Microsoft word - ah2 avera health plans 1page - 4-13-2009

The following is a list of commonly prescribed drugs. It is an abbreviated version of the drug formulary that is the core of your prescription drug isosorbide dinitrate,
mometasone furoate
prazosin hcl
mononitrate
morphine sulfate
prednisolone
itraconazole
mupirocin
prednisolone acetate
(ST) indicates a drug is subject to Step T herapy famotidine
prednisone
( PAR) indicates Prior Authorization is r felodipine er
FORMULARY DRUGS 2009
nabumetone
clorazepate dipotassium
fentanyl
baclofen
clotrimazole
fexofenadine hcl
prenatal rx
clotrimazole/betameth.
finasteride
naproxen
benazepril hcl, /hctz
clozapine
flecainide acetate
primidone
ketoconazole
colchicine
klor-con
acarbose
benzonatate
colestipol hcl
natalcare plus
acetaminophen w/codeine
benztropine mesylate
nefazodone hcl
probenecid
betamethasone
fluconazole
labetalol hcl
neomycin/polymyxin/dexa
prochlorperazine maleate
dipropionate
fludrocortisone acetate
lactulose
fluoxetine hcl
nifedipine
promethazine hcl
bisoprolol fumarate, /hctz
flurazepam hcl
nitroglycerin
promethazine vc
bromocriptine mesylate
fluticasone nasal spray
nizatidine
promethazine vc, w/cod
bumetanide
cyclobenzaprine hcl
fluticasone prop. (oint)
norethindrone acetate
promethazine w/codeine
bupropion hcl, SR, XL
cyclosporine
fluvoxamine maleate
levothroid
nortriptyline hcl
promethazine w/dm
acyclovir
buspirone hcl
folic acid
levothyroxine sodium
butalbital compound
propafenone hcl
butalbital/APAP/caffeine
fosinopril, /hctz
propoxyphene n, /apap
nystatin, /triamcinalone
propranolol hcl
furosemide
lisinopril, /hctz
albuterol
desmopressin acetate
lithium carbonate, citrate
albuterol sulfate
calcitriol
desonide
lorazepam
ofloxacin (eye drops)
aldendronate
captopril, /hctz
desoximetasone
gabapentin
ofloxacin (tabs)
carbamazepine
gemfibrozil
omeprazole
quinapril
alprazolam
carbidopa/levodopa
diclofenac sodium
gentamicin sulfate
lovastatin
ondansetron hcl, -odt
amantadine hcl
carisoprodol, compound
dicyclomine hcl
glimepiride
amiloride hcl w/hctz
cartia xt
glipizide, er, xl
amitriptyline hcl
carvedilol
diflunisal
glyburide
glyburide-metformin
amlodipine
cefaclor
orphenadrine citrate
rifampin
amox tr/pot. clavulanate
cefadroxil
guaifenesin w/codeine
oxaprozin
risperidone
amoxicillin
cefdinir
diltiazem
oxybutynin cl, er
amphetamine salt combo
cefuroxime
medroxyprogesterone
oxycodone apap
haloperidol
dipyridamole
megestrol acetate
oxycodone hcl
doxazosin mesylate
oxycodone, /apap
salsalate
cephalexin
doxepin hcl
meperidine hcl
selenium sulfide
chlordiazepoxide hcl
doxycycline hyclate
mercaptopurine
cimetidine
metformin, er
paroxetine hcl
sertraline
atenolol, /chlorthalidone
hydralazine hcl
methimazole
silver sulfadiazine
hydrochlorothiazide
ciprofloxacin hcl, -er
methocarbamol
hydrocodone bit-ibuprofen
ciprofloxacin hcl (ophth
econazole nitrate
methotrexate
simvastatin
hydrocortisone
methyldopa
penicillin v potassium
hydromorphone hcl
citalopram hbr
methylin, er
hydroxyzine hcl, pamoate
clarithromycin, er
enalapril maleate, /hctz
methylphenidate
pentoxifylline
sod.sulfacetamide/sulfur tf
methylprednisolone
phenazopyridine hcl
clindamycin phosphate
ibuprofen
metoclopramide hcl
phenytoin sodium,
azathioprine
clobetasol propionate
erythromycin
imipramine hcl
metoprolol. /hctz
extended
spironolactone
azithromycin
clonazepam
erythromycin base
indapamide
metronidazole
piroxicam
clonidine hcl
erythromycin ESS
indomethacin
minocycline hcl
sucralfate
estradiol, tds
polymyxin b
ipratropium bromide
mirtazapine
sul/trimethoprim
sulfacetamide sodium
estropipate
etodolac
misoprostol
sulfamethoxazole/trimeth
Avera Health Plans 1 (888) 322-2115 ALL CAPS = BRAND DRUG lower case = generic drug QLL = Quantity Level Limits HSV-FORM-028 (4/09) sulfasalazine
triazolam
terazosin hcL
tobramycin sulfate
warfarin sodium
terbinafine hcl
trimethobenzamide hcl
zolpidem tartrate
terconazole
tetracycline hcl
torsemide
verapamil hcl
theophylline, -er
tramadol, /apap
tamoxifen citrate
thioridazine hcl
trazodone hcl
tretinoin
timolol maleate
triamcinolone acetonide
temazepam
tizanidine hcl
triamterene w/hctz
zaleplon
NON-FORMULARY DRUG
SUGGESTED ALTERNATIVE
NON-FORMULARY DRUG
SUGGESTED ALTERNATIVE
NON-FORMULARY DRUG
SUGGESTED ALTERNATIVE
omeprazole
venlafaxine
enalapril, lisinopril, benazepril
omeprazole
oxybutynin /er, Vesicare
fluticasone propionate
prednisolone
estradiol, CLIMARA, VIVELLE
oxybutynin /er, Vesicare
fexofenadine
estradiol, CLIMARA, VIVELLE
paroxetine
ciprofloxacin, ofloxacin, LEVAQUIN
pravastatin, simvastatin, lovastatin,
enalapril, lisinopril, benazepril
famciclovir
zolpidem tartrate
zolpidem tartrate
tretinoin
omeprazole
sumatriptan, ZOMIG
fluticasone propionate
omeprazole
flurometholone
omeprazole
amphetamine combo, methylphenidate
fluoxetine, paroxetine
ciprofloxacin, ofloxacin, LEVAQUIN
alendronate
oxycodone hcl
tretinoin
sumatriptan, ZOMIG
flumadine
finasteride, FLOMAX
sumatriptan, ZOMIG
sumatriptan, ZOMIG
risperidone ABILIFY,SEROQ, ZYPREXA
fluticasone propionate
zolpidem tartrate
fluticasone propionate
oxybutynin /er, Vesicare
spironolactone
betaxolol, timolol, levobunolol
levothyroxine
alendronate, ACTONEL
oxycodone hcl
ondansetron
ciprofloxacin, ofloxacin, LEVAQUIN
nicardipine, amlodipine
generics
diltiazem xr, amlodipine
simvastatin, lovastatin, pravastatin
simvastatin, lovastatin, pravastatin
amox tr/calv, cefdinir, Augmentin XR
lovastatin, LESCOL, ZOCOR, VYTORIN
zolpidem tartrate
fluticasone propionate
enalapril, lisinopril, benazepril
ciprofloxacin
sumatriptan, ZOMIG
methylphenidate
albuterol
carvedilol
alendronate, ACTONEL, DIDRONEL
fexofenadine
verapamil
alendronate,ACTONEL, DIDRONEL
azithromycin
simvastatin
oxycodone hcl
ondansetron
fluticasone propionate, NASONEX
sertraline
gabapentin
Avera Health Plans 1 (888) 322-2115 ALL CAPS = BRAND DRUG lower case = generic drug QLL = Quantity Level Limits HSV-FORM-028 (04/09)

Source: https://myhealth.sdbor.edu/studenthealth/documents/AHPDrugFormulary_v1.0_20090701.pdf