LifeWise - Pharmacy Services - Preferred Drug List

Alphabetical Listing

Key to Symbols

*	=	Generic forms of this drug are covered at Tier 1 copay. Brand equivalents are Tier 3. Please ask your doctor or practitioner and pharmacist to prescribe/dispense the generic form.
	=	Point of Sale Intervention Program drug; may require prior authorization
	=	This drug is not in the POS Program; however, it may require prior approval in some cases. For approval, call Customer or Member Services.

Go to list: click on the first letter of a drug name:
To find the name of a particular drug, use the letter directory given below. Simply click on the letter that begins the word you are looking for and you will be taken to that letter section of the glossary. Click on "A," for example, and you will be taken to all terms beginning with the letter "A."

A B C D E F G H I K L M N O P Q R S T U V W X Z

A
Generic brand names are listed in lowercase.
Preferred brand name drugs are listed with a capital.

abacavir 2

abacavir/zidovudine/lamivudine 2

ACCOLATE 2

ACCUPRIL 2

ACCUTANE (Oral) 2

* acetaminophen/butalbital 1 *

* acetaminophen/butalbital/caffeine 1 *

* acetaminophen/butalbital/caffeine/codeine 1 *

* acetaminophen/codeine (Liquid is Tier 2) 1 *

* acetaminophen/hydrocodone (Liquid is Tier 2) 1 *

* acetaminophen/oxycodone 1 *

* acetazolamide (500mg Sequels are Tier 2) 1 *

* acetic acid 1 *

* acetic acid/aluminum acetate otic (Generic equivalent of Domeboro Otic) 1 *

* acetic acid/hydrocortisone liquid 1 *

* acetic acid/oxyquin/ricin/glycerin 1 *

* acetylcysteine 1 *

acitretin 2

ACTIMMUNE 2

ACTINEX 2

ACTONEL 2

ACTOS 2

* acyclovir 1 *

acyclovir ointment 2

ADDERALL (Including XR) 2

AEROBID, AEROBID-M 2

AGENERASE 2

* albuterol metered dose inhaler 1 *

* albuterol nebulized 1 *

* albuterol tablet & oral liquid 1 *

alendronate 2

ALESSE 2

ALFERON-N 2

alglucerase 2

ALKERAN 2

ALLEGRA 2

* allopurinol 1 *

ALOMIDE 2

ALORA 2

ALPHAGAN 2

* alprazolam 1 *

ALTACE 2

altretamine 2

aluminum chloride 2

* amantadine 1 *

AMERGE (Max 23 mg/30 days) 2

AMICAR 2

* amiloride 1 *

* amiloride/hctz 1 *

aminocaproic acid 2

aminoglutethimide 2

* aminophylline 1 *

* amiodarone 1 *

* amitriptyline 1 *

* ammonium lactate 1 *

* amoxapine 1 *

* amoxicillin 1 *

amoxicillin/clavulanic acid 2

amphetamine/dextroamphetamine (Including XR) 2

* ampicillin 1 *

amprenavir 2

ANA-KIT 2

anastrozole 2

ANCOBON 2

ANDRODERM 2

anthralin 2

apraclonidine 2

ARICEPT 2

ARIMIDEX 2

ARISTOCORT 2

artificial tear insert 2

ASACOL 2

* aspirin/butalbital/caffeine 1 *

* aspirin/butalbital/caffeine/codeine 1 *

* aspirin/codeine 1 *

* aspirin/oxycodone 1 *

* atenolol 1 *

* atenolol/chlorthalidone 1 *

atorvastatin 2

atovaquone 2

* atropine ophthalmic 1 *

ATROVENT 2

AUGMENTIN 2

auranofin 2

aurothioglucose 2

AVANDIA 2

AVC 2

AVONEX 2

AYGESTIN 2

* azathioprine 1 *

* azathioprine 2 *

* azelaic acid 1 *

azithromycin 2

AZMACORT 2

AZOPT 2

AZULFIDINE EN-TABS 2

B
Generic brand names are listed in lowercase.
* bacitracin ophthalmic 1 *

* baclofen 1 *

BACTROBAN 2

beclomethasone nasal (Including AQ) 2

beclomethasone oral inhaler 2

BECLOVENT 2

BECONASE (Including AQ) 2

* belladonna /phenobarbital 1 *

benazepril 2

benazepril/amlodipine 2

benazepril/hctz
2

BENZAMYCIN 2

* benzocaine/antipyrine liquid 1 *

benzoyl peroxide/erythromycin 2

* benztropine 1 *

* betamethasone dipropionate 1 *

betamethasone dipropionate augmented 2

* betamethasone valerate 1 *

BETASERON 2

betaxolol ophthalmic 2

* bethanechol 1 *

BETOPTIC, BETOPTIC-S 2

BIAXIN (Including XL) 2

bicalutamide 2

BILTRICIDE 2

bimatoprost 2

* bisoprolol/hctz 1 *

BRETHINE 2

BRICANYL 2

brimonidine 2

brinzolamide 2

* bromocriptine 1 *

budesonide inhalation suspension 2

budesonide nasal (Including AQ) 2

budesonide oral inhaler 2

* bumetanide 1 *

* bupropion 1 *

bupropion 2

bupropion sr 2

busulfan 2

butorphanol (Max 3 cannisters/30 days) 2

C
Generic brand names are listed in lowercase.
cabergoline 2

calcipotriene 2

* calcitonin injection 1 *

calcitonin nasal 2

calcitriol 2

capecitabine 2

CAPITROL 2

* captopril 1 *

* captopril/hctz 1 *

* carbachol ophthalmic 1 *

carbamazepine (Including XR) 2

* carisoprodol 1 *

CARMOL 40 2

CARNITOR 2

carvedilol 2

CASODEX 2

CEENU 2

cefdinir suspension 2

cefixime suspension 2

cefprozil suspension 2

CEFTIN 2

cefuroxime 2

CEFZIL SUSPENSION 2

CELEBREX (Reserve for pts at high-risk of NSAID gastropathy - step therapy to be implemented in 2002) 2

celecoxib (Reserve for pts at high-risk of NSAID gastropathy - step therapy to be implemented in 2002) 2

CELEXA 2

CELLCEPT 2

* cephalexin 1 *

CEREDASE 2

CERUMENEX 2

cetirizine 2

CHEMET 2

CHIBROXIN 2

* chloral hydrate 1 *

chlorambucil 2

* chloramphenicol 1 *

* chlorhexidine 1 *

* chloroquine 1 *

* chlorothiazide 1 *

chloroxine 2

* chlorpheniramine/phenyltolox/pe/pp 1 *

* chlorpromazine 1 *

* chlorthalidone 1 *

* cholestyramine 1 *

* cholestyramine light 1 *

* choline/mag salicylates 1 *

ciclopirox 2

CILOXIN 2

* cimetidine 1 *

CIPRO 2

ciprofloxacin 2

ciprofloxacin ophthalmic 2

cisapride (Limited access program by mfr; see http://us.janssen.com for details) 2

citalopram 2

citric acid/gluconic acid 2

clarithromycin (Including XL) 2

CLEOCIN 2

* clidinium/chlordiazepoxide 1 *

CLIMARA 2

* clindamycin (150mg) 1 *

* clindamycin topical 1 *

clindamycin vaginal gel 2

clofazimine 2

* clomipramine 1 *

* clonazepam 1 *

* clonidine 1 *

* clonidine/chlorthalidone 1 *

clopidogrel 2

clotrimazole 2

clotrimazole vaginal suppository 1

* clozapine 1 *

* codeine 1 *

* colchicine 1 *

COLESTID 2

colestipol 2

COMBIVENT 2

COMBIVIR 2

COMTAN 2

CONDYLOX 2

conjugated estrogens (Includes vaginal cream) 2

conjugated estrogens/medroxyprogesterone 2

COPAXONE 2

COREG 2

CORTENEMA 2

CORTIFOAM 2

COSOPT 2

COUMADIN 2

COVERA HS 2

CRIXIVAN 2

* cromolyn inhaled (All forms are covered) 1 *

crotamiton 2

CUPRIMINE 2

cyanocobalamin nasal 2

* cyclobenzaprine 1 *

* cyclopentolate 1 *

cyclophosphamide 2

cycloserine 2

cyclosporine 2

* cyclosporine microemulsion 1 *

CYLERT 2

* cyproheptadine 1 *

CYTADREN 2

CYTOMEL 2

CYTOTEC 2

CYTOVENE 2

CYTOXAN 2

D
Generic brand names are listed in lowercase.
dalteparin 2

* danazol 1 *

DANTRIUM 2

dantrolene 2

DAPSONE 2

DARANIDE 2

DARAPRIM 2

DDAVP TABLET 2

delavirdine 2

demecarium 2

DEMSER 2

DEMULEN 2

DENAVIR 2

DEPAKENE 2

DEPAKOTE 2

* desipramine 1 *

* desmopressin nasal 1 *

desmopressin tablet 2

DESOGEN 2

* desonide 1 *

* desoximetasone 1 *

DETROL 2

* dexamethasone 1 *

* dexamethasone ophthalmic (Maxidex is Tier 2) 1 *

* dextroamphetamine (Spansule is Tier 2) 1 *

* diabetic blood testing strips � *

* diabetic urine testing products � *

DIASTAT 2

* diazepam 1 *

diazepam rectal 2

DIBENZYLINE 2

dichlorphenamide 2

* diclofenac 1 *

* diclofenac ophthalmic 1 *

* dicloxacillin (Liquid is Tier 2) 1 *

* dicyclomine 1 *

didanosine 2

DIDRONEL 2

dienestrol vaginal cream 2

DIFLUCAN 2

DIFLUCAN VC 2

* diflunisal 1 *

digoxin (0.5mg not covered) 2

dihydroergotamine (Max 8 amps/30 days) 2

DILANTIN 2

* diltiazem (XT and CD are Tier 2) 1 *

diltiazem cr 2

DIOVAN 2

DIOVAN HCT 2

* diphenoxylate/atropine 1 *

* dipivefrin ophthalmic 1 *

DIPROLENE 2

DIPROLENE AF 2

* dipyridamole 1 *

* disopyramide (Including CR) 1 *

* disulfiram 1 *

divalproex 2

donepezil 2

DOPAR 2

dornase alfa 2

dorzolamide 2

dorzolamide/timolol 2

DOSTINEX 2

DOVONEX 2

* doxazosin 1 *

* doxazosin 2 *

* doxepin 1 *

* doxycycline 1 *

DRITHOCREME 2

DRYSOL 2

DURAGESIC 2

DYCLONE 2

dyclonine 2

E
Generic brand names are listed in lowercase.
echothiophate ophthalmic 2

efaviren
2

EFFEXOR (Including XR) 2

EFUDEX 2

ELMIRON 2

ELOCON 2

EMCYT 2

* enalapril 1 *

enoxaparin 2

entacapone 2

EPI-PEN 2

epinephrine allergy kit 2

* epinephrine ophthalmic 1 *

epinephrine syringe 2

epinephryl borate 2

EPIVIR 2

EPPY-N 2

ERGAMISOL 2

* ergocalciferol 1 *

* ergoloid mesylates 1 *

ERGOMAR 2

ergotamine 2

* ergotamine/caff/belladonna/phenobarbital 1 *

* ergotamine/caffeine 1 *

* erythromycin (All generic forms) 1 *

* erythromycin ophthalmic 1 *

* erythromycin topical 1 *

* erythromycin/sulfisoxazole 1 *

erythropoietin (Epogen is non-preferred) 2

ESERINE 2

* esterified estrogen 2

esterified estrogens/methyltestosterone 2

ESTRADERM 2

* estradiol micronized (Includes vaginal cream) 1 *

* estradiol transdermal patch 1 *

estradiol vaginal ring 2

estradiol/ethynodiol 2

estradiol/norethindrone 2

estramustine 2

ESTRATEST 2

ESTRING 2

* estropipate 1 *

ethambutol 2

ethinyl estradiol/desogestrel 2

ethinyl estradiol/levonorgestrel 1

* ethinyl estradiol/levonorgestrel 7/7/7 (Triphasil is Tier 2) 1 *

* ethinyl estradiol/norethindrone (Ortho Novum is Tier 2) 1 *

ethinyl estradiol/norethindrone 2

* ethinyl estradiol/norethindrone 10/11 1 *

ethinyl estradiol/norgestimate 2

ethinyl estradiol/norgestrel 1

ETHMOZINE 2

* ethosuximide 1 *

etidronate 2

* etodolac 1 *

etoposide 2

EULEXIN 2

EURAX 2

EVISTA 2

EXELDERM 2

EXELON 2

F
Generic brand names are listed in lowercase.
famciclovir 2

* famotidine 1 *

FAMVIR 2

FANSIDAR 2

FARESTON 2

felbamate 2

FELBATOL 2

FEMARA 2

FEMHRT 2

fenofibrate 2

fentanyl transdermal 2

fexofenadine 2

filgrastim 2

finasteride 2

flecainide 2

FLOMAX 2

FLONASE 2

FLORINEF 2

FLOVENT 2

FLOXIN 2

FLOXIN OTIC 2

fluconazole 2

fluconazole 150mg oral single-dose 2

flucytosine 2

FLUDARA 2

fludarabine 2

fludrocortisone 2

flunisolide oral inhaler 2

* fluocinolone 1 *

* fluocinonide 1 *

* fluoride 1 *

* fluorometholone ophthalmic (FML is Tier 2) 1 *

FLUOROPLEX 2

fluorouracil 2

* fluoxetine 2 *

* fluoxymesterone 1 *

* fluphenazine 1 *

* flurbiprofen 1 *

flutamide 2

fluticasone nasal 2

fluticasone oral inhaler and diskhaler 2

fluvastatin 2

* folic acid 1mg 1 *

FORADIL 2

formoterol 2

FORTOVASE 2

FOSAMAX 2

fosinopril 2

fosinopril/hctz
2

FRAGMIN 2

FURADANTIN 2

furazolidone 2

* furosemide 1 *

FUROXONE 2

G
Generic brand names are listed in lowercase.
gabapentin 2

GABITRIL 2

ganciclovir 2

GANTANOL 2

gatifloxacin 2

* gemfibrozil 1 *

* generic oral contraceptives (All) 1 *

* gentamicin 1 *

* gentamicin ophthalmic 1 *

GEODON 2

glatiramer 2

* glipizide (Including XL) 1 *

* glucagon 1 *

GLUCOPHAGE (XR is Tier 3) 2

GLUCOVANCE 2

* glyburide 1 *

glycerin 2

gold sodium thiomalate 1

granisetron 2

GRANULEX 2

* griseofulvin microsize 1 *

* griseofulvin ultramicrosize 1 *

* guaifenesin/codeine liquid 1 *

* guaifenesin/hydrocodone liquid 1 *

* guanaben 1 *

* guanfacine 1 *

H
Generic brand names are listed in lowercase.
* haloperidol 1 *

* heparin 1 *

HERPLEX 2

HEXALEN 2

HIVID 2

HMS 2

* homatropine ophthalmic 1 *

HUMALOG 2

HUMORSOL 2

HUMULIN 2

* hydralazine 1 *

HYDREA 2

* hydrochlorothiazide 1 *

* hydrocortisone (2.5% only) 1 *

* hydrocortisone anorectal cream 1 *

hydrocortisone enema 2

hydrocortisone foam 2

* hydrocortisone tablet 1 *

* hydrocortisone/pramoxine 1 *

* hydromorphone 1 *

* hydroxychloroquine 1 *

* hydroxyprogesterone 1 *

hydroxyurea 2

* hydroxyzine 1 *

* hyoscyamine 1 *

I
Generic brand names are listed in lowercase.
* ibuprofen 1 *

idoxuridine 2

* imipramine 1 *

IMITREX (Max 1200 mg/30 days: 4 inj kits, 12 nasal sprays, or 24 (50mg) tablets) 2

* indapamide 1 *

indinavir 2

* indomethacin 1 *

insulin aspart 2

insulin glargine 2

insulin lispro 2

* insulin syringes and needles � *

insulin, human 2

interferon alfa-2b 2

interferon alfa-2b/ribavirin 2

interferon alfa-n3 2

interferon beta-1a 2

interferon beta-1b 2

interferon gamma-1b 2

INTRON-A 2

* iodoquinol 1 *

IOPIDINE 2

ipratropium metered dose inhaler 2

ipratropium/albuterol metered dose inhaler 2

* isometheptene/dichloralphenazone/apap 1 *

* isoniazid 1 *

* isosorbide dinitrate 1 *

* isosorbide mononitrate 1 *

* isosorbide mononitrate sr 1 *

isotretinoin (Oral) 2

* isoxsuprine 1 *

ivermectin 2

K
Generic brand names are listed in lowercase.
KALETRA 2

KEPPRA 2

KERALYT 2

KYTRIL 2

L
Generic brand names are listed in lowercase.
* labetalol 1 *

LACRISERT 2

* lactulose liquid 1 *

LAMICTAL 2

LAMISIL 2

lamivudine 2

lamivudine/zidovudine 2

lamotrigine 2

LAMPRENE 2

* lancets � *

LANOXIN (0.5mg not covered) 2

LANTUS 2

LARIAM 2

latanoprost 2

LESCOL 2

letrozole 2

* leucovorin 1 *

LEUKERAN 2

LEUKINE 2

leuprolide 2

levamisole 2

levetiracetam 2

* levobunolol liquid 1 *

levocabastine 2

levocarnitine 2

levodopa 2

* levodopa/carbidopa (Including CR) 1 *

LEVOTHROID 2

levothyroxine 2

LEVOXYL 2

* lidocaine 1 *

* lindane 1 *

liothyronine 2

liotrix 2

* lipase/amylase/protease 1 *

LIPITOR 2

lisinopril 2

lisinopril/hctz
2

* lithium carbonate (Eskalith CR is Tier 2) 1 *

* lithium citrate 1 *

LIVOSTIN 2

lodoxamide 2

LOESTRIN, LOESTRIN FE 2

lomustine 2

LOOVRAL 1

lopinavir/ritonavir 2

LOPROX 2

* lorazepam 1 *

LOTENSIN 2

LOTENSIN HCT 2

LOTREL 2

* lovastatin 1 *

LOVENOX 2

* loxapine 1 *

LUMIGAN 2

LUPRON 2

LYSODREN 2

M
Generic brand names are listed in lowercase.
MACROBID 2

* maprotiline 1 *

masoprocol 2

MATULANE 2

MAVIK 2

MAXALT (Max 120 mg/30 days) 2

* mebendazole 1 *

MECLAN 2

* meclizine 1 *

meclocycline sulfosalicylate 2

* meclofenamate 1 *

* medroxyprogesterone 1 *

medrysone ophthalmic 2

mefloquine 2

* megestrol 1 *

melphalan 2

* meperidine 1 *

* mephobarbital 1 *

MEPHYTON 2

MEPRON 2

mercaptopurine 2

mesalamine (Enema, suppository) 2

mesalamine 2

MESTINON SR 2

metformin (XR is Tier 3) 2

metformin/glyburide 2

* methadone 1 *

* methazolamide 1 *

METHERGINE 2

* methimazole 1 *

* methocarbamol 1 *

* methotrexate 1 *

methoxsalen 2

* methylclothiazide 1 *

* methyldopa 1 *

methylergonovine 2

* methylphenidate (Including generic SR) 1 *

* methylprednisolone 1 *

* methyltestosterone 1 *

metipranolol 2

* metoclopramide 1 *

metolazone 2

* metoprolol 1 *

metoprolol succinate 2

METROGEL 2

METROGEL VAGINAL 2

* metronidazole (375mg is Tier 3) 1 *

metronidazole gel 2

metronidazole vaginal gel 2

metyrosine 2

* mexiletine 1 *

MIACALCIN 2

MICARDIS 2

MICARDIS HCT 2

MICRONOR 2

midodrine 2

MIGRANAL (Max 8 amps/30 days) 2

* minoxidil 1 *

MINTEZOL 2

MIRAPEX 2

misoprostol 2

mitotane 2

MOBAN 2

moexipril 2

moexipril/hctz
2

molindone 2

mometasone 2

MONOPRIL 2

MONOPRIL HCT 2

montelukast 2

moricizine 2

morphine (Suppository) 2

* morphine sulfate 1 *

* morphine sulfate sr 1 *

MS CONTIN 2

* multivitamin/fluoride chew or liquid 1 *

* multivitamin/fluoride/iron chew or liquid 1 *

mupirocin 2

MYAMBUTOL 2

MYCELEX 2

MYCELEX-G 1

MYCOBUTIN 2

mycophenolate 2

MYLERAN 2

MYOCHRYSINE 1

N
Generic brand names are listed in lowercase.
* nadolol 1 *

nafarelin 2

* naphazoline 1 *

* naproxen 1 *

* naproxen sodium 1 *

naratriptan (Max 23 mg/30 days) 2

NARDIL 2

NASACORT (Including AQ) 2

NASCOBAL 2

NEBUPENT 2

nedocromil (All forms are covered) 2

nefazodone 2

nelfinavir 2

* neomycin 1 *

* neomycin/bacitracin/polymyxin/hc ophthalmic 1 *

* neomycin/dexamethasone ophthalmic 1 *

* neomycin/polymyxin/bacitracin ophthalmic 1 *

* neomycin/polymyxin/dexamethasone ophthalmic 1 *

* neomycin/polymyxin/gramicidin ophthalmic 1 *

* neomycin/polymyxin/hc ophthalmic 1 *

* neomycin/polymyxin/hc otic 1 *

neomycin/polymyxin/pred ophthalmic 2

neostigmine 2

NEUMEGA 2

NEUPOGEN 2

NEURONTIN 2

nevirapine 2

niacin sr 2

NIASPAN 2

nicotine nasal spray 2

NICOTROL NS 2

* nifedipine 1 *

* nifedipine cc 1 *

NILANDRON 2

nilutamide 2

nimodipine 2

NIMOTOP 2

nitrofurantoin 2

* nitrofurantoin macro 1 *

nitrofurantoin monohydrate macro 2

* nitroglycerin oral 1 *

nitroglycerin sl 2

* nitroglycerin transdermal 1 *

NITROSTAT 2

NOLVADEX (Tamoxifen is Tier 2) 2

NOR-QD 2

norethindrone 2

norfloxacin 2

* nortriptyline 1 *

NORVIR 2

NOVOLIN 2

NOVOLOG 2

* nystatin 1 *

* nystatin vaginal 1 *

* nystatin/triamcinolone 1 *

O
Generic brand names are listed in lowercase.
octreotide 2

OCUFLOX 2

ofloxacin 2

olanzapine 2

olopatadine 2

omeprazole (PA required for > 90-day Rx) 2

OMNICEF SUSPENSION 2

ondansetron 2

oprelvekin 2

OPTIPRANOLOL 2

ORTHO NOVUM 2

ORTHO NOVUM 10/11 2

ORTHO NOVUM 7/7/7 2

ORTHO-CYCLEN 2

ORTHO-DIENESTROL 2

ORTHO-TRICYCLEN 2

OSMOGLYN 2

OVCON 2

OVRAL 1

OXSORALEN 2

* oxybutynin (XL is Tier 3) 1 *

P
Generic brand names are listed in lowercase.
* pancrelipase 1 *

pantoprazole (PA required for > 90-day Rx) 2

* paregoric 1 *

PARNATE 2

* paromomycin 1 *

paroxetine 2

PATANOL 2

PAXIL 2

PEDIAPRED 2

* peg electrolyte bowel prep 1 *

pemoline 2

penciclovir cream 2

penicillamine 2

* penicillin 1 *

* pentamidine injection 1 *

pentamidine nebulized 2

PENTASA 2

pentazocine/naloxone 2

pentosan polysulfate sodium 2

* pentoxifylline 1 *

* permethrin 1 *

* perphenazine 1 *

* phenazopyridine 1 *

phenelzine 2

pheniramine/pyrilamine/phenyltoloxamine (Liquid) 2

* phenobarbital 1 *

phenoxybenzamine 2

phentolamine mesylate 2

* phenylephrine 1 *

* phenylephrine/chlorpheniramine/hydrocodone liquid 1 *

* phenytoin 1 *

PHOSPHOLINE IODIDE 2

physostigmine 2

phytonadione 2

pilocarpine 2

* pilocarpine ophthalmic 1 *

* pilocarpine/epinephrine ophthalmic 1 *

* pindolol 1 *

pioglitazone 2

* piroxicam 1 *

PLAVIX 2

podofilox 2

POLY-PRED 2

POLYHISTINE (Liquid) 2

* potassium (All generics) 1 *

potassium citrate 2

* potassium iodide 1 *

pramipexole 2

PRAVACHOL 2

pravastatin 2

praziquantel 2

* prazosin 1 *

* prednisolone 1 *

prednisolone 2

* prednisolone ophthalmic 1 *

* prednisone 1 *

PREMARIN (Includes vaginal cream) 2

PREMPRO, PREMPHASE 2

* prenatal vitamins 1 *

PRILOSEC (PA required for > 90-day Rx) 2

* primaquine 1 *

* primidone 1 *

PRINIVIL 2

PRINZIDE 2

PRO-AMITINE 2

* probenecid 1 *

procainamide (All generics are Tier 1) 2

PROCANBID (All generics are Tier 1) 2

procarbazine 2

* prochlorperazine 1 *

PROCRIT (Epogen is non-preferred) 2

PROFENAL 2

* progesterone injection 1 *

progesterone micronized 2

PROGRAF 2

* promethazine 1 *

* promethazine/codeine syrup 1 *

* promethazine/dextromethorphan liquid 1 *

* promethazine/pe/codeine syrup 1 *

PROMETRIUM 2

* propafenone (300mg is Tier 2) 1 *

* propantheline 1 *

* propoxyphene (All generic combinations are Tier 1) 1 *

* propranolol (Including LA) 1 *

* propranolol/hctz 1 *

PROPULSID (Limited access program by mfr; see http://us.janssen.com for details) 2

* propylthiouracil 1 *

PROSCAR 2

PROSTIGMIN 2

PROTONIX (PA required for > 90-day Rx) 2

* protriptyline 1 *

* pseudoephedrine/chlorpheniramine 1 *

* pseudoephedrine/guaifenesin la 1 *

PULMICORT 2

PULMICORT RESPULES 2

PULMOZYME 2

PURINETHOL 2

* pyrazinamide 1 *

* pyridostigmine 1 *

pyridostigmine sr 2

pyrimethamine 2

pyrimethamine/sulfadoxine 2

Q
Generic brand names are listed in lowercase.
quetiapine 2

quinapril 2

* quinidine (Brand-only forms are Tier 2) 1 *

* quinine 1 *

R
Generic brand names are listed in lowercase.
raloxifene 2

ramipril 2

* ranitidine 1 *

REBETRON 2

REGITINE 2

RENACIDIN 2

REQUIP 2

RESCRIPTOR 2

* reserpine 1 *

RETROVIR 2

RHINOCORT (Including AQ) 2

RIDAURA 2

rifabutin 2

* rifampin 1 *

RILUTEK 2

riluzole 2

risedronate 2

RISPERDAL (Liquid not covered) 2

risperidone (Liquid not covered) 2

ritonavir 2

rivastigmine 2

rizatriptan (Max 120 mg/30 days) 2

RMS (Suppository) 2

ROCALTROL 2

rofecoxib (Reserve for pts at high-risk of NSAID gastropathy - step therapy to be implemented in 2002) 2

ropinirole 2

rosiglitazone 2

ROWASA (Enema, suppository) 2

S
Generic brand names are listed in lowercase.
SALAGEN 2

salicylic acid 2

salmeterol (Including Diskus) 2

* salsalate 1 *

SANDIMMUNE 2

SANDOSTATIN 2

saquinavir 2

sargramostim 2

scopolamine 2

SEBIZON 2

secobarbital 2

SECONAL 2

* selegiline 1 *

* selenium sulfide 1 *

SEREVENT (Including Diskus) 2

SEROMYCIN 2

SEROQUEL 2

sertraline 2

SERZONE 2

* silver sulfadiazine 1 *

SINGULAIR 2

SLO-BID 2

* sodium polystyrene sulfonate liquid 1 *

SOLGANAL 2

SORIATANE 2

* sotalol 1 *

* spironolactone 1 *

* spironolactone/hct 1 *

STADOL (Max 3 cannisters/30 days) 2

stavudine 2

* streptomycin 1 *

STROMECTOL 2

succimer 2

* sucralfate 1 *

sulconazole nitrate 2

sulfacetamide 2

* sulfacetamide ophthalmic 1 *

* sulfacetamide/prednisolone ophthalmic 1 *

* sulfacetamide/sulfur 1 *

* sulfadiazine 1 *

sulfamethoxazole 2

sulfanilamide vaginal gel 2

* sulfasalazine 1 *

sulfasalazine ec 2

* sulfinpyrazone 1 *

* sulfisoxazole (Liquid is Tier 2) 1 *

* sulindac 1 *

sumatriptan (Max 1200 mg/30 days: 4 inj kits, 12 nasal sprays, or 24 (50mg) tablets) 2

SUPRAX SUSPENSION 2

suprofen 2

SUSTIVA 2

SYNAREL 2

SYNTHROID 2

T
Generic brand names are listed in lowercase.
tacrolimus 2

TALWIN NX 2

TAMBOCOR 2

tamoxifen (Tamoxifen is Tier 2) 2

tamsulosin 2

tazarotene 2

TAZORAC 2

TEGRETOL (Including XR) 2

telmisartan 2

telmisartan/hctz
2

* temazepam 1 *

TEQUIN 2

TERAZOL 7 2

* terazosin 1 *

terbinafine 2

terbutaline 2

terconazole vaginal cream 2

TESLAC 2

TESTODERM 2

testolactone 50mg 2

testosterone transdermal 2

* tetracycline 1 *

thalidomide 2

THALOMID 2

THEO-DUR 2

* theophylline 1 *

theophylline sr 2

thiabendazole 2

THIOGUANINE 2

* thiothixene 1 *

THYROID 2

THYROLAR 2

tiagabine 2

TIAZAC 2

TICLID 2

ticlopidine 2

TILADE (All forms are covered) 2

* timolol 1 *

* timolol ophthalmic 1 *

TOBI 2

TOBRADEX 2

tobramycin nebulized 2

* tobramycin ophthalmic 1 *

tobramycin/dexamethasone ophthalmic 2

* tolazamide 1 *

* tolmetin 1 *

tolterodine 2

TOPAMAX 2

topiramate 2

TOPROL XL 2

toremifene 2

trandolapril 2

TRANSDERM-SCOP 2

tranylcypromine 2

TRAVATAN 2

travoprost 2

* trazodone 1 *

tretinoin 2

tretinoin (Microsphere is Tier 2; authorization required for patients older than 39 years; no initial 30-day
* triamcinolone 1 *

* triamcinolone in orabase 1 *

triamcinolone nasal (Including AQ) 2

triamcinolone oral 2

triamcinolone oral inhaler 2

* triamterene/hydrochlorothiazide 1 *

* triazolam 1 *

TRICOR 2

triethanolamine 2

* trifluoperazine 1 *

trifluridine ophthalmic 2

* trihexyphenidyl 1 *

* trimethoprim/polymixin b 1 *

* trimethoprim/sulfamethoxazole 1 *

trioxsalen 2

TRIPHASIL 2

* triple sulfa vaginal cream 1 *

TRISORALEN 2

TRIZIVIR 2

* tropicamide 1 *

TRUSOPT 2

trypsin 2

U
Generic brand names are listed in lowercase.
UNIRETIC 2

UNIVASC 2

urea 40% 2

UROCIT-K 2

* ursodiol 1 *

V
Generic brand names are listed in lowercase.
valacyclovir 2

valproic acid 2

valsartan 2

valsartan/hctz
2

VALTREX 2

VANCENASE (Including AQ) 2

VANCERIL (Including DS) 2

VANCOCIN 2

vancomycin 2

venlafaxine (Including XR) 2

VEPESID 2

* verapamil (Including SR) 1 *

verapamil chronobiol la 2

VERELAN PM 2

VESANOID 2

vidarabine ophthalmic 2

VIDEX 2

VIOXX (Reserve for pts at high-risk of NSAID gastropathy - step therapy to be implemented in 2002) 2

VIRA-A 2

VIRACEPT 2

VIRAMUNE 2

VIROPTIC 2

* vitamin a 1 *

* vitamins acd/fluoride/iron chew or liquid 1 *

VIVELLE 2

W
Generic brand names are listed in lowercase.
warfarin 2

WELLBUTRIN SR 2

X
Generic brand names are listed in lowercase.
XALATAN 2

XELODA 2

Z
Generic brand names are listed in lowercase.
zafirlukast 2

zalcitabine 2

ZAROXOLYN 2

ZERIT 2

ZESTORETIC 2

ZESTRIL 2

ZIAGEN 2

zidovudine 2

ziprasidone 2

ZITHROMAX 2

ZOFRAN 2

ZOLOFT 2

ZONEGRAN 2

zonisamide 2

ZOVIRAX 2

ZYBAN 2

ZYPREXA 2

ZYRTEC 2

A Generic brand names are listed in lowercase. Preferred brand name drugs are listed with a capital.
	abacavir	2
	abacavir/zidovudine/lamivudine	2
	ACCOLATE	2
	ACCUPRIL	2
	ACCUTANE (Oral)	2
*	acetaminophen/butalbital	1	*
*	acetaminophen/butalbital/caffeine	1	*
*	acetaminophen/butalbital/caffeine/codeine	1	*
*	acetaminophen/codeine (Liquid is Tier 2)	1	*
*	acetaminophen/hydrocodone (Liquid is Tier 2)	1	*
*	acetaminophen/oxycodone	1	*
*	acetazolamide (500mg Sequels are Tier 2)	1	*
*	acetic acid	1	*
*	acetic acid/aluminum acetate otic (Generic equivalent of Domeboro Otic)	1	*
*	acetic acid/hydrocortisone liquid	1	*
*	acetic acid/oxyquin/ricin/glycerin	1	*
*	acetylcysteine	1	*
	acitretin	2
	ACTIMMUNE	2
	ACTINEX	2
	ACTONEL	2
	ACTOS	2
*	acyclovir	1	*
	acyclovir ointment	2
	ADDERALL (Including XR)	2
	AEROBID, AEROBID-M	2
	AGENERASE	2
*	albuterol metered dose inhaler	1	*
*	albuterol nebulized	1	*
*	albuterol tablet & oral liquid	1	*
	alendronate	2
	ALESSE	2
	ALFERON-N	2
	alglucerase	2
	ALKERAN	2
	ALLEGRA	2
*	allopurinol	1	*
	ALOMIDE	2
	ALORA	2
	ALPHAGAN	2
*	alprazolam	1	*
	ALTACE	2
	altretamine	2
	aluminum chloride	2
*	amantadine	1	*
	AMERGE (Max 23 mg/30 days)	2
	AMICAR	2
*	amiloride	1	*
*	amiloride/hctz	1	*
	aminocaproic acid	2
	aminoglutethimide	2
*	aminophylline	1	*
*	amiodarone	1	*
*	amitriptyline	1	*
*	ammonium lactate	1	*
*	amoxapine	1	*
*	amoxicillin	1	*
	amoxicillin/clavulanic acid	2
	amphetamine/dextroamphetamine (Including XR)	2
*	ampicillin	1	*
	amprenavir	2
	ANA-KIT	2
	anastrozole	2
	ANCOBON	2
	ANDRODERM	2
	anthralin	2
	apraclonidine	2
	ARICEPT	2
	ARIMIDEX	2
	ARISTOCORT	2
	artificial tear insert	2
	ASACOL	2
*	aspirin/butalbital/caffeine	1	*
*	aspirin/butalbital/caffeine/codeine	1	*
*	aspirin/codeine	1	*
*	aspirin/oxycodone	1	*
*	atenolol	1	*
*	atenolol/chlorthalidone	1	*
	atorvastatin	2
	atovaquone	2
*	atropine ophthalmic	1	*
	ATROVENT	2
	AUGMENTIN	2
	auranofin	2
	aurothioglucose	2
	AVANDIA	2
	AVC	2
	AVONEX	2
	AYGESTIN	2
*	azathioprine	1	*
*	azathioprine	2	*
*	azelaic acid	1	*
	azithromycin	2
	AZMACORT	2
	AZOPT	2
	AZULFIDINE EN-TABS	2
B Generic brand names are listed in lowercase.
*	bacitracin ophthalmic	1	*
*	baclofen	1	*
	BACTROBAN	2
	beclomethasone nasal (Including AQ)	2
	beclomethasone oral inhaler	2
	BECLOVENT	2
	BECONASE (Including AQ)	2
*	belladonna /phenobarbital	1	*
	benazepril	2
	benazepril/amlodipine	2
	benazepril/hctz
		2
	BENZAMYCIN	2
*	benzocaine/antipyrine liquid	1	*
	benzoyl peroxide/erythromycin	2
*	benztropine	1	*
*	betamethasone dipropionate	1	*
	betamethasone dipropionate augmented	2
*	betamethasone valerate	1	*
	BETASERON	2
	betaxolol ophthalmic	2
*	bethanechol	1	*
	BETOPTIC, BETOPTIC-S	2
	BIAXIN (Including XL)	2
	bicalutamide	2
	BILTRICIDE	2
	bimatoprost	2
*	bisoprolol/hctz	1	*
	BRETHINE	2
	BRICANYL	2
	brimonidine	2
	brinzolamide	2
*	bromocriptine	1	*
	budesonide inhalation suspension	2
	budesonide nasal (Including AQ)	2
	budesonide oral inhaler	2
*	bumetanide	1	*
*	bupropion	1	*
	bupropion	2
	bupropion sr	2
	busulfan	2
	butorphanol (Max 3 cannisters/30 days)	2
C Generic brand names are listed in lowercase.
	cabergoline	2
	calcipotriene	2
*	calcitonin injection	1	*
	calcitonin nasal	2
	calcitriol	2
	capecitabine	2
	CAPITROL	2
*	captopril	1	*
*	captopril/hctz	1	*
*	carbachol ophthalmic	1	*
	carbamazepine (Including XR)	2
*	carisoprodol	1	*
	CARMOL 40	2
	CARNITOR	2
	carvedilol	2
	CASODEX	2
	CEENU	2
	cefdinir suspension	2
	cefixime suspension	2
	cefprozil suspension	2
	CEFTIN	2
	cefuroxime	2
	CEFZIL SUSPENSION	2
	CELEBREX (Reserve for pts at high-risk of NSAID gastropathy - step therapy to be implemented in 2002)	2
	celecoxib (Reserve for pts at high-risk of NSAID gastropathy - step therapy to be implemented in 2002)	2
	CELEXA	2
	CELLCEPT	2
*	cephalexin	1	*
	CEREDASE	2
	CERUMENEX	2
	cetirizine	2
	CHEMET	2
	CHIBROXIN	2
*	chloral hydrate	1	*
	chlorambucil	2
*	chloramphenicol	1	*
*	chlorhexidine	1	*
*	chloroquine	1	*
*	chlorothiazide	1	*
	chloroxine	2
*	chlorpheniramine/phenyltolox/pe/pp	1	*
*	chlorpromazine	1	*
*	chlorthalidone	1	*
*	cholestyramine	1	*
*	cholestyramine light	1	*
*	choline/mag salicylates	1	*
	ciclopirox	2
	CILOXIN	2
*	cimetidine	1	*
	CIPRO	2
	ciprofloxacin	2
	ciprofloxacin ophthalmic	2
	cisapride (Limited access program by mfr; see http://us.janssen.com for details)	2
	citalopram	2
	citric acid/gluconic acid	2
	clarithromycin (Including XL)	2
	CLEOCIN	2
*	clidinium/chlordiazepoxide	1	*
	CLIMARA	2
*	clindamycin (150mg)	1	*
*	clindamycin topical	1	*
	clindamycin vaginal gel	2
	clofazimine	2
*	clomipramine	1	*
*	clonazepam	1	*
*	clonidine	1	*
*	clonidine/chlorthalidone	1	*
	clopidogrel	2
	clotrimazole	2
	clotrimazole vaginal suppository	1
*	clozapine	1	*
*	codeine	1	*
*	colchicine	1	*
	COLESTID	2
	colestipol	2
	COMBIVENT	2
	COMBIVIR	2
	COMTAN	2
	CONDYLOX	2
	conjugated estrogens (Includes vaginal cream)	2
	conjugated estrogens/medroxyprogesterone	2
	COPAXONE	2
	COREG	2
	CORTENEMA	2
	CORTIFOAM	2
	COSOPT	2
	COUMADIN	2
	COVERA HS	2
	CRIXIVAN	2
*	cromolyn inhaled (All forms are covered)	1	*
	crotamiton	2
	CUPRIMINE	2
	cyanocobalamin nasal	2
*	cyclobenzaprine	1	*
*	cyclopentolate	1	*
	cyclophosphamide	2
	cycloserine	2
	cyclosporine	2
*	cyclosporine microemulsion	1	*
	CYLERT	2
*	cyproheptadine	1	*
	CYTADREN	2
	CYTOMEL	2
	CYTOTEC	2
	CYTOVENE	2
	CYTOXAN	2
D Generic brand names are listed in lowercase.
	dalteparin	2
*	danazol	1	*
	DANTRIUM	2
	dantrolene	2
	DAPSONE	2
	DARANIDE	2
	DARAPRIM	2
	DDAVP TABLET	2
	delavirdine	2
	demecarium	2
	DEMSER	2
	DEMULEN	2
	DENAVIR	2
	DEPAKENE	2
	DEPAKOTE	2
*	desipramine	1	*
*	desmopressin nasal	1	*
	desmopressin tablet	2
	DESOGEN	2
*	desonide	1	*
*	desoximetasone	1	*
	DETROL	2
*	dexamethasone	1	*
*	dexamethasone ophthalmic (Maxidex is Tier 2)	1	*
*	dextroamphetamine (Spansule is Tier 2)	1	*
*	diabetic blood testing strips	�	*
*	diabetic urine testing products	�	*
	DIASTAT	2
*	diazepam	1	*
	diazepam rectal	2
	DIBENZYLINE	2
	dichlorphenamide	2
*	diclofenac	1	*
*	diclofenac ophthalmic	1	*
*	dicloxacillin (Liquid is Tier 2)	1	*
*	dicyclomine	1	*
	didanosine	2
	DIDRONEL	2
	dienestrol vaginal cream	2
	DIFLUCAN	2
	DIFLUCAN VC	2
*	diflunisal	1	*
	digoxin (0.5mg not covered)	2
	dihydroergotamine (Max 8 amps/30 days)	2
	DILANTIN	2
*	diltiazem (XT and CD are Tier 2)	1	*
	diltiazem cr	2
	DIOVAN	2
	DIOVAN HCT	2
*	diphenoxylate/atropine	1	*
*	dipivefrin ophthalmic	1	*
	DIPROLENE	2
	DIPROLENE AF	2
*	dipyridamole	1	*
*	disopyramide (Including CR)	1	*
*	disulfiram	1	*
	divalproex	2
	donepezil	2
	DOPAR	2
	dornase alfa	2
	dorzolamide	2
	dorzolamide/timolol	2
	DOSTINEX	2
	DOVONEX	2
*	doxazosin	1	*
*	doxazosin	2	*
*	doxepin	1	*
*	doxycycline	1	*
	DRITHOCREME	2
	DRYSOL	2
	DURAGESIC	2
	DYCLONE	2
	dyclonine	2
E Generic brand names are listed in lowercase.
	echothiophate ophthalmic	2
	efaviren
		2
	EFFEXOR (Including XR)	2
	EFUDEX	2
	ELMIRON	2
	ELOCON	2
	EMCYT	2
*	enalapril	1	*
	enoxaparin	2
	entacapone	2
	EPI-PEN	2
	epinephrine allergy kit	2
*	epinephrine ophthalmic	1	*
	epinephrine syringe	2
	epinephryl borate	2
	EPIVIR	2
	EPPY-N	2
	ERGAMISOL	2
*	ergocalciferol	1	*
*	ergoloid mesylates	1	*
	ERGOMAR	2
	ergotamine	2
*	ergotamine/caff/belladonna/phenobarbital	1	*
*	ergotamine/caffeine	1	*
*	erythromycin (All generic forms)	1	*
*	erythromycin ophthalmic	1	*
*	erythromycin topical	1	*
*	erythromycin/sulfisoxazole	1	*
	erythropoietin (Epogen is non-preferred)	2
	ESERINE	2
*	esterified estrogen	2
	esterified estrogens/methyltestosterone	2
	ESTRADERM	2
*	estradiol micronized (Includes vaginal cream)	1	*
*	estradiol transdermal patch	1	*
	estradiol vaginal ring	2
	estradiol/ethynodiol	2
	estradiol/norethindrone	2
	estramustine	2
	ESTRATEST	2
	ESTRING	2
*	estropipate	1	*
	ethambutol	2
	ethinyl estradiol/desogestrel	2
	ethinyl estradiol/levonorgestrel	1
*	ethinyl estradiol/levonorgestrel 7/7/7 (Triphasil is Tier 2)	1	*
*	ethinyl estradiol/norethindrone (Ortho Novum is Tier 2)	1	*
	ethinyl estradiol/norethindrone	2
*	ethinyl estradiol/norethindrone 10/11	1	*
	ethinyl estradiol/norgestimate	2
	ethinyl estradiol/norgestrel	1
	ETHMOZINE	2
*	ethosuximide	1	*
	etidronate	2
*	etodolac	1	*
	etoposide	2
	EULEXIN	2
	EURAX	2
	EVISTA	2
	EXELDERM	2
	EXELON	2
F Generic brand names are listed in lowercase.
	famciclovir	2
*	famotidine	1	*
	FAMVIR	2
	FANSIDAR	2
	FARESTON	2
	felbamate	2
	FELBATOL	2
	FEMARA	2
	FEMHRT	2
	fenofibrate	2
	fentanyl transdermal	2
	fexofenadine	2
	filgrastim	2
	finasteride	2
	flecainide	2
	FLOMAX	2
	FLONASE	2
	FLORINEF	2
	FLOVENT	2
	FLOXIN	2
	FLOXIN OTIC	2
	fluconazole	2
	fluconazole 150mg oral single-dose	2
	flucytosine	2
	FLUDARA	2
	fludarabine	2
	fludrocortisone	2
	flunisolide oral inhaler	2
*	fluocinolone	1	*
*	fluocinonide	1	*
*	fluoride	1	*
*	fluorometholone ophthalmic (FML is Tier 2)	1	*
	FLUOROPLEX	2
	fluorouracil	2
*	fluoxetine	2	*
*	fluoxymesterone	1	*
*	fluphenazine	1	*
*	flurbiprofen	1	*
	flutamide	2
	fluticasone nasal	2
	fluticasone oral inhaler and diskhaler	2
	fluvastatin	2
*	folic acid 1mg	1	*
	FORADIL	2
	formoterol	2
	FORTOVASE	2
	FOSAMAX	2
	fosinopril	2
	fosinopril/hctz
		2
	FRAGMIN	2
	FURADANTIN	2
	furazolidone	2
*	furosemide	1	*
	FUROXONE	2
G Generic brand names are listed in lowercase.
	gabapentin	2
	GABITRIL	2
	ganciclovir	2
	GANTANOL	2
	gatifloxacin	2
*	gemfibrozil	1	*
*	generic oral contraceptives (All)	1	*
*	gentamicin	1	*
*	gentamicin ophthalmic	1	*
	GEODON	2
	glatiramer	2
*	glipizide (Including XL)	1	*
*	glucagon	1	*
	GLUCOPHAGE (XR is Tier 3)	2
	GLUCOVANCE	2
*	glyburide	1	*
	glycerin	2
	gold sodium thiomalate	1
	granisetron	2
	GRANULEX	2
*	griseofulvin microsize	1	*
*	griseofulvin ultramicrosize	1	*
*	guaifenesin/codeine liquid	1	*
*	guaifenesin/hydrocodone liquid	1	*
*	guanaben	1	*
*	guanfacine	1	*
H Generic brand names are listed in lowercase.
*	haloperidol	1	*
*	heparin	1	*
	HERPLEX	2
	HEXALEN	2
	HIVID	2
	HMS	2
*	homatropine ophthalmic	1	*
	HUMALOG	2
	HUMORSOL	2
	HUMULIN	2
*	hydralazine	1	*
	HYDREA	2
*	hydrochlorothiazide	1	*
*	hydrocortisone (2.5% only)	1	*
*	hydrocortisone anorectal cream	1	*
	hydrocortisone enema	2
	hydrocortisone foam	2
*	hydrocortisone tablet	1	*
*	hydrocortisone/pramoxine	1	*
*	hydromorphone	1	*
*	hydroxychloroquine	1	*
*	hydroxyprogesterone	1	*
	hydroxyurea	2
*	hydroxyzine	1	*
*	hyoscyamine	1	*
I Generic brand names are listed in lowercase.
*	ibuprofen	1	*
	idoxuridine	2
*	imipramine	1	*
	IMITREX (Max 1200 mg/30 days: 4 inj kits, 12 nasal sprays, or 24 (50mg) tablets)	2
*	indapamide	1	*
	indinavir	2
*	indomethacin	1	*
	insulin aspart	2
	insulin glargine	2
	insulin lispro	2
*	insulin syringes and needles	�	*
	insulin, human	2
	interferon alfa-2b	2
	interferon alfa-2b/ribavirin	2
	interferon alfa-n3	2
	interferon beta-1a	2
	interferon beta-1b	2
	interferon gamma-1b	2
	INTRON-A	2
*	iodoquinol	1	*
	IOPIDINE	2
	ipratropium metered dose inhaler	2
	ipratropium/albuterol metered dose inhaler	2
*	isometheptene/dichloralphenazone/apap	1	*
*	isoniazid	1	*
*	isosorbide dinitrate	1	*
*	isosorbide mononitrate	1	*
*	isosorbide mononitrate sr	1	*
	isotretinoin (Oral)	2
*	isoxsuprine	1	*
	ivermectin	2
K Generic brand names are listed in lowercase.
	KALETRA	2
	KEPPRA	2
	KERALYT	2
	KYTRIL	2
L Generic brand names are listed in lowercase.
*	labetalol	1	*
	LACRISERT	2
*	lactulose liquid	1	*
	LAMICTAL	2
	LAMISIL	2
	lamivudine	2
	lamivudine/zidovudine	2
	lamotrigine	2
	LAMPRENE	2
*	lancets	�	*
	LANOXIN (0.5mg not covered)	2
	LANTUS	2
	LARIAM	2
	latanoprost	2
	LESCOL	2
	letrozole	2
*	leucovorin	1	*
	LEUKERAN	2
	LEUKINE	2
	leuprolide	2
	levamisole	2
	levetiracetam	2
*	levobunolol liquid	1	*
	levocabastine	2
	levocarnitine	2
	levodopa	2
*	levodopa/carbidopa (Including CR)	1	*
	LEVOTHROID	2
	levothyroxine	2
	LEVOXYL	2
*	lidocaine	1	*
*	lindane	1	*
	liothyronine	2
	liotrix	2
*	lipase/amylase/protease	1	*
	LIPITOR	2
	lisinopril	2
	lisinopril/hctz
		2
*	lithium carbonate (Eskalith CR is Tier 2)	1	*
*	lithium citrate	1	*
	LIVOSTIN	2
	lodoxamide	2
	LOESTRIN, LOESTRIN FE	2
	lomustine	2
	LOOVRAL	1
	lopinavir/ritonavir	2
	LOPROX	2
*	lorazepam	1	*
	LOTENSIN	2
	LOTENSIN HCT	2
	LOTREL	2
*	lovastatin	1	*
	LOVENOX	2
*	loxapine	1	*
	LUMIGAN	2
	LUPRON	2
	LYSODREN	2
M Generic brand names are listed in lowercase.
	MACROBID	2
*	maprotiline	1	*
	masoprocol	2
	MATULANE	2
	MAVIK	2
	MAXALT (Max 120 mg/30 days)	2
*	mebendazole	1	*
	MECLAN	2
*	meclizine	1	*
	meclocycline sulfosalicylate	2
*	meclofenamate	1	*
*	medroxyprogesterone	1	*
	medrysone ophthalmic	2
	mefloquine	2
*	megestrol	1	*
	melphalan	2
*	meperidine	1	*
*	mephobarbital	1	*
	MEPHYTON	2
	MEPRON	2
	mercaptopurine	2
	mesalamine (Enema, suppository)	2
	mesalamine	2
	MESTINON SR	2
	metformin (XR is Tier 3)	2
	metformin/glyburide	2
*	methadone	1	*
*	methazolamide	1	*
	METHERGINE	2
*	methimazole	1	*
*	methocarbamol	1	*
*	methotrexate	1	*
	methoxsalen	2
*	methylclothiazide	1	*
*	methyldopa	1	*
	methylergonovine	2
*	methylphenidate (Including generic SR)	1	*
*	methylprednisolone	1	*
*	methyltestosterone	1	*
	metipranolol	2
*	metoclopramide	1	*
	metolazone	2
*	metoprolol	1	*
	metoprolol succinate	2
	METROGEL	2
	METROGEL VAGINAL	2
*	metronidazole (375mg is Tier 3)	1	*
	metronidazole gel	2
	metronidazole vaginal gel	2
	metyrosine	2
*	mexiletine	1	*
	MIACALCIN	2
	MICARDIS	2
	MICARDIS HCT	2
	MICRONOR	2
	midodrine	2
	MIGRANAL (Max 8 amps/30 days)	2
*	minoxidil	1	*
	MINTEZOL	2
	MIRAPEX	2
	misoprostol	2
	mitotane	2
	MOBAN	2
	moexipril	2
	moexipril/hctz
		2
	molindone	2
	mometasone	2
	MONOPRIL	2
	MONOPRIL HCT	2
	montelukast	2
	moricizine	2
	morphine (Suppository)	2
*	morphine sulfate	1	*
*	morphine sulfate sr	1	*
	MS CONTIN	2
*	multivitamin/fluoride chew or liquid	1	*
*	multivitamin/fluoride/iron chew or liquid	1	*
	mupirocin	2
	MYAMBUTOL	2
	MYCELEX	2
	MYCELEX-G	1
	MYCOBUTIN	2
	mycophenolate	2
	MYLERAN	2
	MYOCHRYSINE	1
N Generic brand names are listed in lowercase.
*	nadolol	1	*
	nafarelin	2
*	naphazoline	1	*
*	naproxen	1	*
*	naproxen sodium	1	*
	naratriptan (Max 23 mg/30 days)	2
	NARDIL	2
	NASACORT (Including AQ)	2
	NASCOBAL	2
	NEBUPENT	2
	nedocromil (All forms are covered)	2
	nefazodone	2
	nelfinavir	2
*	neomycin	1	*
*	neomycin/bacitracin/polymyxin/hc ophthalmic	1	*
*	neomycin/dexamethasone ophthalmic	1	*
*	neomycin/polymyxin/bacitracin ophthalmic	1	*
*	neomycin/polymyxin/dexamethasone ophthalmic	1	*
*	neomycin/polymyxin/gramicidin ophthalmic	1	*
*	neomycin/polymyxin/hc ophthalmic	1	*
*	neomycin/polymyxin/hc otic	1	*
	neomycin/polymyxin/pred ophthalmic	2
	neostigmine	2
	NEUMEGA	2
	NEUPOGEN	2
	NEURONTIN	2
	nevirapine	2
	niacin sr	2
	NIASPAN	2
	nicotine nasal spray	2
	NICOTROL NS	2
*	nifedipine	1	*
*	nifedipine cc	1	*
	NILANDRON	2
	nilutamide	2
	nimodipine	2
	NIMOTOP	2
	nitrofurantoin	2
*	nitrofurantoin macro	1	*
	nitrofurantoin monohydrate macro	2
*	nitroglycerin oral	1	*
	nitroglycerin sl	2
*	nitroglycerin transdermal	1	*
	NITROSTAT	2
	NOLVADEX (Tamoxifen is Tier 2)	2
	NOR-QD	2
	norethindrone	2
	norfloxacin	2
*	nortriptyline	1	*
	NORVIR	2
	NOVOLIN	2
	NOVOLOG	2
*	nystatin	1	*
*	nystatin vaginal	1	*
*	nystatin/triamcinolone	1	*
O Generic brand names are listed in lowercase.
	octreotide	2
	OCUFLOX	2
	ofloxacin	2
	olanzapine	2
	olopatadine	2
	omeprazole (PA required for > 90-day Rx)	2
	OMNICEF SUSPENSION	2
	ondansetron	2
	oprelvekin	2
	OPTIPRANOLOL	2
	ORTHO NOVUM	2
	ORTHO NOVUM 10/11	2
	ORTHO NOVUM 7/7/7	2
	ORTHO-CYCLEN	2
	ORTHO-DIENESTROL	2
	ORTHO-TRICYCLEN	2
	OSMOGLYN	2
	OVCON	2
	OVRAL	1
	OXSORALEN	2
*	oxybutynin (XL is Tier 3)	1	*
P Generic brand names are listed in lowercase.
*	pancrelipase	1	*
	pantoprazole (PA required for > 90-day Rx)	2
*	paregoric	1	*
	PARNATE	2
*	paromomycin	1	*
	paroxetine	2
	PATANOL	2
	PAXIL	2
	PEDIAPRED	2
*	peg electrolyte bowel prep	1	*
	pemoline	2
	penciclovir cream	2
	penicillamine	2
*	penicillin	1	*
*	pentamidine injection	1	*
	pentamidine nebulized	2
	PENTASA	2
	pentazocine/naloxone	2
	pentosan polysulfate sodium	2
*	pentoxifylline	1	*
*	permethrin	1	*
*	perphenazine	1	*
*	phenazopyridine	1	*
	phenelzine	2
	pheniramine/pyrilamine/phenyltoloxamine (Liquid)	2
*	phenobarbital	1	*
	phenoxybenzamine	2
	phentolamine mesylate	2
*	phenylephrine	1	*
*	phenylephrine/chlorpheniramine/hydrocodone liquid	1	*
*	phenytoin	1	*
	PHOSPHOLINE IODIDE	2
	physostigmine	2
	phytonadione	2
	pilocarpine	2
*	pilocarpine ophthalmic	1	*
*	pilocarpine/epinephrine ophthalmic	1	*
*	pindolol	1	*
	pioglitazone	2
*	piroxicam	1	*
	PLAVIX	2
	podofilox	2
	POLY-PRED	2
	POLYHISTINE (Liquid)	2
*	potassium (All generics)	1	*
	potassium citrate	2
*	potassium iodide	1	*
	pramipexole	2
	PRAVACHOL	2
	pravastatin	2
	praziquantel	2
*	prazosin	1	*
*	prednisolone	1	*
	prednisolone	2
*	prednisolone ophthalmic	1	*
*	prednisone	1	*
	PREMARIN (Includes vaginal cream)	2
	PREMPRO, PREMPHASE	2
*	prenatal vitamins	1	*
	PRILOSEC (PA required for > 90-day Rx)	2
*	primaquine	1	*
*	primidone	1	*
	PRINIVIL	2
	PRINZIDE	2
	PRO-AMITINE	2
*	probenecid	1	*
	procainamide (All generics are Tier 1)	2
	PROCANBID (All generics are Tier 1)	2
	procarbazine	2
*	prochlorperazine	1	*
	PROCRIT (Epogen is non-preferred)	2
	PROFENAL	2
*	progesterone injection	1	*
	progesterone micronized	2
	PROGRAF	2
*	promethazine	1	*
*	promethazine/codeine syrup	1	*
*	promethazine/dextromethorphan liquid	1	*
*	promethazine/pe/codeine syrup	1	*
	PROMETRIUM	2
*	propafenone (300mg is Tier 2)	1	*
*	propantheline	1	*
*	propoxyphene (All generic combinations are Tier 1)	1	*
*	propranolol (Including LA)	1	*
*	propranolol/hctz	1	*
	PROPULSID (Limited access program by mfr; see http://us.janssen.com for details)	2
*	propylthiouracil	1	*
	PROSCAR	2
	PROSTIGMIN	2
	PROTONIX (PA required for > 90-day Rx)	2
*	protriptyline	1	*
*	pseudoephedrine/chlorpheniramine	1	*
*	pseudoephedrine/guaifenesin la	1	*
	PULMICORT	2
	PULMICORT RESPULES	2
	PULMOZYME	2
	PURINETHOL	2
*	pyrazinamide	1	*
*	pyridostigmine	1	*
	pyridostigmine sr	2
	pyrimethamine	2
	pyrimethamine/sulfadoxine	2
Q Generic brand names are listed in lowercase.
	quetiapine	2
	quinapril	2
*	quinidine (Brand-only forms are Tier 2)	1	*
*	quinine	1	*
R Generic brand names are listed in lowercase.
	raloxifene	2
	ramipril	2
*	ranitidine	1	*
	REBETRON	2
	REGITINE	2
	RENACIDIN	2
	REQUIP	2
	RESCRIPTOR	2
*	reserpine	1	*
	RETROVIR	2
	RHINOCORT (Including AQ)	2
	RIDAURA	2
	rifabutin	2
*	rifampin	1	*
	RILUTEK	2
	riluzole	2
	risedronate	2
	RISPERDAL (Liquid not covered)	2
	risperidone (Liquid not covered)	2
	ritonavir	2
	rivastigmine	2
	rizatriptan (Max 120 mg/30 days)	2
	RMS (Suppository)	2
	ROCALTROL	2
	rofecoxib (Reserve for pts at high-risk of NSAID gastropathy - step therapy to be implemented in 2002)	2
	ropinirole	2
	rosiglitazone	2
	ROWASA (Enema, suppository)	2
S Generic brand names are listed in lowercase.
	SALAGEN	2
	salicylic acid	2
	salmeterol (Including Diskus)	2
*	salsalate	1	*
	SANDIMMUNE	2
	SANDOSTATIN	2
	saquinavir	2
	sargramostim	2
	scopolamine	2
	SEBIZON	2
	secobarbital	2
	SECONAL	2
*	selegiline	1	*
*	selenium sulfide	1	*
	SEREVENT (Including Diskus)	2
	SEROMYCIN	2
	SEROQUEL	2
	sertraline	2
	SERZONE	2
*	silver sulfadiazine	1	*
	SINGULAIR	2
	SLO-BID	2
*	sodium polystyrene sulfonate liquid	1	*
	SOLGANAL	2
	SORIATANE	2
*	sotalol	1	*
*	spironolactone	1	*
*	spironolactone/hct	1	*
	STADOL (Max 3 cannisters/30 days)	2
	stavudine	2
*	streptomycin	1	*
	STROMECTOL	2
	succimer	2
*	sucralfate	1	*
	sulconazole nitrate	2
	sulfacetamide	2
*	sulfacetamide ophthalmic	1	*
*	sulfacetamide/prednisolone ophthalmic	1	*
*	sulfacetamide/sulfur	1	*
*	sulfadiazine	1	*
	sulfamethoxazole	2
	sulfanilamide vaginal gel	2
*	sulfasalazine	1	*
	sulfasalazine ec	2
*	sulfinpyrazone	1	*
*	sulfisoxazole (Liquid is Tier 2)	1	*
*	sulindac	1	*
	sumatriptan (Max 1200 mg/30 days: 4 inj kits, 12 nasal sprays, or 24 (50mg) tablets)	2
	SUPRAX SUSPENSION	2
	suprofen	2
	SUSTIVA	2
	SYNAREL	2
	SYNTHROID	2
T Generic brand names are listed in lowercase.
	tacrolimus	2
	TALWIN NX	2
	TAMBOCOR	2
	tamoxifen (Tamoxifen is Tier 2)	2
	tamsulosin	2
	tazarotene	2
	TAZORAC	2
	TEGRETOL (Including XR)	2
	telmisartan	2
	telmisartan/hctz
		2
*	temazepam	1	*
	TEQUIN	2
	TERAZOL 7	2
*	terazosin	1	*
	terbinafine	2
	terbutaline	2
	terconazole vaginal cream	2
	TESLAC	2
	TESTODERM	2
	testolactone 50mg	2
	testosterone transdermal	2
*	tetracycline	1	*
	thalidomide	2
	THALOMID	2
	THEO-DUR	2
*	theophylline	1	*
	theophylline sr	2
	thiabendazole	2
	THIOGUANINE	2
*	thiothixene	1	*
	THYROID	2
	THYROLAR	2
	tiagabine	2
	TIAZAC	2
	TICLID	2
	ticlopidine	2
	TILADE (All forms are covered)	2
*	timolol	1	*
*	timolol ophthalmic	1	*
	TOBI	2
	TOBRADEX	2
	tobramycin nebulized	2
*	tobramycin ophthalmic	1	*
	tobramycin/dexamethasone ophthalmic	2
*	tolazamide	1	*
*	tolmetin	1	*
	tolterodine	2
	TOPAMAX	2
	topiramate	2
	TOPROL XL	2
	toremifene	2
	trandolapril	2
	TRANSDERM-SCOP	2
	tranylcypromine	2
	TRAVATAN	2
	travoprost	2
*	trazodone	1	*
	tretinoin	2
	tretinoin (Microsphere is Tier 2; authorization required for patients older than 39 years; no initial 30-day
*	triamcinolone	1	*
*	triamcinolone in orabase	1	*
	triamcinolone nasal (Including AQ)	2
	triamcinolone oral	2
	triamcinolone oral inhaler	2
*	triamterene/hydrochlorothiazide	1	*
*	triazolam	1	*
	TRICOR	2
	triethanolamine	2
*	trifluoperazine	1	*
	trifluridine ophthalmic	2
*	trihexyphenidyl	1	*
*	trimethoprim/polymixin b	1	*
*	trimethoprim/sulfamethoxazole	1	*
	trioxsalen	2
	TRIPHASIL	2
*	triple sulfa vaginal cream	1	*
	TRISORALEN	2
	TRIZIVIR	2
*	tropicamide	1	*
	TRUSOPT	2
	trypsin	2
U Generic brand names are listed in lowercase.
	UNIRETIC	2
	UNIVASC	2
	urea 40%	2
	UROCIT-K	2
*	ursodiol	1	*
V Generic brand names are listed in lowercase.
	valacyclovir	2
	valproic acid	2
	valsartan	2
	valsartan/hctz
		2
	VALTREX	2
	VANCENASE (Including AQ)	2
	VANCERIL (Including DS)	2
	VANCOCIN	2
	vancomycin	2
	venlafaxine (Including XR)	2
	VEPESID	2
*	verapamil (Including SR)	1	*
	verapamil chronobiol la	2
	VERELAN PM	2
	VESANOID	2
	vidarabine ophthalmic	2
	VIDEX	2
	VIOXX (Reserve for pts at high-risk of NSAID gastropathy - step therapy to be implemented in 2002)	2
	VIRA-A	2
	VIRACEPT	2
	VIRAMUNE	2
	VIROPTIC	2
*	vitamin a	1	*
*	vitamins acd/fluoride/iron chew or liquid	1	*
	VIVELLE	2
W Generic brand names are listed in lowercase.
	warfarin	2
	WELLBUTRIN SR	2
X Generic brand names are listed in lowercase.
	XALATAN	2
	XELODA	2
Z Generic brand names are listed in lowercase.
	zafirlukast	2
	zalcitabine	2
	ZAROXOLYN	2
	ZERIT	2
	ZESTORETIC	2
	ZESTRIL	2
	ZIAGEN	2
	zidovudine	2
	ziprasidone	2
	ZITHROMAX	2
	ZOFRAN	2
	ZOLOFT	2
	ZONEGRAN	2
	zonisamide	2
	ZOVIRAX	2
	ZYBAN	2
	ZYPREXA	2
	ZYRTEC	2