Generic Preventive Therapy Drug List (as of 01/1/2018)
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1 ANTICOAGULANTS/ANTIPLATELETS ANTICOAGULANTS enoxaparin fondaparinux warfarin Jantoven PLATELET AGGREGATION INHIBITORS clopidogrel dipyridamole dioyridamole ext-rel/aspirin prasugrel ANTICONVULSANTS carbamazepine carbamazepine ext-release clonazepam divalproex sodium delayed-rel divalproex sodium ext-release Epitol ethosuximide felbamate lamotrigine lamotrigine ext-release levetiracetam/xr oxcarbazepine Phenobarbital phenytoin phenytoin sodium extended primidone tiagabine topiramate topiramate ext-release valproic acid vigabatrin zonisamide Lovenox Arixtra Coumadin Plavix Persantine Tegretol Tegretol XR Klonopin Depakote Depakote ER Zarontin Felbatol Lamictal Lamictal Keppra/XR Trileptal Dilantin Phenytek Mysoline Gabitril Topamax Qudexy XR Depakene Zonegran CARDIOVASCULAR CONDITIONS - OTHER ANTIARRHYTHMIC AGENTS amiodarone disopyramide dofetilide flecainide propafenone ext-release propafenone sotalol sotalol AF Pacerone ORAL ANTIANGINAL AGENTS isosorbide dinitrate isosorbide dinitrate ext-rel isosorbide mononitrate isosorbide mononitrate ext-rel SL and chewable formulations are not included on this list. Pacerone Norpace Rythmol XR Rythmol Betapace Betapace AF Isordil Imdur TRANSDERMAL/TOPICAL ANTIANGINAL AGENTS nitroglycerin transdermal Nitrodur Minitran CORONARY ARTERY DISEASE ANTIHYPERLIPIDEMICS amlodipine/atorvastatin atorvastatin cholestyramine colestipol ezetimibe ezetimibe/simvastatin fenofibrate fenofibric acid fenofibric acid delayed-rel Fluvastatin Fluvalstatin ext-rel Caduet Lipitor Questran Colestid Lofibra/Tricor Fibricor Trilipix Lescol
2 CORONARY ARTERY DISEASE ANTIHYPERLIPIDEMICS CONT. gemfibrozil lovastatin niacin ext-rel pravastatin rosuvastatin simvastatin Niacor Prevalite DIABETES Lopid Mevacor Pravachol Crestor Zocor Over-the-Counter (OTC) products require a prescription. Coverage may vary by plan. ORAL DIABETES AGENTS acarbose alogliptin alogliptin/metformin alogliptin/pioglitazone chlorpropamide glimepiride glipizide glipizide ext-release glipizide/metformin glyburide glyburide, micronized glyburide/metformin metformin metformin ext-release miglitol nateglinide pioglitazone pioglitazone/glimepride pioglitazone/metformin repaglinide repaglinide/metformin Precose Diabinese Amaryl Glucotrol Glucotrol XR Metaglip Micronase Glynase Glucovance Glucophage Glucophage XR Starlix Duetact Prandin tolbutamide Orinase HYPERTENSION ACE INHIBITORS/ANGIOTENSIN II RECEPTOR ANTAGONISTS & COMBINATION AGENTS amlodipine/benazepril Lotrel benazepril Lotensin benazepril/hydrochlorothiazide candesartan/hydrochlorothiazide Atacand HCT candesartan Atacand captopril Capoten captopril/hydrochlorothiazide Capozide enalapril Vasotec enalapril/hydrochlorothiazide Vaseretic eprosartan Surmontil fosinopril Monopril fosinopril/hydrochlorothiazide Monopril HCT irbesartan Avapro irbesartan/hydrochlorothiazide Avalide lisinopril Prinivil lisinopril/hydrochlorothiazide Prinizide losartan Cozaar losartan/hydrochlorothiazide Hyzaar moexipril Univasc moexipril/hydrochlorothiazide Unitretic olmesartan olmesartan/hydrochlorothiazide perindopril Aceon quinapril Accupril quinapril/hydrochlorothiazide Accuretic ramipril Altace telmisartan Micardis telmisartan/hydrochlorothiazide Micardis HCT trandolapril Mavik trandolapril/verapamil ext-rel Valsartan Diovan Valsartan/hyrdochlorothiazide Diovan HCT
3 BETA-BLOCKERS AND COMBINATION AGENTS CONT. acebutolol Sectral atenolol Tenmormin atenolol/chlorthalidone Tenoretic betaxolol Kerlone bisoprolol Zebeta bisoprolol/hydrochlorothiazide Ziac carvedilol Coreg carvedilol phosphate ext-rel labetalol Trandate metoprolol metoprolol succinate ext-rel metoprolol/hydrochlorothiazide nadolol Corgard nadolol/bendroflumethiazide Corzide pindolol Visken propranolol propranolol ext-rel InopranXL propranolol/hydrochlorothiazideinderide timolol maleate Blocadren CALCIUM CHANNEL BLOCKERS AND COMBINATION AGENTS amlodipine Norvasc diltiazem Cardizem diltiazem ext-release Cardizem LA diltiazem XR Cardizem CD felodipine ext-release isradipine nicardipine Cardene SR nifedipine Procardia nifedipine ext-release Procardia XL nisoldipine ext-release Sular verapamil Calan verapamil ext-release Calan XR Afeditab CR Cartia XT Dilt-XR Matzim LA Nifediac CC Taztia XT DIURETICS amiloride/hydrochlorothiazide chlorothiazide chlorthalidone hydrochlorothiazide indapamide methyclothiazide spironolactone/hydro chlorothiazide triamterene/hydrochlorothiazide OTHER ANTIHYPERTENSIVE AGENTS amlodipine/telmisartan amlodipine/olmesartan amlodipine/valsartan/hydrochlorothiazide clonidine clonidine transdermal guanabenz guanfacine hydralazine methyldopa methyldopa/hydrochlorothiazide minoxidil OTHER ANTIHYPERTENSIVE AGENTS CONT. olmesartan/amlodipine/hydrochlorothiazide clorpres Moduretic Aldactazide Dyazide Micardis Tenex MENTAL HEALTH ANTIDEPRESSANTS AND OBSESSIVE COMPOULSIVE DISORDER amitriptyline amoxapine bupropion Wellbutrin bupropion ext-release Wellbutrin XL
4 MENTAL HEALTH ANTIDEPRESSANTS AND OBSESSIVE COMPOULSIVE DISORDER CONT. citalopram Celexa clomipramine Anafranil desipramine Norpramin desvenlafaxine ext-rel doxepin duloxetine delayed release Cymbalta escitalopram Lexapro fluoxetine Prozac fluoxetine delayed-rel fluvoxamine Luvox CR fluvoxamine ext-rel imipramine HCl Tofranil imipramine pamoate Tofranil PM maprotiline mirtazapine Remeron nortriptyline paroxetine HCl Paxil paroxetine HCl ext-release Paxil CR phenelzine Nardil protriptyline Vivactil sertraline Zoloft tranylcypromine Parnate trazodone Oleptro CR trimipramine Surmontil venlafaxine Effexor venlafaxine ext-release Effexor XR Irenka ANTIPSYCHOTICS aripiprazole chlorpromazine clozapine fluphenazine fluphenazine decanoate Fazaclo haloperidol loxapine olanzapine olanzapine/odt paliperidone perphenazine quetiapine quetiapine ext-rel risperidone thioridazine thiothixene trifluoperazine ziprasidone OSTEOPOROSIS alendronate calcitonin calcitonin-salmon ibandronate raloxifene risedronate zolendronic 5 mg PREVENTIVE CARE SERVICES AGENTS FOR CHEMICAL DEPENDENCY Acamprosate calcium Buprenorphine sublingual Buprenorphone/naloxone sublingual disulfiram naltrexone Depade ANTI-OBESITY AGENTS benzphetamine diethylpropion diethylpropion ext-rel phendimetrazine Haldol Loxitane Zyprexa Seroquel Risperdal Navane Geodon Fosamax Miacalcin Boniva Evista Actonel Buprenex Suboxone SL Antabuse Revia Bidrex Bontril
5 PREVENTIVE CARE SERVICES ANTI-OBESITY AGENTS CONT. phendimetrazine ext-rel phentermine Adipex-P mycophenolate sodium delayed-release sirolimus tacrolimus Gengraf Myfortic Rapamune Prograf BOWEL PREPARATIONS Peg 3350/electrolytes Gavilyte SMOKING DETERRENTS bupropion ext-release nicotine polacrilex nicotine transdermal Colyte Nulytely Zyban Nicorette MULTIPLE SCLEROSIS AGENTS Glatiramer WOMEN'S HEALTH AROMATASE INHIBITORS anastrozole exemestane letrozole Arimidex Aromasin Femara Over-the-Counter (OTC) products require a prescription. Coverage may vary by plan. RESPIRATORY DISORDERS RESPIRATORY AGENTS budesonice suspension cromolyn sodium fluticasone/salmeterol zafirlukast montelukast zileuton ext-rel VARIOUS CONDITIONS ANTI-MALARIAL AGENTS atovaquone/proguanil chloroquine mefloquine Pulmicort Accolate Singulair Malarone Aralen ANTIESTROGENS Tamoxifen CONTRACEPTIVES CONTRACEPTIVES ALL GENERIC PRESCRIPTION FORMULATIONS Over-the-Counter (OTC) emergency contraceptive products require a prescription. Coverage may vary by plan. PRENATAL VITAMINS PRENATAL VITAMINS ALL GENERIC PRESCRIPTION PRODUCTS DENTAL CARIES PREVENTION Sodium fluoride IMMUNOSUPPRESSIVE AGENTS cyclosporine mycophenolate mofetil Sandimmune Cellcept
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Accupril Accuretic Acebutolol Aceon Activella Actonel Adalat CC Advicor Afeditab CR Aggrenox Aldactone Aldomet Aldoril Alendronate Alora Altace Altoprev Amiloride/HCTZ Amlodipine Amlodipine/Benazepril
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