Preferred drug quick reference list
These drugs are generally approved for all PriorityHMOSM, PriorityEPOSM, PriorityPOSSM, PriorityPPOSM plans when the employer has purchased the prescription drug benefit. Listing on this chart does not guarantee coverage.
Download and print a copy of the Preferred Drug Quick Reference Guide (144KB PDF)
Key
- ALL CAPS = brand name drugs
- lower case = generic drugs
- Initial caps = OTC drugs (Prilosec OTC, for example)
- QL = Quantity limit applies (see notes)
- PA = Prior authorization is required; form is available in the Drug PA forms section
| Anti-infectives |
|---|
| Therapeutic class |
Drug name |
Therapeutic class |
Drug name |
| Antifungals: |
griseofulvin
ketoconazole
terbinafine
|
Antivirals: |
acyclovir
famciclovir
valacyclovir
TAMILFLU (QL) |
| Cephalosporins: |
cefdinir
cefprozil
cefuroxime
cephradine |
Erythromycins/macrolides: |
azithromycin
clarithromycin
clindamycin
erythromycin |
| Fluoroquinolones: |
ciprofloxacin
ofloxacin
AVELOX
LEVAQUIN |
Penicillins: |
amoxicillin
amoxicillin/clavulannate
ampicillin
dicloxacillin
penicillin VK |
Tetracyclines:
|
doxycycline
minocycline
tetracycline
|
|
|
|
| Cardiovascular agents |
|---|
| Therapeutic class |
Drug name |
Therapeutic class |
Drug name |
| ACE inhibitors/ARBS: |
Step 1:
captopril and captopril/HCTZ
enalapril and enalapril/HCTZ
lisinopril and lisinopril /HCTZ
ramipril
losartan and losartan/HCTZ
Step 2:
DIOVAN/DIOVAN HCT
BENICAR/BENICAR HCT
AVAPRO/AVALIDE
Step therapy requires step 1 drug before step 2 drug
|
Beta blockers: |
atenolol
metoprolol/metoprolol ER
propranolol |
| Calcium channel blockers: |
amlodipine/ amlodipine-benazepril
diltiazem
felodipine
nifedipine ER
verapamil |
Cholesterol-lowering (statins): |
lovastatin
pravastatin
CRESTOR |
| Diuretics: |
furosemide
hydrochlorothiazide
triamterene/HCTZ |
|
|
|
| Central nervous system agents |
|---|
| Therapeutic class |
Drug name |
Therapeutic class |
Drug name |
| Antidepressants (SSRI/SNRI): |
Step 1:
citalopram
fluoxetine
paroxetine
sertraline
venlafaxine/venlafaxine ER
Step 2:
CYMBALTA
LEXAPRO
Step therapy requires step 1 drug before step 2 drug |
Antidepressants, misc.: |
bupropion
mirtazapine
venlafaxine |
| ADD/ADHD: |
amphetamine salts
methylphenidate
ADDERALL XR
CONCERTA |
Migraine: |
Step 1:
sumatripan (QL)
Step 2:
MAXALT/MAXALT MLT (QL)
ZOMIG (QL)
Step Therapy requires sumatripan before MAXALT/MAXALT MLT or ZOMIG |
| NSAIDS: |
diclofenac
ibuprofen
meloxicam
nabumetone
naproxen
CELEBREX (PA) |
Sedative hypnotics: |
temazepam
Step 1:
zolpidem
zaleplon
Step 2:
LUNESTA
ROZEREM
Step therapy requires step 1 drug before step 2 drug |
|
| Dermatologic agents |
|---|
| Therapeutic class |
Drug name |
Therapeutic class |
Drug name |
| Acne: |
adapalene
benzoyl peroxide
clindamycin
tretinoin
DIFFERIN |
Misc. topicals: |
calcipotriene
ELIDEL
PROTOPIC |
|
| Endocrine/metabolic agents |
|---|
| Therapeutic class |
Drug name |
Therapeutic class |
Drug name |
Diabetic (oral):
|
glipizide
glyburide
metformin
ACTOS
AVANDIA
BYETTA (requires concurrent use of metformin)
JANUVIA (requires concurrent use of metformin)
ONGLYZA (requires concurrent use of metformin)
VICTOZA (requires concurrent use of metformin) |
Diabetic (insulin): |
HUMULIN/HUMALOG
LANTUS
LEVEMIR
NOVOLIN/NOVOLOG |
| Diabetic test strips: |
ACCU-CHEK (tier 1 copay)
ONE TOUCH (tier 1 copay)
|
Estrogens (oral): |
estradiol
PREMARIN
PREMPRO |
| Estrogens (patch): |
estradiol
CLIMARA
ESTRADERM
VIVELLE/VIVELLE-DOT |
|
|
|
| Gastrointestinal agents |
|---|
| Therapeutic class |
Drug name |
Therapeutic class |
Drug name |
H2 receptor antagonist:
|
ranitidine
cimetidine
famotidine
|
Proton pump inhibitors (PPIs): |
Step 1:
pantoprazole
Prilosec OTC/
omeprazole
Prevacid OTC/
lansoprazole
Zegerid OTC/
omeprazole-sod
bicarbonate |
Misc. GI/GU:
|
oxybutynin/oxybutynin ER
ENABLEX
VESICARE
ondansetron
granisetron |
|
|
|
| Ophthalmic agents |
|---|
| Therapeutic class |
Drug name |
Therapeutic class |
Drug name |
| Allergy: |
cromolyn
Step 1:
Zaditor OTC
Step 2:
PATANOL
OPTIVAR
Step therapy requires step 1 drug before step 2 drug
|
Glaucoma: |
dorzolamide
timolol/timolol XE
AZOPT
XALATAN
|
| Miscellaneous: |
ciprofloxacin
ofloxacin
tobramycin
VIGAMOX
ZYMAR
|
|
|
|
| Respiratory agents |
|---|
| Therapeutic class |
Drug name |
Therapeutic class |
Drug name |
|
|
Steroids (inhaled): |
PULMICORT (tier 1 copay)
QVAR (tier 1 copay)
FLOVENT
|
| Steroids (nasal): |
Step 1:
fluticasone
flunisolide
Step 2:
NASACORT
RHINOCORT
azelastine
TILADE
Step 2 drug requires a trial of fluticasone or flunisolide
|
Miscellaneous: |
ADVAIR
SEREVENT
SYMBICORT (tier 1 copay)
|
