Preferred Drug List
|
DRUG CATEGORY |
Preferred |
Non-Preferred |
|
|
|
Generic
Copayment Preferred Brand-Name Copayment |
Non-Preferred
Brand-Name Copayment |
|
|
ANTI-ULCER DRUGS |
|||
|
H2
Antagonists Note: Most plans allow coverage of Over-the Counter (OTC) products. |
cimetidine ranitidine |
All other brands |
|
|
Proton Pump Inhibitors |
Prevacid® |
AcipHex® Prilosec® |
|
|
ANTIDIABETIC AGENTS |
|||
|
Insulin
Secreting Generics include: glyburide, glipizide, chlorpropamide, etc |
Any
Generic Glucotrol XL® |
Amaryl® Prandin® |
|
|
Insulin
Sensitizing (Biguanides) (Thiazolidinediones) |
Glucophage® Actos®, Avandia® |
|
|
|
Carbohydrate Absorption Inhibitors |
Precose® |
Glyset® |
|
|
CARDIOVASCULAR AGENTS |
|||
|
ACE Inhibitors |
captopril Zestril® Univasc®
Lotensin® Accupril® |
Altace® Mavik® Prinivil® Vasotec® Monopril® |
|
|
Alpha
Blockers Generics
Include: prazosin and terazosin |
Cardura® |
|
|
|
Angiotensin II Receptor Antagonists |
Diovan® Diovan HCT® Avapro®, Avalide® |
Cozaar®,
Atacand® Hyzaar® Micardis® |
|
|
Calcium
Channel
Blockers Generics
include: nifedipine, verapamil, verapamil SR, diltiazem, diltiazem XR |
Any
Generic
Adalat
CC® Norvasc® Sular®
Tiazac® |
Cardene
SR® Verelan®
Cardizem
CD®
Covera
HS® Dynacirc® Dynacirc
CR®
Plendil® Procardia XL® |
|
|
Combination Antihypertensives |
Lotrel® |
Lexxel® Tarka® Teczem CR® |
|
|
Lipotropics (HMG CoA Reductase Inhibitors) |
Lescol®
(Low
Potency) Baycol®
(Medium
Potency) Lipitor® (High Potency) |
Mevacor® Pravachol® Zocor® |
|
|
DRUG CATEGORY |
Preferred |
Non-Preferred |
|
|
ANTIDEPRESSANTS |
|||
|
(SSRIs) Generics include: amitriptyline, desipramine, nortriptyline, trazodone, etc. |
Any
Generic Celexa® Paxil® Zoloft® |
Luvox® Prozac® |
|
|
(Other) |
Any
Generic Serzone® Wellbutrin®* *Some plans require pre-authorization for Wellbutrin |
Effexor® Effexor XR® Remeron® |
|
|
RESPIRATORY AGENTS |
|||
|
Nasal Steroids |
Vancenase® Beconase® Flonase® Nasonex® |
Nasacort/AQ® Nasalide® Nasarel® Rhinocort® |
|
|
Inhaled Steroids |
Beclovent®
Flovent® Vanceril DS® |
Aerobid/M® Azmacort® Pulmicort® |
|
|
Inhaled
Beta-2
Agonists Generics include: albuterol |
Any
Generic
Maxair
Autohaler® Proventil HFA® Serevent ® (long acting) |
Brethaire®
Tornalate® Xopenex®
|
|
Antihistamines
(Non-Sedating) (Low-Sedating) (Low-Sedating) |
Allegra®,
Claritin® Zyrtec® |
|
|
|
Anti-Leukotrienes |
Accolate® Singulair® |
Zyflo® |
|
|
PAIN MANAGEMENT DRUGS |
|||
|
Nonsteroidal
Anti-Inflammatory
Drugs Generics
include:
ibuprofen indomethacin, naproxen, etc. |
Any
Generic
Relafen® Celebrex® (for arthritis) |
Arthrotec®
Daypro® Vioxx® Lodine
XL® Naprelan® Oruvail® Ponstel® |
|
Anti-Migraine
Drugs
|
Imitrex® Zomig® Migranal® |
Amerge®
Maxalt® |
|
|
DRUG CATEGORY |
Preferred |
Non-Preferred |
|
|
WOMEN’S HEALTHCARE PRODUCTS |
|||
|
Oral
Contraceptives Note:
Some
plans
limit
coverage
to Preferred products |
Monophasic
Alesse® Loestrin/Fe® Lo-Ovral®
Nordette® Ortho-Cept®
Ortho-Cyclen®
Triphasic
Estrostep
Fe®
Ortho-Novum
7/7/7®,
Ortho-Tricyclen® Triphasil® Progestin
Only
Micronor® |
All Other Brands |
|
|
Hormone
Replacement
Therapy (Oral) Generics include: estropipate, estradiol, etc. |
Any
Generic Premarin® Premphase® Prempro® |
Estinyl® Estratest®
Cenestin® All Other Brands |
|
|
(Topical) |
Climara® |
Alora®
FemPatch® Vivelle® CombiPatch® |
|
|
ANTI-INFECTIVES |
|
|
|
|
Cephalosporins Generics include: cefaclor, cefadroxil, cephalexin, cephradine |
Any
Generic Cedax®,
Ceftin® Suprax® Vantin® |
Ceclor
CD® Keftab® Cefzil® Lorabid® |
|
|
Macrolides |
erythromycin Zithromax® |
Biaxin® |
|
Quinolones
|
Cipro® Levaquin® |
Floxin® Maxaquin® Penetrex® Zagam® |
|
|
Antivirals
|
acyclovir Famvir® |
Valtrex® |
|
|
|
|
Prescriptions greater than one month’s supply may be subject to multiple copayments. This
Preferred
Drug
List
is
overridden
by
specific
plan
design
features
and
may
change
without
notice. Generic drugs are listed in italics |