high-cost drug exclusions...or tablet, butalbita l-aspirin-caffeine 50 -325-40mg capsule almotriptan...
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Core Formulary
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Asuris Northwest Health 528 East Spokane Falls Blvd, Suite 301 Spokane, WA 99202
© 2021 Asuris Northwest Health
PHARMACY SERVICES
High-Cost Drug ExclusionsThe high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at the lowest cost, consider talking with your doctor about one of the therapeutically equivalent (similar safety and efficacy) or over-the-counter (OTC) alternatives listed below. We encourage you to talk to your doctor about whether one of these options is right for you. Coverage of alternatives will vary.
These high cost medications may be considered medically necessary when ALL of the alternatives in the table below have been ineffective, not tolerated or all are contraindicated, unless otherwise specified. If your doctor believes that the listed alternatives are not right for you, your doctor may request an exception by contacting Customer Service. Please visit your health plan’s website or contact Customer Service at the number listed on the back of your member ID card for more information about medication coverage.
Questions?
Call the Customer Service number on your member ID card.
High-Cost Drug Exclusion List Effective 5/1/2021
Core Formulary
Drug Alternatives
Absorica Amnesteem, Claravis, isotretinoin, Myorisan, Zenatane
Absorica LD Amnesteem, Claravis, isotretinoin, Myorisan, Zenatane
Acanya
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
Acticlate doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
acyclovir 5% cream (generic Zovirax) acyclovir 5% ointment
Aczone
At least three of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
adapalene 0.1% pads, solution (generic Differin)
adapalene 0.1% cream, adapalene 0.1% gel, and at least two of the following lower cost products: adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
AirDuo Digihaler fluticasone-salmeterol (generic AirDuo), Advair Diskus, Advair HFA
Aklief cream tretinoin cream, tretinoin 0.01% and 0.025% gel
Ala-Scalp desoximetasone 0.25% cream, fluocinonide 0.05% solution, hydrocortisone 2.5% lotion
Alkindi Sprinkle hydrocortisone tablet
Allzital
At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen-caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325-40mg capsule or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule
almotriptan (generic Axert)
At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet
Altoprev atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
amcinonide cream, lotion, ointment
betamethasone dipropionate 0.05% cream, desoximetasone 0.25% ointment, fluocinonide 0.05% cream, fluocinonide 0.05% gel, fluocinonide 0.05% ointment, fluticasone propionate 0.005% ointment, triamcinolone 0.5% cream, triamcinolone 0.5% ointment
Amerge
generic naratriptan and at least one of the following lower cost triptan medications: eletriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet
amlodipine-atorvastatin tablet (generic Caduet)
amlodipine in combination with atorvastatin, amlodipine in combination with rosuvastatin or simvastatin
Amrix
cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet
Amzeeq
At least three of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
Page 2 of 15
Core Formulary
Drug Alternatives
Antara
At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule
ApexiCon E desoximetasone 0.05% cream, fluocinonide 0.05% cream, triamcinolone 0.5% cream
Arazlo
tazarotene 0.1% cream and at least two of the following lower cost products: adapalene 0.1% cream/gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/gel/lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel
ArmonAir Digihaler Arnuity Ellipta, Asmanex HFA, Asmanex Twisthaler, Flovent Diskus, Flovent HFA
Atelvia alendronate, ibandronate, risedronate IR (immediate-release)
Belsomra eszopiclone, zaleplon, zolpidem
benzonatate 150mg capsule
benzonatate 100mg and 200mg capsule, guaifenesin-codeine 100-10mg/5ml solution, promethazine-codeine 6.25-10mg/5ml syrup, promethazine-dm 6.25-15mg/5ml syrup
betamethasone valerate 0.12% external foam (generic Luxiq)
betamethasone dipropionate 0.05% cream, betamethasone valerate 0.1% ointment, mometasone furoate 0.1% solution (lotion), triamcinolone 0.5% cream
Bijuva estradiol in combination with progesterone, Fyavolv, Jevantique Lo, Jinteli
Binosto alendronate tablet, alendronate solution
Bryhali betamethasone dipropionate augmented 0.05% lotion, betamethasone valerate 0.1% ointment, clobetasol propionate 0.05% lotion
Bupap
At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen-caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325-40mg capsule or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule
butalbital-acetaminophen 25-325mg tablet
At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen-caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325-40mg capsule or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule
butalbital-acetaminophen 50-300mg capsule (generic Bupap)
At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen-caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325-40mg capsule or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule
Caduet amlodipine in combination with atorvastatin, amlodipine in combination with rosuvastatin or simvastatin
Cafergot At least one of the following lower cost ergot-containing medications: generic ergotamine/ caffeine tablet, generic dihydroergotamine injection
calcipotriene 0.005% foam (generic Sorilux) calcipotriene 0.005% cream/ ointment/ solution, tazarotene 0.1% cream calcitriol 3mcg/gm ointment (generic Vectical) calcipotriene 0.005% cream/ ointment/ solution, tazarotene 0.1% cream
Cambia packets
diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac
Capex fluocinolone 0.01% oil (scalp oil), fluocinolone 0.01% solution
Carac fluorouracil 5% cream, fluorouracil 2% solution, fluorouracil 5% solution
Page 3 of 15
Core Formulary
Drug Alternatives
Centany mupirocin 2% ointment
Chenodal ursodiol 300mg capsule, 250mg tablet, 500mg tablet chlorzoxazone 250mg, 375mg, 750mg tablet (generic Lorzone)
chlorzoxazone 500mg tablet at least two of the following lower cost products: baclofen, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet
Cleocin-T
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
Clindacin-P
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
Clindacin ETZ
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
Clindagel
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
clindamycin 1% topical gel (generic Clindagel)
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
clindamycin foam (generic Evoclin)
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
clindamycin swab (generic Clindacin-P, Clindacin ETZ)
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
clindamycin-benzoyl peroxide 1.2-2.5% (generic Acanya)
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
clindamycin-tretinoin topical gel (generic Veltin, Ziana)
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
clobetasol foam (generic Olux)
At least two lower cost forms of clobetasol propionate including cream, gel, lotion, ointment, and solution
clobetasol emulsion foam (generic Olux-E)
At least two lower cost forms of clobetasol propionate including cream, gel, lotion, ointment, and solution
clobetasol spray (generic Clobex)
At least two lower cost forms of clobetasol propionate including cream, gel, lotion, ointment, and solution
Clobex At least two lower cost forms of clobetasol propionate including cream, gel, lotion, ointment, and solution
clocortolone 0.1% cream (generic Cloderm)
fluocinolone 0.025% ointment, mometasone 0.1% cream, triamcinolone 0.1% cream
Page 4 of 15
Core Formulary
Drug Alternatives
Cloderm cream, pump fluocinolone 0.025% ointment, mometasone 0.1% cream, triamcinolone 0.1% cream
Conjupri amlodipine and at least two additional calcium channel blockers, such as diltiazem, felodipine, nifedipine, or verapamil
Consensi amlodipine in combination with celecoxib
Cordran tape fluocinonide 0.05% ointment, hydrocortisone 1% ointment, triamcinolone 0.1% ointment
Cordran 0.05% cream, ointment
desonide 0.05% cream and lotion, fluocinonide 0.05% ointment, hydrocortisone 1% ointment, triamcinolone 0.1% ointment, triamcinolone 0.025% lotion and ointment
CoreMino doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
Cuprimine penicillamine 250mg tablet (generic Depen Titratabs)
Cutivate betamethasone dipropionate 0.05% lotion, fluocinolone 0.025% cream, triamcinolone 0.1% lotion
cyclobenzaprine 7.5mg tablet (generic Fexmid)
cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet
cyclobenzaprine ER (extended-release) capsule [generic Amrix]
cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet
dapsone 5% and 7.5% gel (generic Aczone)
At least three of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
Dayvigo eszopiclone, zaleplon, zolpidem
Desonate gel At least two lower cost forms of desonide including cream, lotion and ointment desonide 0.05% gel (generic Desonate) At least two lower cost forms of desonide including cream, lotion and ointment desoximetasone 0.05% gel (generic Topicort gel)
betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment
desoximetasone 0.05% ointment (generic Topicort ointment)
betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment
desoximetasone spray (generic Topicort spray)
betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment
Dexabliss dexamethasone tablet dexamethasone dose pack (generic Dexpak) dexamethasone tablet
Dexpak dexamethasone tablet
D.H.E. 45 At least one of the following lower cost ergot-containing medications: generic ergotamine/ caffeine tablet, generic dihydroergotamine injection
diclofenac 35mg capsule (generic Zorvolex)
diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac
Page 5 of 15
Core Formulary
Drug Alternatives diclofenac topical patch (generic Flector)
diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution (generic Pennsaid 1.5%), over-the-counter Voltaren gel
Differin 0.1% lotion
adapalene 0.1% gel, adapalene 0.1% cream and at least one of the following lower cost products: adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
diflorasone cream, ointment (generic Psorcon)
desoximetasone 0.05% cream, fluocinonide 0.05% cream, ointment and solution, triamcinolone 0.5% cream and ointment
dihydroergotamine mesylate nasal spray (generic Migranal)
At least one of the following lower cost ergot-containing medications: generic ergotamine/ caffeine tablet, generic dihydroergotamine injection
doxepin 5% cream (generic Prudoxin, Zonalon)
At least two of the following lower cost products: betamethasone 0.05% cream, clobetasol propionate 0.05% cream, desoximetasone 0.25% cream, pimecrolimus 1% cream, tacrolimus 0.03% ointment, tacrolimus 0.1% ointment, triamcinolone 0.5% cream
Doryx, Doryx MPC (modified polymer coat)
doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
doxycycline hyclate DR (delayed-release) tablet [generic Doryx, Doryx MPC]
doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
doxycycline 40mg ER (extended-release) capsule (for rosacea) [generic Oracea]
doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
doxycycline hyclate 50mg, 75mg, 150mg tablet (generic Acticlate, Targadox)
doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
doxycycline monohydrate capsule
doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
Duaklir Pressair Anoro Ellipta, Stiolto Respimat
Duetact pioglitazone in combination with glimepiride
Duobrii halobetasol propionate 0.05% cream, tazarotene 0.1% cream
Durlaza clopidogrel bisulfate 75mg tablet in combination with over-the-counter aspirin 81mg
dutasteride-tamsulosin (generic Jalyn)
dutasteride in combination with tamsulosin and at least two of the following lower cost products: alfuzosin ER (extended-release) tablet, doxazosin, dutasteride, finasteride, tamsulosin, terazosin
Dutoprol metoprolol in combination with hydrochlorothiazide
Dxevo dexamethasone tablet
Ecoza econazole nitrate 1% cream
Edarbi irbesartan, losartan, olmesartan, telmisartan, valsartan
Edarbyclor chlorothiazide, indapamide, irbesartan-hydrochlorothiazide (HCTZ), losartan-HCTZ, metolazone, olmesartan-HCTZ, telmisartan-HCTZ, valsartan-HCTZ
Edluar eszopiclone, zaleplon, zolpidem
Elepsia XR levetiracetam IR (immediate-release) tablet, levetiracetam ER (extended-release) tablet
Emflaza methylprednisolone, prednisolone syrup, prednisone oral solution, prednisone tablet
Page 6 of 15
Core Formulary
Drug Alternatives
Ergomar At least one of the following lower cost ergot-containing medications: generic ergotamine/ caffeine tablet, generic dihydroergotamine injection
Ertaczo
At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the-counter terbinafine cream
Evoclin
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
Exelderm 1% cream, solution
At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the-counter terbinafine cream
Extina ketoconazole 2% cream, ketoconazole 2% shampoo ezetimibe-simvastatin tablet (generic Vytorin)
ezetimibe in combination with simvastatin, ezetimibe in combination with atorvastatin or rosuvastatin
Fabior
tazarotene 0.1% cream and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel
fenofibrate 40mg tablet, 120mg tablet (generic Fenoglide)
At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule
fenofibrate 50mg and 150mg capsule (generic Lipofen)
At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule
fenofibrate 160mg tablet (generic Triglide)
At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule
fenofibric acid 35mg, 105mg tablet (generic Fibricor)
At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule
Fenoglide
At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule
fenoprofen capsule (generic Fenortho)
fenoprofen calcium 600mg tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac
Fenortho
fenoprofen calcium 600mg tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac
Fexmid
cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet
Fibricor
At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule
Flector diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution (generic Pennsaid 1.5%), over-the-counter Voltaren gel
Fluoroplex fluorouracil 2% solution, fluorouracil 5% solution fluorouracil 0.5% cream (generic Carac) fluorouracil 5% cream, fluorouracil 2% solution, fluorouracil 5% solution
Page 7 of 15
Core Formulary
Drug Alternatives flurandrenolide 0.05% ointment (generic Cordran)
fluocinonide 0.05% ointment, hydrocortisone 1% ointment, triamcinolone 0.1% ointment
fluticasone propionate 0.05% lotion (generic Cutivate)
betamethasone dipropionate 0.05% lotion, fluocinolone 0.025% cream, triamcinolone 0.1% lotion
fluvastatin capsule (generic Lescol) atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin fluvastatin ER (extended-release) tablet [generic Lescol XL] atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
Fortamet metformin, metformin ER (extended-release) [non-osmotic, non-modified release]
Fosamax D alendronate in combination with over-the-counter vitamin D
Frova
At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet
frovatriptan (generic Frova)
At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet
Gimoti metoclopramide IR (immediate-release) tablet, metoclopramide solution
Glumetza metformin, metformin ER (extended-release) [non-osmotic, non-modified release]
glycopyrrolate 1.5mg tablet (generic Glycate) glycopyrrolate 1mg tablet, glycopyrrolate 2mg tablet
Gocovri amantadine capsule/syrup/ tablet, rasagiline, selegiline
Gralise amitriptyline tablet, gabapentin capsule/solution/ tablet, pregabalin capsule/ solution
halcinonide 0.1% cream (generic Halog)
betamethasone AF 0.05% cream, desoximetasone 0.25% cream, fluocinonide 0.05% cream
halobetasol 0.05% foam (generic Lexette) halobetasol cream, halobetasol ointment
Halog cream betamethasone AF 0.05% cream, desoximetasone 0.25% cream, fluocinonide 0.05% cream
Halog ointment betamethasone dipropionate 0.05% ointment, desoximetasone 0.25% ointment, fluocinonide 0.05% ointment
Halog solution betamethasone AF 0.05% cream, desoximetasone 0.25% cream, fluocinonide 0.05% cream, fluocinonide 0.05% solution
Hemady dexamethasone tablet
Hidex dexamethasone tablet
Horizant amitriptyline tablet, gabapentin capsule/solution/ tablet, pregabalin capsule/ solution
hydrocortisone butyrate 0.1% lotion (generic Locoid)
betamethasone dipropionate 0.05% lotion, fluticasone propionate 0.05% cream, triamcinolone 0.1% lotion
hydrocortisone butyrate hydrophilic lipo base 0.1% cream (generic Locoid Lipocream)
betamethasone valerate 0.1% cream, fluticasone propionate 0.05% cream, hydrocortisone valerate 0.2% cream
imiquimod 3.75% cream (generic Zyclara pump) imiquimod 5% cream
Page 8 of 15
Core Formulary
Drug Alternatives
Imitrex injection
generic sumatriptan injection and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, zolmitriptan tablet/ orally disintegrating tablet
Imitrex nasal spray
generic sumatriptan nasal spray and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, zolmitriptan tablet/ orally disintegrating tablet
Imitrex tablet
generic sumatriptan and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, zolmitriptan tablet/ orally disintegrating tablet
Impeklo 0.05% lotion At least two lower cost forms of clobetasol propionate including cream, gel, lotion, ointment, and solution
Impoyz betamethasone 0.05% ointment, desoximetasone 0.25% cream, fluocinonide 0.05% cream
Inderal XL propranolol tablet and solution, propranolol ER (extended-release) capsule [generic Inderal LA], nadolol tablet, timolol tablet
Indocin ibuprofen suspension 100mg/5ml, indomethacin 25mg capsule, indomethacin 50mg capsule, over-the-counter Voltaren gel
indomethacin 20mg capsule (generic Tivorbex)
indomethacin 25mg capsule, indomethacin 50mg capsule, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac
InnoPran XL propranolol tablet and solution, propranolol ER (extended-release) capsule [generic Inderal LA], nadolol tablet, timolol tablet
Intermezzo eszopiclone, zaleplon, zolpidem
Isordil Titradose 40mg tablet isosorbide dinitrate tablet isosorbide tablet 40mg (generic Isordil Titradose) isosorbide dinitrate tablet
Istalol (once daily) eye drops timolol maleate (twice daily) eye drops [generic Timoptic]
Jalyn
dutasteride in combination with tamsulosin and at least two of the following lower cost products: alfuzosin ER (extended-release) tablet, doxazosin, dutasteride, finasteride, tamsulosin, terazosin
Kenalog triamcinolone 0.025% cream, triamcinolone 0.1% cream, triamcinolone 0.025% ointment, triamcinolone 0.1% ointment
ketoconazole 2% foam (generic Extina) ketoconazole 2% cream, ketoconazole 2% shampoo
ketodan (generic Extina) ketoconazole 2% cream, ketoconazole 2% shampoo
ketoprofen 25mg capsule
ketoprofen 50mg capsule and at least three of the following lower cost NSAID products: celecoxib, etodolac, ketoprofen ER (extended-release) 200mg capsule, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac
ketorolac nasal spray (generic Sprix)
At least four of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac
Klisyri fluorouracil 2% solution, fluorouracil 5% solution, fluorouracil 5% cream, imiquimod 5% cream, diclofenac 3% gel
lactulose oral crystal packet lactulose solution, polyethylene glycol 3350 oral powder
Lescol atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
Lescol XL atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
Page 9 of 15
Core Formulary
Drug Alternatives
Lexette halobetasol cream, halobetasol ointment
Licart diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution (generic Pennsaid 1.5%), over-the-counter Voltaren gel
lidocaine-tetracaine 7-7% cream (generic Pliaglis)
lidocaine-prilocaine cream, lidocaine ointment, patch and solution, over-the-counter lidocaine gel
Lipofen
At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule
Livalo atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
Locoid lotion betamethasone 0.05% lotion, fluticasone propionate 0.05% cream, triamcinolone 0.1% lotion
Locoid Lipocream betamethasone valerate 0.1% cream, fluticasone propionate 0.05% cream, hydrocortisone valerate 0.2% cream
Lorzone
chlorzoxazone 500mg tablet at least two of the following lower cost products: baclofen, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet
Luxiq betamethasone dipropionate 0.05% cream, betamethasone valerate 0.1% ointment, mometasone furoate 0.1% solution (lotion), triamcinolone 0.5% cream
luliconazole cream (generic Luzu)
At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the-counter terbinafine cream
Luzu
At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the-counter terbinafine cream
Maxalt
generic rizatriptan and at least one of the following lower cost triptan medications: eletriptan, naratriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet
Maxalt ODT (orally disintegrating tablet)
generic rizatriptan orally disintegrating tablet and at least one of the following lower cost triptan medications: eletriptan, naratriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet
Medrol tablet methylprednisolone tablet, prednisolone syrup, prednisone oral solution, prednisone tablet
meloxicam capsule (generic Vivlodex)
generic meloxicam tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, nabumetone, naproxen, sulindac
metaxalone 400mg tablet
metaxalone 800mg tablet and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, methocarbamol tablet, tizanidine tablet
metformin ER (extended-release) modified release [generic Glumetza]
metformin, metformin ER (extended-release) [non-osmotic, non-modified release]
metformin ER (extended-release) osmotic release [generic Fortamet]
metformin, metformin ER (extended-release) [non-osmotic, non-modified release]
metoclopramide ODT (orally disintegrating tablet) [generic Metozolv ODT] metoclopramide IR (immediate-release) tablet, metoclopramide solution metoprolol-hydrochlorothiazide ER (extended-release) tablet [generic Dutoprol] metoprolol in combination with hydrochlorothiazide
Page 10 of 15
Core Formulary
Drug Alternatives miconazole-zinc oxide-petroleum ointment (generic Vusion)
At least two previous generic antifungals such as clotrimazole 1% cream, ketoconazole 2% cream, nystatin cream, ointment and powder, over-the-counter terbinafine cream, over-the-counter miconazole cream
Migergot At least one of the following lower cost ergot-containing medications: generic ergotamine/ caffeine tablet, generic dihydroergotamine injection
Migranal At least one of the following lower cost ergot-containing medications: generic ergotamine/ caffeine tablet, generic dihydroergotamine injection
Millipred, Millipred DP methylprednisolone tablet, prednisolone syrup, prednisone oral solution, prednisone tablet
minocycline IR (immediate-release) tablet
doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
minocycline ER (extended-release) tablet [generic Solodyn]
doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
minocycline ER (extended-release) capsule [generic Ximino]
doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
Minolira doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
Mondoxyne NL doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
mupirocin calcium cream (generic Bactroban) mupirocin 2% ointment, over-the-counter bacitracin ointment
Mytesi over-the-counter Bismuth, diphenoxylate-atropine, loperamide, opium tincture 1%, paregoric tincture 2mg/5ml
naftifine gel (generic Naftin) naftifine 1% cream, naftifine 2% cream
Naftin gel naftifine 1% cream, naftifine 2% cream
Nalfon
fenoprofen calcium 600mg tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac
Naprelan
naproxen EC (enteric-coated), naproxen DR (delayed-release), naproxen sodium and at least one of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, sulindac
naproxen ER (extended-release) [generic Naprelan]
naproxen EC (enteric-coated), naproxen DR (delayed-release), naproxen sodium and at least one of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, sulindac
Nascobal cyanocobalamin 1000mcg/mL injection
Nexletol atorvastatin, ezetimibe, rosuvastatin, simvastatin
Nexlizet atorvastatin, ezetimibe, rosuvastatin, simvastatin niacin (antihyperlipidemic) [generic Niacor] niacin ER (extended-release) [generic Niaspan], over-the-counter niacin
Niacor niacin ER (extended-release) [generic Niaspan], over-the-counter niacin
Nocdurna
bethanechol, desmopressin nasal spray, desmopressin tablet, flavoxate, oxybutynin, tolterodine ER (extended-release), tolterodine IR (immediate-release), trospium IR
Page 11 of 15
Core Formulary
Drug Alternatives
Noctiva
bethanechol, desmopressin nasal spray, desmopressin tablet, flavoxate, oxybutynin, tolterodine ER (extended-release), tolterodine IR (immediate-release), trospium IR
Norgesic Forte
orphenadrine ER (extended-release) and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet
Noritate metronidazole 0.75% cream, metronidazole 0.75% gel, metronidazole 1% gel, metronidazole 0.75% lotion
Okebo doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
Olux, Olux-E At least two lower cost forms of clobetasol propionate including cream, gel, lotion, ointment and solution
Onexton
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
Onzetra Xsail
At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet
Oracea doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
Orapred ODT (orally disintegrating tablet)
methylprednisolone, prednisolone syrup, prednisone oral solution, prednisone tablet
Oravig clotrimazole lozenge, clotrimazole troche, nystatin suspension orphenadrine-aspirin-caffeine tablet (generic Norgesic Forte)
orphenadrine ER (extended-release) and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet
Orphengesic Forte
orphenadrine ER (extended-release) and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet
Oxistat 1% lotion
At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, oxiconazole cream, terbinafine tablet, over-the-counter terbinafine cream
Ozobax oral solution
baclofen tablets and at least two of the following lower cost products: chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet
Pandel cream betamethasone valerate 0.1% cream, fluocinolone 0.025% cream, hydrocortisone butyrate 0.1% cream
penicillamine capsule (generic Cuprimine) penicillamine tablet (generic Depen Titratabs)
Pennsaid 2% diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution (generic Pennsaid 1.5%), over-the-counter Voltaren gel
pioglitazone-glimepiride tablet (generic Duetact) pioglitazone in combination with glimepiride
Pliaglis 7-7% cream, kit lidocaine-prilocaine cream, lidocaine ointment, patch and solution, over-the-counter lidocaine gel
prednisolone ODT (orally disintegrating tablet) [generic Orapred ODT]
methylprednisolone tablet, prednisolone syrup, prednisone oral solution, prednisone tablet
Prestalia perindopril in combination with amlodipine
Page 12 of 15
Core Formulary
Drug Alternatives
ProAir Digihaler albuterol sulfate HFA (generic ProAir HFA and generic Proventil HFA), Ventolin HFA
Prudoxin
At least two of the following lower cost products: betamethasone 0.05% cream, clobetasol propionate 0.05% cream, desoximetasone 0.25% cream, pimecrolimus 1% cream, tacrolimus 0.03% ointment, tacrolimus 0.1% ointment, triamcinolone 0.5% cream
Psorcon cream desoximetasone 0.05% cream, fluocinonide 0.05% cream, ointment and solution, triamcinolone 0.5% cream and ointment
Pylera metronidazole 250mg tablets in combination with tetracycline capsules and over-the-counter (OTC) bismuth
Qmiiz ODT (orally disintegrating tablet)
ibuprofen 100mg/5ml suspension, meloxicam tablet, over-the-counter Voltaren gel
ramelteon tablet (generic Rozerem) eszopiclone, zaleplon, zolpidem
Rayos dexamethasone tablet, methylprednisolone tablet, prednisolone syrup and solution, prednisone tablet and solution
Relafen DS 1000mg tablet
generic nabumetone and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, naproxen, sulindac
Relpax
generic eletriptan and at least one of the following lower cost triptan medications: naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet
Reltone ursodiol 300mg capsule, 250mg tablet, 500mg tablet
Renagel 800mg tablet sevelamer carbonate 800mg tablet, sevelamer carbonate packet
Retin-A tretinoin cream, tretinoin 0.01% and 0.025% gel risedronate DR (delayed-release) tablet [generic Atelvia] alendronate, ibandronate, risedronate IR (immediate-release)
Roszet ezetimibe in combination with rosuvastatin, ezetimibe in combination with atorvastatin or simvastatin
Rozerem eszopiclone, zaleplon, zolpidem
Sernivo spray At least two lower cost forms of betamethasone including cream, lotion, and ointment
sevelamer hydrochloride 800mg tablet (generic Renagel) sevelamer carbonate 800mg tablet, sevelamer carbonate packet
Seysara doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
Sitavig clotrimazole troches, nystatin suspension
Solodyn doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
Sprix
At least four of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac
sulconazole 1% cream, solution (generic Exelderm)
At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the-counter terbinafine cream
sumatriptan-naproxen (generic Treximet) sumatriptan in combination with naproxen
Page 13 of 15
Core Formulary
Drug Alternatives
Synera lidocaine-prilocaine cream, lidocaine ointment, lidocaine patch, lidocaine solution
Taclonex calcipotriene-betamethasone dipropionate 0.005-0.064% suspension
Talicia rifabutin in combination with amoxicillin and over-the-counter (OTC) omeprazole
Taperdex dexamethasone tablet, prednisone tablet therapy pack
Targadox doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
Tazorac
tazarotene 0.1% cream and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel
Texacort fluocinolone 0.025% cream, hydrocortisone 1% ointment, triamcinolone 0.1% ointment
timolol maleate (once daily) eye drops [generic Istalol] timolol maleate (twice daily) eye drops [generic Timoptic]
Timoptic Ocudose timolol maleate (twice daily) eye drops [generic Timoptic]
Tivorbex
indomethacin 25mg, indomethacin 50mg capsule, and at least two of the following lower cost NSAID products: celecoxib, etodolac, meloxicam tablet, nabumetone, naproxen, sulindac
Tolsura itraconazole capsule, itraconazole solution
Tolak fluorouracil 2% solution, fluorouracil 5% solution
Topicort 0.05% gel
betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment
Topicort 0.05% ointment
betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment
Topicort spray
betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment
Tosymra
generic sumatriptan nasal spray and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, zolmitriptan tablet/ orally disintegrating tablet
Tovet calcipotriene 0.005% cream, ointment, and solution, tazarotene 0.1% cream
Trexall generic methotrexate tablets, methotrexate injection
Treximet sumatriptan in combination with over-the-counter naproxen triamcinolone 0.05% ointment (generic Trianex) triamcinolone 0.025% ointment, triamcinolone 0.1% ointment triamcinolone topical aerosol spray (generic Kenalog)
triamcinolone 0.025% cream, triamcinolone 0.1% cream, triamcinolone 0.025% ointment, triamcinolone 0.1% ointment
Trianex ointment triamcinolone 0.025% ointment, triamcinolone 0.1% ointment
Triglide
At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule
Page 14 of 15
Core Formulary
Drug Alternatives
TussiCaps hydrocodone-chlorpheniramine suspension, promethazine-codeine 6.25-10mg/5ml syrup, promethazine-dm 6.25-15mg/5ml syrup
Ultravate 0.05% lotion halobetasol 0.05% cream, halobetasol 0.05% ointment vancomycin oral solution (reconstituted) Firvanq
Vectical calcipotriene 0.005% cream/ ointment/ solution, tazarotene 0.1% cream
Veltin
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel, and at least one of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream
Verdeso foam At least two lower cost other forms of desonide including cream, lotion, and ointment
Vivlodex
generic meloxicam tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, nabumetone, naproxen, sulindac
Vusion
At least two previous generic antifungals such as clotrimazole 1% cream, ketoconazole 2% cream, nystatin cream, ointment and powder, over-the-counter terbinafine cream, over-the-counter miconazole cream
Vytorin ezetimibe in combination with simvastatin, ezetimibe in combination with atorvastatin or rosuvastatin
Winlevi
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel
Wynzora cream betamethasone 0.05% lotion, calcipotriene 0.005% ointment, calcipotriene-betamethasone dipropionate 0.005-0.064% suspension
Xerese acyclovir ointment in combination with hydrocortisone 1% cream
Ximino doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule
Xolegel ketoconazole 2% cream, ketoconazole 2% shampoo
Zembrace SymTouch
generic sumatriptan injection and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, zolmitriptan tablet/ orally disintegrating tablet
Ziana
clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel, and at least one of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream
zileuton ER (extended-release) [generic Zyflo CR] montelukast tablet, montelukast chew tablet, zafirlukast tablet
Zilxi azelaic acid 15% gel, metronidazole 0.75% cream, metronidazole 0.75% gel, metronidazole 1% gel, metronidazole 0.75% lotion, Soolantra
Zipsor
diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac
zolmitriptan nasal spray (generic Zomig nasal spray)
At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan (also available as a nasal spray), zolmitriptan tablet/ orally disintegrating tablet
zolpidem sublingual tablet (generic Intermezzo) eszopiclone, zaleplon, zolpidem
Page 15 of 15
Core Formulary
Drug Alternatives
Zolpimist eszopiclone, zaleplon, zolpidem
Zomig nasal spray
At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan (also available as a nasal spray), zolmitriptan tablet/ orally disintegrating tablet
Zomig ZMT (orally disintegrating tablet)
generic zolmitriptan orally disintegrating tablet and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan (also available as an orally disintegrating tablet), sumatriptan
Zomig tablet generic zolmitriptan tablet and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan
Zonalon
At least two of the following lower cost products: betamethasone 0.05% cream, clobetasol propionate 0.05% cream, desoximetasone 0.25% cream, pimecrolimus 1% cream, tacrolimus 0.03% ointment, tacrolimus 0.1% ointment, triamcinolone 0.5% cream
Zorvolex
Zovirax cream acyclovir 5% ointment
Ztlido lidocaine ointment, lidocaine patch, lidocaine solution
Zuplenz granisetron, ondansetron, ondansetron ODT (orally disintegrating tablet)
Zyclara imiquimod 5% cream
Zyflo (immediate-release) montelukast tablet, montelukast chew tablet, zafirlukast tablet
Zyflo CR (extended-release) montelukast tablet, montelukast chew tablet, zafirlukast tablet
Zypitamag atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
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