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1199SEIU
Preferred Drug List
Please take this guide
with you the next time
you visit your doctor.
2014 Express Scripts Holding Company. All Rights Reserved.
If you have questions about your prescription drug benefit, 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.
Express Scripts manages your prescription benefit for the 1199SEIU Benefit Funds.
Section II provides a listing of nonpreferred brands and their possible preferred alternatives.
SAFETY CONSIDERATION SYMBOLS
Here is a quick guide that explains our safety symbols. These symbols appear next to certain
medications.
Weigh the risk of birth defects and other adverse outcomes.
PRESCRIPTION PROGRAM CONSIDERATION SYMBOLS
For more information, please call Express Scripts: (800) 753-2851.
This symbol next to a drug name indicates that this medication is subject to the PriorAuthorization Program.
This symbol next to a drug name indicates that this medication is subject to the Step TherapyProgram.
This symbol next to a drug name indicates that this medication is subject to the QuantityDuration Program.
This symbol next to a drug name indicates that this specialty medication must be obtainedthrough Accredo. Please call Accredo: (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/CuraScriptCustomer Service at (800) 467-2006 and inquire about drug coverage.
Shaded areas indicate the most recent additions to the Preferred Drug List.
Drugs Not Covered by the 1199SEIU Benefit Funds
Over-the-counter Drugs (except for diabetic supplies) or as mandatedby PPACA legislation Please refer to your Summary Plan Description for a complete list of excluded drugs. 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.
SECTION I: THERAPEUTIC DRUG CATEGORIES
ADRENAL HORMONES (EFFECTIVE 3-1-11)
ANTIANDROGENS (EFFECTIVE 3-1-11)
ANTICONVULSANTS (EFFECTIVE 7-1-10)
ANTI-INFECTIVES (Antibiotics)
Oral Penicillins
Oral Cephalosporins
Oral Quinolones
Oral Tetracyclines
Oral Erythromycins and other
Macrolides
ANTIPARKINSONISM AGENTS (EFFECTIVE 1-1-10)
ANTIVERTIGO & ANTIEMETIC DRUGS (EFFECTIVE 4-1-10)
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program.
This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.
This symbol 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/CuraScript Customer Service at (800) 467-2006 andinquire about drug coverage.
ANTI-PSORIATIC/ANTI-SEBORRHEIC (EFFECTIVE 3-1-11)
Anti-Psoriatic/Anti-Seborrheic
Topical Agents
BENIGN PROSTATE HYPERPLASIA (BPH) THERAPY
BIOTECHNOLOGY DRUGS)
Factor VIII - Recombinant Drugs
Erythroid Stimulants
(EFFECTIVE 7-1-10)
(EFFECTIVE 3-1-14)
CARDIOVASCULAR (Blood Pressure/Heart/Cholesterol)
Beta Blockers
Select Combination
Antihypertensives
Angiotensin II Blockers
Calcium Channel Blockers
Long-Acting Nitrates (Topical)
Antilipidemics - Statin Drugs
(EFFECTIVE 7-1-10)
Antiplatelet Agents
Dihydropyridines
(EFFECTIVE 7-1-10)
Other Antilipidemics
ACE Inhibitors
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program.
This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.
This symbol 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/CuraScript Customer Service at (800) 467-2006 andinquire about drug coverage.
DRUGS TO TREAT OVERACTIVE BLADDER (UPDATED 3-1-14)
ENDOCRINE (Diabetes/Hormones/Contraceptives)
Insulin Therapy
DPP-4 Inhibitors (EFFECTIVE 6-1-12)
(UPDATED 3-1-14)
Blood Glucose Test Strips
Oral Hypoglycemic Agents
(REVISED – EFFECTIVE 4-1-10)
Estrogen Agents (oral/vaginal)
(UPDATED 1-1-13)
Blood Glucose Monitoring
Androgen Replacement Agents
EVISED – EFFECTIVE 10-1-09)
Contraceptive Agents
Injectable Hypoglycemic Agents
(EFFECTIVE 10-1-09)
Estrogen Patches (EFFECTIVE 7-1-09)
(GLP-1 receptor agonist)
PDATED 3-1-14)
GASTROINTESTINAL
H-Pylori Agents (EFFECTIVE 1-1-13)
Irritable Bowel Syndrome
(EFFECTIVE 3-1-14)
Ulcer Drugs
Ulcerative Colitis Agents
Pancreatic Enzymes
(UPDATED 3-1-14)
(EFFECTIVE 1-1-13)
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program.
This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.
This symbol 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/CuraScript Customer Service at (800) 467-2006 andinquire about drug coverage.
EPINEPHRINE AUTOINJECTORS (EFFECTIVE 3-1-14)
GOUT THERAPY (EFFECTIVE 3-1-11)
GROWTH HORMONES (REVISED – EFFECTIVE 7-1-10)
IMMUNOGLOBULIN AGENTS (INJECTABLES) (EFFECTIVE 5-1-09)
INTERFERONS (EFFECTIVE 10-1-09)
Hepatitis C Agents
Injectable Multiple Sclerosis
Agents (E
FFECTIVE 3-1-11)
PROTEASE INHIBITORS - HEPATITIS C (EFFECTIVE 9-20-11)
SELECT BIOLOGIC AND IMMUNOLOGIC AGENTS (EFFECTIVE 7-1-10)
Rheumatoid Arthritis Agents
Plaque Psoriasis Agents
(Injectables)
(Injectables)
Crohn’s Disease Agents
(Injectables)
MUSCLE RELAXANTS (EFFECTIVE 10-1-09)
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program.
This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.
This symbol 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/CuraScript Customer Service at (800) 467-2006 andinquire about drug coverage.
NARCOTIC ANALGESICS (Pain Relievers)
Narcotics
Miscellaneous Analgesic
Therapy (EFFECTIVE 1-1-09)
NON-NARCOTIC ANALGESICS (Pain Relievers)
Osteoarthritis Agents
NSAID COX-2 Inhibitors
(Injectable) (EFFECTIVE 7-1-09)
Migraine/Headache Therapy
(EFFECTIVE 1-1-09)
OPHTHALMICS (Eye Preparations)
Ophthalmic Combination
Carbonic Anhydrase
Ophthalmic Carbonic Anhydrase
Inhibitors/Beta Agonists
Inhibitors (E
FFECTIVE 1-1-10)
FFECTIVE 7-1-13)
Ophthalmic Beta-Blockers
Ophthalmics-Steroids
(EFFECTIVE 1-1-10)
(EFFECTIVE 1-1-10)
Ophthalmic Anti-Inflammatory
Agents (NSAIDs) (EFFECTIVE 3-1-11)
Miscellaneous Ophthalmics-
Antibiotic-Ophthalmics
Antihistamine & Mast-Cell
(EFFECTIVE 1-1-09)
Stabilizers (EFFECTIVE 3-1-11)
Ophthalmic Steroid-Antibiotic
Combinations (EFFECTIVE 3-1-11)
Miscellaneous Glaucoma Agents
(EFFECTIVE 5-1-09)
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program.
This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.
This symbol 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/CuraScript Customer Service at (800) 467-2006 andinquire about drug coverage.
OSTEOPOROSIS/PAGET’S DISEASE
OTICS (Ear Preparations) (EFFECTIVE 4-1-10)
PSYCHOTHERAPEUTICS (Anxiety/Depression)
Hypnotic Agents
Anxiolytics
Miscellaneous Antidepressants
SSRI Antidepressants
Attention Deficit Hyperactivity
Disorder (EFFECTIVE 5-1-09)
Antipsychotics
RESPIRATORY (Allergy/Asthma/COPD)
Beta Agonist Agents
Inhaled Corticosteroid Therapy
Pulmonary Arterial Hypertension
(UPDATED 1-1-13)
(UPDATED 7-1-13)
(PAH) Agents
(EFFECTIVE 6-1-12)
Short-Acting Beta Agonist (nebulized solutions) Anticholinergic Agents
PDATED 3-1-14)
Miscellaneous Pulmonary Agents
Nasal Corticosteroids
(UPDATED 3-1-14)
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program.
This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.
This symbol 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/CuraScript Customer Service at (800) 467-2006 andinquire about drug coverage.
TOPICAL ACTINIC KERATOSE AGENTS (EFFECTIVE 1-1-13)
TOPICAL ACNE THERAPY (EFFECTIVE 1-1-09)
TOPICAL ANTIFUNGALS
TOPICAL ANTIVIRAL THERAPY (EFFECTIVE 1-1-09)
TOPICAL CORTICOSTEROIDS (Topical Skin Products)
Low Potency
Medium Potency
Very High Potency
High Potency
betamethasone dipropionate(cream, gel, lotion, ointment) VITAMINS — All generics are preferred (Most commonly used listed below) (EFFECTIVE 1-1-09)
Prenatal Vitamin Therapy
Multivitamin Therapy
Vitamin D Analog Agents
(EFFECTIVE 1-1-13)
Iron Supplement Therapy
Vitamin B Therapy
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program.
This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program.
This symbol 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/CuraScript Customer Service at (800) 467-2006 andinquire about drug coverage.
If your prescribed drug is in the “nonpreferred” column, ask your doctor if she or he can prescribe oneof the alternatives listed.
SECTION II: NONPREFERRED DRUGS AND THEIR POSSIBLE PREFERRED ALTERNATIVES
Nonpreferred Product
Possible Preferred Alternatives
Nonpreferred Product
Possible Preferred Alternatives
clozapine (generic), olanzapine (generic), quetiapine fumarate ciprofloxacin (generic), erythromycin ointment (generic), (generic), risperidone (generic), ziprasidone HCl (generic) gentamicin (generic), levofloxacin (generic), ofloxacin olanzapine (generic), Risperdal Consta® (Janssen) (generic), tobramycin (generic), Vigamox® (Alkon) Androderm® (Watson Pharmaceuticals), Androgel® (Unimed clindamycin (generic) + benzoyl peroxide (generic) lansoprazole (generic), omeprazole (generic), pantoprazole (generic), rabeprazole (generic), Nexium®(AstraZeneca) alendronate 5mg (generic), alendronate 10mg (generic), corvita (generic), nicotinamide (generic), therobec plus alendronate 35mg (generic), alendronate 70mg (generic), flunisolide (generic), fluticasone propionate (generic), alendronate 35mg (generic), alendronate 70mg (generic), triamcinolone acetonide (generic), Nasonex® (Schering) candesartan (generic), eprosartan mesylate (generic), alendronate (generic), ibandronate (generic) irbesartan (generic), losartan potassium (generic), telmisartan(generic), Micardis® (BIPI) candesartan/HCTZ (generic), irbesartan/HCTZ (generic), bromfenac (generic), diclofenac (generic), flurbiprofen losartan/HCTZ (generic), valsartan/HCTZ (generic), Micardis benzoyl peroxide (generic), clindamycin phosphate (generic), azelastine (generic), cromolyn (generic), epinastine (generic), epinephrine (generic), Epi Pen® (Mylan), Epi Pen Jr® (Mylan) ciprofloxacin (generic), erythromycin ointment (generic), Dulera® (Merck), Symbicort® (AstraZeneca) gentamicin (generic), levofloxacin (generic), ofloxacin(generic), tobramycin (generic), Vigamox® (Alkon) Dulera® (Merck), Symbicort® (AstraZeneca) betaxolol (generic), carteolol (generic), timolol (generic), levobunolol (generic), metipranolol (generic) atorvastatin (generic), lovastatin (generic), pravastatin betaxolol (generic), carteolol (generic), timolol (generic), (generic), simvastatin (generic), Niaspan ER® (Abbott) levobunolol (generic), metipranolol (generic) Alvesco® (Sunovion Pharmaceuticals), Asmanex® (Merck), Pulmicort Flexhaler® (AstraZeneca), Qvar® (IVAX) Ferrex 28 (generic), Ferrex 150 Forte (generic), Ferrex 150 Alvesco® (Sunovion Pharmaceuticals), Asmanex® (Merck), Forte Plus (generic), Multigen Plus (generic), Poly-Iron 150 Pulmicort Flexhaler® (AstraZeneca), Qvar® (IVAX) azelastine (generic), cromolyn (generic), epinastine (generic), Flebogamma® (Grifols Biologicals, Inc), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), azelastine (generic), cromolyn (generic), epinastine (generic), Advair® (GlaxoSmithKline), Dulera® (Merck), azelastine (generic), cromolyn (generic), epinastine (generic), paroxetine mesylate (generic), citalopram (generic), estradiol patch (generic), Estraderm (Novartis),Vivelle escitalopram (generic), fluvoxamine (generic) paroxetine mesylate (generic), fluoxetine (generic), ondansetron (generic), granisetron (generic), Emend® (Merck) fluorometholone (generic), prednisolone (generic) bromfenac sodium (generic), diclofenac (generic), flurbiprofen (generic), ketorolac (generic) atorvastatin (generic), fluvastatin (generic), lovastatin(generic), pravastatin (generic), simvastatin (generic) albuterol inhalant solution (generic), levalbuterol inhalantsolution (generic) chloral hydrate (generic), temazepam (generic), triazolam losartan/HCTZ (generic) + amlodipine (generic), Micardis HCT (BIPI) + amlodipine (generic) acebutolol HCl (generic), atenolol HCl (generic), ondansetron (generic), granisetron (generic), Emend® (Merck) metoprolol tartrate (generic), metoprolol succinate bupropion (generic), bupropion SR (generic) fluorouracil (generic), imiquimod (generic), Picato® Gel (Leo Labs) amlodipine besylate (generic), nicardipine HCl (generic), epinephrine (generic), Epi Pen® (Mylan), Epi Pen Jr® (Mylan) Flebogamma® (Grifols Biologicals, Inc), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), alfuzosin HCl (generic), finasteride (generic), tamsulosin dexamethasone (generic), metoclopramide (generic), naratriptan (generic), rizatriptan (generic), sumatriptan granisetron (generic), ondansetron (generic), Emend® (Merck) (generic), zolmitriptan (generic), Relpax® (Pfizer) *Branded generics have the same co-payment as regular generics.
Nonpreferred Product
Possible Preferred Alternatives
Nonpreferred Product
Possible Preferred Alternatives
candesartan/HCTZ (generic), irbesartan/HCTZ (generic), losartan/HCTZ (generic), valsartan/HCTZ (generic), Micardis neomycin/polymyxin/HC (generic), ofloxacin (generic) neomycin/polymyxin/HC (generic), ofloxacin (generic) estradiol patch (generic), Estraderm® (Novartis), Vivelle® azelastine (generic), cromolyn (generic), epinastine (generic), flavoxate (generic), oxybutynin (generic), oxybutynin ER(generic), tolterodine tartrate (generic), trospium (generic), Myrbetriq® (Astellas), Vesicare® (GlaxoSmithKline) betamethasone valerate cream (generic), desoximetasone cream (generic), fluocinolone acetonide cream (generic),hydrocortisone valerate cream (generic), triamcinolone adapalene (generic) + benzoyl peroxide (generic) hydrocortisone acetate/pramoxine (generic) neomycin/polymyxin/HC (generic), ofloxacin (generic) carbamazepine (generic), divalproex (generic) econazole nitrate (generic), ketoconazole (generic), betamethasone valerate cream (generic), desoximetasone lansoprazole (generic), omeprazole (generic), cream (generic), fluocinolone acetonide cream (generic), pantoprazole (generic), rabeprazole (generic), Nexium® hydrocortisone valerate cream (generic), triamcinolone estradiol patch (generic), Estraderm® (Novartis), Vivelle® neomycin/polymyxin/HC (generic), ofloxacin (generic) corvita (generic), nicotinamide (generic), therobec plus Hyalgan® (Sanofi Pharm), Synvisc® (Genzyme), Ferrex 28 (generic), Ferrex 150 Forte (generic), Ferrex 150 Forte Plus (generic), Multigen Plus (generic), Poly-Iron 150 hydromorphone (generic), morphine ER (generic), verapamil HCl tablet, sustained action (generic) econazole nitrate (generic), ketoconazole (generic), atorvastatin (generic), fluvastatin (generic), lovastatin (generic), pravastatin (generic), simvastatin (generic) amlodipine (generic), benazepril (generic), metformin HCl (generic), Byetta® (Amlyin Pharmaceuticals), Janumet® (Merck & Co.), Januvia® (Merck & Co.), Onglyza® Avonex® (Biogen), Betaseron® (Berlex Laboratories), dextroamphetamine-amphetamine (generic), methylphenidate tretinoin (generic), Azelex® (Allergan), Finacea® (Bayer) ciprofloxacin (generic), levofloxacin (generic), ofloxacin balsalazide disodium (generic), mesalamine enema (generic), sulfasalazine (generic), Apriso® (Salix), Asacol HD® (Procter & clozapine (generic), olanzapine (generic), quetiapine fumarate Gamble), Canasa® (Aptalis), Pentasa® (Shire US) (generic), risperidone (generic), ziprasidone HCl (generic) desonide (generic), alclometasone (generic), Accu-Chek Aviva Plus® (Roche), Breeze 2® (Bayer), Contour lansoprazole (generic), omeprazole (generic), pantoprazole (generic), rabeprazole (generic), Nexium®(AstraZeneca) meclizine (generic), promethazine (generic), adapalene (generic), tretinoin (generic), Azelex® (Allergan), Ferrex 28 (generic), Ferrex 150 Forte (generic), Ferrex 150 Forte Plus (generic), Multigen Plus (generic), Poly-Iron 150 candesartan (generic), eprosartan mesylate (generic), irbesartan (generic), losartan (generic), Micardis® (BIPI) Androderm® (Watson Pharmaceuticals), Androgel® (Unimed) sulfasalazine (generic), balsalazide (generic), Asacol® (Procter & Gamble), Delzicol® (Warner Chilcott),Pentasa® (Shire US) etodolac (generic), ibuprofen (generic), meloxicam (generic),naproxen (generic), Alvesco® (Sunovion Pharmaceuticals), Asmanex® (Merck), ibuprofen (generic), famotidine (generic) Pulmicort Flexhaler® (AstraZeneca), Qvar® (IVAX) Alvesco® (Sunovion Pharmaceuticals), Asmanex® (Merck), metoprolol succinate (generic), hydrochlorothiazide (generic) Pulmicort Flexhaler® (AstraZeneca), Qvar® (IVAX) fluticasone propionate + azelastine nasal spray (generic) fluorouracil (generic), imiquimod (generic), Picato® Gel amlodipine besylate (generic), nifedipine ER (generic) candesartan (generic), eprosartan mesylate (generic), irbesartan (generic), losartan (generic), telmisartan (generic), dexmethylphenidate (generic), dextroamphetamine- amphetamine (generic), methylphenidate ER (generic) *Branded generics have the same co-payment as regular generics.
Nonpreferred Product
Possible Preferred Alternatives
Nonpreferred Product
Possible Preferred Alternatives
Arcapta Neohaler® (Novartis), Serevent Diskus® (GSK) fentanyl lozenge (generic), fentanyl patch (generic) Androderm® (Watson Pharmaceuticals), Androgel® (Unimed acebutolol HCl (generic), atenolol (generic), metoprolol Accu-Chek Aviva Plus® (Roche), Breeze 2® (Bayer), Contour balsalazide disodium (generic), mesalamine enema (generic), sulfasalazine (generic), Apriso® (Salix), Asacol HD® (Procter &Gamble), Canasa® (Aptalis), Pentasa® (Shire US) naratriptan (generic), rizatriptan (generic), sumatriptan(generic), zolmitriptan (generic), Relpax (Pfizer) acyclovir ointment (generic), lidocaine gel (generic) Flebogamma® (Grifols Biologicals, Inc), Gamunex® (Talecris Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), atorvastatin (generic), Zetia® (Merck-Schering Plough) atorvastatin (generic), fluvastatin (generic), lovastatin Gammagard® Liquid Flebogamma® (Grifols Biologicals, Inc), Gamunex® (Talecris (generic), pravastatin (generic), simvastatin (generic) Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics),Hizentra® (CSL Behring AG) Junel FE® (Barr Pharmaceuticals), Microgestin FE® (WatsonPharmaceuticals) Flebogamma® (Grifols Biologicals, Inc), Gamunex® (TalecrisBiotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Gildess FE® (Dynamic Pharma), Junel FE® (Barr Pharmaceuticals), Microgestin FE® (Watson Pharmaceuticals) Flebogamma® (Grifols Biologicals, Inc), Gamunex® (Talecris Junel FE® (Barr Pharmaceuticals), Microgestin FE® (Watson Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), Gildess FE® (Dynamic Pharma), Junel FE® (Barr Flebogamma® (Grifols Biologicals, Inc), Gamunex® (Talecris Pharmaceuticals), Microgestin FE® (Watson Pharmaceuticals) Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), fluorometholone (generic), prednisolone (generic) fenofibrate (generic), Niaspan ER® (Abbott) oxybutynin (generic), oxybutynin ER (generic), Vesicare® latanoprost (generic), travoprost (generic) temazepam (generic), triazolam (generic), zolpidem (generic), oxybutynin (generic), oxybutynin ER (generic), Vesicare® Hyalgan® (Sanofi Pharm), Synvisc® (Genzyme), Synvisc-One® (Genzyme) fluorometholone (generic), prednisolone (generic) Norditropin® (Nov Nordisk), Tev-Tropin® (Gate estradiol (generic), estropipate (generic), Cenestin estradiol patch (generic), Estraderm (Novartis),Vivelle(Novartis), Vivelle-Dot (Novartis) folbee (generic), folbee plus (generic), folbic (generic), renal caps (generic), triphrocaps (generic) desoximetasone cream (generic), fluocinonide cream econazole nitrate (generic), ketoconazole (generic), Junel FE® (Barr Pharmaceuticals), Microgestin FE® (Watson Norditropin® (Nov Nordisk), Tev-Tropin® (Gate bromfenac (generic), diclofenac (generic), flurbiprofen estradiol patch (generic), Estraderm (Novartis),Vivelle metronidazole topical (generic), Finacea® (Bayer) dextroamphetamine/amphetamine (generic), methylphenidate ciprofloxacin (generic), erythromycin ointment (generic), olanzapine (generic), quetiapine fumarate (generic), gentamicin (generic), levofloxacin (generic), ofloxacin risperidone (generic), ziprasidone HCl (generic) (generic), tobramycin (generic), Vigamox® (Alkon) olanzapine (generic), Risperdal Consta® (Janssen) econazole nitrate (generic), ketoconazole (generic), ciprofloxacin (generic), erythromycin ointment (generic), gentamicin (generic), levofloxacin (generic), ofloxacin etodolac (generic), ibuprofen (generic), indomethacin (generic), tobramycin (generic), Vigamox® (Alkon) (generic), naproxen (generic), sulindac (generic) betaxolol (generic), carteolol (generic), timolol (generic), levobunolol (generic), metipranolol (generic) ciprofloxacin (generic), erythromycin ointment (generic), tamsulosin (generic) + finasteride (generic) gentamicin (generic), levofloxacin (generic), ofloxacin Janumet (Merck & Co.), Janumet XR (Merck & Co.), (generic), tobramycin (generic), Vigamox® (Alkon) Januvia® (Merck & Co.), simvastatin (generic) Januvia® (Merck & Co.), Onglyza® (Bristol Myers Squibb) Janumet (Merck & Co.), Janumet XR (Merck & Co.), pramipexole Di-HCl (generic), ropinirole (generic), Apokyn® bromfenac (generic), diclofenac (generic), flurbiprofen bicalutamide (generic), flutamide (generic) azelastine (generic), cromolyn sodium (generic), epinastine (generic), Pataday® (Alcon), Patanol® (Alcon) clozapine (generic), olanzapine (generic), quetiapine fumarate ciprofloxacin (generic), levofloxacin (generic), ofloxacin (generic), risperidone (generic), ziprasidone HCl (generic) *Branded generics have the same co-payment as regular generics.
Nonpreferred Product
Possible Preferred Alternatives
Nonpreferred Product
Possible Preferred Alternatives
tobramycin-dexamethasone (generic), neomycin/bacitracin/polymyxin B/HC (generic), neomycin/ polymyxin B/dexamethasone (generic), neomycin/ polymyxin B/HC (generic), TobraDex® Oint (Alcon) folbee (generic), folbee plus (generic), folbic (generic), Norditropin® (NovoNordisk), Tev-Tropin® (Gate renal caps (generic), triphrocaps (generic) carbamazepine (generic), levetiracetam (generic), Norditropin® (NovoNordisk), Tev-Tropin® (Gate topiramate (generic), Banzel® (Eisai Inc.) metformin (generic),+ Prandin® (Novo Nordisk) Norditropin® (NovoNordisk), Tev-Tropin® (Gate Accu-Chek Aviva Plus® (Roche), Breeze 2® (Bayer), Contour tobramycin-dexamethasone (generic), neomycin/bacitracin/polymyxin B/HC (generic), neomycin/ polymyxin B/dexamethasone (generic), neomycin/ PNV-DHA (generic), Zatean-PN Plus (generic), polymyxin B/HC (generic), TobraDex® Oint (Alcon) Zatean-PN DHA (generic), Zatean-PN (generic), Prenatal PNV-DHA (generic), Zatean-PN Plus (generic), Flebogamma® (Grifols Biologicals, Inc), Gamunex® (Talecris Zatean-PN DHA (generic), Zatean-PN (generic), Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), estradiol (generic), Cenestin® (Barr/Duramed), Enjuvia® flunisolide (generic), fluticasone propionate (generic), PNV-DHA (generic), Zatean-PN Plus (generic), triamcinolone acetonide (generic), Nasonex® (Schering) Zatean-PN DHA (generic), Zatean-PN (generic), Norditropin® (Nov Nordisk), Tev-Tropin® (Gate Accu-Chek Aviva Plus® (Roche), Breeze 2® (Bayer), ContourNext® (Bayer) Accu-Chek Aviva Plus® (Roche), Breeze 2® (Bayer), ContourNext® (Bayer) venlafaxine HCl (generic), citalopram HBR (generic), duloxetine (generic), fluoxetine HCl (generic), paroxetine HCl Accu-Chek Aviva Plus® (Roche), Breeze 2® (Bayer), Contour Flebogamma® (Grifols Biologicals, Inc), Gamunex® (Talecris felbamate (generic), lamotrigine (generic), Biotherapeutics), Gamunex-C® (Talecris Biotherapeutics), topiramate (generic), Banzel® Tablet (Eisai Inc.) bromfenac sodium (generic), diclofenac (generic), flurbiprofen (generic), ketorolac (generic) doxycycline monohydrate (generic), minocycline (generic) ciprofloxacin HCl (generic), levofloxacin (generic), ofloxacin(generic), Avelox® (Schering) MonoNessa® (Watson), TriNessa® (Watson) flunisolide (generic), fluticasone propionate (generic), triamcinolone acetonide (generic), Nasonex® (Schering) Hyalgan® (Sanofi Pharm), Synvisc® (Genzyme), doxazosin (generic), terazosin (generic), finesteride (generic), Januvia® (Merck & Co.) + pioglitazone (generic) dorzolamide (generic), dorzolamide/timolol (generic), latanoprost (generic), travoprost (generic) flunisolide (generic), fluticasone propionate (generic), triamcinolone acetonide (generic), Nasonex® (Schering) econazole nitrate (generic), ketoconazole (generic), nystatin (generic) sodium sulfacetamide 10% and sulfur 5% (generic) flavoxate (generic), oxybutynin (generic), oxybutynin ER(generic), tolterodine tartrate (generic), trospium (generic), temazepam (generic), triazolam (generic), zolpidem (generic), Creon® (Abbott), Zenpep® (Aptalis Pharma) Creon® (Abbott), Zenpep® (Aptalis Pharma) divalproex (generic), lamotrigine (generic), levetiracetam(generic) betamethasone valerate cream (generic), desoximetasonecream (generic), fluocinolone acetonide cream (generic), hydrocortisone valerate cream (generic), triamcinolone Norditropin® (NovoNordisk), Tev-Tropin® (Gate ondansetron (generic), granisetron (generic), Emend® (Merck) cloxapine (generic), olanzepine (generic), quetiapine fumarate(generic), risperidone (generic), ziprasidone HCl (generic) etodolac (generic), ibuprofen (generic), naproxen (generic) albuterol sulfate (generic), levalbuterol HCl (generic) Norditropin® (NovoNordisk), Tev-Tropin® (Gate Creon® (Abbott), Zenpep® (Aptalis Pharma) zolpidem (generic), temazepam (generic), triazolam (generic), *Branded generics have the same co-payment as regular generics.
Nonpreferred Product
Possible Preferred Alternatives
Nonpreferred Product
Possible Preferred Alternatives
pancrelipase (generic), Creon® (Abbott), Zenpep® (Aptalis simvastatin (generic) + Niaspan ER® (Abbott) amlodipine (generic) + losartan (generic) or Micardis® (BIPI) fenofibrate (generic), Niaspan ER® (Abbott) Ferrex 28 (generic), Ferrex 150 Forte (generic), Ferrex 150 cefaclor (generic), cefuroxime axetil (generic) Forte Plus (generic), Multigen Plus (generic), Poly-Iron 150 etodolac (generic), ibuprofen (generic), naproxen (generic) valproic acid (generic), divalproex (generic) Androderm® (Watson Pharmaceuticals), Androgel (Unimed flunisolide (generic), fluticasone propionate (generic), triamcinolone acetonide (generic), Nasonex® (Schering) corvita (generic), nicotinamide (generic), therobec plus (generic), V-C Forte citalopram (generic), fluoxetine HCl (generic), paroxetine HCl (generic), sertraline HCl (generic) Hyalgan® (Sanofi Pharm), Synvisc® (Genzyme), Creon® (Abbott), Zenpep® (Aptalis Pharma) cefuroxime axetil (generic), cefdinir (generic) Creon® (Abbott), Zenpep® (Aptalis Pharma) Accu-Chek Aviva Plus® (Roche), Breeze 2® (Bayer), ContourNext® (Bayer) PNV-DHA (generic), Zatean-PN Plus (generic), Zatean-PN DHA (generic), Zatean-PN (generic), PNV-DHA (generic), Zatean-PN Plus (generic), Zatean-PN DHA (generic), Zatean-PN (generic), Prenatal Plus (generic) betamethasone dipropionate/calcipotriene (generic) folbee (generic), folbee plus (generic), folbic (generic), renal caps (generic), triphrocaps (generic) tretinoin (generic), Azelex® (Allergan), Finacea® (Bayer) Creon® (Abbott), Zenpep® (Aptalis Pharma) eprosartan mesylate (generic) + amlodipine besylate etodolac (generic), ibuprofen (generic), naproxen (generic) (generic), Micardis (BIPI) + amlodipine besylate (generic),losartan potassium (generic) + amlodipine besylate (generic) atorvastatin (generic), simvastatin (generic), Zetia®(Merck-Schering Plough) candesartan (generic), eprosartan mesylate (generic),irbesartan (generic), losartan potassium (generic), telmisartan acyclovir ointment (generic) + hydrocortisone (generic) econazole nitrate (generic), ketoconazole (generic), candesartan/HCTZ (generic), irbesartan/HCTZ (generic), losartan/HCTZ (generic), valsartan/HCTZ (generic), Micardis flunisolide (generic), fluticasone propionate (generic), triamcinolone acetonide (generic), Nasonex® (Schering) clindamycin phosphate (generic), tretinoin (generic) candesartan/HCTZ (generic), irbesartan/HCTZ (generic), diclofenac sodium (generic), ibuprofen(generic), naproxen losartan/HCTZ (generic), valsartan/HCTZ (generic), Micardis fluocinolone acetonide solution, non oral (generic) tobramycin-dexamethasone (generic), neomycin/bacitracin/polymyxin B/HC (generic), neomycin/ zolpidem tartrate (generic), zaleplon (generic) polymyxin B/dexamethasone (generic), neomycin/ polymyxin B/HC (generic), TobraDex® Oint (Alcon) alclometasone dipropionate (generic), fluocinolone flavoxate (generic), oxybutynin (generic), oxybutynin ER acetonide (generic), hydrocortisone (generic) (generic), tolterodine tartrate (generic), trospium (generic), diclofenac (generic), etodolac (generic), ibuprofen (generic), Myrbetriq® (Astellas), Vesicare® (GlaxoSmithKline) Januvia® (Merck & Co.), Onglyza® (Bristol Myers Squibb) latanoprost (generic), travaprost (generic) fluorouracil (generic), imiquimod (generic), Picato® Gel sumatriptan (generic), naproxen (generic) eprosartan mesylate (generic) + amlodipine besylate tobramycin-dexamethasone (generic), neomycin/ (generic), Micardis (BIPI) + amlodipine besylate (generic), bacitracin/polymyxin B/HC (generic), neomycin/ losartan potassium (generic) + amlodipine besylate (generic) polymyxin B/dexamethasone (generic), neomycin/polymyxin B/HC (generic), TobraDex® Oint (Alcon) ciprofloxacin (generic), erythromycin ointment (generic), gentamicin (generic), levofloxacin (generic), ofloxacin epinephrine (generic), Epi Pen® (Mylan), Epi Pen Jr® (Mylan) (generic), tobramycin (generic), Vigamox® (Alkon) Creon® (Abbott), Zenpep® (Aptalis Pharma) olanzapine (generic), Risperdal Consta® (Janssen) *Branded generics have the same co-payment as regular generics.

Source: http://1199familyoffunds.com/wp-content/uploads/2010/12/Preferred-Drug-List.pdf