1199SEIUPreferred Drug ListPlease take this guide with you the next time you visit your doctor.

© 2019 Express Scripts. All Rights Reserved. Express Scripts and the “E” Logo are trademarks of Express Scripts Strategic Development, Inc. All other trademarks are the property of their respective owners.

If you have questions about your prescription plan, visit express-scripts.com or call Express Scripts Member Services at (800) 818-6720.

For questions about your 1199SEIU benefits, call the 1199SEIU Benefit Funds’ Member Services Representatives at (646) 473-9200.

CRPXXX EME50443 MG48511O (Ed. 04/01/2019)

Express Scripts manages your prescription benefit for the 1199SEIU Benefit Funds.

1

Section II provides a listing of nonpreferred brands and their possible preferred alternatives. KEYG = Preferred generic medication.P = Preferred brand-name medication.

SAFETY CONSIDERATION SYMBOLSHere is a quick guide that explains our safety symbols. These symbols appear next to certain medications.

Weigh the risk of birth defects or other adverse outcomes.

Do not use during pregnancy.

PRESCRIPTION PROGRAM CONSIDERATION SYMBOLSFor more information, please call Express Scripts at (800) 753-2851.

[PA] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.

[QD] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.

OTHER SYMBOLS:

[AC] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo. Please call Accredo at (800) 803-2523.

[PICA] This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

Shaded areas indicate the most recent additions to the Preferred Drug List.

Information was in effect at the time of printing and may be subject to change.

For the most up-to-date 1199SEIU Benefit Funds Preferred Drug List, go to www.1199SEIUBenefits.org.

Drugs Not Covered by the 1199SEIU Benefit Funds

Cosmetic Drugs

Non-sedating Antihistamines

Fertility Drugs

Over-the-Counter Drugs (except for diabetic supplies) or as mandated by PPACA legislation

Investigational/Experimental Drugs

Select Cough & Cold Drugs

Erectile Dysfunction Drugs

Please refer to your Summary Plan Description for a complete list of excluded drugs.

[PA] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.[QD] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.[AC] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo.

Please call (800) 803-2523.[PICA] This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program

called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

G = Preferred generic medication.P = Preferred brand-name medication. = Weigh the risk of birth defects or

other adverse outcomes. = Do not use during pregnancy.

Key:

2

G abiraterone acetate 250mg tablet [AC/PA/QD/PICA]

G bicalutamide [PICA]

G flutamide [PICA]G nilutamide [PICA]P Xtandi [AC/PA/QD/PICA]

P Zytiga 500mg tablet [AC/PA/QD/PICA]

AntiAnDrogens (effective 3-1-11)

G cortisone acetateG dexamethasone tablet, dose packG fludrocortisone acetate

G hydrocortisoneG methylprednisoloneG prednisolone

G prednisolone sodium phosphateG prednisone

ADrenAl hormones (effective 3-1-11)

G donepezil G galantamine G memantine

G memantine ER G rivastigmine P Exelon Solution

P Namenda Dose Pak P Namzaric

AlZheimer’s Agents (effective 1-1-16)

G carbamazepineG carbamazepine XRG clobazamG clonazepamG diazepam kitG divalproex sodiumG divalproex sodium ERG divalproex sodium sprinklesG ethosuximideG felbamateG gabapentinG lamotrigineG lamotrigine dosepak

G lamotrigine ODTG lamotrigine XRG levetiracetamG levetiracetam XRG oxcarbazepineG phenobarbitalG phenytoin chewable tabletG phenytoin extended-releaseG phenytoin suspensionG primidoneG RoweepraG tiagabineG topiramate [PA]

G valproic acidG zonisamideP Banzel TabletP CelontinP DiastatP Dilantin 30mgP Epidiolex [AC/PA]P Lyrica [QD]P Lyrica CR [QD] P PeganoneP Vimpat

AnticonvulsAnts (effective 7-1-10)

Section I: TheRapeUtic DRUg CategoRies

Oral Acne Therapy(effective 10-1-17)G ClaravisG MyorisanG ZenataneTopical Acne Therapy(effective 1-1-09)G adapaleneG adapalene/benzoyl peroxideG azelaic acid gelG clindamycin/benzoyl peroxide

G clindamycin phosphate G clindamycin phosphate/tretinoin [PA]G erythromycin base/benzoyl

peroxideG erythromycin base/ethyl alcohol G erythromycin base/ethyl alcohol gelG erythromycin base/ ethyl alcohol

swabsG metronidazole cream, gel, lotion G Neuac Gel G sulfacetamide sodium/sulfur G sulfacetamide sodium/sulfur/urea

G tazarotene 0.1% cream [PA]G tretinoin [PA]G tretinoin microspheres [PA]P Azelex P Finacea foam

Acne therApy

G ClaravisG ClaravisG MyorisanG MyorisanG ZenataneG Zenatane

[pa] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.[qd] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.[ac] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo.

Please call (800) 803-2523.[pica] This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program

called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

G = Preferred generic medication.P = Preferred brand-name medication. = Weigh the risk of birth defects or

other adverse outcomes. = Do not use during pregnancy.

Key:

3

Antipsoriatic/Antiseborrheic Topical AgentsG calcipotrieneG calcipotriene/betamethasone

G calcitriol ointmentG Drithocreme HPG hydrocortisone acetate/

pramoxineG selenium sulfide

G sodium sulfacetamideP EnstilarP PramosoneP Pramosone E

AntipsoriAtic/Antiseborrheic (Updated 1-1-17)

Oral PenicillinsG amoxicillin trihydrateG amoxicillin trihydrate/

potassium clavulanate, ERG amoxicillin trihydrate/

potassium clavulanate chewableG amoxicillin trihydrate/

potassium clavulanate suspensionG ampicillin trihydrateG dicloxacillin sodiumG penicillin v potassiumP Augmentin Suspension

125 - 31.25mg/5mlOral TetracyclinesG demeclocycline HClG doxycycline hyclate capsuleG doxycycline hyclate enteric coated tabletG doxycycline hyclate tabletG doxycycline monohydrateG minocycline HCl

G minocycline HCl ER tablet 65mg, 115mg

G minocycline XRG tetracycline HClOral CephalosporinsG cefaclorG cefaclor ERG cefadroxil hydrateG cefdinirG cefditoren pivoxilG cefixime suspensionG cefpodoxime proxetil G cefprozilG ceftibutenG cefuroxime axetil G cephalexin monohydrateP Ceftin SuspensionOral Erythromycins and other MacrolidesG azithromycinG clarithromycin

G clarithromycin ERG erythromycin baseG erythromycin ethylsuccinate tabletG erythromycin ethylsuccinate

suspension 200mg/5mlG erythromycin ethylsuccinate/

sulfisoxazole acetylG erythromycin stearateP DificidP Eryped SuspensionOral QuinolonesG ciprofloxacin ERG ciprofloxacin HCl tabletG ciprofloxacin suspensionG levofloxacinG moxifloxacinG ofloxacin

Antiinfectives (Antibiotics)

G alfuzosin HCl ERG doxazosinG dutasteride

G dutasteride-tamsulosinG finasterideG silodosin

G tamsulosin HClG terazosin

benign prostAte hyperplAsiA (bph) therApy

G aprepitant [QD/PICA]G ondansetron HCl [QD/PICA]G ondansetron ODT [QD/PICA]

G granisetron HCl [QD/PICA]P Emend 40mg capsule [QD/PICA]P Emend suspension [QD/PICA]

Antivertigo & Antiemetic Drugs (effective 4-1-10)

Injectable (effective 1-1-18)P Dupixent [PA/AC/PICA]

Topical (effective 1-1-18)G pimecrolimus cream

G tacrolimus ointmentP Eucrisa cream

Atopic DermAtitis

G amantadineG benztropineG bromocriptineG carbidopaG carbidopa/levadopaG carbidopa/levadopa ER

G carbidopa/levadopa/entacaponeG entacaponeG pramipexole Di-HClG pramipexole ERG rasagiline mesylate G ropinirole

G selegilineG tolcaponeG trihexylphenidylP Apokyn [AC]

AntipArkinsonism Agents (effective 1-1-10)

[pa] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.[qd] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.[ac] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo.

Please call (800) 803-2523.[pica] This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program

called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

G = Preferred generic medication.P = Preferred brand-name medication. = Weigh the risk of birth defects or

other adverse outcomes. = Do not use during pregnancy.

Key:

4

G darifenacin hydrobromideG flavoxateG oxybutynin chlorideG oxybutynin chloride ER

G tolterodine tartrateG tolterodine tartrate ERG trospium chlorideG trospium chloride ER

P MyrbetriqP Vesicare

Drugs to treAt overActive blADDer (Updated 3-1-14)

Beta BlockersG acebutolol HClG atenololG betaxolol HClG bisoprolol fumarateG carvedilolG carvedilol ERG labetalol HClG metoprolol succinate XLG metoprolol tartrateG nadololG pindololG propranolol HClG propranolol HCl capsule, sustained

action 24 hrG timolol maleateP HemangeolCalcium Channel BlockersG diltiazem HClG diltiazem HCl capsule, sustained

release 12 hrG diltiazem HCl capsule, sustained

release 24 hrG nimodipineG �verapamil ERG �verapamil ER PMG verapamil HClG �verapamil HCl capsule, 24 hr

sustained release pelletsDihydropyridinesG amlodipine besylateG felodipineG isradipineG nicardipineG nifedipine tablet, sustained actionG nifedipine tablet, sustained release

osmotic pushG nisoldipineACE InhibitorsG benazepril HClG captoprilG enalapril maleateG fosinopril sodiumG lisinoprilG moexipril HClG perindopril erbumineG quinaprilG ramipril capsules

G trandolaprilAngiotensin II BlockersG candesartan G candesartan/hydrochlorothiazide G eprosartan mesylateG irbesartan G irbesartan/hydrochlorothiazide G losartan/hydrochlorothiazide G losartan potassium G olmesartanG olmesartan/hydrochlorothiazideG telmisartan G telmisartan/hydrochlorothiazideG valsartan G valsartan/hydrochlorothiazide

Antilipidemics - Statin DrugsG amlodipine/atorvastatin [QD]G atorvastatin calcium [QD]G ezetimibe/simvastatin [QD] G fluvastatin [QD]G fluvastatin ER [QD]G lovastatin [QD]G pravastatin [QD]G rosuvastatin [QD] G simvastatin [QD]Other AntilipidemicsG colestipol HClG cholestyramine/aspartameG cholestyramine/sucroseG colesevelam tabletG colesevelam powder packet G ezetimibeG fenofibrateG fenofibrate, micronizedG fenofibrate, nanocrystalG fenofibric acidG gemfibrozilG niacin ERG omega-3 acid ethyl esters [PA]P ColestidP Juxtapid [PA/AC]Select Combination AntihypertensivesG amlodipine besylate/benazeprilG amlodipine/olmesartanG amlodipine/valsartanG amlodipine/valsartan/HCTZG atenolol/chlorthalidone

G benazepril HCl/HCTZG bisoprolol fumarate/

hydrochlorothiazideG captopril/hydrochlorothiazideG enalapril maleate/HCTZG fosinopril/hydrochlorothiazideG lisinopril/hydrochlorothiazideG methyldopa/hydrochlorothiazideG metoprolol/hydrochlorothiazideG metoprolol succinate/HCTZ ERG moexipril/hydrochlorothiazideG nadolol/bendroflumethiazideG olmesartan/amlodipine/

hydrochlorothiazideG propranolol/hydrochlorothiazideG quinapril/hydrochlorothiazideG telmisartan/amlodipineG trandolapril/verapamilLong-acting Nitrates (Topical)(effective 7-1-10)G nitroglycerin patches, ointmentAntiplatelet Agents (oral) (effective 7-1-10)G cilostazolG clopidogrel bisulfateG dipyridamoleG aspirin/dipyridamoleG prasugrel HClP BrilintaP ZontivityPCSK9 Inhibitors (effective 1-1-16)P Praluent Pen [PA/AC]P Praluent Syringe [PA/AC]P Repatha Pushtronex [PA/AC]P Repatha Sureclick [PA/AC]P Repatha Syringe [PA/AC]Anticoagulants (oral) (eff. 7-1-14)G warfarinP Eliquis P PradaxaP SavaysaP Xarelto

Antidotes (effective 1-1-16)P Praxbind

cArDiovAsculAr (Blood Pressure/Heart/Cholesterol)

Erythroid Stimulants(effective 3-1-14)P Aranesp [AC/PA/PICA]P Procrit [AC/PA/PICA]

Hereditary Angioedema (Updated 4-1-19)C1 Esterase InhibitorsP Berinert [AC/PA]P Cinryze [AC/PA]P Haegarda [AC/PA]

P Ruconest [AC/PA]Bradykinin Receptor AntagonistP Firazyr [AC/PA]Plasma Kallikrein InhibitorsP Kalbitor [AC/PA]P Takhzyro [AC/PA]

biotechnology Drugs

[pa] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.[qd] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.[ac] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo.

Please call (800) 803-2523.[pica] This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program

called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

G = Preferred generic medication.P = Preferred brand-name medication. = Weigh the risk of birth defects or

other adverse outcomes. = Do not use during pregnancy.

Key:

5

Insulin Therapy (Updated 1-1-18)Rapid ActingP AfrezzaP HumalogShort ActingP Humulin RP Humulin R KwikpenIntermediate ActingP Humulin NP Humulin N KwikpenP Humulin 70/30P Humulin 70/30 KwikpenP Humalog Mix 75-25P Humalog Mix 50-50Long ActingP LantusP Lantus SolostarP LevemirP Levemir FlextouchP Toujeo Max SolostarP Toujeo Solostar P Tresiba FlextouchOral Hypoglycemic Agents(Revised – effective 4-1-10)G acarboseG glimepirideG glipizideG glipizide ERG glipizide/metformin HCl [QD]G glyburideG glyburide/metforminG glyburide micronizedG metformin HClG metformin HCl ERG miglitol G nateglinideG pioglitazone HCl [QD]G pioglitazone/glimepiride [QD]G pioglitazone/metformin [QD]G repaglinideG repaglinide/metformin [QD]G tolazamideG tolbutamideP Avandamet [QD]P Avandaryl [QD]P Avandia [QD]Injectable Insulin/GLP-1 receptor agonist Combination (effective 10-1-17)P Soliqua SGLT2 - Sodium Glucose Co-transporter Agents (Updated 4-1-19)P Farxiga [QD] P Invokamet [QD]P Invokamet XR [QD]P Invokana [QD]P Jardiance [QD]P Synjardy [QD]P Synjardy XR [QD]P Xigduo XR [QD]

SGLT2/DPP-4 Inhibitor Combinations (effective 1-1-16)P GlyxambiInjectable Hypoglycemic Agents(GLP-1 receptor agonist)(Updated 10-1-18)P Bydureon [PA/QD]P Bydureon Bcise [PA/QD]P Bydureon Pen [PA/QD]P Byetta [PA/QD]P Ozempic [PA/QD]P Trulicity [PA/QD]DPP-4 Inhibitors(Updated 7-1-16)P JanumetP Janumet XRP JanuviaP Jentadueto [QD]P Jentadueto XR [QD]P Tradjenta [QD]Blood Glucose Test Strips (Updated 7-1-16)

P ACCU-CHEK Aviva Plus Test StripsP ACCU-CHEK Guide Test StripsP ACCU-CHEK SmartView Test StripP Breeze 2P Contour Next Test StripsP Contour Next One Test StripsP Contour Test StripsP True Metrix Glucose Test StripsBlood Glucose Monitoring Devices (Updated 7-1-16)P ACCU-CHEK Aviva PlusP ACCU-CHEK Guide Monitor

SystemP ACCU-CHEK Nano SmartViewP Contour Next EZ MonitorP Contour Next MeterP Contour Next MonitorP Contour Next One MeterP Contour Next One MonitorP Contour Next USB MeterP Contour Next USB MonitorP Contour USB MeterP True Metrix Blood Glucose MeterP True Metrix Air Glucose MeterP True Metrix Go MeterContinuous Glucose Monitoring (CGM) Systems (effective 1-1-19)P FreeStyle Libre systemContraceptive Agents(Updated 1-1-19)G AmethiaG Amethia LoG CryselleG FayosimG GianviG Gildess FEG Gildess 24 FEG Junel FE

G Lomedia 24 FEG LorynaG Mibelas 24 FEG MicrogestinG Microgestin FEG MononessaG NeconG Next ChoiceG Next Choice One DoseG norgestimate-ethinyl estradiolG norethindrone-e.estriadol-ironG OrsythiaG PrevifemG RajaniG RivelsaG SyedaG TrinessaG Trinessa LoG Tri-PrevifemG Wymzya FEG Xulane PatchG Zenchent FEP EllaP Lo Loestrin FEP NuvaringIntrauterine Devices/Subdermal Implants (effective 1-1-16)P Liletta [AC]P Nexplanon [AC]Estrogen Agents (oral/vaginal) (Updated 1-1-13)G estradiol cream, tabletsG estropipateG YuvafemP EstringP OsphenaEstrogen Patches (effective 7-1-09)G estradiolEndometriosis (effective 4-1-19)P Orilissa [PA]Oral/Transdermal Testosterone Replacement Agents(Updated 7-1-16)G methyltestosterone capsuleG testosterone gel in packet

25mg (1%), 50mg (1%), 1.25gm (1.62%), 2.5gm (1.62%) [PA]

G testosterone gel pump 1.25gm (1%), 10mg (2%) [PA]

G testosterone solution metered pump [PA]

P Androderm Patch [PA]P Methitest

enDocrine (Diabetes/Hormones/Contraceptive)

[pa] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.[qd] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.[ac] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo.

Please call (800) 803-2523.[pica] This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program

called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

G = Preferred generic medication.P = Preferred brand-name medication. = Weigh the risk of birth defects or

other adverse outcomes. = Do not use during pregnancy.

Key:

6

P Egrifta [PA]P Norditropin Flexpro [PA/AC/PICA]

P Norditropin Nordiflex [PA/AC/PICA]P Zomacton [PA/AC/PICA]

P Zorbtive [PA/AC/PICA]

growth hormones (Revised – effective 7-1-10)

G allopurinolG probenecid

G probenecid w/colchicineP Colcrys

P Krystexxa [AC/PA]P Uloric [QD]

gout therApy (effective 3-1-11)

P Carimune NF Nanofiltered [PA/AC]P Flebogamma DIF [PA/AC]

P Gamunex [PA/AC]P Gamunex-C [PA/AC]

P Hizentra [PA/AC]

immunoglobulin Agents (injectAbles) (effective 5-1-09)

P Grastek [PA] P Oralair [PA] P Ragwitek [PA]

immunotherApy (orAl) (effective 10-1-14)

Genotype 1P Mavyret [PA/AC/QD]P Zepatier [PA/AC/QD]Genotype 2P Mavyret [PA/AC/QD]

Genotype 3P Mavyret [PA/AC/QD]Genotype 4P Mavyret [PA/AC/QD]P Zepatier [PA/AC/QD]

Genotype 5,6P Mavyret [PA/AC/QD]Treatment ExperiencedP Vosevi [PA/AC/QD]

hepAtitis c AntivirAls (Direct-Acting/proteAse inhibitors) (Updated 4-1-19)

H-Pylori Agents (effective 1-1-13)G lansoprazole/amoxicillin/

clarithromycinP PyleraUlcer DrugsG cimetidine tabletG esomeprazole capsule [QD]G famotidine tab, suspensionG lansoprazole [QD]G misoprostolG nizatidineG omeprazole [QD]G pantoprazole [QD]G rabeprazole [QD]G ranitidine HClP Nexium OTC [QD]P Nexium Rx Suspension [QD]

Pancreatic Enzymes (effective 1-1-13)P CreonP ZenpepBowel Evacuants (Updated 10-1-18)G Gavilyte-CG Gavilyte-G G Gavilyte-H with bisacodylG Gavilyte-NG PEG 3350 bowel preparationG Peg-PrepG Trilyte w/ flavor packetP ClenpiqP PrepopikP Suprep

Irritable Bowel Syndrome (effective 3-1-14)P LinzessUlcerative Colitis Agents (Updated 7-1-16)G balsalazide disodiumG mesalamine enemaG mesalamine enteric coated tabletG mesalamine suppository G sulfasalazineP AprisoPhosphate Binders (effective 6-1-15)G calcium acetateG lanthanum carbonate chewable

tabletG sevelamar carbonate

gAstrointestinAl

G epinephrine injection, USP auto-injector 0.3mg, 0.15mg (Mylan) [PICA]

G epinephrine injection, USP auto-injector 0.3mg, 0.15mg (Impax) [PICA]

P EpiPen 0.3mg (Mylan)P EpiPen Jr. 0.15mg (Mylan)

epinephrine Autoinjectors (Updated 5-1-17)

P Granix [PA/AC/PICA] P Neupogen [PA/AC/PICA] P Zarxio [PA/AC/PICA]

grAnulocyte colony stimulAting fActor proDucts (effective 1-1-18)

[pa] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.[qd] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.[ac] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo.

Please call (800) 803-2523.[pica] This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program

called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

G = Preferred generic medication.P = Preferred brand-name medication. = Weigh the risk of birth defects or

other adverse outcomes. = Do not use during pregnancy.

Key:

7

G baclofenG carisoprodol cmpd/codeine G chlorzoxazoneG cyclobenzaprine

G cyclobenzaprine XRG dantrolene sodiumG meprobamate G metaxalone

G methocarbamolG orphenadrine citrate G tizanidine

muscle relAxAnts (effective 10-1-09)

Ankylosing Spondylitis Agents P Cosentyx [PA/AC/PICA]P Enbrel [PA/AC/PICA]P Humira [PA/AC/QD/PICA]P Inflectra [PA/AC]P Remicade [PA/AC]P Renflexis [PA/AC]Crohn’s Disease Agents P Humira [PA/AC/QD/PICA]P Humira Pediatric [PA/AC/QD/PICA]P Inflectra [PA/AC]P Remicade [PA/AC]P Renflexis [PA/AC]P Stelara SC [PA/AC/PICA]Juvenile Idiopathic Arthritis Agents P Enbrel [PA/AC/PICA]P Humira [PA/AC/QD/PICA]

Plaque Psoriasis Agents P Cosentyx [PA/AC/PICA]P Humira [PA/AC/QD/PICA]P Inflectra [PA/AC]P Otezla [PA/AC]P Remicade [PA/AC]P Renflexis [PA/AC]P Stelara SC [PA/AC/PICA]Psoriatic Arthritis Agents P Cosentyx [PA/AC/PICA]P Enbrel [PA/AC/PICA]P Humira [PA/AC/QD/PICA]P Inflectra [PA/AC]P Remicade [PA/AC]P Renflexis [PA/AC]P Stelara SC [PA/AC/PICA] P Xeljanz [PA/AC]P Xeljanz XR [PA/AC]

Rheumatoid Arthritis Agents P Actemra SC [PA/AC/PICA]P Enbrel [PA/AC/PICA]P Humira [PA/AC/QD/PICA]P Inflectra [PA/AC]P Remicade [PA/AC]P Renflexis [PA/AC]P Xeljanz [PA/AC] P Xeljanz XR [PA/AC] Ulcerative Colitis Agents P Humira [PA/AC/QD/PICA]P Inflectra [PA/AC]P Remicade [PA/AC]P Renflexis [PA/AC]P Xeljanz [PA/AC]

select biologic AnD immunologic Agents (Updated 1-1-19)

CCR5 AntagonistsP SelzentryFusion InhibitorsP FuzeonIntegrase InhibitorsP Isentress, P Isentress HDP TivicayNon-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)G efavirenzG nevirapine G nevirapine ERP EdurantP IntelenceP Pifeltro

Nucleoside Reverse Transcriptase Inhibitors (NRTIs)G abacavir G lamivudineG tenofovir disoproxil fumarateG zidovudineP EmtrivaPharmacokinetic EnhancersP TybostPost-Attachment InhibitorsP TrogarzoProtease Inhibitors (PIs)G atazanavir sulfateG fosamprenavir calciumG ritonavirP AptivusP InviraseP Prezista

Combination AgentsG abacavir/lamivudineG abacavir/lamivudine /zidovudineG lamivudine/zidovudineP AtriplaP BiktarvyP CimduoP CompleraP DescovyP EvotazP DelstrigoP GenvoyaP JulucaP KaletraP OdefseyP PrezcobixP StribildP SymfiP Symfi Lo P SymtuzaP TriumeqP Truvada

hiv AntiretrovirAl therApy (Art) (effective 1-1-19) *The below list is based on current guidelines from the U.S. Department of Health and Human Services (HHS). It is not comprehensive and is for reference only*

G glatiramer acetate 40mg/ml [PA/AC/PICA]

G Glatopa 20mg/ml [PA/AC/PICA]P Avonex [PA/AC/PICA]

P Betaseron [PA/AC/PICA] P Copaxone 40mg/ml

[PA/AC/PICA]P Extavia [PA/AC/PICA]

P Plegridy [PA/AC/PICA]P Rebif [PA/AC/PICA]P Rebif Rebidose [PA/AC/PICA]

multiple sclerosis injectAbles (Updated 5-1-17)

[pa] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.[qd] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.[ac] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo.

Please call (800) 803-2523.[pica] This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program

called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

G = Preferred generic medication.P = Preferred brand-name medication. = Weigh the risk of birth defects or

other adverse outcomes. = Do not use during pregnancy.

Key:

8

NSAIDsG diclofenac/misoprostolG diclofenac potassiumG diclofenac sodiumG diclofenac sodium topical

drops, gelG etodolacG etodolac tablet, sustained

release 24 hrG fenoprofen calcium 600mgG flurbiprofenG ibuprofenG indomethacin [QD]G indomethacin capsule, sustained

action [QD]G ketoprofenG ketoprofen capsule, 24 hr

sustained release pelletsG ketorolac tabletsG meclofenamate sodiumG mefenamic acidG meloxicam [QD]G nabumetoneG naproxen

G naproxen sodiumG naproxen sodium ERG oxaprozinG piroxicamG sulindacG tolmetin sodiumNSAID COX-2 InhibitorsG celecoxib

Migraine/Headache Therapy (effective 1-1-09)TriptansG almotriptan malate [QD]G eletriptan HBr [QD] G frovatriptan succinate [QD] G naratriptan [QD]G rizatriptan (tabs, disintegrating tabs) [QD]G sumatriptan (tabs, nasal spray) [QD]G sumatriptan injection [QD/PICA]G sumatriptan succinate/naproxen

sodium [QD]G zolmitriptan [QD]G zolmitriptan ODT [QD]

Calcitonin Gene-Related Peptide Inhibitor (CGRP-1) Injectable Migraine Agents (effective 4-1-19)P Aimovig [PA] P Ajovy [PA] P Emgality [PA]Osteoarthritis Agents(Injectable) (Updated 7-1-16)P Euflexxa [AC/PA/QD]P Monovisc [AC/PA]P Orthovisc [AC/PA]

non-nArcotic AnAlgesics (Pain Relievers)

NarcoticsG acetaminophen/butalbitalG acetaminophen/caffeine/

butalbitalG aspirin/caffeine/butalbitalG aspirin/caffeine/dihydrocodeine

[QD]G buprenorphine 5mcg, 10mcg,

15mcg, 20mcg patch [PA/QD]G buprenorphine HCl SL tablets [PA/QD]G codeine/acetaminophen [QD]G codeine [QD]G codeine/acetaminophen/caffeine/

butalbital [QD]G codeine/aspirin/caffeine/butalbital

[QD]G codeine phosphate/acetaminophen

[QD]

G codeine sulfate tablet [QD]G dihydrocodeine/acetaminophen/

caffeine [QD]G fentanyl citrate lozenges [QD]G fentanyl patch [PA]G hydrocodone bit/acetaminophenG hydrocodone/ibuprofen [QD]G hydromorphone [QD/PA]G hydromorphone ER [QD/PA]G levorphanol tartrate [QD]G meperidine tabs, solution [QD]G methadone [PA]G morphine sulfate [QD/PA]G morphine sulfate, sustained action

[QD/PA]G oxycodone/acetaminophen [QD]G oxycodone/aspirin [QD]G oxycodone HCl [QD/PA]

G oxycodone/ibuprofen [QD]G oxymorphone [QD]G oxymorphone ER [QD/PA]P Oxycontin [QD/PA]Miscellaneous AnalgesicTherapy (effective 1-1-09)G tramadol [QD/PA]G tramadol ER tablets [QD/PA]G tramadol/acetaminophen [QD]Opiate Antagonist -NaloxoneProducts (effective 10-1-17)G naloxone syringeG naloxone vialP Narcan nasal spray

nArcotic AnAlgesics (Pain Relievers)

[pa] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.[qd] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.[ac] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo.

Please call (800) 803-2523.[pica] This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program

called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

G = Preferred generic medication.P = Preferred brand-name medication. = Weigh the risk of birth defects or

other adverse outcomes. = Do not use during pregnancy.

Key:

9

BisphosphonatesG alendronate solution [QD]G alendronate tab [QD]G alendronate weekly [QD]G ibandronate [QD]G risedronate sodium DR [QD]G risedronate sodium tablet [QD]

Calcitonin Salmon AgentsG calcitonin-salmon nasal sprayP Miacalcin injectionSelective Estrogen Receptor Modifiers G raloxifene HCl

Parathyroid Hormone Analogs (effective 1-1-18)P Forteo [PA/AC/PICA]P Tymlos [PA/AC/PICA]

osteoporosis/pAget’s DiseAse

G neomycin/polymyxin/HC G ofloxacin

otics (Ear Preparations) (effective 4-1-10)

Dry Eye Therapy (effective 5-1-17)P Restasis [PA]P Restasis Multidose [PA] Ophthalmic Alpha Agonists (Updated 1-1-17)G apraclonidine HClG brimonidine 0.15%P Alphagan-P 0.1%Ophthalmic Combination Alpha Agonists/Beta Antagonists (Updated 1-1-17)P CombiganOphthalmic Combination Carbonic Anhydrase Inhibitors/Beta Antagonists (effective 7-1-13)G dorzolamide/timolol G dorzolamide/timolol PFOphthalmics-Steroids (effective 1-1-10)G dexamethasone G fluorometholone G prednisolone acetateG prednisolone sodium phosphateP FML S.O.P.

Miscellaneous Ophthalmics- Antihistamine & Mast-Cell Stabilizers (effective 3-1-11)

G azelastineG cromolynG epinastine HClG olopatadine HClOphthalmic Prostaglandin- Analogues (effective 5-1-09)G bimatoprostG latanoprostOphthalmic Carbonic Anhydrase Inhibitors (effective 1-1-10)G dorzolamide Ophthalmic Beta-Blockers (effective 1-1-10)G betaxolol HClG carteololG levobunololG metipranololG timolol maleate

Antibiotic-Ophthalmics (effective 1-1-09)G bacitracinG bacitracin/polymyxin BG ciprofloxacin dropsG erythromycin base ointmentG gatifloxacinG gentamicin sulfate ointment, dropsG levofloxacinG moxifloxacin HCl dropsG neomycin sulfate/bacitracin/

polymyxin B ointmentG neomycin sulfate/gramicidin D/

polymyxin B dropsG ofloxacin dropsG polymyxin B/trimethoprim dropsG tobramycin sulfate dropsP Ciloxan Oph OintmentP Tobrex Oph OintmentOphthalmic Antiinflammatory Agents (NSAIDs) (effective 3-1-11)G bromfenac sodiumG diclofenac sodiumG flurbiprofen sodiumG ketorolac tromethamineOphthalmic Steroid-Antibiotic Combinations (effective 3-1-11)G neomycin/bacitracin/

polymyxin B/HCG neomycin/polymyxin B/

dexamethasoneG neomycin/polymyxin B/HCG tobramycin-dexamethasone

suspensionP TobraDex Oint

ophthAlmics (Eye Preparations)

[pa] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.[qd] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.[ac] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo.

Please call (800) 803-2523.[pica] This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program

called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

G = Preferred generic medication.P = Preferred brand-name medication. = Weigh the risk of birth defects or

other adverse outcomes. = Do not use during pregnancy.

Key:

10

Oral Hypnotic AgentsG estazolam [QD]G eszopiclone [QD]G flurazepam HCl [QD]G temazepam [QD]G triazolam [QD]G zaleplon [QD]G zolpidem [QD]G zolpidem ER [QD]G zolpidem SL tablet [QD]Miscellaneous AntidepressantsG amitriptyline-chlordiazepoxideG amitriptyline HClG amitriptyline-perphenazineG amoxapineG bupropion HCl tablet [QD]G bupropion HCl tablet, sust. action [QD]G clomipramine HClG desipramine HClG desvenlafaxine succinate [QD]G doxepin HClG duloxetine HCl [QD]G imipramine HClG imipramine pamoateG maprotiline HClG mirtazapine tabletG mirtazapine tablet, rapid dissolveG nortriptyline HClG phenylzine sulfateG protriptyline HClG tranylcypromine sulfateG trazodone HClG trimipramine maleateG venlafaxine HCl [QD]G venlafaxine HCl ER [QD]P MarplanP Nuplazid [AC]AnxiolyticsG alprazolamG alprazolam ERG alprazolam ODTG buspirone HClG chlordiazepoxide HClG clorazepate dipotassiumG diazepamG lorazepamG oxazepam

SSRI AntidepressantsG citalopram HBr [QD]G escitalopram oxalate [QD]G fluoxetine DR 90mg [QD]G fluoxetine HCl capsules, oral

solution, tablets [QD]G fluvoxamine maleate, ER [QD]G paroxetine HCl [QD]G sertraline HCl [QD]Antipsychotics (Oral) (Updated 7-1-16)G aripiprazole [QD]G aripiprazole ODT [QD]G chlorpromazine tabletG clozapineG clozapine ODTG fluphenazineG haloperidolG haloperidol lactate concentrateG loxapineG molindoneG olanzapine [QD]G olanzapine ODT [QD]G olanzapine-fluoxetine [QD]G paliperidone [QD]G perphenazineG pimozideG quetiapine fumarateG quetiapine fumarate ERG risperidone tab [QD]G risperidone ODT [QD]G thioridazineG thiothixeneG trifluoperazine HClG ziprasidone HCl [QD]P FazacloAntipsychotics (Injectable) (Updated 7-1-16)G chlorpromazine injection [PICA]G fluphenazine injection [PICA]G fluphenazine decanoate injection

[PICA]G haloperidol injection [PICA]G haloperidol decanoate injection

[PICA]G haloperidol lactate injection [PICA]G olanzapine injection [QD/PICA]P Aristada [PICA]P Aristada Initio [PICA]P Risperdal Consta [PICA]

Attention Deficit Hyperactivity Disorder (effective 5-1-09)G amphetamine [PA] G amphetamine and

dextroamphetamine salts [PA]G amphetamine and

dextroamphetamine salts ER [PA]G atomoxetine HCl [PA]G clonidine ER [PA]G D-amphetamine tablet [PA]G D-amphetamine ER [PA] G dexmethylphenidate [PA]G dexmethylphenidate ER [PA]G guanfacine ER [PA]G methylphenidate CD [PA]G methylphenidate ER [PA]G methylphenidate LA [PA]G methylphenidate tablet, chewable

tablet, solution [PA]G Zenzedi 5mg, 10mg [PA]P Vyvanse [PA]

psychotherApeutics (Anxiety/Depression)

[pa] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.[qd] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.[ac] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo.

Please call (800) 803-2523.[pica] This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program

called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

G = Preferred generic medication.P = Preferred brand-name medication. = Weigh the risk of birth defects or

other adverse outcomes. = Do not use during pregnancy.

Key:

11

G ciclopiroxG ciclopirox solutionG clotrimazoleG clotrimazole/betamethasone

G econazole nitrateG ketoconazoleG naftifine creamG nystatin

G nystatin w/triamcinoloneG oxiconazole nitrate 1% cream

topicAl AntifungAls

G acyclovir ointment P Denavir Cream

topicAl AntivirAl therApy (effective 1-1-09)

Beta Agonist Agents(Updated 1-1-19)Short-acting Beta Agonist (inhalers)P ProAir HFAP ProAir RespiclickP Ventolin HFAShort-acting Beta Agonist (nebulized solutions)G albuterol sulfate inhalant solution G levalbuterol inhalation solutionLong-acting Beta Agonist (inhalers)P Arcapta NeohalerP Serevent Diskus [QD]Nasal CorticosteroidsG budesonideG flunisolideG fluticasone propionateG mometasone furoate G triamcinolone acetonideInhaled Corticosteroid Therapy (Updated 7-1-13)G budesonide soln [QD]P Alvesco [QD]P Asmanex [QD]P Asmanex HFA [QD]P Pulmicort Flexhaler [QD]P QVAR Redihaler [QD]

Inhaled Corticosteroid /Anticholinergic/Long-acting Beta Agonist Agents (effective 1-1-19)P Trelegy Ellipta [QD]Inhaled Corticosteroid/Long-acting Beta Agonist Agents (Updated 1-1-18)G fluticasone/salmeterol [QD]P Advair Diskus [QD]P Advair HFA [QD]P Airduo [QD]P Breo Ellipta [QD]P Dulera [QD]P Symbicort [QD]Pulmonary Arterial Hypertension (PAH) Agents(Endothelial Receptor Antagonist)(effective 6-1-12)P Opsumit [AC/PA]P Tracleer [AC/PA]

Anticholinergic/Muscarinic Agents (Updated 1-1-19)Short-acting AgentsG ipratropium inhalant solnP Atrovent HFA InhalerLong-acting Agents (LAMA)P Incruse Ellipta [QD] P Spiriva Inhaler [QD]P Spiriva Respimat [QD]Long-acting Muscarinic/ Beta 2 Combination Agents (Updated 1-1-18)P Anoro Ellipta [QD]P Bevespi Aerosphere [QD] P Stiolto Respimat [QD]P Utibron Neohaler [QD]Short-acting Beta Agonist/Anticholinergic Combination Agent (Updated1-1-18)P Combivent Respimat

respirAtory (Allergy/Asthma/COPD)

G fluorouracil cream 5%G fluorouracil solution 2%, 5%

G imiquimod 5%P Picato Gel 0.015%, 0.05%

topicAl Actinic kerAtosis Agents (effective 1-1-13)

G bupropion HCl tablet, sust. action [QD]

P Chantix [QD]

P Nicotrol Inhaler [QD]P Nicotrol Nasal Spray [QD]

smoking cessAtion (effective 1-1-19)

[pa] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.[qd] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.[ac] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo.

Please call (800) 803-2523.[pica] This symbol next to a drug name indicates that this specialty drug is available through the NYC Municipal Program

called PICA. NYC municipal employees can contact Accredo Customer Service at (800) 467-2006 and inquire about drug coverage.

G = Preferred generic medication.P = Preferred brand-name medication. = Weigh the risk of birth defects or

other adverse outcomes. = Do not use during pregnancy.

Key:

12

G lidocaine (cream, oint, gel, patch) [PA/QD]

topicAl miscellAneous Anesthetic prepArAtions (effective 6-1-15)

Prenatal Vitamin TherapyG Prenatal PlusG PNV-DHAG Zatean-PN DHAG Zatean-PN PlusIron Supplement TherapyG Ferrex 28G Ferrex 150 ForteG Ferrex 150 Forte Plus

G Multigen PlusG Poly-Iron 150 ForteMultivitamin TherapyG CorvitaG V-C ForteVitamin B TherapyG FolbeeG Folbee PlusG Folbic

G Renal CapsG TriphrocapsVitamin D Analog Agents (effective 1-1-13)G calcitriolG doxercalciferolG paricalcitol

vitAmins — Most commonly used listed below (effective 1-1-09)

G benzphetamine HCl [PA]G diethylpropion HCl [PA]G diethylpropion ER [PA]

G phendimetrazine tartrate [PA]G phentermine HCl [PA]P Contrave [PA]

P Qsymia [PA]P Saxenda [PA]P Xenical [PA]

weight loss Agents (effective 1-1-16)

Low PotencyG alclometasone (cream, ointment)G desonide 0.05% (cream, lotion,

ointment)G fluocinolone (cream, ointment) G hydrocortisone (cream, ointment, lotion)P Capex Shampoo 0.01%Medium PotencyG betamethasone valerate (cream

lotion, foam)G desoximetasone 0.05% (cream,

ointment)G fluocinolone 0.025% (cream,

ointment)G flurandrenolide 0.05% (cream,

ointment, lotion)G fluticasone (cream, ointment, lotion)G hydrocortisone butyrate (cream,

ointment, solution)

G hydrocortisone butyrate/emollient (cream)

G hydrocortisone valerate (cream)G mometasone 0.1% (cream, ointment,

solution)G prednicarbate 0.1% (cream,

ointment)G triamcinolone 0.025%, 0.1% (cream,

ointment, lotion, aerosol)P Cordran TapeHigh PotencyG amcinonide (cream, ointment, lotion)G apexicon E (cream)G betamethasone dipropionate

(cream, gel, lotion, ointment)G betamethasone DP augmented

(cream, lotion)G betamethasone valerate 0.1%

(ointment)

G desoximetasone (cream, ointment, spray 0.25%, gel 0.05%)

G diflorasone diacetate 0.05% (cream)G fluocinonide (gel, cream, ointment,

solution)G fluocinonide-E (cream)G triamcinolone acetonide 0.5%

(cream, ointment)Very High PotencyG betamethasone augmented

(ointment)G clobetasol E (cream)G clobetasol propionate (cream,

ointment, lotion, solution, spray, foam, gel, shampoo)

G clodan shampooG diflorasone diacetate (ointment)G halobetasol propionate (cream,

ointment)

topicAl corticosteroiDs (Topical Skin Products)

13

Abilify Maintena® Aristada® (Alkermes, Inc.), Aristada Initio® (Alkermes, Inc), Risperdal Consta® (Janssen)

Abilify vial® olanzapine (generic)Absorica® Claravis (generic), Myorisan (generic), Zenatane (generic)Abstral® fentanyl citrate lozenge (generic)Aciphex Sprinkle® Nexium OTC® (AstraZeneca), esomeprazole (generic),

lansoprazole (generic), omeprazole (generic), pantoprazole (generic), rabeprazole (generic)

Actoplus Met XR® pioglitazone/metformin (generic)Acuvail® bromfenac (generic), diclofenac (generic), flurbiprofen (generic),

ketorolac (generic)Aczone® benzoyl peroxide (generic), clindamycin phosphate (generic),

dapsone 5% gel (generic), erythromycin (generic)Adasuve Inhaler® loxapine (generic)Adlyxin® Bydureon® (Amylin Pharmaceuticals), Bydureon

Bcise® (Amylin Pharmaceuticals), Bydureon Pen® (Amylin Pharmaceuticals), Byetta® (Amylin Pharmaceuticals), Ozempic® (Novo Nordisk), Trulicity® (Eli Lilly)

Advicor® atorvastatin (generic), fluvastatin (generic), lovastatin (generic), pravastatin (generic), rosuvastatin (generic), simvastatin (generic), niacin ER (generic)

Adzenys® XR-ODT dextroamphetamine/amphetamine ER (generic)Aerospan® Alvesco® (Sunovion Pharmaceuticals), Asmanex® (Merck &

Co.), Asmanex® HFA (Merck & Co.), Pulmicort Flexhaler® (AstraZeneca), QVAR Redihaler® (Teva)

Aktipak® erythromycin-benzoyl peroxide (generic)Akynzeo® aprepitant (generic), granisetron (generic), ondansetron

(generic), Emend® (Merck & Co.)Altreno® (Acne use only) tazarotene 0.1% cream (generic), tretinoin (generic), Azelex®

(Allergan), Finacea® (Bayer)Allzital® acetaminophen/butalbital (generic) Alocril® azelastine (generic), cromolyn (generic),

epinastine (generic), olopatadine (generic)Alodox® erythromycin (generic), gentamicin (generic), tobramycin

(generic)alogliptin (Perrigo) Januvia® (Merck & Co.), Tradjenta® (Boehringer Ingelheim)alogliptin-metformin (Perrigo) Janumet® (Merck & Co.), Janumet XR® (Merck & Co.),

Jentadueto® (Boehringer Ingelheim)alogliptin-pioglitazone (Perrigo) Januvia® (Merck & Co.), Tradjenta® (Boehringer Ingelheim),

pioglitazone (generic)Alomide® azelastine (generic), cromolyn (generic),

epinastine (generic), olopatadine (generic)Alora® estradiol patch (generic)Alrex® fluorometholone (generic), prednisolone (generic)Altoprev® atorvastatin (generic), fluvastatin (generic), lovastatin (generic),

pravastatin (generic), rosuvastatin (generic), simvastatin (generic)Amitiza® Linzess® (Actavis/Ironwood)Amrix® cyclobenzaprine (generic)Amturnide® candesartan/HCTZ (generic) + amlodipine (generic),

irbesartan/HCTZ (generic) + amlodipine (generic), losartan/HCTZ (generic) + amlodipine (generic), telmisartan/HCTZ (generic) + amlodipine (generic), valsartan/HCTZ (generic) + amlodipine (generic)

Anastia® lidocaine lotion (generic)Antara® 30mg, 90mg fenofibrate (generic)Anzemet® aprepitant (generic), granisetron (generic), ondansetron

(generic), Emend® (Merck & Co.)Apidra® Humalog® (Eli Lilly)Apidra Solostar® Humalog® (Eli Lilly)Aplenzin® bupropion (generic), bupropion SR (generic)Aptensio XR® methylphenidate ER (generic)Aptiom® carbamazepine (generic), lamotrigine (generic), levetiracetam

(generic), gabapentin (generic), topiramate (generic)Armonair Respiclick® Alvesco® (Sunovion Pharmaceuticals), Asmanex®

(Merck & Co.), Asmanex® HFA (Merck & Co.), Pulmicort Flexhaler® (AstraZeneca), QVAR Redihaler® (Teva)

Arymo Er® morphine sulfate ER (Generic)Arnuity Ellipta® Alvesco® (Sunovion Pharmaceuticals), Asmanex® (Merck &

Co.), Asmanex® HFA (Merck & Co.), Pulmicort Flexhaler® (AstraZeneca), QVAR Redihaler® (Teva)

Asmalpred®, Asmalpred Plus® prednisolone sodium phosphate (generic)Auvi-Q® epinephrine autoinjector (Mylan and Impax), Epi Pen® (Mylan),

Epi Pen Jr.® (Mylan)

Avar® (foam, pads), Avar-E®, Avar LS® sulfacetamide sodium/sulfur (generic)Azasite® ciprofloxacin (generic), erythromycin ointment (generic),

gentamicin (generic), levofloxacin (generic), moxifloxacin (generic), ofloxacin (generic), tobramycin (generic)

Azopt® dorzolamide (generic)Bacmin® Corvita (generic), V-C Forte (generic)Balcoltra® Gildess FE® (Dynamic Pharma), Junel FE® (Barr Pharmaceuticals),

Microgestin FE® (Watson Pharmaceuticals)Banzel® Suspension Banzel® Tablets (Eisai Inc.)Basaglar Kwikpen® Lantus® (Sanofi-Aventis), Lantus Solostar® (Sanofi-Aventis),

Levemir® (Novo Nordisk), Levemir Flextouch® (Novo Nordisk), Toujeo Solarstar® (Sanofi-Aventis), Tresiba Flextouch® (Novo Nordisk)

Baxdela® ciprofloxacin HCl (generic), levofloxacin (generic), moxifloxacin (generic), ofloxacin (generic)

Beconase AQ® budesonide (generic), flunisolide (generic), fluticasone propionate (generic), mometasone furoate (generic), triamcinolone acetonide (generic)

Belbuca® buprenorphine tablets (generic)Belsomra® estazolam (generic), eszopiclone (generic), flurazepam (generic),

temazepam (generic), zaleplon (generic), zolpidem (generic)Belviq® Contrave ER® (Takeda), Qsymia® (Vivus, Inc.), Saxenda® (Novo

Nordisk), Xenical® (Genentech)Belviq XR® Contrave ER® (Takeda), Qsymia® (Vivus, Inc.), Saxenda® (Novo

Nordisk), Xenical® (Genentech)Benzamycin® Pak erythromycin/benzoyl peroxide (generic)BenzEFoam®/BenzEFoam® Ultra benzoyl peroxide (generic)Bepreve® azelastine (generic), cromolyn (generic), epinastine (generic),

olopatadine (generic)Besivance® ciprofloxacin (generic), erythromycin ointment (generic),

gentamicin (generic), levofloxacin (generic), moxifloxacin (generic), ofloxacin (generic), tobramycin (generic)

Betimol® betaxolol (generic), carteolol (generic), levobunolol (generic), metipranolol (generic), timolol maleate (generic)

Betoptic S® betaxolol (generic), carteolol (generic), levobunolol (generic), metipranolol (generic), timolol maleate (generic)

Bifera Rx® Ferrex 28 (generic), Ferrex 150 Forte (generic), Ferrex 150 Forte Plus (generic), Multigen Plus (generic), Poly-Iron 150 Forte (generic)

Binosto® alendronate (generic)Bivigam® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma

DIF® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG)

Briviact® levetiracetam (generic), gabapentin (generic), topiramate (generic), lamotrigine (generic)

Bromsite® bromfenac (generic), diclofenac (generic), flurbiprofen (generic), ketorolac (generic)

Brovana® Solution albuterol inhalant solution (generic), levalbuterol inhalant solution (generic)

Bryhali® clobetasol propionate lotion (generic), halobetasol propionate cream (generic)

buprenorphine 7.5 mcg patch buprenorphine 5mcg patch (generic), buprenorphine 10mcg patch (Rhodes Pharmaceutical) (generic), buprenorphine 15mcg patch (generic), buprenorphine

20mcg patch (generic), buprenorphine HCl (generic)bupropion 450mg XL tablet ® bupropion XL (generic)Butisol® temazepam (generic), triazolam (generic)Butrans® 7.5 mcg patch buprenorphine 5mcg patch (generic), buprenorphine 10mcg

patch (generic), buprenorphine 15mcg patch (generic), buprenorphine 20mcg patch (generic), buprenorphine HCl (generic)

Bystolic® acebutolol HCl (generic), atenolol HCl (generic), metoprolol tartrate (generic), metoprolol succinate (generic), propranolol HCl (generic)

Byvalson® metoprolol tartrate (generic) + valsartan (generic)Cambia® diclofenac potassium (generic)Capital® w/codeine acetaminophen/codeine (generic)Carac® fluorouracil (generic), imiquimod (generic), Picato® Gel (Leo

Pharma Inc.)Cardizem® LA 120mg dilitazem ER (generic)Cequa® Restasis® (Allergan), Restasis Multidose® (Allergan)Cimzia® (Ankylosing Spondylitis Cosentyx® (Novartis), Enbrel® (Amgen), indication only) Humira® (Abbott)

Nonpreferred Product Possible Preferred Alternatives Nonpreferred Product Possible Preferred Alternatives

Section II: NonpRefeRRed DRUgs and theiR Possible PRefeRRed AlteRnatives*

*This is a partial list of nonpreferred drugs. Please be sure that your drug is listed in Section I.

If your prescribed drug is in the “nonpreferred” column, ask your doctor if she or he can prescribe one of the alternatives listed.

14

Cimzia® (Crohn’s Disease Humira® (Abbott), Humira Pediatric® (Abbott), Stelara SC® (Janssen) indication only)Cimzia® (Plaque Psoriasis Cosentyx® (Novartis), Humira® (Abbott), indication only) Otezla® (Celgene), Stelara SC® (Centocor)Cimzia® (Psoriatic Arthritis Cosentyx® (Novartis), Enbrel® (Amgen), Humira® (Abbott), indication only) Stelara SC® (Centocor), Xeljanz® (Pfizer), Xeljanz XR® (Pfizer)Cimzia® (Rheumatoid Arthritis Actemra SC® (Genentech), Enbrel® (Amgen), Humira® (Abbott), indication only) Xeljanz® (Pfizer), Xeljanz XR (Pfizer)Ciprodex® neomycin/polymyxin/HC (generic), ofloxacin (generic) Cipro HC® neomycin/polymyxin/HC (generic), ofloxacin (generic) Citranatal Rx® PNV-DHA (generic), Zatean-PN Plus (generic),

Zatean-PN DHA (generic), Prenatal Plus (generic) Clenpiq® Gavilyte-C (generic), Gavilyte-H with bisacodyl (generic), Gavilyte-N

(generic), PEG 3350 bowel preparation (generic), Trilyte w/ Flavor packet (generic), Prepopik® (FerringPharmaceutical), Suprep® (Braintree Laboratories)

Clindacin ETZ®, Clindacin PAC® clindamycin (generic)Clindagel® clindamycin phosphate (generic)Clodan® Kit clobetasol propionate (generic)Cloderm® betamethasone valerate cream (generic), desoximetasone

cream (generic), fluocinolone acetonide cream (generic), hydrocortisone valerate cream (generic), triamcinolone acetonide cream (generic)

clozapine ODT 150mg, 200mg clozapine ODT (generic), Fazaclo® (Jazz)codeine solution codeine sulfate tablets (generic) colchicine tablet, capsule Colcrys® (Takeda)Coly-Mycin S® neomycin/polymyxin/HC (generic), ofloxacin (generic) Colyte® 227.1-21.5 PEG3350-electrolyte (generic)Conzip® tramadol ER (generic)Cortisporin-TC® neomycin/polymyxin/HC (generic), ofloxacin (generic) Corvite® Corvita (generic), V-C Forte (generic)Corvite FE® Ferrex 28 (generic), Ferrex 150 Forte (generic), Ferrex 150

Forte Plus (generic), Multigen Plus (generic), Poly-Iron 150 Forte (generic)

Cotempla XR-ODT® dextroamphetamine/amphetamine ER (generic)Cuvitru® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma

DIF® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG)

Cycloset® metformin HCl (generic), Byetta® (Amylin Pharmaceuticals), Janumet® (Merck & Co.), Januvia® (Merck & Co.)

Daklinza® (Genotype 1) Mavyret® (Abbvie), Zepatier® (Merck)Daklinza® (Genotype 3) Mavyret® (Abbvie)Daxbia® cephalexin (generic)Daytrana® dextroamphetamine-amphetamine (generic), methylphenidate ER

(generic)Delzicol® balsalazide disodium (generic), mesalamine enteric coated

tablet (generic), mesalamine suppository (generic), sulfasalazine (generic), Apriso® (Salix)

Desonate® Gel desonide (generic), alclometasone (generic), hydrocortisone (generic)

desvenlafaxine ER duloxetine (generic), venlafaxine HCl ER (generic)Dexcom® FreeStyle Libre system® (Abbott) Dexilant® Nexium OTC® (AstraZeneca), esomeprazole (generic),

lansoprazole (generic), omeprazole (generic), pantoprazole (generic), rabeprazole (generic)

Dexycu® dexamethasone (generic), prednisolone (generic), fluorometholone (generic)

Diclegis® aprepitant (generic), granisetron (generic), ondansetron (generic), Emend® (Merck & Co.)

Diclofono Gel Packet® diclofenac sodium drops (generic), diclofenac sodium gel (generic)

Differin® Lotion adapalene cream (generic)Dipentum® balsalazide disodium (generic), mesalamine enteric coated

tablet (generic), mesalamine suppository (generic), sulfasalazine (generic), Apriso® (Salix)

Divigel® estradiol patch (generic)Dolgic Plus® butalbital/APAP/caffeine (generic)Doral® estazolam (generic), eszopiclone (generic), flurazepam (generic),

temazepam (generic), zaleplon (generic), zolpidem (generic)doxycycline IR-DR doxycycline monohydrate (generic), minocycline (generic)Duexis® ibuprofen (generic) + famotidine (generic)Durezol® prednisolone (generic) Durlaza® cilostazol (generic), clopidogrel (generic), dipyridamole (generic),

aspirin/dipyridamole (generic), prasugrel HCl (generic), Brilinta® (AstraZeneca), Zontivity® (Merck & Co)

Dutoprol® metoprolol succinate (generic), hydrochlorothiazide (generic)Duzallo® allopurinol (generic), probenecid (generic), probenecid w/

colchicine (generic), Colcrys® (Takeda) Dyanavel XR® dextroamphetamine/amphetamine ER (generic)

Dymista® fluticasone propionate + azelastine nasal spray (generic)E.E.S. suspension® Eryped Suspension® (Southwood Pharm)Ecoza® econazole nitrate (generic)Edarbi® candesartan (generic), eprosartan mesylate (generic), irbesartan

(generic), losartan (generic), telmisartan (generic), valsartan (generic)

Edarbyclor® candesartan/HCTZ (generic), irbesartan/HCTZ (generic), losartan/HCTZ (generic), telmisartan/HCTZ (generic), valsartan/HCTZ (generic)

Edluar® zolpidem (generic)Elenza Patch® lidocaine cream, ointment, patch (generic)Elestrin® estradiol patch (generic)Emadine® azelastine (generic), cromolyn (generic), epinastine (generic),

olopatadine (generic)Embeda® morphine sulfate ER (generic)Emsam® phenylzine sulfate (generic)Enbrel® (Plaque Psoriasis Cosentyx® (Novartis), Humira® (Abbott), indication only) Otezla® (Celgene), Stelara SC® (Centocor)Epaned® enalapril maleate (generic)Epclusa® (Genotype 1,2,3,4,5,6) Mavyret® (Abbvie), Zepatier® (Merck)Epiduo Forte® adapalene/benzoyl peroxide (generic)Epifoam® hydrocortisone acetate/pramoxine (generic)Epogen® Aranesp® (Amgen), Procrit® (Janssen)Equetro® carbamazepine (generic), divalproex (generic)Ertaczo® econazole nitrate (generic), ketoconazole (generic),

nystatin (generic)Ery-Tab® 500mg erythromycin base (generic)Esomep-EZS® Nexium OTC® (AstraZeneca), esomeprazole (generic),

lansoprazole (generic), omeprazole (generic), pantoprazole (generic), rabeprazole (generic)

Esomeprazole strontium® Nexium OTC® (AstraZeneca), esomeprazole magnesium (generic), lansoprazole (generic), omeprazole (generic), pantoprazole (generic), rabeprazole (generic)

Estrogel® estradiol patch (generic)Evamist® estradiol patch (generic)Evzio Auto-Injector® naloxone syringe, vial (generic), Narcan nasal spray® (Adapt

Pharmaceutical) Exelderm® econazole nitrate (generic), ketoconazole (generic),

nystatin (generic)Fabior® tretinoin (generic), Azelex® (Allergan), Finacea® (Bayer)Factive® ciprofloxacin (generic), levofloxacin (generic), moxifloxacin

(generic), ofloxacin (generic)Fanapt® aripiprazole (generic), clozapine (generic), olanzapine (generic),

paliperidone (generic), quetiapine fumarate (generic), risperidone (generic), ziprasidone HCl (generic)

Farxiga® Invokana® (Janssen), Invokamet® (Janssen), Jardiance® (Boehringer Ingelheim), Synjardy® (Eli Lilly)

Femring® Estring® (Pfizer)fenoprofen calcium capsule fenoprofen calcium tablet (generic)Fenortho® fenoprofen calcium tablet (generic)Fentora® fentanyl lozenge (generic)Ferralet 90® Ferrex 28 (generic), Ferrex 150 Forte (generic), Ferrex 150

Forte Plus (generic), Multigen Plus (generic), Poly-Iron 150 Forte (generic)

Fetzima® duloxetine (generic), venlafaxine HCl (generic)Fiasp® Humalog® (Eli Lilly)Fiasp Flextouch® Humalog® (Eli Lilly)First-Lansoprazole® Nexium® Rx Suspension (AstraZeneca)First-Omeprazole® Nexium® Rx Suspension (AstraZeneca)First-Testosterone® testosterone gel in packet (generic), testosterone gel pump

(generic), testosterone solution metered pump (generic), Androderm® (Watson)

Flarex® fluorometholone (generic)Flector® Patch diclofenac sodium drops (generic), diclofenac sodium gel

(generic)Flo-Pred® prednisolone sodium phosphate (generic)Flovent Diskus® Alvesco® (Sunovion Pharmaceuticals), Asmanex® (Merck &

Co.), Asmanex® HFA (Merck & Co.), Pulmicort Flexhaler® (AstraZeneca), QVAR Redihaler® (Teva)

Flovent HFA® Alvesco® (Sunovion Pharmaceuticals), Asmanex® (Merck & Co.), Asmanex® HFA (Merck & Co.), Pulmicort Flexhaler® (AstraZeneca), QVAR Redihaler® (Teva)

Fluoroplex® fluorouracil (generic), imiquimod (generic), Picato® Gel (Leo Pharma Inc.)

FML-Forte® fluorometholone (generic) Foradil® Arcapta Neohaler® (Novartis), Serevent Diskus® (GSK)Forfivo XL® bupropion XL (generic)Fosamax D® alendronate (generic), ibandronate (generic), risedronate

(generic)

Nonpreferred Product Possible Preferred Alternatives Nonpreferred Product Possible Preferred Alternatives

*This is a partial list of nonpreferred drugs. Please be sure that your drug is listed in Section I.

15

Fosrenol Powder Packet® calcium acetate (generic), lanthanum carbonate chewable tablet (generic), sevelamar carbonate (generic)

Freestyle® ACCU-CHEK® (Roche), Breeze 2® (Ascensia Diabetes Care), Contour® (Ascensia Diabetes Care), True Metrix® (Trividia Health)

Frotek Cream® diclofenac sodium drops (generic), diclofenac sodium gel (generic)

Fycompa® carbamazepine (generic), lamotrigine (generic), levetiracetam (generic), gabapentin (generic), topiramate (generic)

Gamastan S-D® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG)

Gammagard® Liquid Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG)

Gammagard S-D® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG)

Gammaked® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG)

Gammaplex® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG)

Gelnique® Metered Dose Gel oxybutynin (generic), oxybutynin ER (generic), Myrbetriq® (Astellis), Vesicare® (GlaxoSmithKline)

Gelnique® 10% Packets oxybutynin (generic), oxybutynin ER (generic), Myrbetriq® (Astellis), Vesicare® (GlaxoSmithKline)

Gel-One® Euflexxa® (Ferring B.V), Monovisc® (Depuy Mitek), Orthovisc® (Depuy Mitek)

Gelsyn-3® Euflexxa® (Ferring B.V.), Monovisc® (Depuy Mitek), Orthovisc® (Depuy Mitek)

Genotropin® Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex® (Novo Nordisk), Zomacton® (Ferring Pharmaceuticals)

Genvisc-850® Euflexxa® (Ferring B.V), Monovisc® (Depuy Mitek), Orthovisc® (Depuy Mitek)

Geodon® vial olanzapine (generic)Gialax® Gavilyte-C (generic), Gavilyte-H with bisacodyl (generic),

Gavilyte-N (generic), PEG 3350 bowel preparation (generic), Trilyte w/ Flavor packet (generic), Prepopik® (Ferring Pharmaceutical), Suprep® (Braintree Laboratories)

Giazo® balsalazide sodium (generic)Gocovri® amantadine HCl (generic), levodopa/carbidopa (generic),

levodopa/carbidopa/entacapone (generic), pramipexole Di-HCl (generic), rasagline mesylate (generic), ropinirole HCl (generic), selegiline (generic)

Golytely Packet® Gavilyte-C (generic), Gavilyte-H with bisacodyl (generic), Gavilyte-N (generic), PEG 3350 bowel preparation (generic), Trilyte w/ Flavor packet (generic), Prepopik® (Ferring Pharmaceutical), Suprep® (Braintree Laboratories)

Gralise® gabapentin (generic)Halog® desoximetasone cream (generic), fluocinonide cream (generic)Harvoni® (Genotype 1,4) Mavyret® (Abbvie), Zepatier® (Merck)Harvoni® (Genotype 5,6) Mavyret® (Abbvie)Helidac® lansoprazole/amoxicillin/clarithromycin (generic), Pylera®

(Aptalis Pharma)Hetlioz® eszopiclone (generic), temazepam (generic), triazolam (generic),

zaleplon (generic), zolpidem (generic)Humatrope® Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex®

(Novo Nordisk), Zomacton® (Ferring Pharmaceuticals)Hyalgan® Euflexxa® (Ferring B.V), Monovisc® (Depuy Mitek), Orthovisc®

(Depuy Mitek)Hymovis® Euflexxa® (Ferring B.V.), Monovisc® (Depuy Mitek), Orthovisc®

(Depuy Mitek)HyQvia® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma

DIF® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG)

Hysingla ER® morphine sulfate ER (generic), hydromorphone ER (generic)Ilevro® bromfenac (generic), diclofenac (generic), flurbiprofen (generic),

ketorolac (generic)Ilumya® Cosentyx® (Novartis), Humira® (Abbott), (Plaque Psoriasis indication only) Otezla® (Celgene), Stelara SC® (Centocor)Imvexxy® estradiol (generic), estropipate (generic), Osphena® (Shionogi)Inderal XR® propranolol LA (generic)Indocin® Suspension indomethacin capsule (generic), naproxen tablet (generic)Innopran XL® propranolol LA (generic)Invega Sustenna® Aristada® (Alkermes, Inc.), Aristada Initio® (Alkermes, Inc),

Risperdal Consta® (Janssen)

Invega Trinza® Aristada® (Alkermes, Inc.), Aristada Initio® (Alkermes, Inc), Risperdal Consta® (Janssen)

Inveltys® fluorometholone (generic), prednisolone (generic)Ionsys® fentanyl patch (generic)Jublia® ciclopirox solution (generic)Kadian ER 200mg Capsule® morphine sulfate ER (generic)Kapspargo® metoprolol succinate XL (generic)Kazano® Janumet® (Merck & Co.), Janumet XR® (Merck & Co.),

Jentadueto® (Boehringer Ingelheim)Kerydin® ciclopirox solution (generic)Kevzara® (Rheumatoid Arthritis Actemra SC® (Genentech), Enbrel® (Amgen), indication only) Humira® (Abbott), Xeljanz® (Pfizer), Xeljanz XR® (Pfizer)Khedezla® duloxetine (generic), venlafaxine HCl ER (generic)Kineret® (Rheumatoid Arthritis Actemra SC® (Genentech), Enbrel® (Amgen), indication only) Humira® (Abbott), Xeljanz® (Pfizer), Xeljanz XR® (Pfizer)Klarity® Restasis® (Allergan), Restasis Multidose® (Allergan)Kombiglyze® XR Janumet® (Merck & Co.), Janumet XR® (Merck & Co.),

Jentadueto® (Boehringer Ingelheim)Lamictal® XR Dosepak lamotrigine XR (generic)Lastacaft® azelastine (generic), cromolyn sodium (generic), epinastine

(generic), olopatadine (generic)Latuda® aripiprazole (generic), clozapine (generic), olanzapine (generic),

paliperidone (generic), quetiapine fumarate (generic), risperidone (generic), ziprasidone HCl (generic)

Lazanda® fentanyl lozenge (generic), fentanyl patch (generic)Ledipasvir/Sofosbuvir® Mavyret® (Abbvie), Zepatier® (Merck) (Genotype 1,4) Ledipasvir/Sofosbuvir® Mavyret® (Abbvie) (Genotype 5,6) Letairis® Opsumit® (Actelion), Tracleer® (Actelion)Levatol® acebutolol HCl (generic), atenolol (generic), metoprolol tartrate

(generic)levalbuterol tartrate HFA ProAir HFA® (Teva), ProAir Respiclick® (Teva)Lexette® clobetasol propionate lotion (generic), halobetasol propionate

cream (generic)Lidovir® acyclovir ointment (generic), lidocaine jelly (generic)Lipofen® fenofibrate (generic)Liptruzet® atorvastatin (generic), ezetimibe (generic)Livalo® atorvastatin (generic), fluvastatin (generic), lovastatin (generic),

pravastatin (generic), rosuvastatin (generic), simvastatin (generic)Locort® tablet, Dosepak dexamethasone tablets (generic)Lomaira® phentermine (generic), Contrave ER® (Takeda), Qsymia®

(Vivustro), Saxenda® (Novo Nordisk), Xenical® (Genentech)Lo-Minastrin FE® Gildess FE® (Dynamic Pharma), Junel FE® (Barr

Pharmaceuticals), Microgestin FE® (Watson Pharmaceuticals)Lorzone® chlorzoxazone (generic)Lotemax® fluorometholone (generic), prednisolone (generic)Luliconazole® ciclopirox (generic), clotrimazole (generic), econazole nitrate

(generic), ketoconazole (generic), naftifine cream (generic), nystatin (generic), oxiconazole nitrate 1% cream (generic)

Lumigan® 0.01% bimatoprost (generic), latanoprost (generic), travaprost (generic)Luzu® econazole nitrate (generic), ketoconazole (generic),

nystatin (generic)Magnacet® oxycodone w/APAP (generic)Maxidex® fluorometholone (generic), prednisolone (generic)Menest® estradiol (generic), estropipate (generic)Menostar® estradiol patch (generic)Mentax® econazole nitrate (generic), ketoconazole (generic),

nystatin (generic)Metanx® Capsule Folbee (generic), Folbee Plus (generic), Folbic (generic), Renal

Caps (generic), Triphrocaps (generic)miconazole/zinc oxide/petroleum® ciclopirox (generic), clotrimazole (generic), econazole nitrate (generic), (Mylan) ketoconazole (generic), naftifine cream (generic), nystatin

(generic), oxiconazole nitrate 1% cream (generic)Minitran Patch® nitroglycerin patch (generic)minocycline 55mg ER tablet doxycycline monohydrate (generic), doxycycline hyclate

(generic), minocycline (generic), tetracycline (generic)Minolira ER® doxycycline monohydrate (generic), doxycycline hyclate

(generic), minocycline (generic), tetracycline (generic)Mircera® Aranesp® (Amgen), Procrit® (Janssen)Mirvaso® metronidazole topical (generic), Finacea® (Bayer)Mitigare® Colcrys® (Takeda)Momexin® mometasone furoate (generic)Morgidox® doxycycline hyclate capsules (generic)Morphabond ER® morphine sulfate ER (generic)Morphine® sulfate oral syringe morphine sulfate (generic)

Nonpreferred Product Possible Preferred Alternatives Nonpreferred Product Possible Preferred Alternatives

*This is a partial list of nonpreferred drugs. Please be sure that your drug is listed in Section I.

16

Nonpreferred Product Possible Preferred Alternatives Nonpreferred Product Possible Preferred Alternatives

*This is a partial list of nonpreferred drugs. Please be sure that your drug is listed in Section I.

MoviPrep® Gavilyte-C (generic), Gavilyte-H with bisacodyl (generic), Gavilyte-N (generic), PEG 3350 bowel preparation (generic), Trilyte w/ Flavor packet (generic), Prepopik® (Ferring Pharmaceutical), Suprep® (Braintree Laboratories)

Moxatag® amoxicillin trihydrate (generic)Moxeza® ciprofloxacin (generic), erythromycin ointment (generic),

gentamicin (generic), levofloxacin (generic), moxifloxacin (generic), ofloxacin (generic), tobramycin (generic)

Mydayis® amphetamine and dextroamphetamine salts ER (generic), D-amphetamine ER (generic), dexmethylphenidate ER (generic), methylphenidate ER (generic), Vyvanse®(Shire)

Naftin® gel econazole nitrate (generic), ketoconazole (generic), nystatin (generic)

Nalfon® etodolac (generic), ibuprofen (generic), indomethacin (generic), naproxen (generic), sulindac (generic)

Nalocet® oxycodone w/APAP (generic)Naprelan® 750mg naproxen sodium ER (generic)Natacyn® ciprofloxacin (generic), erythromycin ointment (generic),

gentamicin (generic), levofloxacin (generic), moxifloxacin (generic), ofloxacin (generic), tobramycin (generic)

Natazia® Necon (generic)Natesto® testosterone gel in packet (generic), testosterone gel pump

(generic), testosterone solution metered pump (generic), Androderm® (Watson)

Nesina® Januvia® (Merck & Co.), Tradjenta® (Boehringer Ingelheim)Neuac® Kit clindamycin phosphate/benzoyl peroxide (generic), Neuac® Gel

(Medimetriks Pharmaceuticals)Neupro Patch® pramipexole Di-HCl (generic), pramipexole ER (generic),

ropinirole (generic), Apokyn® (U.S. World Meds)Nevanac® bromfenac (generic), diclofenac (generic), flurbiprofen (generic),

ketorolac (generic)Nitro-Dur Patch® nitroglycerin patch (generic)Noritate® metronidazole cream (generic)Novolin® Humulin® (Eli Lilly)Novolog® Humalog® (Eli Lilly)Novolog Mix® Humalog Mix® (Eli Lilly)Nucort® hydrocortisone lotion (generic)Nucynta®, Nucynta ER® tramadol (generic)Nuox® benzoyl peroxide (generic), sulfacetamide sodium/sulfur (generic)Nutropin AQ Nuspin® Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex®

(Novo Nordisk), Zomacton® (Ferring Pharmaceuticals)Nuzyra® doxycycline monohydrate (generic), doxycycline hyclate

(generic), minocycline (generic), tetracycline (generic)Nyata® nystatin (generic)Nymalize® nimodipine (generic)OB Complete One® PNV-DHA (generic), Zatean-PN Plus (generic),

Zatean-PN DHA (generic), Prenatal Plus (generic) Octagam® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma

DIF® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG)

Oleptro ER® trazodone HCl (generic)Olumiant® (Rheumatoid Arthritis Actemra SC® (Genentech), Enbrel® (Amgen), Humira® (Abbott), indication only) Xeljanz® (Pfizer), Xeljanz XR (Pfizer)Olysio® Zepatier® (Merck& Co.)Omeclamox-Pak® lansoprazole/amoxicillin/clarithromycin (generic), Pylera®

(Aptalis Pharma)Omeprazole® + SyrSpend® SF Alka Nexium® Rx Suspension (AstraZeneca)Omnaris® budesonide (generic), flunisolide (generic), fluticasone

propionate (generic), mometasone furoate (generic), triamcinolone acetonide (generic)

Omnitrope® Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex® (Novo Nordisk), Zomacton® (Ferring Pharmaceuticals)

One Touch® ACCU-CHEK® (Roche), Breeze 2® (Ascensia Diabetes Care), Contour® (Ascensia Diabetes Care), True Metrix® (Trividia Health)

Onexton® clindamycin/benzoyl peroxide (generic)Onglyza® Januvia® (Merck & Co.), Tradjenta® (Boehringer Ingelheim)Onzetra Xsail® sumatriptan nasal spray (generic)Opana ER® morphine sulfate ER (generic), Oxycontin® (Purdue Pharma)Oracea® doxycycline monohydrate (generic), minocycline (generic)Orencia® SC Cosentyx® (Novartis), Enbrel® (Amgen), Humira® (Abbott), (Psoriatic Arthritis indication only) Stelara SC® (Centocor), Xeljanz® (Pfizer), Xeljanz XR® (Pfizer) Orencia® SC, Orencia Clickject® Actemra SC® (Genentech), Enbrel® (Amgen), Humira® (Rheumatoid Arthritis indication only) (Abbott), Xeljanz® (Pfizer), Xeljanz XR® (Pfizer)Orencia SC® Enbrel® (Amgen), Humira® (Abbott) (Juvenile Idiopathic Arthritis indication only)Oseni® Januvia® (Merck & Co.), Tradjenta® (Boehringer Ingelheim),

pioglitazone (generic)

Osmolex® amantadine HCl (generic), levodopa/carbidopa (generic), levodopa/carbidopa/entacapone (generic), pramipexole Di-HCl (generic), rasagline mesylate (generic), ropinirole HCl (generic), selegiline (generic)

OsmoPrep® Gavilyte-C (generic), Gavilyte-H with bisacodyl (generic), Gavilyte-N (generic), PEG 3350 bowel preparation (generic), Trilyte w/ Flavor packet (generic), Prepopik® (Ferring Pharmaceutical), Suprep® (Braintree Laboratories)

Otezla® (Psoriatic Arthritis Cosentyx® (Novartis), Enbrel® (Amgen), Humira® (Abbott), indication only) Stelara SC® (Centocor), Xeljanz® (Pfizer), Xeljanz XR® (Pfizer) Otovel® neomycin/polymyxin/HC (generic)Otrexup® methotrexate (generic)Ovace® 9.8% Plus Lotion sulfacetamide sodium (generic), Enstilar® (Leo Pharma Inc.),

Pramosone® (Sebela Pharmaceuticals), Pramosone E® (Sebela Pharmaceuticals)

Ovace® 10% Plus Cleanser sulfacetamide sodium (generic), Enstilar® (Leo Pharma Inc.), Pramosone® (Sebela Pharmaceuticals), Pramosone E® (Sebela Pharmaceuticals)

Ovace® 10% Plus Cream sulfacetamide sodium (generic), Enstilar® (Leo Pharma Inc.), Pramosone® (Sebela Pharmaceuticals), Pramosone E® (Sebela Pharmaceuticals)

Ovace® Plus Foam sulfacetamide sodium (generic), Enstilar® (Leo Pharma Inc.), Pramosone® (Sebela Pharmaceuticals), Pramosone E® (Sebela Pharmaceuticals)

Ovace® 10% Plus Shampoo sulfacetamide sodium (generic), Enstilar® (Leo Pharma Inc.), Pramosone® (Sebela Pharmaceuticals), Pramosone E® (Sebela Pharmaceuticals)

Oxaydo® oxycodone (generic), Oxycontin® (Purdue Pharma)Oxecta® oxycodone (generic), morphine sulfate (generic),

oxymorphone (generic), Oxycontin® (Purdue Pharma)Oxistat® lotion econazole nitrate (generic), ketoconazole (generic),

nystatin (generic)Oxtellar XR® oxcarbazepine (generic)oxycodone HCl ER oxycodone IR (generic), Oxycontin® (Purdue Pharma)Oxytrol® flavoxate (generic), oxybutynin (generic), oxybutynin ER

(generic), tolterodine tartrate (generic), trospium (generic), Myrbetriq® (Astellis), Vesicare® (GlaxoSmithKline)

Pacnex® MX, HP, LP benzoyl peroxide (generic)Pancreaze® Creon® (Abbott), Zenpep® (Aptalis Pharma) Pandel® betamethasone valerate cream (generic), desoximetasone cream

(generic), fluocinolone acetonide cream (generic), hydrocortisone valerate cream (generic), triamcinolone acetonide cream (generic)

Paxil® Suspension fluoxetine solution (generic)Pazeo® azelastine (generic), cromolyn (generic), epinastine (generic),

olopatadine (generic)PCE® erythromycin base (generic)Pediapak® ciclopirox (generic)Pennsaid Solution® diclofenac sodium drops (generic), diclofenac sodium gel

(generic)Pentasa® balsalazide disodium (generic), mesalamine enteric coated

tablet (generic), mesalamine suppository (generic), sulfasalazine (generic), Apriso® (Salix)

Perforomist® albuterol sulfate (generic), levalbuterol HCl (generic)Pertzye® Creon® (Abbvie), Zenpep® (Actavis)Pexeva® paroxetine HCl (generic)Phoslyra® calcium acetate (generic), lanthanum carbonate chewable tablet

(generic), sevelamar carbonate (generic)Phrenilin Forte® butalbital/acetaminophen (generic)Plexion® sulfacetamide/sulfur (generic)Plixda® adapalene cream (generic)Potaba® Folbee (generic), Folbee Plus (generic), Folbic (generic),

Renal Caps (generic), Triphrocaps (generic)Potiga® carbamazepine (generic), levetiracetam (generic),

topiramate (generic), Banzel® tablet (Eisai Inc.)Precision® ACCU-CHEK® (Roche), Breeze 2® (Ascensia Diabetes Care),

Contour® (Ascensia Diabetes Care), True Metrix® (Trividia Health)

Pred-G® tobramycin-dexamethasone (generic), neomycin/ bacitracin/polymyxin B/HC (generic), neomycin/ polymyxin B/dexamethasone (generic), neomycin/ polymyxin B/HC (generic), TobraDex® Oint (Alcon)

Pred Mild® prednisolone acetate (generic)Prefera-OB One® PNV-DHA (generic), Zatean-PN Plus (generic),

Zatean-PN DHA (generic), Prenatal Plus (generic) Premarin® Tabs estradiol (generic), estropipate (generic)Premarin® Vaginal Cream yuvifem (generic), Osphena® (Shionogi)Prenate Essential® PNV-DHA (generic), Zatean-PN Plus (generic),

Zatean-PN DHA (generic), Prenatal Plus (generic) Prilosec® Suspension Nexium® Rx Suspension (AstraZeneca)Primlev® oxycodone w/APAP (generic)

17

Privigen® Carimune NF Nanofiltered® (CSL Behring AG), Flebogamma DIF® (Grifols Biologicals, Inc.), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Hizentra® (CSL Behring AG)

Prolensa® bromfenac sodium (generic), diclofenac (generic), flurbiprofen (generic), ketorolac (generic)

Promiseb Complete® calcipotriene (generic), selenium sulfide (generic), sodium sulfacetamide (generic)

Protonix® granules Nexium® Rx Suspension (AstraZeneca)Proventil HFA® ProAir HFA (Teva), ProAir Respiclick (Teva), Ventolin HFA

(GlaxoSmithKline) Qbrelis® lisinopril (generic)Quillichew ER® methylphenidate ER (generic)Quillivant XR® methylphenidate ER (generic)Qnasl® budesonide (generic), flunisolide (generic), fluticasone

propionate (generic), mometasone furoate (generic), triamcinolone acetonide (generic)

Qroxin® lidocaine cream, ointment, patch (generic)QTERN® Glyxambi® (Boehringer Ingelheim)Qudexy XR® topiramate IR sprinkle caps (generic)Rayaldee® calcitriol (generic), doxercalciferol (generic), paricalcitol (generic)Rayos® prednisone (generic)Reciphexamine® lidocaine cream, ointment, patch (generic)Relexxii® methylphenidate ER (generic)Relyyks® lidocaine cream, ointment, patch (generic)Relyyt® lidocaine cream, ointment, patch (generic)Renagel® calcium acetate (generic), lanthanum carbonate chewable tablet

(generic), sevelamar carbonate (generic)Renovo® lidocaine cream, ointment, patch (generic)Retacrit® Aranesp® (Amgen), Procrit® (Janssen)Rexulti® aripiprazole (generic), clozapine (generic), olanzapine (generic),

paliperidone (generic), quetiapine fumarate (generic), risperidone (generic), ziprasidone HCl (generic)

Rhofade® metronidazole cream (generic), sulfacetamide sodium-sulfur (generic)

Riomet® Solution metformin (generic)Rosadan® metronidazole cream (generic)Rosula® Cleanser sulfacetamide sodium/sulfur cleanser (generic)Roxybond® oxycodone (generic), morphine sulfate (generic), oxymorphone

(generic), Oxycontin® (Purdue Pharma)Rozerem® eszopiclone (generic), temazepam (generic), triazolam (generic),

zaleplon (generic), zolpidem (generic)Rytary® carbidopa/levodopa ER (generic)Sabril® tablet divalproex (generic), lamotrigine (generic), levetiracetam

(generic)Saizen® Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex®

(Novo Nordisk), Zomacton® (Ferring Pharmaceuticals)Saizenprep® Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex®

(Novo Nordisk), Zomacton® (Ferring Pharmaceutical)Sancuso® aprepitant (generic), granisetron (generic), ondansetron

(generic), Emend® (Merck & Co.)Saphris® aripiprazole (generic), clozapine (generic), olanzapine

(generic), paliperidone (generic), quetiapine fumarate (generic), risperidone (generic), ziprasidone HCl (generic)

Seebri Neohaler® Incruse Ellipta® (GlaxoSmithKline), Spiriva® (Boehringer Ingelheim), Spiriva Respimat® (Boehringer Ingelheim)

Segluromet® Farxiga® (AstraZeneca), Invokana® (Janssen), Invokamet® (Janssen), Jardiance® (Boehringer Ingelheim), Synjardy® (Eli Lilly), Synjardy XR® (Eli Lilly), Xigduo XR® (AstraZeneca)

SelRx® selenium sulfide (generic)Sernivo® betamethasone dipropionate (generic)Serostim® Norditropin Flexpro® (Novo Nordisk), Norditropin Nordiflex®

(Novo Nordisk), Zomacton® (Ferring Pharmaceuticals)Silalite Pak® betamethasone valerate cream (generic), desoximetasone

cream (generic), fluocinolone acetonide cream (generic), hydrocortisone valerate cream (generic), triamcinolone acetonide cream (generic)

Silenor® eszopiclone (generic), temazepam (generic), triazolam (generic), zaleplon (generic), zolpidem (generic)

Siliq® Cosentyx® (Novartis), Humira® (Abbott), Otezla® (Plaque Psoriasis indication only) (Celgene), Stelara SC® (Janssen)Simbrinza® dorzolamide/timolol (generic)Simcor® simvastatin (generic) + niacin ER (generic)Simponi SC® Cosentyx® (Novartis), Enbrel® (Amgen), (Ankylosing Spondylitis Humira® (Abbott) indication only)Simponi SC® (Psoriatic Arthritis Cosentyx® (Novartis), Enbrel® (Amgen), Humira® (Abbott), indication only) Stelara SC® (Centocor), Xeljanz® (Pfizer), Xeljanz XR® (Pfizer) Simponi SC® (Ulcerative Colitis Humira® (Abbott), Xeljanz® (Pfizer) indication only)

Simponi SC® Actemra SC® (Genentech), Enbrel® (Amgen), (Rheumatoid Arthritis indication only) Humira® (Abbott), Xeljanz® (Pfizer), Xeljanz XR® (Pfizer)Sinelee® lidocaine cream, ointment, patch (generic)Sofosbuvir/Velpatasvir® Mavyret® (Abbvie), Zepatier® (Merck) (Genotype 1,2,3,4,5,6) Solodyn® 55mg & 80mg & 105mg minocycline (generic), minocycline ER (generic)Soolantra® metronidazole topical (generic), sulfacetamide sodium/sulfur

(generic)Sorilux® calcipotriene (generic)Sovaldi® (Genotype 1,4) Mavyret® (Abbvie), Zepatier® (Merck)Sovaldi® (Genotype 2,3) Mavyret® (Abbvie)Spectracef® cefaclor (generic), cefuroxime axetil (generic)Spritam® levetiracetam solution (generic), levetiracetam tablet (generic),

gabapentin (generic), topiramate (generic)Sprix® etodolac (generic), ibuprofen (generic), naproxen (generic)Steglatro® Farxiga® (AstraZeneca), Invokana® (Janssen), Invokamet®

(Janssen), Jardiance® (Boehringer Ingelheim), Synjardy® (Eli Lilly), Synjardy XR® (Eli Lilly), Xigduo XR® (AstraZeneca)

Steglujan® Glyxambi® (Boehringer Ingelheim)Striant® testosterone gel in packet (generic), testosterone gel pump

(generic), testosterone solution metered pump (generic), Androderm® (Watson)

Striverdi Respimat® Arcapta Neohaler® (Novartis), Serevent Diskus® (GSK)Strovite One® Corvita (generic), V-C Forte (generic)Subsys® fentanyl citrate lozenges (generic)Suclear® Gavilyte-C (generic), Gavilyte-H with bisacodyl (generic),

Gavilyte-N (generic), PEG 3350 bowel preparation (generic), Trilyte w/ Flavor packet (generic), Prepopik® (Ferring Pharmaceutical), Suprep® (Braintree Laboratories)

Sumavel® DosePro® sumatriptan (generic)Sumaxin TS® sulfacetamide/sulfur (generic)Supartz® Euflexxa® (Ferring B.V), Monovisc® (Depuy Mitek), Orthovisc®

(Depuy Mitek)Supartz Fx® Euflexxa® (Ferring B.V), Monovisc® (Depuy Mitek), Orthovisc®

(Depuy Mitek)Suprax® cefuroxime (generic), CefdinirSuprenza ODT® phentermine (generic), Contrave ER® (Takeda), Qsymia®

(Vivustro), Saxenda® (Novo Nordisk), Xenical® (Genentech)Sympazan® clobazam (generic), felbamate (generic), lamotrigine (generic),

topiramate (generic), Banzel® Tablet (Eisai Inc.)Synalar TS®, Synalar® fluocinolone acetonide (generic)Synalgos-DC® hydrocodone/APAP (generic)Synapryn® tramadol HCl (generic)Synvexia® lidocaine cream, ointment, patch (generic)Synvisc® Euflexxa® (Ferring B.V), Monovisc® (Depuy Mitek), Orthovisc®

(Depuy Mitek)Synvisc-One® Euflexxa® (Ferring B.V), Monovisc® (Depuy Mitek), Orthovisc®

(Depuy Mitek)Taclonex® Suspension calcipotriene-betamethasone ointment (generic), selenium sulfide

(generic), Enstilar® (Leo Pharma Inc.), Pramosone® (Sebela Pharmaceuticals), Pramosone E® (Sebela Pharmaceuticals)

Taltz® Cosentyx® (Novartis), Humira® (Abbott), (Plaque Psoriasis indication only) Otezla® (Celgene), Stelara SC® (Centocor)Taltz® Cosentyx® (Novartis), Enbrel® (Amgen), Humira® (Abbott), (Psoriatic Arthritis indication only) Stelara SC® (Centocor), Xeljanz® (Pfizer), Xeljanz XR® (Pfizer) Targadox® doxycycline hyclate tablet (generic)Taytulla® Lo Loestrin FE (Allergan), Lomedia 24 FE (generic), Junel FE

(generic), Microgestin FE (generic)Tazorac® Gel/Tazorac® 0.05% cream tazarotene 0.1% cream (generic), tretinoin (generic), (Acne use only) Azelex® (Allergan), Finacea® (Bayer)Tekamlo® candesartan (generic) + amlodipine (generic), eprosartan

(generic) + amlodipine (generic) irbesartan (generic) + amlodipine (generic), losartan (generic) + amlodipine (generic), telmisartan (generic) + amlodipine (generic), valsartan (generic) + amlodipine (generic)

Tekturna® candesartan (generic), eprosartan mesylate (generic), irbesartan (generic), losartan potassium (generic), telmisartan (generic), valsartan (generic)

Tekturna/HCT® candesartan/HCTZ (generic), irbesartan/HCTZ (generic), losartan/HCTZ (generic), telmisartan/HCTZ (generic), valsartan/HCTZ (generic)

Tersi® Foam selenium sulfide (generic)Texacort® fluocinolone acetonide solution, non oral (generic)Ticanase® budesonide (generic), flunisolide (generic), fluticasone

propionate (generic), mometasone furoate (generic), triamcinolone acetonide (generic)

Timoptic PF® betaxolol (generic), carteolol (generic), timolol maleate (generic), levobunolol (generic), metipranolol (generic)

Tivorbex® indomethacin (generic)

Nonpreferred Product Possible Preferred Alternatives Nonpreferred Product Possible Preferred Alternatives

*This is a partial list of nonpreferred drugs. Please be sure that your drug is listed in Section I.

18

TobraDex® ST tobramycin-dexamethasone (generic), neomycin/ bacitracin/polymyxin B/HC (generic), neomycin/ polymyxin B/dexamethasone (generic), neomycin/ polymyxin B/HC (generic), TobraDex® Oint (Alcon)

Tolak® fluorouracil (generic), imiquimod (generic), Picato Gel® (Leo Pharma Inc.)

Topiramate ER® topiramate (generic)Toviaz® flavoxate (generic), oxybutynin (generic), oxybutynin ER

(generic), tolterodine tartrate (generic), trospium (generic), Myrbetriq® (Astellas), Vesicare® (GlaxoSmithKline)

Tramadol ER® Capsules tramadol ER tablets (generic)Travatan Z® bimatoprost (generic), latanoprost (generic), travaprost (generic)Tremfya® Cosentyx® (Novartis), Humira® (Abbott), (Plaque Psoriasis indication only) Otezla® (Celgene), Stelara SC® (Centocor)Tretin-X® Cream, Kit tretinoin (generic)Triglide® fenofibrate (generic)Trintellix® paroxetine (generic), citalopram (generic),

escitalopram (generic), fluvoxamine (generic)Trivisc® Euflexxa® (Ferring B.V), Monovisc® (Depuy Mitek), Orthovisc®

(Depuy Mitek)Trokendi XR® topiramate (generic)Trulance® Linzess® (Actavis/Ironwood)Tudorza Pressair® Incruse Ellipta® (GlaxoSmithKline), Spiriva® (Boehringer

Ingelheim), Spiriva Respimat® (Boehringer Ingelheim)Ultravate Lotion® clobetasol propionate lotion (generic), halobetasol

propionate cream (generic)Ultresa® pancrelipase (generic), Creon® (Abbott), Zenpep® (Aptalis Pharma)Vanoxide HC® benzoyl peroxide, hydrocortisone cream (generic)Varubi® aprepitant (generic), granisetron (generic), ondansetron

(generic), Emend® (Merck & Co.)Vascepa® fenofibrate (generic), niacin ER (generic)Velphoro® calcium acetate (generic), lanthanum carbonate chewable tablet

(generic), sevelamar carbonate (generic)Veltin® clindamycin phosphate/tretinoin (generic)Veramyst® budesonide (generic), flunisolide (generic), fluticasone

propionate (generic), mometasone furoate (generic), triamcinolone acetonide (generic)

Verdeso® desonide (generic)Versacloz® clozapine ODT (generic)Vexol® fluorometholone (generic)Vibramycin® Syrup doxycycline monohydrate suspension (generic)Victoza® Bydureon® (Amylin Pharmaceuticals), Bydureon Bcise® (Amylin

Pharmaceuticals), Bydureon Pen® (Amylin Pharmaceuticals), Byetta® (Amylin Pharmaceuticals), Ozempic® (Novo Nordisk), Trulicity® (Eli Lilly)

Viekira Pak® (Genotype 1) Mavyret® (Abbvie), Zepatier® (Merck)Viibryd® citalopram (generic), fluoxetine HCl (generic),

paroxetine HCl (generic), sertraline HCl (generic)Vimovo® naproxen (generic) + esomeprazole magnesium (generic)Viokace® Creon® (Abbott), Zenpep® (Aptalis Pharma) Vitafol-OB + DHA® PNV-DHA (generic), Zatean-PN Plus (generic),

Zatean-PN DHA (generic), Prenatal Plus (generic) Vitafol-One® PNV-DHA (generic), Zatean-PN Plus (generic),

Zatean-PN DHA (generic), Prenatal Plus (generic) Vital-D Rx® Folbee (generic), Folbee Plus (generic), Folbic (generic), Renal

Caps (generic), Triphrocaps (generic)Vivlodex® meloxicam (generic)Vogelxo® testosterone gel in packet (generic), testosterone gel pump

(generic), testosterone solution metered pump (generic), Androderm® (Watson)

Vraylar® aripiprazole (generic), clozapine (generic), olanzapine (generic), paliperidone (generic), quetiapine fumarate (generic), risperidone (generic), ziprasidone HCl (generic)

Vyzulta bimatoprost (generic), latanoprost (generic), travaprost (generic)Xadago® levodopa/carbidopa (generic), rasagline mesylate (generic),

levodopa/carbidopa/entacapone (generic), pramipexole Di-HCl (generic), ropinirole HCl (generic), tolcapone (generic), selegiline (generic)

Xartemis XR® oxycodone/APAP (generic), hydrocodone/APAP (generic)Xerese® acyclovir ointment (generic) + hydrocortisone (generic)Xigduo XR® Invokana® (Janssen), Invokamet® (Janssen), Jardiance®

(Boehringer Ingelheim), Synjardy® (Eli Lilly)Xiidra® Restasis® (Allergan), Restasis Multidose® (Allergan)Xolegel® econazole nitrate (generic), ketoconazole (generic), nystatin (generic)Xopenex HFA® ProAir HFA (Teva), ProAir Respiclick (Teva), Ventolin HFA

(GlaxoSmithKline)Xtampza ER® oxycodone HCl (generic), Oxycontin® (Purdue Pharma)Xultophy® Soliqua® (Sanofi-Aventis)Xyosted® testosterone gel in packet (generic), testosterone gel pump

(generic), testosterone solution metered pump (generic), Androderm® (Watson)

Yupelri® Incruse Ellipta® (GlaxoSmithKline), Spiriva® (Boehringer Ingelheim), Spiriva Respimat® (Boehringer Ingelheim)

Zecuity® sumatriptan succinate (generic)Zelapar® selegiline (generic)Zembrace Symtouch® sumatriptan succinate injection (generic)Zenzedi® 2.5mg, 7.5mg, 15mg, 20mg, 30mg dextroamphetamine sulfate (generic)Zetonna® budesonide (generic), flunisolide (generic), fluticasone

propionate (generic), mometasone furoate (generic), triamcinolone acetonide (generic)

Zioptan® bimatoprost (generic), latanoprost (generic)Zipsor® diclofenac sodium (generic), ibuprofen(generic), naproxen

(generic), nabumetone (generic)Zithranol® , Zithranol-RR® calcipotriene-betamethasone ointment (generic), selenium sulfide

(generic), Enstilar® (Leo Pharma Inc.), Pramosone® (Sebela Pharmaceuticals), Pramosone E® (Sebela Pharmaceuticals)

Zmax® azithromycin (generic)Zodex® dexamethasone tablets (generic)Zohydro ER® morphine sulfate ER (generic), oxymorphone ER (generic),

Oxycontin® (Purdue Pharma)Zolpimist® zolpidem tartrate (generic), zaleplon (generic)Zomig® Nasal Spray sumatriptan nasal spray (generic)Zorvolex® diclofenac (generic), etodolac (generic), ibuprofen (generic),

ketoprofen (generic)Zovirax® Cream Denavir® Cream (Novartis)Zuplenz® ondansetron ODT (generic)Zurampic® allopurinol (generic), probenecid (generic), probenecid/

colchicine (generic), Colcrys® (Takeda), Uloric® (Takeda)Zyclara® fluorouracil (generic), imiquimod (generic), Picato® Gel

(Leo Pharma Inc.)Zydone® hydrocodone w/acetaminophen (generic)Zylet® tobramycin-dexamethasone (generic), neomycin/

bacitracin/polymyxin B/HC (generic), neomycin/ polymyxin B/dexamethasone (generic), neomycin/ polymyxin B/HC (generic), TobraDex® Oint (Alcon)

Zypitamag® atorvastatin (generic), fluvastatin (generic), lovastatin (generic), pravastatin (generic), rosuvastatin (generic), simvastatin (generic)

Zyprexa Relprevv® Aristada® (Alkermes, Inc.), Aristada Initio® (Alkermes, Inc), Risperdal Consta® (Janssen)

Nonpreferred Product Possible Preferred Alternatives Nonpreferred Product Possible Preferred Alternatives

*This is a partial list of nonpreferred drugs. Please be sure that your drug is listed in Section I.