Custom Select Drug List. Alternatives for Most Common Drug Exclusions

Transcription

1 Custom Select Drug List Alternatives for Most Common Drug Exclusions If you are currently taking: Any brand-name drug with a generic equivalent Absorica Abstral Ask your doctor to consider prescribing the generic equivalent, which is just as safe and effective as the brand. Generics use the same active ingredients as their brand-name counterparts. fentanyl citrate, morphine sulfate IR, oxycodone IR, hydromorphone Acanya Aciphex Sprinkle omeprazole, lansoprazole, pantoprazole, rabeprazole Acticlate, Acticlate CAP minocycline hcl (generic Minocin ), doxycycline monohydrate capsule (generic Monodox ), doxycycline hyclate (generic Vibramycin ), tetracycline hcl Aczone 7.5% adapalene 0.1 % lotion adapalene 0.1% cream, adapalene 0.1% gel Adzenys XR- ODT amphetamine/dextroamphetamine, methylphenidate hcl Afrezza Novolin, Novolog AirDuo RespiClick Advair Diskus, Breo Ellipta, Symbicort, Spiriva, Spiriva Respimat Allzital butalbital/acetaminophen/caffeine (generic Esgic, generic Fioricet ), bultalbital/aspirin/caffeine (generic Fiorinal ), butalbital/acetaminophen (generic Phrenilin ) Updated 12/14/2017 Page 1 of 18

2 Altoprev atorvastatin, lovastatin, pravastatin, simvastatin Amnesteem Amrix cyclobenzaprine, baclofen, carisoprodol, chlorzoxazone, dantrolene sodium, diazepam, metaxalone, methocarbamol, orphenadrine citrate, tizanidine Apidra Novolin, Novolog Aptensio XR amphetamine/dextroamphetamine, methylphenidate hcl Aptiom carbamazepine, divalproex, phenytoin, levetiracetam, lamotrigine, gabapentin, topiramate, oxcarbazepine ArmonAir RespiClick Asmanex, Flovent HFA, Pulmicort Flexhaler, generic Pulmicort solution, Qvar Arymo ER morphine sulfate ER, hydromorphone ER, tramadol ER, fentanyl patch, methadone Astepro azelastine, fluticasone propionate Avinza morphine sulfate ER, hydromorphone ER, tramadol ER, fentanyl patch, methadone Axiron testosterone cypionate, testosterone gel (Androgel ), Androderm Azelex Beconase AQ fluticasone propionate, azelastine, ipratropium bromide nasal spray Updated 12/14/2017 Page 2 of 18

3 Belbuca morphine sulfate ER, hydromorphone ER, tramadol ER, fentanyl patch, methadone Belsomra zolpidem, eszopiclone, zaleplon, trazodone, flurazepam, temazepam Benzoyl Peroxide Betimol levobunolol, betaxolol, carteolol, metipranolol, timolol Bevespi Aerosphere Serevent Diskus plus Spiriva, Anoro Ellipta, Stiolto Respimat Brisdelle paroxetine, venlafaxine, venlafaxine ER BromSite bromfenac 0.09% ophthalmic solution Byvalson metoprolol ER or atenolol plus valsartan, Bystolic plus valsartan Cambia generic nonsteroidal anti-inflammatory drugs such as diclofenac potassium, diclofenac sodium, naproxen, ibuprofen Carac Tolak, fluorouracil (generic Efudex ), imiquimod (generic Aldara ) Carospir generic Aldactone Centany mupirocin ointment (generic Bactroban ) Cialis daily for BPH alfuzosin, doxazosin mesylate, dutasteride, dutasteride/tamsulosin, tamsulosin, terazosin Updated 12/14/2017 Page 3 of 18

4 clindamycin phosphate (lotion, gel, solution) clindamycin phosphate swabs, adapalene 0.1%, clindamycin phosphate/benzoyl peroxide, erythromycin/benzoyl peroxide Combigan brimonidine tartrate plus timolol maleate, dorzolamide hcl/timolol maleate, Cosopt PF Cordran Cotempla XR betamethasone dipropionate, betamethasone valerate, fluticasone, hydrocortisone butyrate, mometasone, triamcinolone amphetamine/dextroamphetamine, methylphenidate hcl Cuprimine Depen Cuvitru Gammagard liquid, Gammaked, Gamunex-C sub-q, Hizentra, HyQvia Demerol morphine sulfate IR, oxycodone hcl IR, hydromorphone hcl, tramadol desoximetasone desvenlafaxine ER desvenlafaxine succinate (generic Pristiq ) betameth diprop/prop gly, betamethasone dipropionate, betamethasone valerate, diflorasone diacetate, fluocinonide, triamcinolone acetonide Dexilant, Dexilant Solutab omeprazole, lansoprazole, pantoprazole, rabeprazole Differin lotion adapalene 0.1% cream, adapalene 0.1% gel Donnatal chlordiazepoxide/clidinium br, hyoscyamine sulfate Doryx minocycline hcl (generic Minocin ), doxycycline monohydrate capsule (generic Monodox ), doxycycline hyclate (generic Vibramycin ), tetracycline hcl Updated 12/14/2017 Page 4 of 18

5 Doxycycline IR-DR minocycline hcl (generic Minocin ), doxycycline monohydrate capsule (generic Monodox ), doxycycline hyclate (generic Vibramycin ), tetracycline hcl Duac Duexis ibuprofen plus famotidine Durlaza aspirin 81mg, aspirin 325mg Duzallo colchicine/probenecid, colchicine tablet, probenecid, Uloric, allopurinol Dyanavel XR amphetamine/dextroamphetamine, methylphenidate hcl Dymista azelastine plus fluticasone propionate Ecoza fluconazole, terbinafine, ketoconazole, econazole, itraconazole Edluar zolpidem tartrate, zaleplon, estazolam Enablex oxybutynin, tolterodine, trospium Enstilar calcipotriene plus betamethasone dipropionate, calcipotriene/betamethasone Epaned enalapril tablet Epanova omega-3 acid ethyl esters Updated 12/14/2017 Page 5 of 18

6 Epiduo, Epiduo Forte Epipen epinephrine auto-injector erythromycin topical soln, gel clindamycin phosphate swabs, erythromycin/benzoyl peroxide esomeprazole omeprazole, lansoprazole, pantoprazole, rabeprazole Evekeo amphetamine/dextroamphetamine, methylphenidate hcl Evzio Narcan nasal spray, naloxone injection Fabior fenoprofen 200mg and 400mg (Fenortho, Nalfon ) Fentora diclofenac, etodolac, fenoprofen 600mg, ibuprofen, meloxicam, naproxen, piroxicam morphine sulfate IR, oxycodone IR, hydromorphone, fentanyl citrate Fetzima citalopram, fluoxetine, venlafaxine, sertraline, bupropion Flector FloLipid generic nonsteroidal anti-inflammatory drugs such as diclofenac sodium, meloxicam, etodolac, naproxen, ibuprofen simvastatin, pravastatin, atorvastatin, lovastatin, fluvastatin, rosuvastatin Fluocinonide 0.1% cream clobetasol, betamethasone, halobetasol Updated 12/14/2017 Page 6 of 18

7 Focalin XR amphetamine/dextroamphetamine, methylphenidate hcl Forfivo XL citalopram, fluoxetine, sertraline, venlafaxine, bupropion Fortesta testosterone cypionate, testosterone gel (Androgel ), Androderm Fosrenol calcium acetate, Renagel, sevelamer carbonate (generic Renvela ) Gelnique tolterodine, oxybutynin, darifenacin, trospium Glumetza metformin Glyxambi glimepiride, glyburide, metformin, pioglitazone, Janumet, Janumet XR, Januvia, Jardiance Onglyza, Invokana, Farxiga, Synjardy, Synjardy XR Gocovri amantadine (generic Symmetrel ) Gralise gabapentin, generic tricyclic antidepressants, tramadol, duloxetine Grastek zafirlukast, montelukast, fluticasone propionate, levocetirizine, azelastine Hemangeol propranolol oral solution Horizant pramipexole, gabapentin, generic tricyclic antidepressants, ropinirole Humalog Novolin, Novolog Updated 12/14/2017 Page 7 of 18

8 Humulin Novolin, Novolog hydrocortisone (Anusol HC, Proctocream-HC ) Hysingla ER hydrocortisone/pramoxine, hydrocortisone/lidocaine, hydrocortisone acetate fentanyl patch, hydromorphone ER, morphine sulfate ER, methadone Ilevro ketorolac, bromfenac, flurbiprofen, diclofenac, Nevanac Incruse Ellipta Atrovent HFA, Spiriva, Spiriva Respimat, Tudorza Pressair Intermezzo zolpidem tartrate, zaleplon Intuniv amphetamine/dextroamphetamine, methylphenidate, clonidine ER, atomoxetine (generic Strattera ) isotretinoin Jadenu, Jadenu Sprinkle deferoxamine, Exjade Jentadueto metformin/glipizide, glyburide/metformin, pioglitazone/metformin, Janumet, Janumet XR Jentadueto XR glimepiride, glyburide, metformin, pioglitazone, Janumet, Janumet XR, Januvia, Jardiance Onglyza, Invokana, Farxiga, Synjardy, Synjardy XR Jublia topical ciclopirox, oral itraconazole, oral terbinafine, griseofulvin Juxtapid Kynamro Updated 12/14/2017 Page 8 of 18

9 Kadian morphine sulfate ER, hydromorphone ER, tramadol ER, fentanyl patch, methadone Karbinal ER levocetirizine, clemastine Kazano glimepiride, glyburide, metformin, pioglitazone, Janumet, Janumet XR, Januvia, Onglyza, Invokana, Farxiga, Synjardy, Synjardy XR Kerydin topical ciclopirox, oral itraconazole, oral terbinafine, griseofulvin Khedezla citalopram, fluoxetine, venlafaxine, sertraline, bupropion Kristalose lactulose Levsinex hyoscyamine, dicyclomine Lidoderm lidocaine 5% ointment, lidocaine/prilocaine cream Liptruzet atorvastatin plus ezetimibe Locoid lotion Luxiq Luzu topical mometasone furoate (generic Elocon ), topical triamcinolone (generic Kenalog ), topical hydrocortisone (generic Locoid, generic Westcort ), topical fluocinolone acetonide (generic Synalar ) clobetasol shampoo, hydrocortisone butyrate solution, flucinonide solution, mometasone furoate solution, Capex shampoo ketoconazole, ciclopirox, clotrimazole, nystatin, econazole meclizine promethazine Updated 12/14/2017 Page 9 of 18

10 Mirapex ER pramipexole Mircera Procrit, Aranesp Epogen Mitigare colchicine tablet, Colcrys Movantik Amitiza, Glycolax, lactulose Mydayis amphetamine/dextroamphetamine, methylphenidate hcl Myorisan Namzaric memantine plus donepezil Naprelan diclofenac, naproxen, ibuprofen, meloxicam, nabumetone, etodolac, flurbiprofen Nasalide fluticasone propionate, azelastine, ipratropium bromide nasal spray Nasonex fluticasone propionate, azelastine, ipratropium bromide nasal spray Natesto testosterone cypionate, testosterone gel (Androgel ), Androderm Nesina glimepiride, glyburide, metformin, pioglitazone, Janumet, Janumet XR, Januvia, Onglyza, Invokana, Farxiga, Synjardy, Synjardy XR Norgesic Forte baclofen, cyclobenzaprine, chlorzoxazone, methocarbamol, metaxalone, carisprodol, tizanidine Updated 12/14/2017 Page 10 of 18

11 Oleptro ER trazodone omeprazole-sodium bicarbonate (generic Zegerid ) Omnaris omeprazole, lansoprazole, pantoprazole, rabeprazole fluticasone propionate, azelastine, ipratropium bromide nasal spray Omtryg omega-3 acid ethyl esters Onexton Onmel topical ciclopirox, oral itraconazole, oral terbinafine, griseofulvin Onzetra Xsail sumatriptan nasal spray, Zomig nasal spray, oral sumatriptan, naratriptan, frovatriptan, rizatriptan Opana morphine sulfate IR, oxycodone IR, hydromorphone Opana ER fentanyl patch, hydromorphone ER, morphine sulfate ER, methadone Oracea minocycline hcl (generic Minocin ), doxycycline monohydrate capsule (generic Monodox ), doxycycline hyclate (generic Vibramycin ), tetracycline hcl Oralair zafirlukast, montelukast, fluticasone propionate, levocetirizine, azelastine Oseni glimepiride, glyburide, metformin, pioglitazone, Janumet, Janumet XR, Januvia, Onglyza Invokana, Farxiga, Synjardy, Synjardy XR Osmoprep polyethylene glycol 3350 (generic Glycolax ), generic Colyte, generic Golytely, generic Nulytely Updated 12/14/2017 Page 11 of 18

12 Otrexup methotrexate Oxaydo tolterodine, oxybutynin, darifenacin, trospium Oxistat Oxtellar XR ketoconazole, ciclopirox, clotrimazole, nystatin, econazole, oral fluconazole, oral itraconazole, oral terbinafine divalproex sodium, gabapentin, topiramate, lamotrigine, oxcarbazepine, carbamazepine oxymorphone hcl (generic Opana ) morphine sulfate IR, oxycodone IR, hydromorphone oxymorphone hcl ER (generic Opana ER ) Oxytrol fentanyl patch, methadone, morphine sulfate ER tolterodine, oxybutynin, darifenacin, trospium Pancreaze Creon, Zenpep Patanase fluticasone propionate, azelastine, ipratropium bromide nasal spray Pazeo olopatadine (generic Patanol, generic Pataday ), azelastine, epinastine, Alocril, Pennsaid oral diclofenac, naproxen, ibuprofen, meloxicam, nabumetone, etodolac, flurbiprofen Pertyze Creon, Zenpep Phenytek phenytoin Updated 12/14/2017 Page 12 of 18

13 Plegridy glatiramer acetate (Copaxone ), Avonex, Gilenya, Rebif, Tecfidera Prepopik polyethylene glycol 3350 (generic Glycolax ), generic Colyte, generic Golytely, generic Nulytely Prestalia perindopril plus amlodipine, amlodipine/valsartan, amlodipine/benazepril, amlodipine/telmisartan Prevacid Solutab lansoprazole Prevpac lansoprazole plus amoxicillin plus clarithromycin Prolensa ketorolac, bromfenac, flurbiprofen, diclofenac, Nevanac Qbrelis lisinopril tablet Qnasl, Qnasl children s fluticasone propionate, azelastine, ipratropium bromide nasal spray Qtern glimepiride, glyburide, metformin, pioglitazone, Janumet, Janumet XR, Januvia, Jardiance Onglyza, Invokana, Farxiga, Synjardy, Synjardy XR Qudexy XR levetiracetam, valproic acid, divalproex, lamotrigine, carbamazepine, oxcarbazepine, topiramate Quillichew ER amphetamine/dextroamphetamine, methylphenidate hcl Quillivant XR amphetamine/dextroamphetamine, methylphenidate hcl Ragwitek zafirlukast, montelukast, fluticasone propionate, levocetirizine, azelastine Updated 12/14/2017 Page 13 of 18

14 Rasuvo methotrexate Rayos prednisone, cortisone, prednisolone Relistor Amitiza, Glycolax, lactulose Retin-A Micro Rexulti aripiprazole, clozapine, risperidone, quetiapine, olanzapine, ziprasidone Rytary carbidopa/levodopa, carbidopa/levodopa/entacapone Sernivo Spray betamethasone dipropionate, betamethasone valerate, fluticasone, hydrocortisone butyrate, mometasone, triamcinolone Signifor LAR ketoconazole, Signifor Silenor zolpidem tartrate, trazodone, zaleplon Siliq Humira, methotrexate, Cosentyx, Otezla, Stelara Simbrinza dorzolamide/timolol, brimonidine, bimatoprost, Cosopt PF Sitavig acyclovir, famciclovir, valacyclovir Soliqua Bydureon, Bydureon Bcise, Victoza, Trulicity Updated 12/14/2017 Page 14 of 18

15 Solodyn minocycline hcl (generic Minocin ), doxycycline monohydrate capsule (generic Monodox ), doxycycline hyclate (generic Vibramycin ), tetracycline hcl Soma compound baclofen, cyclobenzaprine, chlorzoxazone, methocarbamol, metaxalone, carisprodol, tizanidine Soolantra Sotylize topical metronidazole 0.75%, Finacea gel, minocycline hcl (generic Minocin ), doxycycline monohydrate capsule (generic Monodox ), doxycycline hyclate (generic Vibramycin ), tetracycline hcl sotolol, verapamil, diltiazem, propranolol Spritam levetiracetam, valproic acid, divalproex, lamotrigine, carbamazepine, oxcarbazepine, topiramate Striverdi Respimat Serevent Diskus, Spiriva, Spiriva Respimat Subsys morphine sulfate IR, oxycodone hcl IR, hydromorphone hcl, fentanyl citrate Suclear polyethylene glycol 3350 (generic Glycolax ), generic Colyte, generic Golytely, generic Nulytely Sumavel Dosepro naratriptan hcl, sumatriptan, nizatriptan benzoate, zolmitriptan Symproic Amitiza, Glycolax lactulose Syndros granisetron, ondansetron, aprepitant, promethazine, megesterol, dronabinol Taltz Humira, methotrexate, Cosentyx, Otezla, Stelara Tanzeum Bydureon, Bydureon Bcise, Victoza, Trulicity Updated 12/14/2017 Page 15 of 18

16 Testim testosterone cypionate, testosterone gel (Androgel ), Androderm Tivorbex oral diclofenac, naproxen, ibuprofen, meloxicam, nabumetone, etodolac, flurbiprofen Tobi Podhaler tobramycin nebulizer solution (generic Tobi ) Treximet Trokendi XR Trulance generic triptan (such as naratriptan hcl, sumatriptan, nizatriptan benzoate, zolmitriptan) plus generic nonsteroidal anti-inflammatory (such as naproxen or ibuprofen) levetiracetam, valproic acid, divalproex, lamotrigine, carbamazepine, oxcarbazepine, topiramate, metoprolol, propranolol, amitriptyline Amitiza, Glycolax, lactulose Uceris sulfasalazine, balsalazide, mesalamine, Delzicol, Pentasa, prednisolone, prednisone Ultravate lotion betamethasone dipropionate lotion, clobetasol, fluocinonide, halobetasol cream/ointment Varubi granisetron, ondansetron, Emend Vascepa gemfibrozil, omega-3 acid ethyl esters, fenofibrate, fenofibrate (micronized), fenofibric acid Velphoro calcium acetate, Renagel, sevelamer carbonate (generic Renvela ) Veramyst fluticasone propionate, azelastine, ipratropium bromide nasal spray Versacloz clozapine Updated 12/14/2017 Page 16 of 18

17 Viberzi hyoscyamine, dicyclomine, citalopram, fluoxetine, sertraline, amitriptyline Viekira XR Zepatier, Epclusa Vimovo generic proton pump inhibitor (such as omeprazole, pantoprazole, lansoprazole, rabeprazole ) plus generic non-steroidal antiinflammatory (such as naproxen or ibuprofen) Viokace Creon, Zenpep Vivlodex oral diclofenac, naproxen, ibuprofen, meloxicam, nabumetone, etodolac, flurbiprofen Vogelxo testosterone cypionate, testosterone gel (Androgel ), Androderm Xhance fluticasone propionate, azelastine, ipratropium bromide nasal spray Ximino minocycline hcl (generic Minocin ), doxycycline monohydrate capsule (generic Monodox ), doxycycline hyclate (generic Vibramycin ), tetracycline hcl Xtampza ER fentanyl patch, hydromorphone ER, morphine sulfate ER, methadone Zegerid omeprazole, lansoprazole, pantoprazole, rabeprazole Zembrace SymTouch sumatriptan, naratriptan, frovatriptan, rizatriptan Zenatane Zohydro ER generic fentanyl patch, methadone, morphine sulfate ER, hydromorphone ER Updated 12/14/2017 Page 17 of 18

18 Zorvolex oral diclofenac, naproxen, ibuprofen, meloxicam, nabumetone, etodolac,flurbiprofen Zovirax cream acyclovir ointment, acyclovir tablets, valacyclovir tablets Zurampic colchicine/probenecid, colchicine tablet, probenecid, Uloric, allopurinol Updated 12/14/2017 Page 18 of 18