Upper Peninsula Health Plan Advantage (HMO) (List of Covered Drugs)
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1 Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 morphine sulfate 30 mg tablet er Opioid Analgesics, Short-acting fentanyl citrate 200 mcg lozenge hd hydrocodone/acetaminophen 5 mg-325mg tablet oxycodone hcl/acetaminophen 10mg-325mg tablet tramadol hcl 50 mg tablet Antibacterials Aminoglycosides amikacin sulfate 500 mg/2ml vial tobramycin sulfate 40 mg/ml vial Antibacterials, Other vancomycin hcl 500 mg vial Beta-lactam, Cephalosporins cephalexin 500 mg capsule Beta-lactam, Penicillins amoxicillin 500 mg capsule Macrolides ERYPED 200 Quinolones ciprofloxacin hcl 250 mg tablet Tetracyclines doxycycline hyclate 100 mg tablet minocycline hcl 75 mg capsule H2161_002_2015_P1085_Accepted
2 Anticonvulsants Upper Peninsula Health Plan Advantage (HMO) (List of Covered Drugs) Sodium Channel Agents VIMPAT 150 MG TABLET Antidementia Agents Cholinesterase Inhibitors donepezil hcl 5 mg tablet N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA 5 MG TABLET Antidepressants Antidepressants, Other mirtazapine 15 mg tablet SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibito citalopram hydrobromide 40 mg tablet fluoxetine hcl 20 mg capsule VENLAFAXINE HCL ER 37.5 MG TAB Antiemetics Antiemetics, Other meclizine hcl 12.5 mg tablet promethazine hcl 12.5 mg tablet Emetogenic Therapy Adjuncts granisetron hcl 1 mg tablet Antifungals fluconazole 10 mg/ml susp recon 2
3 Antimycobacterials Antituberculars isoniazid (100 mg tablet, 300 mg tablet) rifampin 300 mg capsule Antineoplastics Antineoplastics, Other doxorubicin hcl 2 mg/ml vial Antipsychotics 2nd Generation/Atypical risperidone (0.5 mg tablet, 2 mg tablet) Antivirals Anti-hepatitis B (HBV) Agents SYLATRON 300 MCG 4-PACK Antiherpetic Agents famciclovir 250 mg tablet Anxiolytics diazepam 5 mg tablet Bipolar Agents Mood Stabilizers lithium carbonate 300 mg tablet Blood Glucose Regulators Antidiabetic Agents pioglitazone hcl 15 mg tablet 3
4 Cardiovascular Agents Alpha-adrenergic Agonists midodrine hcl 2.5 mg tablet Angiotensin II Receptor Antagonists irbesartan 150 mg tablet Angiotensin-converting Enzyme (ACE) Inhibitors captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet) lisinopril 5 mg tablet Beta-adrenergic Blocking Agents metoprolol succinate 100 mg tab er 24h metoprolol tartrate (50 mg tablet, 100 mg tablet) Cardiovascular Agents, Other digoxin 250 mcg tablet lisinopril/hydrochlorothiazide 20-25mg tablet quinapril/hydrochlorothiazide 20-25mg tablet Diuretics, Loop bumetanide 2 mg tablet furosemide 40 mg tablet Diuretics, Potassium-sparing eplerenone spironolactone 50 mg tablet Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines dextroamphetamine/amphetamine 25 mg cap er 24h Dermatological Agents calcipotriene % solution 4
5 isotretinoin 40 mg capsule TAZORAC 0.1% GEL Gastrointestinal Agents Histamine2 (H2) Receptor Antagonists famotidine 10 mg/ml vial ranitidine hcl 15 mg/ml syrup Genitourinary Agents Antispasmodics, Urinary TOVIAZ ER 4 MG TABLET Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) dexamethasone 6 mg tablet dexamethasone sod phosphate 4 mg/ml vial hydrocortisone 10 mg tablet hydrocortisone 2.5 % oint. (g) mometasone furoate (0.1 % oint. (g), 0.1 % solution) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) norethindrone-ethinyl estrad 1 mg-35mcg tablet Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents propylthiouracil 50 mg tablet Immunological Agents Immune Suppressants methotrexate sodium/pf 25 mg/ml vial 5
6 Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs LUMIGAN 0.01% EYE DROPS Otic Agents CIPRODEX Respiratory Tract/ Pulmonary Agents Respiratory Tract Agents, Other ADVAIR HFA MCG INHALER Sleep Disorder Agents GABA Receptor Modulators zaleplon 10 mg capsule Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/Mineral Replacement dextrose 2.5 % and 0.45 % sodium chloride water for irrigation,sterile 6
7 This formulary was updated on 10/27/2015. For more recent information or other questions, please contact us, Upper Peninsula Health Plan Advantage (HMO), at or, for TTY users, TTY/TDD 711 or 711, 8 am to 9 p.m. Eastern time, Monday through Friday, with weekend hours October 1 through February 14, or visit
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Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 fentanyl citrate 200 mcg lozenge hd morphine sulfate 30 mg tablet er oxymorphone hcl 7.5 mg tab er 12h Opioid Analgesics, Short-acting
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