Swhp alpha

SCOTT AND WHITE HEALTH PLAN
FORMULARY
OCTOBER 2012
Amcinonide
Baclofen
Carbachol Ophth
ACCU-CHEK
Amiloride
Bactrim*
Carbamazepine
Acebutolol
Amiloride /HCTZ
BACTROBAN CREA
Carbamazepine XR
Acetazolamide
Aminocaproic Acid
BACTROBAN NASAL
CARBATROL
Acetic Acid /HC Otic
Aminophylline
Benazepril
Carbidopa /Levodopa
Acetic Acid Otic
Amiodarone
Benazepril & HCTZ
Cardizem CD*
Carisoprodol 350 tab
Aclovate*
Amitrip /Chlordiazepo
BENICAR HCT
Carisoprodol/ASA
Activella*
Amitriptyline
BENZACLIN PUMP
Carteolol Ophth
Amlodipine
Benzamycin
Casodex*
Actoplus Met*
Amoxicillin
Benztropine
Catapres-TTS*
Ampicillin
Betamethasone
CAVERJECT
Analpram-HC*
Betaxolol
Acyclovir
ANDRODERM
Bethanechol
ANDROGEL
BETOPTIC-S
Cefaclor
Adderall XR*
Biaxin XL*
Cefaclor CD 500
Adderall*
Antipyrine-Benzocaine
Cefadroxil
ADRENACLICK
APAP /Codeine
Bicitra*
Cefpodoxime
Bisoprolol
Cefprozil
ADVAIR HFA
Bisoprolol /HCTZ
Arimidex*
BLEPHAMIDE OPTH
CELEBREX
AGGRENOX
ARMOUR THYROID
BRILINTA
Cephalexin
Agrylin*
Aromasin*
Brimonidine Opth
CERUMENEX
AKNE-MYCIN
Bumetanide
Chloral Hydrate Syrup
Bupropion
Chloramphenicol Opht
Albuterol Nebules
Atenolol
Bupropion SR
Chlordiazepox /Clindin
Albuterol Syrup
Atenolol/Chlorthal
Bupropion XL
Chlordiazepoxide
Albuterol Tab
Buspirone
Chlorhexidine
ALDACTAZIDE 50mg
Atropine Ophth
Butalbital /APAP
Chloroquine
ATROVENT HFA
Chlorothiazide
Allopurinol
Augmentin*
BYSTOLIC
Chlorpromazine
Cabergoline
Chlorpropamide
Calcitonin
Chlorthalidone
ALPHAGAN P
Aygestin*
Chlorzoxazone
Alprazolam Tab
Azathioprine
Cholestyramine
Captopril
Ciclopirox 0.77%
Amantadine
Captopril /HCTZ
Cilostazol
Cimetidine 300mg Tab
Bacitracin
CARAFATE SUSP
Cimetidine 400mg Tab
A = A Tier Generic B = B Tier Preferred Brand C= C Tier Nonpreferred DRUG = Brand Drug drug = Generic Drug P = Prior Authorization M = Maintenance Benefit
drug* = Brand name listed for reference only, a generic equivalent is available
S = Step Therapy Required
+ = Preferred Test Strip
Brand name products where generic is availabe; copay penalties may apply
R = Restricted
Prescription formularies continually change to reflect the most recent advances in drug therapy. Therefore, this list is not inclusive and does not guarantee coverage. However, it represents an abbreviation of the member's prescription drug coverage. Cimetidine 800mg Tab
COUMADIN
Diclofenac Ophth
DURICEF SUSP
Cimetidine Solution
Diclofenac XR
Dicloxacillin
CIPRODEX
Dicyclomine
Econazole Cream
Ciprofloxacin
CRIXIVAN
Didanosine
Ciprofloxacin (Ophth)
Cromolyn Neb
Didronel*
Effexor XR caps*
Citalopram
Cromolyn Ophth
DIFFERIN
CLEOCIN VAG SUPP
CUPRIMINE
Differin 0.1% CRM*
Climara*
Cyanocobalamin
Differin Gel 0.1%*
Elimite*
Clindamycin Cap
Cyclobenzaprine
Diflorasone
Clindamycin Sol
CYCLOGYL 0.5%
Diflunisal
Clindamycin Topical
Cyclopentolate
Clindamycin-Benzoyl*
Cyclophosphamide tabs A
Clobetasol Cream
Cyclosporine
Dihistine DH*
Enalapril
Clobetasol Gel
CYMBALTA
Dihydroergotamine
Enalapril/HCTZ
Clobetasol Oint
Cyproheptadine
DILANTIN
Entocort EC*
Clobetasol Soln
CYTADREN
Diltiazem ER Cap CR
Clomipramine
Cytomel*
Diltiazem ER Cap SA
Clonazepam
Diltiazem ERCapSR12
EPIVIR HBV
Clonidine
Dantrium*
Diltiazem HCl Tab
EPIVIR SOLN
Clonidine /Chlorthal
Epivir Tab*
Clorazepate
DARAPRIM
Diovan HCT*
Ergoloid Mesylate
Clotrimazole Troche
DAYTRANA
DIPENTUM
Ergotamine-Caffeine
Clozapine
DDAVP Tabs*
Diphenoxyl /Atropine
Codeine*
Delestrogen 10mg/ml In A
Diprolene AF*
Colazal*
Demeclocycline
Diprolene* Cr & Oint
Erythromycin
Colchicine /Probenicid
DEPAKENE
Dipyridamole
Erythromycin Ophth
DEPAKOTE
Disopyramide
Erythromycin Stearate
Colestid*
DEPAKOTE ER
Disulfiram
Erythromycin Top
COLYMYCIN-S
DEPO-ESTRADIOL
DIURIL SUSP
Erythromycin/Sulfisox
DEPO-PROVERA 400
Divalproex sodium
Esgic-Plus*
COMBIGAN
Desipramine
Divalproex Sodium ER
Eskalith Cr*
COMBIVENT
Desmopressin
Donepezil
Estazolam
Combivir*
Desmopressin Inj
Donepezil ODT
ESTRACE VAG
Desonide
Donnatal*
Estradiol
Concerta*
Desoximetasone
Dovonex Cream*
Estradiol 20mg/ml Val
CONDYLOX GEL
DETROL LA
Dovonex Sol*
Estradiol 40mg/ml Val
Control Solution
Dexamethasone
Doxazosin
ESTRATEST
Dexamethasone Opth
ESTRATEST HS
CORTIFOAM
Dextroamphetamine
Doxycycline 100mg
Ethambutol
Cortisone
Doxycycline 50mg
Ethosuximide
CORTISPORIN OPTH
Etodolac
Cortisporin Otic*
Diazepam
Etodolac XL
Corzide*
DIBENZYLINE
Diclofenac
Duragesic*
A = A Tier Generic B = B Tier Preferred Brand C= C Tier Nonpreferred DRUG = Brand Drug drug = Generic Drug P = Prior Authorization M = Maintenance Benefit
drug* = Brand name listed for reference only, a generic equivalent is available
S = Step Therapy Required
+ = Preferred Test Strip
Brand name products where generic is availabe; copay penalties may apply
R = Restricted
Prescription formularies continually change to reflect the most recent advances in drug therapy. Therefore, this list is not inclusive and does not guarantee coverage. However, it represents an abbreviation of the member's prescription drug coverage. EXELDERM
Fortical Nasal Spray*
Hydrocortisone Supp.
Ketoprofen
Exelon Caps*
Fosamax*
Hydrocortisone Tablet
Ketoprofen SR
EXELON LIQUID
Fosinopril
Hydrocortisone Top 2.5 A
Ketorolac
EXELON PATCH
Fosinopril/Hctz
Hydrocortisone Valerat A
Furosemide
Hydromorphone
KLONOPIN
EXFORGE HCT
Gabapentin
Hydroxychloroquine
K-Lyte CL*
Famciclovir
GABITRIL
Hydroxyurea
FARESTON
Ganciclovir Cap
Hydroxyzine
KOMBIGLYZE XR
Felbamate
GANTRISIN PED
Hyoscyamine
FELBATOL
Gemfibrozil
K-Phos Neutral*
Felodipine
Gentamicin
Ibuprofen
K-PHOS-2
Gentamicin Ophth
Imipramine HCl
Labetalol
Fenofibrate
Imiquimod Cream
LACRISERT
Fenoprofen Tab
Glipizide
Imitrex Nasal*
Lactulose
Fioricet #3*
Glipizide XL
Imitrex Tabs*
LAMICTAL
Fioricet*
GLUCAGON
Indapamide
Lamisil*
Fiorinal w/codeine*
Glucophage XR*
Inderal LA*
Lamotrigine
Fiorinal*
Glyburide
INDOCIN SUPP
Glyburide Micro
INDOCIN SUSP
Flavoxate
Glyburide-Metformin
Indomethacin
Flecainide
Golytely*
INTAL INHALER
Leucovorin
Granisetron 1mg Tab
INVIRASE
LEUKERAN
Flonase*
Granulex*
Iodoquinol / HC
Leuprolide 5mg/ml
Florinef*
GRIFULVIN Tab
Iopidine*
FLOVENT DISKUS
Griseofulvin Susp*
Ipratropium
Levetiracetam
FLOVENT HFA
GRIS-PEG
Isoniazid
Levobunolol
Fluconazole
Guaifenesin/Codeine
ISOPTO HYOSCINE
Levocarnitine
Flumadine*
Guanabenz
ISOPTO-CARBACHO
Levo-Dromoran*
Fluocinolone Top
Guanfacine
ISORDIL TAB 40MG
Levofloxacin Oral
Fluocinonide
Isosorbide Dinitrate
Levothroid*
Fluorometholone
Haloperidol
Isosorbide Mononitrate
Levothyroxine
Fluorouracil (Topical)
Isotretinoin
Fluoxetine
Histussin HC*
Lidocaine
Fluoxymesterone
Itraconazole Cap
Lidocaine Viscous
Fluphenazine
Homatropine Ophth
Jantoven
Lidocaine/prilocaine C
Flurazepam
Flurbiprofen
HUMALOG MIX
Lipitor*
Flurbiprofen Ophth
HUMULIN Insulins
Lisinopril
Flutamide
Hycodan*
Kayexalate*
Lisinopril/Hctz
Fluticasone Topical
Hydralazine
KENALOG INJ
Lithium Carbonate
FML FORTE
Hydrochlorothiazide
KENALOG SPRAY
Lithium Citrate
Hydrocodone/ APAP
KEPPRA Oral
Lithobid*
Hydrocodone/ IBU
Ketoconazole Cream
LITHOSTAT
Folic Acid
Hydrocortisone Enema
Ketoconazole Rx Sham
Hydrocortisone Rectal
Ketoconazole Tab
LOESTRIN 24 FE
A = A Tier Generic B = B Tier Preferred Brand C= C Tier Nonpreferred DRUG = Brand Drug drug = Generic Drug P = Prior Authorization M = Maintenance Benefit
drug* = Brand name listed for reference only, a generic equivalent is available
S = Step Therapy Required
+ = Preferred Test Strip
Brand name products where generic is availabe; copay penalties may apply
R = Restricted
Prescription formularies continually change to reflect the most recent advances in drug therapy. Therefore, this list is not inclusive and does not guarantee coverage. However, it represents an abbreviation of the member's prescription drug coverage. Lofibra*
Methergine Tab*
Naproxen EC
Loprox Shampoo*
Methimazole
Nasacort AQ*
Orphenadrine
LOPROX TOPICAL
Methocarbamol
NASCOBAL
Oxaprozin
Lorazepam
Methotrexate
Oxazepam Cap
Methotrexate Inj.
NEBUPENT
Oxcarbazepine
Methyclothiazide
Neo-Decadron*
Lotrisone Cream*
Methyldopa
Neomycin
OXSORALEN-UL
Lotrisone Lotion*
Methyldopa /HCTZ
NEPHROCAPS
Oxybutynin
LOTRONEX
Methylphenidate
NEURONTIN
Oxycodone
Lovastatin
Methylphenidate Soln
Oxycodone /APAP
Methylphenidate SR
Nifedipine XL
Oxycodone /ASA
Loxapine
Methylprednisolone
Nimodipine
OXYCONTIN
Metoclopramide
NITRO-DUR 0.3MG
Pacerone
Metolazone
Nitrofurantoin
Panafil*
Metoprolol
Nitrofurantoin Monohy A
PANCREAZE
MACRODANTIN 25M
Metoprolol & HCTZ
Nitroglycerin Oint
Parlodel*
Malarone*
METROGEL
Nitroglycerin Patch
Paroxetine
Marinol*
Metrogel Vag*
Nitroglycerin SR
Metrolotion*
Nitrolingual Spray*
Paxil CR*
Mexiletine
NITROSTAT
PAXIL SUSP
Nizatidine Caps
Penicillin VK
Maxitrol*
MIGRANAL
Norgesic Forte*
Minocycline Caps
Norgesic*
Pentoxifylline
Mebendazole
Minoxidil
NORITATE
Phenazopyridine
Meclofenamate
Mirapex*
NORPACE CR
Phenelzine
MEDROL 2MG
Mirtazapine
Nortriptyline
Phenergan DM*
Medroxy 150mg INJ
Misoprostol
Phenergan VC*
Medroxyprogest Tab
Mometasone Topical
NOVOLIN INSULIN
Phenobarb /Belladonna
Mefenamic Acid
Morphine Sulfate
Phenobarbital
Megestrol
Morphine Sulfate CR
NOVOLOG MIX
Phenylephrine Ophth
Phenytoin
Meperidine /Prometh
Mupirocin Oint
Nulytely*
Meperidine Oral
NUVARING
PHOSPHOLINE
Mephobarbital
MYCOBUTIN
Pilocarpine
MEPHYTON
Mycophenolate Mofetil
Nystatin
Pilocarpine Tabs
Meprobamate
Nystatin /Triamcinolon
Pindolol
Mercaptopurine Tab
MYOCHRYSINE
Nystatin Topical
Piroxicam
Mesalamine Rectal
MYSOLINE
Ofloxacin Ophth
PKU Formula
METADATE CD
Nabumetone
Ofloxacin Otic
Metaproterenol
Podofilox
Metformin
Olanzapine
Polycitra-K*
Methadone
NALFON CAP
Omnicef*
POLY-PRED
Methazolamide
Naltrexone
Polysporin*
Methenamine Hippurat
Optipranolol*
Polytrim*
Methenamine Mandela
Naproxen
Oral Contraceptive*
Poly-Vi-Flor + FE*
A = A Tier Generic B = B Tier Preferred Brand C= C Tier Nonpreferred DRUG = Brand Drug drug = Generic Drug P = Prior Authorization M = Maintenance Benefit
drug* = Brand name listed for reference only, a generic equivalent is available
S = Step Therapy Required
+ = Preferred Test Strip
Brand name products where generic is availabe; copay penalties may apply
R = Restricted
Prescription formularies continually change to reflect the most recent advances in drug therapy. Therefore, this list is not inclusive and does not guarantee coverage. However, it represents an abbreviation of the member's prescription drug coverage. Poly-Vi-Flor*
Quinidine Gluconate
Sodium Poly Sulf
Testosterone Enanth In
Potasium Iodide
Quinidine Sulfate
Tetracycline
Potassium Chloride
Quinidine Sulfate CR
SORIATANE
TEXACORT
THALITONE
PRAMOSONE
Pramoxine /HC
Ranitidine 300mg Tabs
Spironolactone
Theophylline
Pravachol*
Ranitidine Caps
Spironolactone /HCTZ
Theophylline SR
Prazosin
Ranitidine Syrup
SPORANOX SOLN
Thioridazine
Precose*
REGRANEX
Stadol Nasal Soln*
Thiothixene Cap
PRED MILD
Starlix*
THYROLAR
Prednisolone
STRATTERA
Ticlopidine
Prednisolone Ophth
RESCRIPTOR
STROMECTOL
Timolide*
Prednisone
Reserpine
Sucralfate
Prednisone Intensol
RESTASIS
Sulfacetamide / Pred
Timolol Ophth
Pref RX Prenatal Vit*
RETIN-A MICRO
Sulfacetamide /Sulphur
Tizanidine Tab
PREMARIN
Retrovir* oral
Sulfacetamide Ophth
Tobradex*
PREMARIN CREAM
Sulfadiazine
Tobramycin Ophth Sol
PREMPHASE
Ribavirin
Sulfasalazine
TOBREX OINT
Sulfasalazine EC
Tolazamide
PRIMAQUINE
Rifampin
Sulfisoxazole
Tolbutamide
Primidone
Sulindac
Tolmetin
PROAIR HFA
Risperdal*
Sumatriptan Inj*
Probenecid
RITALIN LA 10mg
Topiramate
Prochlorperazine
Ritalin LA*
Surmontil*
Toprol XL*
PROCTOFOAM HC
Rocaltrol*
PROGLYCEM
SYMBICORT
Torsemide
Promethazine
Roxicodone*
TACLONEX
TRANSDERM-SCOP
Promethazine / COD
Talwin NX*
TRANXENE SD
Promethazine VC
Salsalate
Tamoxifen
Tranylcypromine Sulfa
Propafenone Tabs
Trazodone
Propantheline 15mg
TEGRETOL
Tretinoin Topical
PROPINE OPHTH
Selegiline
TEGRETOL XR
Triamcinolone
Propranolol
Selenium Sulfide
TEKTURNA
Triamcinolone/Orabase A
Propranolol /HCTZ
SELZENTRY
TEKTURNA-HCT
Triamterene /HCTZ
Propylthiouracil
SEREVENT DISKUS
Temazepam 15mg
Triazolam
Proscar*
Seroquel*
Temazepam 30mg
TRIBENZOR
PROTOPIC
Silver Sulfadiazine
Temazepam 7.5mg
Tricitrates*
Provigil*
TERAZOL 3 SUPP
TRIDESILON
Psorcon E*
Simvastatin
Terazol Cr*
Trifluoperazine
Psorcon*
Singulair*
Terazosin
Trihexyphenidyl
Pulmicort 1mg/2ml
Skelaxin*
Terbutaline
TRILEPTAL
Pulmicort Neb*
Sodium Chloride Nebs
Tessalon*
TRILIPIX
Pyrazinamide
Sodium Cit-Cit Acid
TESTIM GEL
Trilisate*
Pyridostigmine
Sodium Fluoride
Testosterone Cyp Inj
Trimeth/Sulfameth
A = A Tier Generic B = B Tier Preferred Brand C= C Tier Nonpreferred DRUG = Brand Drug drug = Generic Drug P = Prior Authorization M = Maintenance Benefit
drug* = Brand name listed for reference only, a generic equivalent is available
S = Step Therapy Required
+ = Preferred Test Strip
Brand name products where generic is availabe; copay penalties may apply
R = Restricted
Prescription formularies continually change to reflect the most recent advances in drug therapy. Therefore, this list is not inclusive and does not guarantee coverage. However, it represents an abbreviation of the member's prescription drug coverage. Trimethobenzamide
XARELTO 10MG
Trimethoprim
Triple Antibiotic Opht
Triple Antibiotic+HC
Yohimbine
TRIZIVIR
ZARONTIN
Tropicamide
ZEMPLAR ORAL
Trusopt*
Zerit Caps*
Tussi Organidin*
Zerit Soln*
Tussionex*
Zithromax*
Zofran Inj*
Ultravate*
Zofran ODT*
Urocit-k*
Uroxatral*
ZONEGRAN
Ursodiol
Zonisamide
ZOVIRAX TOPICAL
Valproic Acid
ZYCLARA CREAM
Valtrex*
Vancocin*
VANTIN SUSP
Venlafaxine IR tab
VENTOLIN HFA
Verapamil
VESICARE
VIBRAMYCIN SYRUP B
VIRACEPT
Viramune*
Viroptic*
Vitamin D 50,000 IU
VIVELLE-DOT
VIVOTIF BERN
VOSPIRE ER
Warfarin
Xalatan*
A = A Tier Generic B = B Tier Preferred Brand C= C Tier Nonpreferred DRUG = Brand Drug drug = Generic Drug P = Prior Authorization M = Maintenance Benefit
drug* = Brand name listed for reference only, a generic equivalent is available
S = Step Therapy Required
+ = Preferred Test Strip
Brand name products where generic is availabe; copay penalties may apply
R = Restricted
Prescription formularies continually change to reflect the most recent advances in drug therapy. Therefore, this list is not inclusive and does not guarantee coverage. However, it represents an abbreviation of the member's prescription drug coverage.

Source: https://www.swhp.org/sites/default/files/SwhpFormularyAlpha.pdf