Omc-formulary updated 11-29-11.xls

0400 ANTIHISTAMINES &ANTIHISTAMINE/
DECONGESTANT COMBINATIONS
Generic combination cough and cold products are on the formulary.
Antihistamines
First Generation
DIMETANE*, DIMETANE EXTENTABS 8, 12MG* (OTC) RONDEC*, ANDEC*, ANDEHIST NR*, CARBIC-D*, CARBISET*, CARDEC* DECONAMINE SR*, CHLOR-TRIMETON DECONGESTANT*, DURATAP/PD* TANNIHIST-12 S*, TUSSI-12 S*, TANNATE-12 S* Chlorpheniramine/Phenylephrine/Methscopolamine* Chlorpheniramine/Phenylephrine/Pyrilamine* Dexbrompheniramine/Pseudoephedrine* (OTC) DRIXORAL COLD & ALLERGY* (OTC), DEXAPHEN SA* Second Generation
CLARITIN-D 24* (D 24 Hour only) (OTC) (QL)Cetirizine (OTC) ZYRTEC (OTC) (QL)Fexofenadine Suspension*ALLEGRA SUSPENSION*Fexofenadine*ALLEGRA* 30MG, 60MG, 180MG 0800 ANTI-INFECTIVE AGENTS
Antifungals
Clotrimazole*
Cephalosporins and Related Antibiotics
1st Generation
Cephalexin*
KEFLEX*
Cefadroxil*
DURICEF*
2nd Generation
Cefaclor*
CECLOR, CECLOR CD* (QL)
Cefuroxime Axetil*
CEFTIN*
Cefprozil
CEFZIL
3rd Generation
Cefdinir
OMNICEF
Cefpodoxime Proxetil*
VANTIN*
Erythromycins/Macrolides
Erythromycin Base 250,333,and 500mg tabs *
ERY-TAB *, E-MYCIN*
Erythromycin Base Enteric Pellets*
ERYC*
Erythromycin Estolate*
ILOSONE* (suspension only)
Erythromycin Ethylsuccinate*EES* 400 tab,EES* 200,400 suspensionErythromycin Stearate*ERYTHROCIN*Erythromycin w/Sulfisoxazole*PEDIAZOLE*Azithromycin*ZITHROMAX (QL)*Clarithromycin*BIAXIN, BIAXIN XL (QL)* Penicillins
Amoxicillin*
AMOXIL*, TRIMOX*
Ampicillin*
PRINCIPEN*
Penicillin VK*
PEN VEE K*, BEEPEN-VK*, VEETIDS*
Amoxicillin/Clavulanate*
AUGMENTIN*, AUGMENTIN ES*, AUGMENTIN XR*
Tetracyclines
Doxycycline*
VIBRAMYCIN*
Tetracycline*
ACHROMYCIN V *(tabs non-formulary)
Minocycline*
MINOCIN*
Doxycycline Monohydrate*
ADOXA*
Doxycycline Hyclate*
DOXYCYCLINE*
Antituberculosis
Ethambutol*
MYAMBUTOL*
Isoniazid*
ISONIAZID*
Pyrazinamide*
PYRAZINAMIDE*
Rifampin*
RIFADIN*
Antivirals
Amantadine*
SYMMETREL*
Acyclovir*
ZOVIRAX* (oral only)
Ganciclovir*
CYTOVENE* (oral only)
Entecavir
BARACLUDEFamciclovir* FAMVIR* (QL)Oseltamivir PhosphateTAMIFLU (QL)Valacyclovir*VALTREX* ALL CLASSES OF HIV-DRUGS ARE COVERED BY THE STATE OF
MICHIGAN, CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE
THRU FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
Antimalarials
Primaquine*
PRIMAQUINE*
Hydroxychloroquine*
PLAQUENIL*
Fluoroquinolones
Ofloxacin*
FLOXIN*
Quinolones
Ciprofloxacin*
CIPRO*
Moxifloxacin
AVELOX (QL)
Sulfonamides
Sulfisoxazole*
GANTRISIN*
Sulfamethoxazole/Trimethoprim*
SEPTRA*,BACTRIM*, BACTRIM DS*, SEPTRA DS*
Sulfones
Dapsone*
DAPSONE*
Urinary Anti-Infectives/Analgesics
Trimethoprim*
TRIMPEX*
Phenazopyridine*
PYRIDIUM*
Methylene Blue/ Benzoic Acid/ Hyoscyamine/ Atropine/ Phenylsalicylate/
Methenamine
URISED
Nitrofurantoin*
FURADANTIN*
Nitrofurantoin Macrocrystals*
MACROBID*, MACRODANTIN*
Miscellaneous
Neomycin*
NEOMYCIN*
Metronidazole*
FLAGYL *(Flagyl ER non-formulary)
Acetic Acid
ACI-JEL
Sodium Borate, Boric Acid
TRIMO-SAN GEL (OTC)
Mebendazole*
VERMOX*
Clindamycin Palmitate*
CLEOCIN PEDIATRIC*
Tobramycin (solution for inhalation)
TOBI (AR)
1000 ANTINEOPLASTICS
COVERAGE OF ONCOLOGY/TRANSPLANT DRUGS
All oral antineoplastics and immunosuppressants are covered for FDA-approved indications.
Alkylating Agents
Altretamine
HEXALEN
Busulfan
MYLERAN
Chlorambucil
LUEKERAN
Cyclophosphamide*
CYTOXAN*
Estramustine Phosphate Sodium
EMCYT
Lomustine
CEENU
Melphalan
ALKERAN
Antimetabolites
Capecitabine
XELODA (PA)
Mercaptopurine*
PURINETHOL*
Thioguanine*
THIOGUANINE*
Hormones
Anastrazole*
ARIMIDEX* (PA)
Bicalutamide
CASODEX
Dietheylstilbestrol Diphosphate*STILPHOSTROL*Flutamide*EULEXIN*LetrozoleFEMARA (PA)Megestrol Acetate*MEGACE*NilutamideNILANDRONTamoxifen Citrate*TAMOXIFEN*, NOLVADEX*TestolactoneTESLACToremifene CitrateFARESTONTamoxifen oral solutionSOLTAMOX Miscellaneous
Bexarotene
TARGRETIN
Etoposide
VEPESID
Erlotinib
TARCEVA
Hydroxyurea*
HYDROXYUREA*,HYDREA*,DROXIA
Imatinib Mesylate
GLEEVEC (PA)
Levamisole HCl
ERGAMISOL
Mitotane
LYSODREN
Procarbazine HCI
MATULANE
Temozolomide
TEMODAR (PA)
Tretinoin*
VESANOID*
Nilotinib
TASIGNA (ST) (QL)
Immunosuppressives
Azathioprine*
IMURAN*
Cyclosporine*
SANDIMMUNE*, NEORAL
Mycophenolate Mofetil*
CELLCEPT*
Sirolimus
Immunomodulators
Thalidomide
THALOMID (PA)
1200 AUTONOMIC DRUGS
Antiparkinson Agents
Levodopa/Carbidopa*
SINEMET*,SINEMET CR*
Bromocriptine*
PARLODEL*
Pergolide*
PERMAX*
Selegiline*
ELDEPRYL*
Ropinirole Hydrochloride
REQUIP
Skeletal Muscle Relaxants
Carisoprodol*
SOMA*
Carisoprodol/ASA*
SOMA Compound*
Methocarbamol*
ROBAXIN*
Baclofen*
LIORESAL*
Cyclobenzaprine*
FLEXERIL* (10mg only)
Chlorzoxazone*
PARAFON*, PARAFON FORTE*
Dantrolene Sodium*
DANTRIUM*
Tizanidine* (tabs)
ZANAFLEX* 2mg, 4mg
Cholinergic Agents
Bethanechol*
URECHOLINE*
Pyridostigmine*
MESTINON*
Donepezil*
ARICEPT*
Memantine Hcl
NAMENDA (ST)
Antispasmodic,Urinary
Oxybutynin*
DITROPAN* (XL non-formulary)Flavoxate*URISPAS* Drugs for Migraine-Abortive
Acetaminophen/Dichloralphenazone/Isometheptene*
MIDRIN*
Ergotamine/Caffeine*
CAFERGOT*,WIGRAINE*
Sumatriptan*
IMITREX* (QL)
Naratriptan*
AMERGE* (QL)
Anticholinergics
Benztropine*
COGENTIN*
Chlordiazepoxide/Clidinium*
LIBRAX*
Dicyclomine*
BENTYL*
Ergotamine-PB-Belladona*
BELLERGAL-S*
Trihexyphenidyl*
ARTANE*
Hyoscyamine*
LEVSIN*,LEVSINEX*,ANASPAZ*,CYSTOSPAZ*
Propantheline*
PROBANTHINE*
Adrenergic Agents/Beta-Agonists,Oral
Albuterol* (tablets,syrup)
PROVENTIL*,VENTOLIN*
Metaproterenol*(10mg,20mg tablets)
ALUPENT*, METAPREL*
Beta-Agonists/Broncodilators, inhaled
Albuterol* (inhaled, nebulizer soln)
PROVENTIL*
Metaproterenol (inhaler, nebulized soln)
ALUPENT
Ipratropium* (inhaler, nebulized soln)
ATROVENT*
Salmeterol
SEREVENT DISKUS
Vasoconstrictors
Epinephrine
EPIPEN, EPIPEN JR, ADRENALIN, ANAKIT, ANAGUARD KIT
Racemic Epinephrine (nebulizer)
S2 INH
2000 BLOOD FORMATION &COAGULATION
Coagulants,Anticoagulants,and Antiplatelets
Aspirin*
ASPIRIN*
Dipyridamole*
PERSANTINE*
Warfarin*
COUMADIN*
Ticlopidine*
TICLID*
Aminocaproic Acid*
AMICAR*
Cilostazol*
PLETAL*
Clopidogrel
PLAVIX, PLAVIX 300 (QL)
Hemorrheologic Agents
Pentoxifylline*
TRENTAL*
2400 CARDIOVASCULAR DRUGS
Antihypertensives
Calcium Channel Blockers
Diltiazem*
CARDIZEM*
Verapamil*
CALAN* (Verelan non-formulary) (QL)
Verapamil*(long-acting tablet)
CALAN-SR (Verelan SR non-formulary)
Nifedipine*(sustained-release)
ADALAT CC*, PROCARDIA XL* (QL)
Diltiazem*(long-acting capsule)
CARDIZEM SR*, CARDIZEM CD*, CARTIA XT*, DILACOR XR* (QL)
Felodipine*
PLENDIL*
Amlodipine*
NORVASC*
Verapamil*
VERELAN*, VERELAN SR*
Beta Blockers
Atenolol*
TENORMIN*
Propranolol Hcl*
INDERAL*, INDERAL LA*
Atenolol/Chlorthalidone*
TENORETIC*
Metoprolol Tartrate*
LOPRESSOR* Nadolol*CORGARD*Pindolol*VISKEN*Acebutolol*SECTRAL*Metoprolol Succinate Er*TOPROL XL*Bisoprolol*ZEBETA* (QL) Alpha and Beta Blockers
Labetalol*
NORMODYNE*, TRANDATE*
Carvedilol*
COREG*
Alpha Adrenergic Blockers and Centrally Acting Agents
Clonidine*
CATAPRES* (oral only)
Methyldopa*
ALDOMET*
Methyldopa/HCTZ*
ALDORIL*
Prazosin*
MINIPRESS*
Guanfacine*
TENEX*
Doxazosin*
CARDURA*
Terazosin*
HYTRIN*
Ace Inhibitors
Captopril*
CAPOTEN*
Quinapril*
ACCUPRIL*
Quinapril/HCTZ*
ACCURETIC*
Captopril/HCTZ*
CAPOZIDE*
Enalapril*
VASOTEC*
Lisinopril*
PRINIVIL*, ZESTRIL*
Lisinopril/HCTZ*
PRINZIDE*, ZESTERETIC*
Enalapril/HCTZ*
VASERETIC*
Moexipril*UNIVASC*Fosinopril*MONOPRIL*Benazepril*LOTENSIN* (QL)Benazepril-HCT*LOTENSIN-HCT* (QL)Moexipril-HCT*UNIRETIC* Ramipril*ALTACE* Angiotension II Receptor Antagonists
Losartan*
COZAAR*
Losartan-HCT*
HYZAAR*
Irbesartan*
AVAPRO* (ST)
Irbesartan -HCTZ
AVALIDE
Endothelin Receptor Antagonists
Bosentan
TRACLEER (PA)
Vasodilators
Hydralazine*
APRESOLINE*
Hydralazine/HCTZ*
APRESAZIDE*, HYDRAZIDE*
Minoxidil*
LONITEN*
Diuretics
Spironolactone/HCTZ*
ALDACTAZIDE*
Chlorothiazide*
DIURIL*
Chlorthalidone*
HYGROTON*
Amiloride*
MIDAMOR*
Amiloride/HCTZ*
MODURETIC*
Hydrochlorothiazide*(HCTZ)
HYDRODIURIL*,MICROZIDE*
Furosemide*
LASIX*
Spironolactone*
ALDACTONE*
Triamterene/HCTZ*MAXZIDE*,DYAZIDE*Bumetanide*BUMEX*Indapamide*LOZOL* Antiarrhythmics and Cardiac Glycosides
Antiarrhythmics
Digoxin*
LANOXIN*
Quinidine Sulfate*
CIN-QUIN*,QUINORA*
Procainamide*
PRONESTYL*
Disopyramide*
NORPACE*, NORPACE CR
Quinidine Gluconate*
QUINAGLUTE*
Quinidine Sulfate*(sustained-release)
QUINIDEX*
Sotalol*
BETAPACE*,BETAPACE AF*
Amiodarone*
CORDARONE*
Antilipemic Agents
Niacin*
Bile Sequestrants
Cholestyramine*
PREVALITE*,QUESTRAN*,QUESTRAN LIGHT*
Colestipol*
COLESTID*
Fibric Acid Derivatives
Gemfibrozil*
LOPID*
Fenofibrate*
LOFIBRA*
Statins
Simvastatin*
ZOCOR* (80mg requires PA)
Atorvastatin Calcium*
LIPITOR* (ST)
Pravastatin*
PRAVACHOL* (QL)
Lovastatin*
MEVACOR*
Atorvastatin Calcium*
Vasodilating Agents,Coronary
Dipyridamole*
PERSANTINE*
Isosorbide Dinitrate*(chew tab non-formulary)
ISORDIL*
Nitroglycerin Ointment*
NITROL*,NITROBID*
Nitrolglycerin Oral*
NITROBID*
Nitroglycerin Sublingual*
NITROSTAT SL*
Isosorbide Dinitrate*(sustained-release)
ISORDIL Tembids*
Isosorbide Mononitrate*
IMDUR*, ISMO*, MONOKET*
Nitroglycerin Patches*
NITRO-DUR*
Nitroglycerin
NITROLINGUAL SPRAY
Phosphodiesterase Inhibitor
Tadalafil
ADCIRCA (PA)
2800 CENTRAL NERVOUS SYSTEM AGENTS
Nonsteroidal Anti-Inflammatory Agents
Ibuprofen* (OTC)/RX
MOTRIN*
Acetaminophen* (OTC)
TYLENOL*
Aspirin* (OTC)
ECOTRIN*, St. JOSEPH*
Indomethacin*(suppository non-formulary)
INDOCIN*, INDOCIN SR*
Piroxicam*
FELDENE*
Salsalate*
DISALCID*
Choline Magnesium Salicylate*
TRILISATE*
Diflunisal*
DOLOBID*
Naproxen* (Naprelan non-formulary)
NAPROSYN*, NAPROSYN EC*
Naproxen Sodium*
ANAPROX*,ANAPROX DS*
Sulindac*
CLINORIL*
Diclofenac Sodium, Diclofenac Sodium ER*
VOLTAREN, VOLTAREN XR*Flurbiprofen*ANSAID*Etodolac, Etodolac ER*LODINE, LODINE XL*Ketorolac*TORADOL* (QL)Diclofenac Potassium*CATAFLAM*Meloxicam*MOBIC*Oxaprozin*DAYPRO*Nabumetone*RELAFEN*Tolmetin Sodium*TOLECTIN, TOLECTIN DS* Narcotic Analgesics
Codeine/Aspirin*
EMPIRIN #2,3,4*
Codeine/Acetaminophen*
TYLENOL #2,3,4* (capsules non-formulary)
Hydrocodone Bitartrate/Acetaminophen* (2.5/500, 5/500, 7.5/500, 7.5/650, 10/650 only)
VICODIN*, VICODIN ES*
Methadone*
DOLOPHINE*
Morphine Sulfate*
MSIR* (oral only)
Codeine Sulfate*
CODEINE*
Oxycodone/Acetaminophen Tablet*
PERCOCET*,TYLOX* (5/325 and 5/500 only)
Oxycodone/Aspirin*
PERCODAN*
Oxycodone*
OXYIR*
Meperidine*
DEMEROL*
Morphine*(sustained-release)
MS CONTIN*
Fentanyl*
DURAGESIC* (QL)
Oxymorphone HCL
OPANA ER
Non-Narcotic Analgesic Combinations
Acetaminophen/Dichloralphenazone/Isometheptine*
MIDRIN*
Butalbital/Acetaminophen/Caffeine*
FIORICET*, ESGIC*
Butalbital/Aspirin/Caffeine*FIORINAL* (capsules non-formulary)Tramadol HCl*ULTRAM*Tramadol HCI/Acetaminophen*ULTRACET* (QL) Opiate Antagonist
Naltrexone*
REVIA*
Anticonvulsants
THIS DRUG CLASS IS COVERED BY THE STATE OF MICHIGAN,
CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE THRU
FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
2816 ANTIDEPRESSANT AGENTS
Tricyclic Antidepressants
THIS DRUG CLASS IS COVERED BY THE STATE OF MICHIGAN,
CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE THRU
FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
Tetracyclic Antidepressants
THIS DRUG CLASS IS COVERED BY THE STATE OF MICHIGAN,
CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE THRU
FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
Secondary Amines
THIS DRUG CLASS IS COVERED BY THE STATE OF MICHIGAN,
CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE THRU
FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
SSRIs
THIS DRUG CLASS IS COVERED BY THE STATE OF MICHIGAN,
CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE THRU
FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
Tricyclic Antidepressants/Antipsychotics
THIS DRUG CLASS IS COVERED BY THE STATE OF MICHIGAN,
CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE THRU
FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
Miscellaneous Antidepressants
THIS DRUG CLASS IS COVERED BY THE STATE OF MICHIGAN,
CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE THRU
FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
MAO-I
THIS DRUG CLASS IS COVERED BY THE STATE OF MICHIGAN,
CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE THRU
FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
Antimanic Agents
THIS DRUG CLASS IS COVERED BY THE STATE OF MICHIGAN,
CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE THRU
FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
Tetracyclic Antidepressants
THIS DRUG CLASS IS COVERED BY THE STATE OF MICHIGAN,
CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE THRU
FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
ALL CLASSES OF ANTIPSYCHOTICS ARE COVERED BY THE
STATE OF MICHIGAN PSYCHOTROPIC CARVE OUT, CLAIMS
SHOULD BE ADJUDICATED AT POINT OF SALE THRU FIRST
HEALTH, OR CONTACT FIRST HEALTH AT (877) 624-5204
2820 CEREBRAL STIMULANTS
Respiratory and Cerebral Stimulants
THIS DRUG CLASS IS COVERED BY THE STATE OF MICHIGAN,
CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE THRU
FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
2824 ANXIOLYTICS,SEDATIVES,&HYPNOTICS
Anxiolytics,Sedatives,and Hypnotics
THIS DRUG CLASS IS COVERED BY THE STATE OF MICHIGAN,
CLAIMS SHOULD BE ADJUDICATED AT POINT OF SALE THRU
FIRST HEALTH, OR CONTACT FIRST HEALTH AT
(877) 624-5204.
4000 ELECTROLYTIC,CALORIC & WATER
Diuretics
Spironolactone/HCTZ*
ALDACTAZIDE*
Chlorothiazide*
DIURIL*
Chlorthalidone*
HYGROTON*
Amiloride*
MIDAMOR*Amiloride/HCTZ*MODURETIC*Hydrochlorothiazide*(HCTZ)HYDRODIURIL*,MICROZIDE*Furosemide*LASIX*Spironolactone*ALDACTONE*Triamterene/HCTZ*MAXZIDE*,DYAZIDE*Bumetanide*BUMEX*Indapamide*LOZOL* Antidiuretic
Desmopressin*
DDAVP*
Uricosuric Agents
Probenecid*
BENEMID*
Sulfinpyrazone*
ANTURANE*
Potassium Supplements
Tablets
Potassium Chloride 8mEq*
SLOW K*,KLOR-CON*
Potassium Chloride 10mEq,20mEq*
K-DUR*
Powders/Effervescent Tablets
Packets*20mEq,25mEq,50mEq,15mEq
K-LOR*,K-LYTE*,KLORVESS*,KLOR-CON*
Liquids
Potassium Chloride*
KAOCHLOR*
Hyperkalemic Agent
Sodium Polystyrene Sulfonate*
KAYEXALATE*
Alkalinizing Agent
Potassium Citrate
UROCIT K
Ammonia Detoxicants
Lactulose*
Urinary Acidifiers
Phosphorous Replacement
K-PHOS NEUTRAL
Potassium Phosphate
K-PHOS
Laxative
PEG 3350*
MIRALAX*
4800 ANTITUSSIVE,EXPECTORANT &MUCOLYTIC AGENTS
Mucolytic Agents
Acetylcysteine*
MUCOMYST*
Dornase Alfa
PULMOZYME (AR)
Antitussive/Decongestants
Benzonatate*
TESSALON PERLES* (100mg only)
Codeine/Bromodiphenhydramine*
AMBENYL*
Codeine/Guaifenesin*
ROBITUSSIN AC*,GUAITUSS AC*,CHERACOL*
Codeine/Promethazine*
PHENERGAN W/CODEINE*
Codeine/Promethazine/Phenylephrine*
PHENERGAN VC/CODEINE*
Codeine/Pseudophedrine/Chlorpheniramine*
NOVAHISTINE DH*
Codeine/Pseudoephedrine/Guaifenesin*
ROBITUSSIN DAC*
Codeine/Triprolidine/Pseudoephedrine*
ACTIFED-C*
Dextromethorphan/Brompheniramine/Pseudoephedrine*
BROMFED DM*
Dextromethorphan/Carbinoxamine/Pseudoephedrine*
CARBOFED*
Dextromethorphan/Guaifenesin* (OTC)
ROBITUSSIN DM*, FENESIN DM* (OTC), CHLORDEX GP*
Dextromethorphan/Promethazine*
PHENERGAN DM*
Dextromethorphan/Pseudoephedrine/Guaifenesin* (OTC)
PEDIACARE* (OTC)
Guaifenesin* (OTC)
ROBITUSSIN* (OTC)
Guaifenesin/Phenylephrine*
CRANTEX*
Guaifenesin/Hydrocodone/Pseudoephedrine*
C-COF XP*
Hydrocodone/Chlorpheniramine/Phenylephrine*HISTUSSIN HC*Hydrocodone/Guaifenesin*HYCOTUSS*Hydrocodone/Homatropine*HYCODAN*Hydrocodone/Pseudoephedrine*HISTUSSIN D*Promethazine/Phenylephrine*PHENERGAN VC*Pseudoephedrine/Guaifenesin* (OTC)ROBITUSSIN - PE* (OTC) Expectorant and Expectorant Combinations
Dextromethorphan/Carbinoxamine/Pseudoephedrine*
RONDEC DM*
Guaifenesin/Pseudoephedrine*
ZEPHREX LA*,ENTEX PSE*
Guaifenesin*
HUMIBID LA,*FENESIN*
5200 EYE,EAR,NOSE &THROAT
Topical Anti-Infectives/Anti-Inflammatory (otic)
Carbamide Peroxide 6.5%* (OTC)
DEBROX* (OTC)
Acetic Acid*
VOSOL*
Benzocaine/Acetic Acid
A/B OTIC
Aluminum Acetate/Acetic Acid*
DOMEBORO OTIC SOLUTION*
Hydrocortisone/Acetic Acid*
VOSOL HC OTIC*
Ofloxacin*
FLOXIN* OTIC
Pramoxine/Chloroxylenol*
PRAMOTIC*
Hydrocortisone/Neomycin Sulfate/Polymyxin B Sulfate*
CORTISPORIN* OTIC
Anti-Infectives (ophthalmic)
Bacitracin*
BACITRACIN*
Erythromycin*
ILOTYCIN*
Gentamicin*
GENOPTIC*,GARAMYCIN*
Neomycin/Dexamethasone*
NEO-DECADRON*
Neomycin Sulfate/Gramicidin/Polymyxin B Sulfate*
NEOSPORIN Solution*
Polymyxin B Sulfate/Neomycin Sulfate/Dexamethasone*MAXITROL*Sulfacetamide/Phenylephrine*VASOSULF*Sulfacetamide 10%*BLEPH 10*,SODIUM SULAMYD*,CETAMIDE*, SULFACET R*Neomycin/Bacitracin/Polymyxin B Sulfate*NEOSPORIN Ointment*Ofloxin*OCUFLOX*Tobramycin Sulfate*TOBREX*Prednisolone/Sulfacetamide*VASOCIDIN* Antivirals (ophthalmic)
Trifluridine*
VIROPTIC*
Ophthalmic Anti-Inflammatories
Dexamethasone*
DECADRON*
Prednisolone Phosphate*
INFLAMASE*,INFLAMASE FORTE*
Fluorometholone*
FML*,FML FORTE*, FLUOR-OP*
Prednisolone Acetate*
PRED MILD*,PRED FORTE*,ECONOPRED*,ECONOPRED PLUS*
Flurbiprofen*
OCUFEN*
Carbonic Anhydrase Inhibitors
Acetazolamide*
DIAMOX* (oral only)
Methazolamide*
NEPTAZANE*,GLAUCTABS*
Brinzolamide
AZOPT (ST)
Dorzolamide*
TRUSOPT*
Miotics
Pilocarpine*(Ocusert non-formulary)
ISOPTO CARPINE*
Cyclopentolate*
CYCLOGYL*
Dipivefrin HCl*
PROPINE*
Mydriatics
Artificial Tears* (OTC)
ISOPTO TEARS* (OTC)Atropine*ISOPTO ATROPINE*Homatropine Hydrobromide*ISOPTO HOMATROPINE* Vasoconstrictors
Naphazoline*
PRIVINE*, ALBALON*
Naphaxoline/Pheniramine* (OTC)
NAPHCON-A* (OTC)
Beta Blockers
Levobunolol*
BETAGAN*
Timolol*
TIMOPTIC*,TIMOPTIC XE*
Carteolol HCl*
OCUPRESS*
Carteolol*
CARTEOLOL*
Beta Blockers (Beta-1 Selective)
Betaxolol*
BETOPTIC*
Misc EENT
Phenylephrine* (OTC)
NEO-SYNEPHRINE* (OTC)
Naphazoline/antazoline* (OTC)
VASOCON-A* (OTC)
Sodium chloride spray* (OTC)
OCEAN SPRAY* (OTC)
Benzocaine/Pectin* (OTC)
ORABASE-B* (OTC)
Menthol/Cetylpyridium Lozenge* (OTC)
CEPACOL* (OTC)
Cromolyn*
CROLOM*
Travoprost
TRAVATAN Z (QL)
Metipranolol
OPTIPRANOLOL
Brimonidine*
ALPHAGAN* (P is non-formulary)
Ketotifen* (OTC)
ZADITOR*, ALAWAY* (QL), (OTC)
Latanoprost*
XALATAN*
Nasal Steroids/Anti-Inflammatory
Cromolyn* (OTC)NASALCROM* (OTC)Flunisolide*NASALIDE*Fluticasone*FLONASE*Mupirocin CalciumBACTROBAN NASALTriamcinolone Acetonide*NASACORT AQ*PEAK FLOW METER (QL)AEROCHAMBER (QL) 5600 GASTROINTESTIONAL DRUGS
Miscellaneous
Bismuth subsalicylate* (OTC)
PEPTO-BISMOL* (OTC)
Calcium carbonate* (OTC)
TUMS* (OTC)
Electrolyte Rehydrating (OTC)
PEDIALYTE* (OTC)
Loperamide* (OTC)
IMODIUM A-D* (OTC)
Aluminum Carbonate* (OTC)
BASALJEL* (OTC)
Ipecac syrup* (OTC)
IPECAC SYRUP* (OTC)
Magnesium Hydroxide/Aluminum Hydroxide* (OTC)
MAALOX* (OTC)
Simethicone* (OTC)
MYLICON* (OTC)
Lactase* (OTC)
LACTAID* (OTC)
Lactobacillus Acidophilus* (OTC)
LACTINEX* (OTC)
Diphenoxylate/Atropine*
LOMOTIL*
Lactulose*
CEPHULAC*
Polyethylene glycol/electrolyte solution*
GOLYTELY*, NULYTELY*
Polyethylene Glycol 3350*
MIRALAX*
Pancreatin
CREON
Pancrelipase*
PANCREASE* (all strengths)
H2 Antagonists (OTC) and RX
Cimetidine*
TAGAMET HB* (OTC)
Ranitidine*ZANTAC* (OTC) efferdose non-formularyFamotidine*PEPCID AC* (OTC)Nizatadine*AXID AR* (OTC) Proton Pump Inhibitors
All prescription PPI's require PA's for long term use >8 weeks (Prilosec OTC does not require PA)
Omeprazole Magnesium
PRILOSEC OTC (QL)
Omeprazole*
PRILOSEC 10MG*, 20MG*, 40MG* (QL), PRILOSEC SUSPENSION
Lansoprazole
PREVACID OTC (QL)
Lansoprazole*
PREVACID RX.*
Pantoprazole*
PROTONIX*
GI Motility
Metoclopramide*
REGLAN*
Cytoprotective Agents
Sucralfate*
CARAFATE*
Prostaglandins
Misoprostol
CYTOTEC
Antiemetics
Meclizine * (OTC)/RX
MECLIZINE* (OTC)/RX
Trimethobenzamide*
TIGAN*
Prochlorperazine*
COMPAZINE*
Ondansetron*
ZOFRAN (QL)*
Misc.GI Drugs
Sulfasalazine*
AZULFIDINE*, AZULFIDINE EN*
Mesalamine
ASACOL, CANASA
Ursodiol*
ACTIGALL*
Balsalazide*
COLAZAL*
Laxatives and Stool Softeners (OTC)
Bisacodyl* (OTC)
DULCOLAX* (OTC)
Docusate Calcium* (OTC)
SURFAK* (OTC)
Docusate Potassium* (OTC)
DIALOSE* (OTC)
Docusate Sodium* (OTC)
COLACE* (OTC)
Docusate Sodium/Casanthrol* (OTC)
PERI-COLACE* (OTC)
Magnesium Citrate* (OTC)
CITRATE OF MAGNESIA* (OTC)
Magnesium Hydroxide* (OTC)
MILK OF MAGNESIA* (OTC)
Methylcellulose* (OTC)
CITRUCEL* (OTC)
Mineral Oil* (OTC)
MINERAL OIL* (OTC)
Senna* (OTC)
SENOKOT* (OTC)
Senna/Docusate Sodium* (OTC)
SENOKOT -S* (OTC)
Sodium Phosphate/Sodium Biphosphate* (OTC)
FLEET ENEMA* (OTC)
6000 ARTHRITIS/GOUT
Nonsteroidal anti-inflammatory agents
Probenecid*
BENEMID*
Allopurinol*
ZYLOPRIM*
Colchicine*
COLCHICINE*
Colchicine/Probenecid*
COLBENEMID*
Methotrexate*
METHOTREXATE*, RHEUMATREX
Leflunomide*
ARAVA*
6400 RESPIRATORY DRUGS
Bronchodilators
Sodium Chloride* (OTC)
BRONCHO SALINE* (OTC)
Sodium Chloride Soln for Inhalation* (OTC)
SODIUM CHLORIDE * (OTC)
Ipratropium*
ATROVENT, ATROVENT HFA
Metaproterenol Sulfate
ALUPENTAlbuterol Tablets*VOLMAX*, VOSPIRE ER*Terbutaline*BRETHINE*SalmeterolSEREVENT DISKUSAlbuterol/IpratropiumCOMBIVENTTiotropiomSPIRIVAAlbuterol/Ipratropium*DUONEB*Albuterol*ACCUNEB*Albuterol*VENTOLIN HFA* Inhaled Anti-Inflammatory Agents
Beclomethatsone Diproprionate
QVAR
Fluticasone
FLOVENT
Salmeterol/Fluticasone
ADVAIR, ADVAIR HFA
Budesonide (inhalation)* (Tubohaler non-formulary)
PULMICORT RESPULES* (only for 5yrs. And under)
Formoterol/Mometasone
DULERA
Leukotriene Antagonist
Montelukast
SINGULAIR (ST)
Zafirlukast*
ACCOLATE*
Theophylline and other Xanthines
Solids
Theophylline*
THEO-24*,THEO-DUR*,THEO-VENT*,THEOCHRON*,T-PHYL*
SLO-BID*,RESPBID*,QUIBRON-T*,UNI-DUR*,UNIPHYL*
(Combination products of Theophylline are non-formulary)
Liquids
Theophylline* (80mg/15cc)
THEOLAIR 80*,SLO-PHYLLIN*
Beta-Agonists, Oral
Albuterol (soln, syrup, tablets)*
PROVENTIL*
Metaproterenol*
6800 HORMONES & SYNTHETIC SUBSTITUTES
Estrogens
Estrogens,Conjugated
PREMARIN
Estradiol*
ESTRACE*, ESTRACE VAGINAL
Diethylstilbestrol*
DES*
Estropipate*
OGEN*
Estradiol Transdermal System*
ESTRADERM*, CLIMARA*
Esterified Estrogen
MENEST (QL)
Estradiol
VAGIFEM
Estrogens /Progestin
Estrogens, Conjugated/Medroxyprogesterone
PREMPRO, PREMPHASE
Estrogens Agonist - Antagonist
Raloxifene
EVISTA
Anti-Estrogen
Tamoxifen*
NOLVADEX*, TAMOXIFEN*
Contraceptives
CONDOMS (QL)
Etonogestrel-Ethinyl Estradiol
NUVARING
Medroxyprogesterone Acetate* (Contraceptive)
DEPO-PROVERA INJ. (QL)*
Levonorgestrel
PLAN B (QL)
Oral Contraceptives
Desogestrel/Ethinyl Estradiol
ORTHO-CEPT
Ethynodiol/Ethinyl Estradiol*
DEMULEN*,ZOVIA*
Levonorgestrel/Ethinyl Estradiol*
NORDETTE*,LEVORA*
Levonorgestrel/Ethinyl Estradiol*
ALESSE*,AVIANE*,LESSINA*
Norethindrone/Ethinyl EstradiolORTHO-NOVUM 1/35Norethindrone/Ethinyl EstradiolMODICONNorgestrel/Ethinyl Estradiol*LO/OVRAL*,LOW-OGESTREL*Norethindrone/Ethinyl Estradiol*LOESTRIN FE 1.5/20*, MICROGESTIN FE 1.5/30*, JUNEL FE 1.5/20*Norethindrone/Ethinyl Estradiol*OVCON-50*, OVCON-35*Norethindrone/Ethinyl Estradiol*LOESTRIN FE 1/20*, MICROGESTIN FE 1/20*, JUNEL FE 1/20*Norethindrone/Ethinyl EstradiolORTHO-NOVUM 10/11Norethindrone/Ethinyl Estradiol*MIRCETTE*, KARIVA*Norethindrone/MestranolORTHO-NOVUM 1/50Norgestrel/Ethinyl Estradiol*OVRAL-28*, OGESTREL*Norgestimate/Ethinyl EstradiolORTHO-CYCLENEthinyl EstradiolYASMINEthinyl Estradiol*CYCLESSA*Drospirenone/Ethinyl Estradiol*OCELLA* Multiphasics (oral contraceptives)
Levonorgestrel/Ethinyl Estradiol*
TRIPHASIL*,TRIVORA*
Norethindrone/Ethinyl Estradiol*
ESTROSTEP FE*
Norethindrone/Ethinyl Estradiol
ORTHO-NOVUM 7/7/7
Norethindrone/Ethinyl Estradiol*
TRI-NORINYL*
Norgestimate/Ethinyl Estradiol
ORTHO-TRI-CYCLEN
Progestin-Only (oral contraceptives)
Medroxyprogesterone*
CYCRIN*, PROVERA*
Norethindrone
ORTHO-MICRONOR, AYGESTIN*
Norgestrel
OVRETTE
Progesterone, micronized
PROMETRIUM
Anti-Androgens
Finasteride*
PROSCAR*
Tamsulosin*
FLOMAX*
Alpha-Adrenergic Blockers
Alfuzosin Hct*
UROXATRAL*
Androgens
Methyltestosterone
ANDROID
Testosterone
TESTIM (PA)
Testosterone Cypionate*
DEPO-TESTOSTERONE INJECTION*
Drugs to Treat Endometriosis
Danazol*
DANOCRINE*
Thyroid and Antithyroid Agents
Levothyroxine*(use same brand consistently)
LEVOXYL*,LEVOTHROID*,SYNTHROID*
Methimazole*
TAPAZOLE*
Propylthiouracil*
PROPYLTHIOURACIL* (PTU)
Thyroid
ARMOUR THYROID
Antidiabetic Agents
Oral Agents
Acetohexamide*
DYMELOR*
Chlorpropamide*
DIABINESE*
Tolbutamide*
ORINASE*
Tolazamide*
TOLINASE*
Glyburide*
MICRONASE*,DIABETA*,GLYNASE*
Glipizide*
GLUCOTROL*, GLUCOTROL XL*
Metformin*
GLUCOPHAGE*
Metformin ext-rel.*
GLUCOPHAGE XR* (QL)
Pioglitazone
ACTOS (PA)Glyburide/Metformin*GLUCOVANCE*SitagliptinJANUVIA (PA) (QL)Metformin/SitagliptinJANUMET (PA) (QL)Metformin/Glipizide*METAGLIP* (QL)Acarbose*PRECOSE* Glimepiride*AMARYL*ExenatideBYETTA (PA) Insulin-Lilly Brands Only
Human Insulin,NPH,Regular,Mix
HUMULIN, HUMALOG (not pens)
Insulin Human Glargine
LANTUS
Insulin Human Glargine
LANTUS PEN SOLOSTAR (PA)
Insulin Lispro
HUMALOG PEN
Insulin Regular
HUMULIN-R PEN
Note: Insulin pens, cartridges, needles are non-formulary and need prior authorization.
Lifescan glucometers are covered on the formulary with a written prescription (QL) Corticosteroids
Prednisone*
DELTASONE*,ORASONE*
Hydrocortisone*
CORTEF*
Dexamethasone*
DECADRON*
Methylprednisolone*
MEDROL*
Prednisolone*
PRELONE*, ORAPRED*, PEDIAPRED*
Bone Metabolism
Alendronate*
FOSAMAX*
7200 LOCAL ANESTHETICS
Lidocaine Viscous*
XYLOCAINE VISCOUS*
Lidocaine/Prilocaine*EMLA* (cream only)LidocaineLIDODERM (PA)Lidocaine*XYLOCAINE GEL 2% JELLY* 7600 OXYTOCICS
Methylergonovine Maleate
METHERGINE
8400 SKIN &MUCOUS MEMBRANE
Antibiotics-Topical
Bacitracin* (OTC)
BACITRACIN * (OTC)
Hydrogen Peroxide 3%* (OTC)
HYDROGEN PEROXIDE 3%* (OTC)
Neomycin/Polymyxin B/Bacitracin* (OTC)
NEOSPORIN* (OTC)
Polymyxin B/Bacitracin* (OTC)
POLYSPORIN* (OTC)
Bacitracin*
BACIGUENT*
Polymyxin B/Bacitracin*
POLYSPORIN*
Gentamicin*
GARAMYCIN*
Silver Sulfadiazine*
SILVADENE*
Mupirocin*
BACTROBAN*
Antiacne
Aluminum Chloride*
DRYSOL*
Erythromycin Solution*, Gel*, Pads*
A/T/S*,ERY-DERM*,T-STAT*,ERYMAX*, T-STAT*, ERY-PADS*, EMGEL*, ERY-SOL*, ERYCETTE*
Clindamycin*
CLEOCIN T* (lotion,gel,solution,pads), CLINDETS*
Tretinoin*
RETIN A* (micro non-formulary), AVITA*
Tazarotene
TAZORAC (QL)
Erythromycin/Benzoyl Peroxide*
BENZAMYCIN*
Antibiotic-Vaginal
Butoconazole* (OTC)
FEMSTAT-3* (OTC)
Miconazole* (OTC)
MONISTAT* (OTC)
Clotrimazole* (OTC)GYNE-LOTRIMIN* (OTC)Ticonazole* (OTC)VAGISTAT-1* (OTC)Amino Acid, Urea*AMINO-CERV*Metronidazole*METROGEL-VAG GEL 0.75%Clotrimazole* (OTC)MYCELEX* (OTC)Terconazole*TERAZOL*Butoconazole NitrateGYNAZOLE-1 Antifungal-Topical
Benzoyl Peroxide* (OTC)
BENZOYL PEROXIDE* (OTC), BENOXYL*
Clotrimazole* (OTC)
MYCELEX*, NIS LOTRIMIN*, LOTRIMIN*, FUNGOID, LOTRIMIN AF (OTC)* (1% Soln)
Miconazole* (OTC)
MICATIN* (OTC)
Butenafine
MENTAX
Tolnaftate* (OTC)
TINACTIN* (OTC)
Nystatin*
MYCOSTATIN*,NILSTAT*
Clotrimazole/Betamethasone Diproprionate*
LOTRISONE*
Nystatin/Triamcinolone*
MYCOLOG II*
Econazole*
SPECTAZOLE*
Ketoconazole*
NIZORAL*
Ciclopirox*
LOPROX*
Scabicides and Pediculicides
Permethrin 1%* (OTC)
NIX* (OTC)
Pyrethrins Spray* (OTC)
A-200 LICE CONTROL* (OTC)
Pyrethrins/Piperonyl Butoxide* (OTC)
RID* (OTC)
Permethrin*
ELIMITE*
Malathion*
OVIDE* (QL)
Anti-Inflammatory Agents (Topical)
Group VII (Lowest Potency)
Hydrocortisone 2.5%*
HYDROCORTISONE*, HYTONE*, CORT-DOME*
Hydrocortisone 0.5,1%* (OTC)
CORTAID* (OTC)
Alclometasone Dipropionate Cream, Oint. 0.05%* (QL)
ACLOVATE* (QL)
Group VI
Clotrimazole/Betamethasone Diproprionate*
LOTRISONE*
Fluocinolone Acetonide*Soln,Cream 0.01%
SYNALAR*, FLUROSYN*
Triamcinolone Acetonide*Cream,Oint.0.025%
KENALOG*, ARISTOCORT*
Betamethasone Valerate Lotion 0.1%*
VALISONE*
Desonide*Cream,Oint 0.05%
DESOWEN*
Amcinonide*
CYCLOCORT*
Group V
Triamcinolone Acetonide*Lot,Cream,Oint 0.1%
KENALOG*, ARTISTOCORT*
Betamethasone Valerate*Cream 0.1%
VALISONE*
Fluocinolone Acetonide*Cream 0.025%
SYNALAR*, FLUROSYN*
Hydrocortisone Butyrate*
LOCOID*
Fluticasone Propionate* (QL)
CUTIVATE* (QL)
Fluocinolone Acetonide
DERMOTIC OIL
Group IV
Triamcinolone*Cream,Oint 0.5%
KENALOG*, ARTISTOCORT*
Fluocinolone Acetonide*Oint 0.025%
SYNALAR*, FLUROSYN*
Group III
Betamethasone Valerate*Oint 0.1%
VALISONE*
Mometasone Furoate* (cream,ointment,lotion)
ELOCON*
Group II
Betamethasone Dipropionate*Cream,Oint,Lot 0.05%
DIPROSONE*Fluocinonide*Cream,Oint,Gel,Soln 0.05%LIDEX*Desoximetasone*Cream,Oint,GelTOPICORT* Group 1 (Highest Potency)
Betamethasone Dipropionate*, Diflorasone Diacetate*
DIPROLENE AF*, PSORCON*, PSORCON E*
Clobetasol* (Cream,Oint,Soln, Lotion) 0.05%
TEMOVATE*, CORMAX*, CLOBEX*
Halobetasol Propionate*
ULTRAVATE* (QL)
Antipsoriatics and Antipruritics
Selenium Sulfide 2.5%*
SELSUN*,EXSEL*
Rectal
Hydrocortisone*
ANUSOL-HC*
Keratolytic Agent
Amlactin* (OTC)
LAC-HYDRIN* (OTC)
Podofilox*
CONDYLOX*
Salicyclic Acid (RX) (OTC)
KERALYT GEL (RX) (OTC)
Misc.Skin and Mucous Membrane Agent
Salicylic Acid 17%/Collodion* (OTC)
DUOFILM* (OTC)
Mineral Oil/Petrolatum Ointment* (OTC)
AQUAPHOR*, EUCERIN* (OTC)
Benzocaine Aerosol* (OTC)
DERMACORT*
Zinc Oxide Oint* (OTC)
ZINC OXIDE* (OTC)
Diphenhydramine Cream 2%* (OTC)
BENADRYL* (OTC)
Vitamin A&D Ointment* (OTC)
A&D OINT* (OTC)
Calamine Lotion* (OTC)
CALAMINE LOTION* (OTC)
Glycerin/Benzoyl ale/Petrolatum Cream* (OTC)
MOISTUREL* (OTC)
Urea
ZIOX
Triamcinolone 0.1%in Orabase*
KENALOG IN ORABASE*
FluorouracilEFUDEXPimecrolimusELIDEL (AR-for ages below 16yo only) (QL)ImiquimodALDARAEnzyme combination, topicalGRANULEX WOUND CARE
Papain/Urea*
PANAFIL*
8800 VITAMINS
Folic Acid*
FOLIC ACID*
Vitamin B-12
Cyanocobalamin injection*
VITAMIN B-12*
Vitamin D
Ergocalciferol*
CALCIFEROL, DRISDOL, CALCIDOL*
Calcitriol*
ROCALTROL*
Paricalcitol
ZEMPLAR
Vitamin K
Phytonadione
MEPHYTON
Prenatal
Most generic prenatal vitamins (OTC/Rx) are covered. This list is not all inclusive.
ADVANCED NATALCARE*
ANEMAGEN OB*
FERREX PC FORTE*
MATERNAL VITAMIN & MINERAL*
MATERNITY-90*
NATAFOLIC-PN*
NATALCARE 3*
NATALCARE CPL*
NATALCARE RX*
NATALCARE CFE 60*
NATALCARE PIC FORTE*
NATALCARE PLUS*
NATALINS RX*
NATAREX*
NATATAB CFE*
NATATAB FA*
NATATAB RX*PRENATAB CBF*PRENATAB*PRENATABS FA*PRENATABS RX*PRENATAL 1/ IRON*PRENATAL 1+ BETA CAROTENE*PRENATAL 1+1*PRENATAL 19 CHEW *PRENATAL 19*PRENATAL AD*PRENATAL FOR*PRENATAL M*PRENATAL MR 90 FE*PRENATAL MTR SELENIUM*PRENATAL NF PLUS*PRENATAL OPT ADVANCE*PRENATAL PLUS*PRENATAL PLS /IRON*PRENATAL RX*PRENATAL RX BETA-CAROTENE*PRENATAL S*PRENATAL Z*PRENATAL Z ADV FORM*PRENATAL-H*PRENATAL CARE*PRETERNA*TERNAMAR*ULTRA NATALCARE*ULTRA NATAL*ULTRA*VINATE 90*VINATE GT*VINATE M*VINATE ADVANCED*VINATE ULTRA*DUET DHA* Pediatric/Fluoride
Multivitamin* (OTC)
POLY-VI-SOL* (OTC)
Multivitamin + Iron (pediatric)* (OTC)
POLY-VI-SOL IRON* (OTC)
Fluoride/Polyvitamins*(drops and tablets)
POLY-VI-FL OR*
Vitamin, A, D, and C*
TRI-VI-SOL*
Vitamin, A, D, and C with Iron*
TRI-VI-SOL with IRON*
Sodium Fluoride*(drops and tablets)
KARIDIUM*,LURIDE*
Minerals
Calcium Carbonate * (OTC)
TUMS* (OTC)
Calcium Carbonate w/Vitamin D* (OTC)
CALTRATE 600+D* (OTC)
Calcium Gluconate* (OTC)
CALCIUM GLUCONATE* (OTC)
Calcium Lactate* (OTC)
CALCIUM LACTATE* (OTC)
Ferrous Fumarate* (OTC)
FERROUS FUMARATE* (OTC)
Ferrous Gluconate* (OTC)
FERGON* (OTC)
Ferrous Sulfate* (OTC)
FEOSOL* (OTC)
Sodium Biphosate/Potassium Phosphate* (OTC)
NEUTRA-PHOS POWDER* (OTC)
Calcium Acetate*
PHOSLO*
MISC DRUGS
Somatropin
OMNITROPE (PA)
Rho (D) Immunle Globulin Injectable
RHOGAM, BAYRHO, WINRHO (QL)
Epinephrine
EPIPEN, EPIPEN JR, ADRENALIN, ANAKIT, ANAGUARD KIT, TWINJECT
Enoxaparin Sodium*
LOVENOX* (PA) (QL)
Dalteparin Sodium
FRAGMIN (PA) (QL)
Fondaparinux Sodium
ARIXTRA (PA) (QL)
Penicillin G
BICILLIN-LA (QL)
Ceftriaxone Sodium
ROCEPHIN (QL)
Dexamethasone Injection
DECADRON (QL)
Hydroxyzine HCl Injection* (single dose vial)
VISTARIL* (QL)
Glucagen Injection
GLUCAGON
Silver Nitrate*
Silver Nitrate*
Succimer
CHEMET
Dental Products
Fluoride Rinse* (OTC)
ACT*, GEL-KAM*, PERIOMED*, PREVIDENT*, PERIO-RINSE* (OTC)Stannous Fluoride* (OTC)/RXPERIOMED*, GEL-KAM*, ETHEDENT* (OTC)Chlorhexidine Gluconate*PERIDEX*, PERIOGARD* Common OTCs Covered by the OmniCare Health Plan
Drugs are listed by brand name for reference only. This is not a
complete OTC list. Brand name OTCs will not be covered if a
generic is available.
Analgesics:
Tylenol®
Bayer®, Ecotrin®, St. Joseph's Baby Aspirin®
Aleve®
Motrin® IB, Advil®
Antacids/Anti-gas Products:
Tums®
Maalox®
Mylicon®
Antidiarrheal Products:
Pepto-Bismol®
Pedialyte®
Imodium® A-D
Antihistamines
Chlor-Trimeton®
Tavist®
Claritin®
Benadryl®
Cough and Cold Products:
Robitussin® DM
Robitussin®
Sudafed®
Robitussin®-PE
Eye, Ear, and Nose Products:
Isopto® Tears, Tears Naturale®
Debrox®
Vasocon®-A
Neo-Synephrine®
Ocean Mist®
Laxative Products:
Dulcolax®
Surfak®
Dialose®
Colace®
Peri-Colace®
Citrate of Magnesia®
Citrucel®
Milk of Magnesia®
Mineral Oil*
Senokot®
Senokot-S®
Fleet® Enema, Fleet® Phospho® Soda
Mouth and Throat Products:
Orabase®-B
Cepacol®
Cepastat®
Pediculicide Products:
Nix®
RID®
A-200® Lice Control
Smoking Deterrents:
Nicotine* (OTC)
NICODERM CQ PATCH* (OTC)
Nicotine Polacrilex* (OTC)
NICORETTE GUM* (OTC)
Nicotine Polacrilex * (OTC)
COMMIT LOZENGES* (OTC)
Bupropion*
ZYBAN*
Topical Antifungal Products:
Lotrimin® AF
Micatin®
Tinactin®
Topical Antimicrobial Products:
Bacitracin
Hydrogen Peroxide 3%
Neosporin®
Polysporin®
Topical Miscellaneous Products:
Dr. Smith's Ointment®
Dermacoat®
Calamine Lotion USP®
Benadryl®
Moisturel®
Cortaid®
Eucerin®
Aquaphor®
Duofilm®
A+D® Ointment
Cortaid®
Zinc Oxide
Abreva®
Vaginal Antifungal Products:
Femstat 3®
Gyne-Lotrimin®
Monistat®
Vagistat-1®
Mycelex
Vitamin and Mineral Products:
Prenatal Vitamins
Caltrate 600+D®
Calcium Gluconate
Calcium Lactate
Ferrous Fumarate
Fergon®
Feosol®
Fer-In-Sol®
Os-Cal®
Poly-Vi-Sol®
Poly-Vi-Sol® Iron
Miscellaneous Products:
Condoms (QL 12)
Ipecac Syrup®
Lactinex®
Lactaid®
Broncho Saline®
Neutra-Phos®
Legend:QL = Quantity LimitAR = Age RestrictionPA = Prior Authorization RequiredST = Step Therapy* = Generic AvailableRX = Prescription NeededOTC = Over The Counter RONDEC*, ANDEC*, ANDEHIST NR*, CARBIC-D*, CARBISET*, CARDEC* DECONAMINE SR*, CHLOR-TRIMETON DECONGESTANT*, DURATAP/PD* Hydrocodone Bitartrate/Acetaminophen* (2.5/500, 5/500, 7.5/500, 7.5/650, 10/650 only) All prescription PPI's require PA's for long term use >8 weeks (Prilosec OTC does not require PA)
Note: Insulin pens, cartridges, needles are non-formulary and need prior authorization.
A/T/S*,ERY-DERM*,T-STAT*,ERYMAX*, T-STAT*, ERY-PADS*, EMGEL*, ERY-SOL*, ERYCETTE* MYCELEX*, NIS LOTRIMIN*, LOTRIMIN*, FUNGOID, LOTRIMIN AF (OTC)* (1% Soln) Most generic prenatal vitamins (OTC/Rx) are covered. This list is not all inclusive.
EPIPEN, EPIPEN JR, ADRENALIN, ANAKIT, ANAGUARD KIT, TWINJECT

Source: http://chcmedicaid-michigan.coventryhealthcare.com/web/groups/public/@cvty_medicaid_michigan/documents/document/c066050.pdf