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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.

Generic drugs appear in lowercase, brand-name drugs appear in UPPERCASE. OTC drugs appear with initial capitals, i.e. Prilosec OTC.

Jump to:
Anti-infectives
Cardiovascular agents
Central nervous system agents
Dermatologic agents
Endocrine/metabolic agents
Gastrointestinal agents
Ophthalmic agents
Respiratory agents

Key
QL = Quantity limit applies (see notes)
PA = Prior authorization required, form is available in the Drug PA forms section

Therapeutic class drug name Therapeutic class drug name
Anti-infectives
Antifungals griseofulvin
ketoconazole
terbinafine (PA)
Antivirals Step 1:
acyclovir
famciclovir
Step 2:
VALTREX (requires use of famciclovir)
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
ACE inhibitors/ARBS Step therapy requires step 1 drug before step 2 drug  
1st line:
captopril and captopril/HCTZ
enalapril and enalapril/HCTZ
lisinopril and lisinopril /HCTZ
2nd line:
COZAAR/HYZAAR
DIOVAN/DIOVAN HCT
AVAPRO/AVALIDE
Beta blockers atenolol
metoprolol/metoprolol ER
propranolol
Calcium channel blockers amlodipine/ amlodipine-benazepril
diltiazem
felodipine
nifedipine ER
verapamil
Cholesterol-lowering (statins) Step therapy requires two step-1 drugs before step 2 drug
Step 1:

lovastatin
pravastatin
simvastatin
Step 2 (available by PA; 1st line if >40% reduction in LDL required):
CRESTOR
VYTORIN
Diuretics furosemide
hydrochlorothiazide
triamterene/HCTZ
   
Central nervous system agents
Antidepressants (SSRI/SNRI) Step therapy requires step 1 drug before step 2 drug
Step 1:
citalopram
fluoxetine
paroxetine
sertraline
Step 2:
EFFEXOR XR
CYMBALTA
LEXAPRO
Antidepressants, misc. bupropion
mirtazapine
venlafaxine
ADD/ADHD amphetamine salts
methylphenidate
ADDERALL XR
CONCERTA
Migraine IMITREX (QL)
MAXALT/MAXALT MLT (QL)
(Step therapy requires IMITREX before MAXALT/MAXALT MLT)
NSAIDS diclofenac
ibuprofen
meloxicam
nabumetone
naproxen
CELEBREX (PA)
Sedative hypnotics temazepam

Step therapy requires 1st line drug before 2nd line drug
Step 1:
zolpidem
Step 2:
AMBIEN CR
LUNESTA
SONATA
Dermatologic agents
Acne benzoyl peroxide
clindamycin
tretinoin
DIFFERIN
Misc. topicals DOVONEX
ELIDEL
PROTOPIC
Endocrine/metabolic agents
Diabetic (oral)
glipizide
glyburide
metformin
ACTOS
AVANDIA
BYETTA (requires also using 2 oral diabetes drugs)
JANUVIA (requires concurrent use of metformin, 1500mg daily)
Diabetic (insulin) HUMULIN/HUMALOG
LANTUS
LEVEMIR
NOVOLIN/NOVOLOG
Diabetic test strips ACCU-CHEK
ONE TOUCH
Estrogens (oral) estradiol
PREMARIN
PREMPRO
Estrogens (patch) estradiol
CLIMARA
ESTRADERM
VIVELLE/VIVELLE-DOT


Gastrointestinal agents
H2 receptor antagonist
ranitidine
cimetidine
Proton pump inhibitors (PPIs) Step therapy requires steps 1 and 2 drugs before step 3 and step 3 before step 4 drug
Step 1 and 2:
pantoprazole
Prilosec OTC/omeprazole
Step 3:
ACIPHEX
Step 4:
PREVACID SOLUTAB
Misc. GI/GU
oxybutynin/oxybutynin ER
ENABLEX
VESICARE
PEG 3350 (generic MIRALAX)
AMITIZA (PA)
ondansetron (QL: 20 tabs per 30 days)
granisetron (QL: 20 tabs per 30 days)
 
Ophthalmic agents
Allergy cromolyn
Step therapy requires step 1 drug before step 2 drug
Step 1:
Zaditor OTC
Step 2:
PATANOL
OPTIVAR
Glaucoma timolol/timolol XE
AZOPT
BETIMOL
TRUSOPT
XALATAN
Miscellaneous ciprofloxacin
ofloxacin
tobramycin
 
Respiratory agents
Antihistimines cetirizine
fexofenadine
loratadine
Steroids (inhaled) FLOVENT
PULMICORT
QVAR
Steroids (nasal) Step 1:
fluticasone
flunisolide
ASTELIN
TILADE
Step 2 (requires a trial of fluticasone or flunisolide):
NASACORT
Miscellaneous ADVAIR
SEREVENT


List updated 06/08
Last modified 06/26/08