Allergy Chlorpheniramine Tablet* Diphenhydramine Tablet* Diphenhydramine Liquid* Loratadine Tablet* Cetirizine Tablet* Loratadine 10mg ODT* Less than $10 Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL* Levocetirizine Tablet Fexofenadine 180 mg Tablet* Fluticasone nasal spray* Claritin 5 mg Reditabs (no generic available) Fexofenadine 60 mg Tablet Cetirizine chewables* Allegra ODT Azelastine nasal spray Allegra oral suspension Flunisolide nasal spray* Rhinoquart Aqua Nasal Spray Levocetirizine Liquid Nasonex Nasal Spray Patanase 0.6% Nasal Spray * formulary, step therapy $15-$25 $25 -$35 $45-$55 Greater than $125
Asthma Controllers Montelukast Tablets* Montelukast Chewables* Less than $20 Montelukast Granules* Flovent Diskus * Asmanex Twisthaler * $130 to $150 Pulmicort Flexhaler * Qvar Inhaler * Flovent HFA Inhaler* $150 to $200 Dulera Inhaler Symbicort Inhaler $200 to $250 Advair Diskus Advair HFA Inhaler $275 to $350 Budesonide Nebules Pulmicort Respules (1mg not available generically) >$700 * formulary, step therapy age limit Quantity Limit COPD Foradil Aerolizer $150 to $200 Serevent Diskus Atrovent HFA Inhaler Tudorza Pressair Inhaler $200 to $250 Symbicort Inhaler Combivent Respimat * Spiriva Handihaler * Advair Diskus $250 to $300 Advair HFA Inhaler * formulary, step therapy
ADHD Methylphenidate (Equivalent to Methylin )* Methylphenidate SR (Equivalent to Methylin ER )* Dexmethylphenidate IR (Equivalent to Focalin )* Dextroamphetamine IR (Equivalent to Dexedrine )* Amphetamine Salts IR (Equivalent to Adderall )* Methylphenidate ER (Equivalent to Ritalin LA ) Amphetamine Salts XR (Equivalent to Adderall XR )* Dextroamphetamine ER (Equivalent to Dexedrine Spanules )* Methylphenidate CD (Equivalent to Metadate CD ) Ritalin LA $20 to $30 $45 to $80 $125 to $155 Dexmethylphenidate XR (Equivalent to Focalin XR ) $160 to $200 Methylphenidate ER (Equivalent to Concerta ) Vyvanse Focalin XR Kapvay ER Intuniv ER Strattera $200 to $300 Daytrana Patch Quillivant XR Methylphenidate solution^ Nuvigil Modafinil (Equivalent to Provigil ) Greater than $400
* formulary, step therapy, ^Cost increases with higher doses 2014 Relative Cost for Select Drug Classes Neighborhood Health Plan of RI Second Generation Antipsychotics Olanzapine Tablets* Quetiapine Tablets* Risperidone Tablets* Risperidone Solution* $15 to $40 Ziprasidone Capsules*^ $85-$120 Abilify 1mg/ml Solution Abilify 15 mg Tablets Latuda Tablets Seroquel XR Tablets Invega ER <9 mg Tablets Saphris Tablets $400 to $450 $500 to $600 Abilify 20 mg Tablets $625 to $800 Invega ER 9 Mg Tablets Risperdal Consta Invega Sustenna * formulary, step therapy Quantity Limit Greater than $800 Quetiapine 25mg and 50 mg tablets require a prior authorization after 60 days of therapy. ^ Higher Strengths associated with higher costs for ziprasidone
Antidepressants Citalopram * Trazodone * Fluoxetine * Sertraline* Escitalopram* Paroxetine* Venlafaxine ER *^ Fluvoxamine* Buproprion SR* Venlafaxine IR*^ Buproprion XL* Buproprion IR* Duloxetine Viibryd Pristiq Fluvoxamine ER * formulary, step therapy Less than $10 $10 to $20 $25 to $35 Greater than $140 ^Note: Venlafaxine ER capsules are preferred. Tablets are non-formulary.
Proton Pump Inhibitors Omeprazole Capsules*^ Pantoprazole Tablets* Less than $15 Lansoprazole Capsules Prevacid 24HR Capsules Rabeprazole DR (generic Aciphex DR) $30 to $100 Omeprazole Reconstitution Dexilant Capsules Prevacid Solutab Prilosec Protonix Suspension $150 to $200 $200 to $300 Nexium Capsules Zegrid Packets Greater than $600 * formulary ^Note: Omeprazole Capsules are preferred. The OTC tablets are non-formulary.