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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.

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

Key
UPPERCASE names = brand name drugs
lower case names = generic drugs
Initial capitals = 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: 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
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 
Step 2:
COZAAR/HYZAAR
DIOVAN/DIOVAN 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
simvastatin
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
Step 2:
EFFEXOR XR
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: sumatripan (QL)
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:
AMBIEN CR
LUNESTA

Step therapy requires step 1 drug before step 2 drug
Dermatologic agents
Therapeutic class Drug name Therapeutic class Drug name
Acne: benzoyl peroxide
clindamycin
tretinoin
DIFFERIN
Misc. topicals: DOVONEX
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)
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
Step 2:
ACIPHEX

Step therapy requires all three step 1 drugs before step 2 drug
Misc. GI/GU:
oxybutynin/oxybutynin ER
ENABLEX
VESICARE
ondansetron
granisetron (QL: 20 tabs per 30 days)


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
Antihistimines: cetirizine
fexofenadine
loratadine
Steroids (inhaled): PULMICORT (tier 1 copay)
QVAR (tier 1 copay)
FLOVENT (tier 2 copay)
Steroids (nasal): Step 1:
fluticasone
flunisolide
ASTELIN
TILADE
Step 2:
NASACORT
RHINOCORT

Step 2 drug requires a trial of fluticasone or flunisolide
Miscellaneous: ADVAIR
SEREVENT
SYMBICORT


List updated 12/09
Last modified 02/24/10