general revenue prescription drug formulary updated
TRANSCRIPT
General Revenue Prescription Drug Formulary
Updated January 2021
General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,
whichever is less expensive at the time of dispensing.
1
Generic Name Brand Name
Analgesics Acetaminophen Tylenol
Acetaminophen/ Codeine Tylenol with Codeine #3
Acetaminophen/ Oxycodone Percocet
Celecoxib Celebrex Diclofenac Gel 1 % Voltaren Gel
Fentanyl Duragesic Hydrocodone/ Acetaminophen
Vicodin
Ibuprofen Motrin, Advil
Lidocaine 5% patch Lidoderm patch Lidocaine Viscous Xylocaine
Meloxicam Mobic
Methadone Methadose Morphine Sulfate (ER/IR) MS Contin, Roxanol
Naproxen Naprosyn Oxycodone Oxycodone
Tramadol Ultram
Anti-gout Allopurinol Zyloprim
Colchicine Colcrys Appetite Stimulants
Dronabinol Marinol
Megestrol Megace Antimicrobials/antifungals/antiparasitics
Albendazole Albenza
Amikacin Amikin Amoxicillin Amoxil
Amoxicillin/Clavulanate Augmentin Atovaquone Mepron
Azithromycin Zithromax Capreomycin Capastat
Cefdinir Omnicef
Cephalexin Keflex Chloroquine Phosphate Aralen
Ciprofloxacin Cipro Clarithromycin Biaxin
Clindamycin Cleocin
Clotrimazole Troche Mycelex Troche Cycloserine Seromycin
Dapsone Aczone Dicloxacillin Dycill, Pathocil
Doxycycline V”Pibramycin, Vibratab
Erythromycin Base Erythromycin Base Ethambutol Myambutol
General Revenue Prescription Drug Formulary
Updated January 2021
General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,
whichever is less expensive at the time of dispensing.
2
Fluconazole Diflucan
Hydroxychloroquine Plaquenil Isonicotinic acid hydrazide Isoniazid, INH
Itraconazole Sporanox
Ivermectin Stromectol Levofloxacin Levaquin
Linezolid Zyvox Metronidazole Flagyl
Minocycline Minocin Nitazoxanide Alinia
Nitrofurantoin Macrobid
Nystatin Mycostatin, Nystop Paromomycin Humatin
Penicillin G Benzathine/Penicillin G Procaine
Bicillin
Penicillin V Potassium Pen VK
Primaquine Phosphate Primaquine Probenecid Benemid
Pyrazinamide Pyrazinamide
Pyrimethamine Daraprim Rifabutin Mycobutin
Rifampin Rifadin Rifapentine Priftin
Streptomycin Streptomycin
Sulfadiazine Sulfadiazine Sulfamethoxazole/ Trimethoprim
Bactrim, Septra
Terbinafine Lamisil
Voriconazole Vfend
Antivirals Acyclovir Zovirax
Famciclovir Famvir Oseltamivir Tamiflu
Valacyclovir Valtrex Valganciclovir Valcyte
Antiepileptics
Carbamazepine Tegretol Gabapentin Neurontin
Lacosamide Vimpat Lamotrigine Lamictal
Levetiracetam Keppra
Oxcarbazepine Trileptal Phenobarbital Phenobarbital
Phenytoin Dilantin Topiramate Topamax
Valproic acid Divalproex, Depakote Anti-migraine
General Revenue Prescription Drug Formulary
Updated January 2021
General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,
whichever is less expensive at the time of dispensing.
3
Butalbital/Acetaminophen/ caffeine
Capacet, Fioricet
Naratriptan Amerge
Rizatriptan Maxalt Sumatriptan Imitrex
Anti-neoplastic
Anastrozole Arimidex Tamoxifen Soltamox, Nolvadex
Antiretrovirals Abacavir Ziagen
Abacavir/Dolutegravir/ Lamivudine
Triumeq
Abacavir/Lamivudine Epzicom Abacavir/Lamivudine/ Zidovudine
Trizivir
Atazanavir Reyataz
Atazanavir/Cobicistat Evotaz
Bictegravir/Emtricitabine/ TAF
Biktarvy
Cobicistat Tybost Darunavir Prezista
Darunavir/Cobicistat Prezcobix Darunavir/Cobicistat/ Emtricitabine/TAF
Symtuza
Delavirdine Rescriptor
Didanosine Videx Dolutegravir Tivicay
Dolutegravir/Rilpivirine Juluca
Doravirine Pifeltro Doravirine/Lamivudine/ TDF Delstrigo
Efavirenz Sustiva Efavirenz/Emtricitabine/ TDF Atripla
Efavirenz/Lamivudine/ TDF Symfi, Symfi Lo Elvitegravir/Cobicistat/ Emtricitabine/TAF
Genvoya
Elvitegravir/Cobicistat/ Emtricitabine/TDF
Stribild
Emtricitabine Emtriva
Emtricitabine/Rilpivirine/ TAF
Odefsey
Emtricitabine/Rilpivirine/ TDF
Complera
Emtricitabine/Tenofovir Alafenamide
Descovy
Emtricitabine/Tenofovir Disoproxil Fumarate
Truvada
Enfuvirtide Fuzeon
Etravirine Intelence
General Revenue Prescription Drug Formulary
Updated January 2021
General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,
whichever is less expensive at the time of dispensing.
4
Fosamprenavir Lexiva
Fostemsavir Rukobia Indinavir Crixivan
Lamivudine Epivir
Lamivudine/Dolutegravir Dovato Lamivudine/Tenofovir Disoproxil Fumarate
Cimduo
Lamivudine/Zidovudine Combivir
Lopinavir/Ritonavir Kaletra Maraviroc Selzentry
Nelfinavir Viracept Nevirapine Viramune
Raltegravir Isentress
Rilpivirine Edurant Ritonavir Norvir
Saquinavir Invirase Stavudine Zerit
Tenofovir Disoproxil Fumarate
Viread
Tipranavir Aptivus
Zidovudine Retrovir Cardiac
Amiloride Amiloride Amlodipine Norvasc
Amlodipine/Atorvastatin Caduet
Amlodipine/Benazepril Lotrel Atenolol Tenormin
Benazepril Lotensin
Bumetanide Bumex Candesartan Atacand
Candesartan/HCTZ Atacand HCT Carvedilol Coreg
Chlorthalidone Thalitone Clonidine Catapres
Digoxin Lanoxin
Diltiazem Cardizem Doxazosin Cardura
Enalapril/HCTZ Vaseretic Epinephrine EpiPen 2-Pak
Flecainide Flecainide
Furosemide Lasix Hydralazine Apresoline
Hydrochlorothiazide HydroDiuril Isosorbide Dinitrate Isordil
Isosorbide Mononitrate Imdur Labetalol Trandate
Lisinopril Zestril, Prinivil
Lisinopril/HCTZ Prinzide, Zestoretic
General Revenue Prescription Drug Formulary
Updated January 2021
General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,
whichever is less expensive at the time of dispensing.
5
Losartan Cozaar
Losartan/HCTZ Hyzaar Methyldopa Aldomet
Metoprolol Succinate Toprol XL
Metoprolol Tartrate Lopressor Minoxidil Minoxidil
Nadolol Corgard Nifedipine Adalat CC, Nifediac CC,
Afeditab CR, Procardia, Procardia XL
Nitroglycerin Nitrostat, NitroQuick Olmesartan Benicar
Prazosin Minipress Ranolazine Ranexa
Sacubitril/Valsartan Entresto
Simvastatin Zocor Spironolactone Aldactone
Spironolactone/HCTZ Aldactazide Triamterene/HCTZ Dyazide, Maxzide
Valsartan/HCTZ Diovan HCT
Verapamil Calan, Verelan Contraceptives
Ethinyl Estradiol and Desogestrel
Ethinyl Estradiol and Desogestrel
Ethinyl Estradiol and Drospirenone
Ethinyl Estradiol and Drospirenone
Ethinyl Estradiol and Etonogestrel
Nuvaring
Ethinyl Estradiol and Levonorgestrel
Ethinyl Estradiol and Levonorgestrel
Ethinyl Estradiol and Norethindrone
Ethinyl Estradiol and Norethindrone
Ethinyl Estradiol and Norethindrone and FE
Ethinyl Estradiol and Norethindrone and FE
Ethinyl Estradiol and Norgestimate
Ethinyl Estradiol and Norgestimate
Ethinyl Estradiol and Norgestrel
Ethinyl Estradiol and Norgestrel
Medroxyprogesterone Depo-Provera
Medroxyprogesterone Provera Norethindrone Norethindrone
Corticosteroids
Dexamethasone Dexamethasone Fludrocortisone Fludrocortisone
Methylprednisolone Medrol DosePak Prednisolone Orapred, Prelone
Prednisone Prednisone Dental
General Revenue Prescription Drug Formulary
Updated January 2021
General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,
whichever is less expensive at the time of dispensing.
6
Chlorhexidine Gluconate Peridex
Sodium Fluoride 1.1% PreviDent 5000 Dry Mouth Toothpaste
Diabetes Canagliflozin Invokana
Canagliflozin/Metformin Invokamet, Invokamet XR
50% Insulin Lispro protamine /50% Insulin Lispro
Humalog Mix 50/50
70% human insulin isophane/ 30% human insulin
Humulin 70/30, Novolin 70/30
70% Insulin Aspart protamine /30% Insulin Aspart
Novolog Mix 70/30
75% Insulin Lispro protamine/25% Insulin Lispro
Humalog Mix 75/25
Empagliflozin Jardiance Exenatide ER Bydureon
Glipizide Glucotrol Glipizide/Metformin Glipizide/Metformin
Glyburide Diabeta, Micronase
Glyburide/Metformin Glucovance
Insulin Aspart Novolog, Novolog Flexpen
Insulin Glargine Lantus, Lantus Solostar Insulin Lispro Humalog, Humalog
Kwikpen Insulin NPH Humulin N, Novolin N
Insulin Regular Humulin R, Novolin R
Liraglutide Saxenda, Victoza Metformin Glucophage
Pioglitazone Actos Sitagliptin Januvia
Sitagliptin/Metformin Janumet Gastrointestinal/Urinary
Aprepitant Emend
Atropine/Diphenoxylate Lomotil Bisacodyl Dulcolax
Calcium Polycarbophil Calcium Polycarbophil Clidinium/Chlordiazepoxide Librax
Dicyclomine Bentyl
Diphenhydramine Elixir, Nystatin Oral Suspension, Lidocaine 2% Viscous
Magic Mouthwash
Docusate Colace
General Revenue Prescription Drug Formulary
Updated January 2021
General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,
whichever is less expensive at the time of dispensing.
7
Electrolyte Solution Golytely
Enema Fleet Enema Esomeprazole Nexium
Famotidine Pepcid
Hydrocortisone Suppository
Anusol HC Suppository
Lactobacillus acidophilus Culturelle Lactulose Enulose
Loperamide Imodium Mesalamine Asacol HD, Delzicol
Methylcellulose Citrucel Metoclopramide Reglan
Ondansetron Zofran
Oxybutynin Ditropan Pantoprazole Protonix
Paregoric Camphorated Tincture of Opium
Phentermine Adipex-P, Lomaira Polyethylene glycol 3350 MiraLax
Pramoxine/Hydrocortisone Proctofoam HC
Psyllium Metamucil, Konsyl Rifaximin Xifaxan
Sennosides Senna Sodium Bicarbonate Neut
Solifenacin Succinate Vesicare
Tamsulosin Flomax Tolterodine Detrol
Ursodiol Actigall
Hematology Apixaban Eliquis
Aspirin Aspirin Cilostazol Pletal
Clopidogrel Plavix Dabigatran Pradaxa
Eltrombopag Promacta
Enoxaparin Lovenox Epoetin Alfa Procrit
Filgrastim Neupogen Hydroxyurea Hydrea
Peg-filgrastim Neulasta
Prasugrel Effient Rivaroxaban Xarelto
Warfarin Coumadin Hormones
Conjugated Estrogens Premarin Danazol Danocrine
Estradiol Estrace
Estradiol Patch Climara
General Revenue Prescription Drug Formulary
Updated January 2021
General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,
whichever is less expensive at the time of dispensing.
8
Estradiol Valerate Delestrogen
Finasteride Proscar Testosterone Androderm,
Depo-Testosterone, Androgel
Hyperlipidemia Atorvastatin Lipitor
Ezetimibe Zetia
Fenofibrate Tricor Gemfibrozil Lopid
Omega-3-Acid-Ethyl Esters Lovaza Pravastatin Pravachol
Rosuvastatin Crestor Mental Health
Alprazolam Xanax
Amitriptyline Elavil Amphetamine/ dextroamphetamine
Adderall, Adderall XR
Aripiprazole Abilify
Atomoxetine Strattera
Benztropine Cogentin
Bupropion Wellbutrin
Buspirone Buspar Carbidopa/ Levodopa Rytary, Sinemet
Chlorpromazine Chlorpromazine
Citalopram Celexa Clonazepam Klonopin
Desvenlafaxine Khedezla, Pristiq
Donepezil Aricept Doxepin Silenor
Duloxetine Cymbalta Escitalopram Lexapro
Eszopiclone Lunesta Fluoxetine Prozac
Haloperidol Haldol
Hydroxyzine Vistaril Imipramine Tofranil
Lithium Eskalith Lorazepam Ativan
Melatonin Melatonin
Methylphenidate Ritalin Mirtazapine Remeron
Nortriptyline Pamelor Olanzapine Zyprexa
Paliperidone Invega Paroxetine Paxil
Pregabalin Lyrica
Prochlorperazine Compazine
General Revenue Prescription Drug Formulary
Updated January 2021
General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,
whichever is less expensive at the time of dispensing.
9
Propranolol Inderal
Quetiapine Seroquel Risperidone Risperdal
Ropinirole Requip
Sertraline Zoloft Temazepam Restoril
Trazodone Desyrel Venlafaxine Effexor
Vilazodone Viibryd Ziprasidone Geodon
Zolpidem Ambien
Ophthalmic Acetazolamide Diamox
Atropine Sulfate 1% Isopto Atropine Bacitracin Bacitracin
Brimonidine Alphagan
Brimonidine/Timolol Combigan Cyclopentolate Cyclogyl
Dexamethasone Sod Phosphate 0.1%
Maxidex
Dorzolamide Trusopt Dorzolamide Hydrochloride-Timolol Maleate
Cosopt
Erythromycin Base Ophthalmic
Erythromycin Base Ophthalmic
Gentamycin Sulfate Gentak
Hydrocortisone/Neomycin/Polymyxin B
Hydrocortisone/Neomycin/Polymyxin B
Ketorolac Acular Latanoprost Xalatan
Methazolamide Neptazane
Moxifloxacin Vigamox Neomycin/Polymyxin/Dexamethasone 0.1%
Maxitrol
Olopatadine Pataday, Patanol, Pazeo
Polymyxin B Sulfate/TMP drops
Polytrim
Prednisolone Acetate 1% Pred Forte Sulfacetamide Sodium Sulfacetamide Sodium
Timolol Timoptic Tobramycin Sulfate 0.3% Tobrex
Osteoporosis
Alendronate Fosamax Otic
Hydrocortisone/Neomycin/Polymyxin B Solution
Cortisporin
Ofloxacin Floxin Otic
General Revenue Prescription Drug Formulary
Updated January 2021
General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,
whichever is less expensive at the time of dispensing.
10
Renal
Calcitriol Rocaltrol Calcium Acetate Phoslo
Cinacalcet Sensipar
Lanthanum Fosrenol Sevelamer Renagel, Renvela
Sodium Citrate and Citric Acid
Bicitra
Sodium Polystyrene Sulfonate
Kayexalate
Respiratory/Asthma/Allergy Albuterol Sulfate Proventil, Ventolin
Albuterol/Ipratropium Combivent Azelastine Astepro
Beclomethasone QVAR
Budesonide Rhinocort Budesonide/Formoterol Symbicort
Cetirizine Zyrtec Cetirizine/ Pseudoephedrine
Zyrtec D
Cyproheptadine Periactin
Diphenhydramine Benadryl
Fexofenadine Allegra Fluticasone Flonase
Fluticasone/ Salmeterol Advair, AirDuo, Wixela
Fluticasone/ Vilanterol Breo Ellipta Guaifenesin with Codeine Robitussin AC
Guaifenesin with Dextromethorphan
Robitussin DM
Hydroxyzine Vistaril, Atarax
Ipratropium Atrovent Loratadine Claritin
Loratadine/ Pseudoephedrine
Claritin D
Mometasone Asmanex, Nasonex Mometasone/ Formoterol Dulera
Montelukast Singulair Olopatadine Patanase
Salmeterol Serevent Diskus
Tiotropium Bromide Spiriva Skeletal Muscle Relaxant
Baclofen Lioresal Cyclobenzaprine Flexeril
Thyroid
Levothyroxine Synthroid Liothyronine Cytomel
Methimazole Tapazole Propylthiouracil (PTU) Propylthiouracil (PTU)
General Revenue Prescription Drug Formulary
Updated January 2021
General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,
whichever is less expensive at the time of dispensing.
11
Substance Abuse
Buprenorphine Buprenex, Butrans Buprenorphine/Naloxone Suboxone
Disulfiram Antabuse
Naloxone Narcan Spray Naltrexone Vivitrol, oral Naltrexone
Nicotine Nicoderm, Nicorette Topical
Ammonium Lactate 12% Lac-Hydrin Betamethasone Valerate/Dipropionate
Diprolene, Celestone
Clindamycin/Benzoyl Peroxide
Clindamycin/Benzoyl Peroxide
Clobetasol Propionate Clobetasol Propionate
Clotrimazole Lotrimin
Clotrimazole/ Betamethasone
Lotrisone
Dry Mouth Moisturizing Spray
Biotene
Fluocinolone Fluocinolone Fluocinonide Fluocinonide
Fluorouracil topical Efudex Hydrocortisone Hydrocortisone
Hydrocortisone/ Pramoxine Procort, Proctofoam HC
Hydrophor Aquaphor
Hydroquinone Nuquin HP Imiquimod 5% Aldara
Ketoconazole Nizoral
Metronidazole Metrogel Miconazole Monistat
Mupirocin 2% Bactroban Nystatin Mycostatin
Permethrin 5% Elimite Podofilox Condylox
Selenium Sulfide Selenium Sulfide
Silver Sulfadiazine 1% Silvadene Tacrolimus (topical only) Protopic
Terconazole Terazol Tretinoin Retin-A
Triamcinolone Acetonide Triamcinolone Acetonide
Nutrition/Vitamins
Calcium Carbonate + Vitamin D
Calcium Carbonate + Vitamin D
Cholecalciferol Vitamin D3 Doxercalciferol Hectorol
Ergocalciferol Vitamin D2 Ferrous Sulfate Ferrous Sulfate
General Revenue Prescription Drug Formulary
Updated January 2021
General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,
whichever is less expensive at the time of dispensing.
12
Folic Acid Folic Acid
Folinic Acid Leucovorin Magnesium Oxide Magnesium Oxide
Multivitamin Multivitamin
Multivitamin-Renal Rena-Vite Potassium Chloride Potassium Chloride
Prenatal Vitamins Prenatal Vitamins UltraMeal Advance Protein Powder
UltraMeal Advance Protein Powder
Vitamin B-1 (Thiamine) Vitamin B-1 (Thiamine)
Vitamin B-12 (Cyanocobalamin)
Vitamin B-12 (Cyanocobalamin)
Vitamin B-6 (Pyridoxine) Vitamin B-6 (Pyridoxine)
Vitamin D3 Vitamin D3
Medical Equipment Lancets
Lancing Device
Syringes/Needles True Track/True Metrix Glucometer
True Track/True Metrix Test Strips