride Buprenorphine Hcl Tablet; Sublingual PA Generic Preferred Codeine Sulfate Codeine Sulfate Tablet

BRAND GENERIC

AVAILABLE DEMEROL MEPERIDINE HCL TABLET

BRAND GENERIC

AVAILABLE DILAUDID HYDROMORPHON

E HCL TABLET

BRAND GENERIC

AVAILABLE DILAUDID HYDROMORPHON

E HCL LIQUID (ML)

Generic Preferred Diskets Methadone Hcl Tablet; Soluble

BRAND GENERIC

AVAILABLE DOLOPHINE HCL METHADONE HCL TABLET

(31)

BRAND/

AVAILABLE DURAGESIC FENTANYL PATCH;

TRANSDERMAL

72 HOURS patch 12/28 days BRAND GENERIC

AVAILABLE EXALGO HYDROMORPHONE

ER TABLET 3/day

Generic Preferred Fentanyl Fentanyl Patch;

Transdermal 72

Hours patch 12/28 days Generic Preferred Fentanyl Citrate Fentanyl Citrate Lozenge On A

Handle

Generic Preferred Hydromorphone Hcl Hydromorphone

Hcl Suppository;

Rectal

Hcl Liquid (Ml)

Hcl Tablet

Generic Preferred Hydromorphone Hcl

ER Hydromorphone

Hcl Tablet 3/day

BRAND GENERIC

AVAILABLE KADIAN MORPHINE

SULFATE

CAPSULE;

EXTENDED RELEASE PELLETS

PA 2/day

Generic Preferred Levorphanol Tartrate Levorphanol

Tartrate Tablet

Generic Preferred Meperidine Hcl Meperidine Hcl Cartridge (Ml)

Generic Preferred Meperitab Meperidine Hcl Tablet

Generic Preferred Methadone Hcl Methadone Hcl Concentrate; Oral

Generic Preferred Methadone Hcl Methadone Hcl Solution; Oral

Generic Preferred Methadone Hcl Methadone Hcl Tablet

Generic Preferred Methadone Hcl Methadone Hcl Tablet; Soluble

Generic Preferred Methadose Methadone Hcl Tablet

Generic Preferred Methadose Methadone Hcl Concentrate; Oral

Generic Preferred Methadose Methadone Hcl Tablet; Soluble

Generic Preferred Morphine Sulfate Morphine Sulfate Solution; Oral

(32)

Generic Preferred Morphine Sulfate Morphine Sulfate Tablet; Extended

Release

Generic Preferred Morphine Sulfate Morphine Sulfate Suppository;

Rectal

Generic Preferred Morphine Sulfate Morphine Sulfate Cartridge (Ml)

Generic Preferred Morphine Sulfate Morphine Sulfate Tablet

Generic Preferred Morphine Sulfate Er Morphine Sulfate Capsule;

Extended Release

Pellets 2/day

Generic Preferred Morphine Sulfate Er Morphine Sulfate Tablet; Extended

Release 3/day

Generic Preferred Morphine Sulfate Er Morphine Sulfate Capsule;

Extended Release

Multiphase 24hr 1/day BRAND GENERIC

AVAILABLE MS CONTIN MORPHINE

SULFATE

TABLET;

EXTENDED

RELEASE 3/day

BRAND GENERIC

AVAILABLE OPANA OXYMORPHONE

HCL TABLET 4/day

BRAND PREFERRED OPANA ER OXYMORPHONE

HCL

TABLET;

EXTENDED

RELEASE 12 HR PA 2/day BRAND GENERIC

AVAILABLE ORAMORPH SR MORPHINE SULFATE

TABLET;

EXTENDED

RELEASE PA

Generic Preferred Oxycodone Hcl Oxycodone Hcl Capsule

Generic Preferred Oxycodone Hcl Oxycodone Hcl Concentrate; Oral

Generic Preferred Oxycodone Hcl Oxycodone Hcl Solution; Oral

Generic Preferred Oxycodone Hcl Oxycodone Hcl Tablet

Generic Preferred Oxycodone controlled

release ER Oxycodone Hcl Tablet; Extended

Release 12 Hr 3/day

BRAND GENERIC

AVAILABLE OXYCONTIN OXYCODONE HCL TABLET;

EXTENDED

RELEASE 12 HR PA 3/day Generic Preferred Oxymorphone Hcl Oxymorphone Hcl Tablet 4/day

Generic Preferred Oxymorphone Hcl Er Oxymorphone Hcl Tablet; Extended

Release 12 Hr PA 2/day BRAND GENERIC

AVAILABLE ROXICODONE OXYCODONE HCL TABLET

(33)

BRAND/

AVAILABLE SUBUTEX BUPRENORPHINE

HCL TABLET;

SUBLINGUAL

COMBINATION NARCOTIC /ANALGESICS

Generic Preferred Acetaminophen

W/Butalbital Butalbital/

Acetaminophen Tablet

W/Codeine Acetaminophen

With Codeine Elixir

With Codeine Solution; Oral Generic Preferred Acetaminophen

With Codeine Tablet

Generic Preferred Alagesic Lq Butalb/

Acetaminophen/

Caffeine Solution; Oral Generic Preferred Apap-Caffeine-

Dihydrocodeine

Dhcodeine Bt/Acetaminophn/

Caff Tablet

Generic Preferred Asa-Butalb-Caff-Cod Codeine/Butalbital

/Asa/Caffein Capsule

Generic Preferred Ascomp With Codeine Codeine/Butalbital

/Asa/Caffein Capsule

Generic Preferred Aspirin-Caffeine-

Dihydrocodein Dihydrocodeine/

Aspirin/Caffeine Capsule

Generic Preferred Bupap Butalbital/

Generic Preferred Butalbital Compound Butalbital/Aspirin/

Caffeine Capsule

Generic Preferred Butalbital Compound Butalbital/Aspirin/

Caffeine Tablet

Generic Preferred Butalbital Compound W/Codeine

Codeine/

Butalbital/Asa/

Caffeine Capsule

Generic Preferred Butalbital/Apap/

Caffeine

Butalb/

Acetaminophen/

Caffeine Capsule

Generic Preferred Butalbital/Apap/

Caffeine

Butalb/

Acetaminophen/

Caffeine Tablet

Generic Preferred Butalbital/Caff/Apap/

Codeine

Butalbit/

Acetamin/Caff/

Codeine Capsule

Generic Preferred Butalbital-Asp-

Caffeine Butalbital/Aspirin/

Caffeine Tablet

Generic Preferred Butalbital-Asp-

Caffeine Butalbital/Aspirin/

Caffeine Capsule

(34)

Generic Preferred Capacet Butalb/Acetamino

phen/Caffeine Capsule

Generic Preferred Cephadyn Butalbital/Acetami

nophen Tablet

Generic Preferred Cocet Acetaminophen

With Codeine Tablet

Generic Preferred Co-Gesic Hydrocodone/

Generic Preferred Endocet Oxycodone Hcl/

Generic Preferred Endodan Oxycodone

Hcl/Aspirin Tablet

BRAND GENERIC

AVAILABLE ESGIC BUTALB/

ACETAMINOPHEN

CAFFEINE TABLET

BRAND GENERIC

AVAILABLE ESGIC BUTALB/

ACETAMINOPHEN

CAFFEINE CAPSULE

BRAND GENERIC

AVAILABLE ESGIC-PLUS BUTALB/ACETAMI NOPHEN/

CAFFEINE CAPSULE

BRAND GENERIC

AVAILABLE ESGIC-PLUS BUTALB/

ACETAMINOPHEN

/CAFFEINE TABLET

BRAND GENERIC

AVAILABLE FIORICET BUTALB/

ACETAMINOPHEN

/CAFFEINE TABLET

BRAND GENERIC

AVAILABLE FIORICET BUTALB/

ACETAMINOPHEN

/CAFFEINE CAPSULE

BRAND GENERIC

AVAILABLE FIORICET WITH CODEINE

BUTALBIT/

ACETAMIN/CAFF/

CODEINE CAPSULE

BRAND GENERIC

AVAILABLE FIORINAL BUTALBITAL/

ASPIRIN/

CAFFEINE CAPSULE

BRAND GENERIC

AVAILABLE FIORINAL W/CODEINE

CODEINE/

BUTALBITAL/ASA

/CAFFEIN CAPSULE

BRAND GENERIC

AVAILABLE HYCET HYDROCODONE/

ACETAMINOPHEN SOLUTION; ORAL Generic Preferred Hydrocodone Bit-

Ibuprofen Hydrocodone/

Ibuprofen Tablet

Generic Preferred Hydrocodone

W/Acetaminophen Hydrocodone/

Acetaminophen Capsule

Generic Preferred Hydrocodone

Acetaminophen Solution; Oral

(35)

BRAND/

STATUS TRADE NAME GENERIC NAME DOSE DESCRIPTION PA ST QL/SP COMMENTS Generic Preferred Hydrocodone

Generic Preferred Hydrogesic Hydrocodone/

BRAND GENERIC

AVAILABLE IBUDONE HYDROCODONE/

IBUPROFEN TABLET

BRAND GENERIC

AVAILABLE LORCET 10-650 HYDROCODONE/

ACETAMINOPHEN TABLET

BRAND GENERIC

AVAILABLE LORCET PLUS HYDROCODONE/

BRAND GENERIC

AVAILABLE LORTAB HYDROCODONE/

BRAND GENERIC

AVAILABLE LORTAB HYDROCODONE/

ACETAMINOPHEN SOLUTION; ORAL Generic Preferred Margesic Butalb/Acetamino

phen/Caffeine Capsule

Generic Preferred Marten-Tab Butalbital/Acetami

nophen Tablet

BRAND GENERIC

AVAILABLE MAXIDONE HYDROCODONE/

BRAND GENERIC

AVAILABLE NORCO HYDROCODONE/A

CETAMINOPHEN TABLET

Generic Preferred Oxycodone Hcl-

Ibuprofen Ibuprofen/

Oxycodone Hcl Tablet

Generic Preferred Oxycodone

W/Acetaminophen Oxycodone Hcl/

Generic Preferred Oxycodone

W/Acetaminophen Oxycodone Hcl/

Generic Preferred Oxycodone W/Aspirin Oxycodone Hcl/Aspirin Tablet

Generic Preferred Oxycodone W/Aspirin Oxycodone Hcl/ Oxycodon Ter/Asa Tablet

BRAND GENERIC

AVAILABLE PANLOR SS DHCODEINE

BT/ACETAMINOP

HN/CAFF TABLET

BRAND GENERIC

AVAILABLE PERCOCET OXYCODONE HCL/

BRAND GENERIC

AVAILABLE PERCODAN OXYCODONE

HCL/ASPIRIN TABLET

BRAND GENERIC

AVAILABLE PHRENILIN BUTALBITAL/

(36)

Generic Preferred Promacet Butalbital/

Generic Preferred Repan Butalb/

Acetaminophen/

Caffeine Tablet

Generic Preferred Reprexain Hydrocodone/

Ibuprofen Tablet

Generic Preferred Roxicet Oxycodone Hcl/

Generic Preferred Sedapap Butalbital/

Generic Preferred Stagesic Hydrocodone/

Generic Preferred Tencon Butalbital/

Generic Preferred Trezix Dhcodeine

Bt/Acetaminophn/

Caff Capsule

BRAND GENERIC

AVAILABLE TYLENOL

W/CODEINE ACETAMINOPHEN

WITH CODEINE TABLET

BRAND GENERIC

AVAILABLE TYLOX OXYCODONE

HCL/ACETAMINOP

HEN CAPSULE

BRAND GENERIC

AVAILABLE VICODIN HYDROCODONE/A

CETAMINOPHEN TABLET

BRAND GENERIC

AVAILABLE VICODIN ES HYDROCODONE/A

CETAMINOPHEN TABLET

BRAND GENERIC

AVAILABLE VICODIN HP HYDROCODONE/A

CETAMINOPHEN TABLET

BRAND GENERIC

AVAILABLE VICOPROFEN HYDROCODONE/I

BUPROFEN TABLET

BRAND GENERIC

AVAILABLE XODOL HYDROCODONE/A

CETAMINOPHEN TABLET

Generic Preferred Xolox Oxycodone Hcl/

Generic Preferred Zamicet Hydrocodone/

Acetaminophen Solution; Oral

Generic Preferred Zerlor Dhcodeine

Bt/Acetaminophn/

Caff Tablet

NON-NARCOTIC ANALGESICS NSAIDS

BRAND GENERIC

AVAILABLE ANAPROX NAPROXEN

SODIUM TABLET

(37)

BRAND/

AVAILABLE ANAPROX DS NAPROXEN

SODIUM TABLET

BRAND GENERIC

AVAILABLE ANSAID FLURBIPROFEN TABLET

BRAND GENERIC

AVAILABLE ARTHROTEC DICLOFENAC

SODIUM/

MISOPROSTOL

TABLET;IMMEDI ATE & DELAY REL;

MULTIPHASIC

PA 4 tabs/day

BRAND GENERIC

AVAILABLE CATAFLAM DICLOFENAC

POTASSIUM TABLET

BRAND GENERIC

AVAILABLE CLINORIL SULINDAC TABLET

BRAND GENERIC

AVAILABLE DAYPRO OXAPROZIN TABLET

Generic Preferred Diclofenac Potassium Diclofenac

Potassium Tablet

Generic Preferred Diclofenac Sodium Diclofenac Sodium Tablet; Extended

Release 24 Hr Generic Preferred Diclofenac Sodium Diclofenac Sodium Tablet; Enteric

Coated

Generic Preferred Diclofenac Sodium- Misoprostol

Diclofenac Sodium/

Misoprostol

Tablet;Immediate

& Delay

Rel;Multiphasic PA 4 tabs/day BRAND GENERIC

AVAILABLE EC-NAPROSYN NAPROXEN TABLET;

ENTERIC

COATED

Generic Preferred Etodolac Etodolac Capsule

Generic Preferred Etodolac Etodolac Tablet

Generic Preferred Etodolac Etodolac Tablet; Extended

Release 24 Hr BRAND GENERIC

AVAILABLE FELDENE PIROXICAM CAPSULE

Generic Preferred Fenoprofen Calcium Fenoprofen

Calcium Tablet

Generic Preferred Flurbiprofen Flurbiprofen Tablet

Generic Preferred Ibuprofen Ibuprofen Suspension; Oral

(Final Dose Form)

Generic Preferred Ibuprofen Ibuprofen Tablet

Generic Preferred Indomethacin Indomethacin Capsule;

Extended Release

Preferred Drug List. (List of Covered Drugs) This document includes Passport Health Plan s complete 2015 formulary.