12
General Revenue Prescription Drug Formulary Updated January 2021 General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic, whichever is less expensive at the time of dispensing. 1 Generic Name Brand Name Analgesics Acetaminophen Tylenol Acetaminophen/ Codeine Tylenol with Codeine #3 Acetaminophen/ Oxycodone Percocet Celecoxib Celebrex Diclofenac Gel 1 % Voltaren Gel Fentanyl Duragesic Hydrocodone/ Acetaminophen Vicodin Ibuprofen Motrin, Advil Lidocaine 5% patch Lidoderm patch Lidocaine Viscous Xylocaine Meloxicam Mobic Methadone Methadose Morphine Sulfate (ER/IR) MS Contin, Roxanol Naproxen Naprosyn Oxycodone Oxycodone Tramadol Ultram Anti-gout Allopurinol Zyloprim Colchicine Colcrys Appetite Stimulants Dronabinol Marinol Megestrol Megace Antimicrobials/antifungals/antiparasitics Albendazole Albenza Amikacin Amikin Amoxicillin Amoxil Amoxicillin/Clavulanate Augmentin Atovaquone Mepron Azithromycin Zithromax Capreomycin Capastat Cefdinir Omnicef Cephalexin Keflex Chloroquine Phosphate Aralen Ciprofloxacin Cipro Clarithromycin Biaxin Clindamycin Cleocin Clotrimazole Troche Mycelex Troche Cycloserine Seromycin Dapsone Aczone Dicloxacillin Dycill, Pathocil Doxycycline V”Pibramycin, Vibratab Erythromycin Base Erythromycin Base Ethambutol Myambutol

General Revenue Prescription Drug Formulary Updated

  • Upload
    others

  • View
    8

  • Download
    0

Embed Size (px)

Citation preview

General Revenue Prescription Drug Formulary

Updated January 2021

General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,

whichever is less expensive at the time of dispensing.

1

Generic Name Brand Name

Analgesics Acetaminophen Tylenol

Acetaminophen/ Codeine Tylenol with Codeine #3

Acetaminophen/ Oxycodone Percocet

Celecoxib Celebrex Diclofenac Gel 1 % Voltaren Gel

Fentanyl Duragesic Hydrocodone/ Acetaminophen

Vicodin

Ibuprofen Motrin, Advil

Lidocaine 5% patch Lidoderm patch Lidocaine Viscous Xylocaine

Meloxicam Mobic

Methadone Methadose Morphine Sulfate (ER/IR) MS Contin, Roxanol

Naproxen Naprosyn Oxycodone Oxycodone

Tramadol Ultram

Anti-gout Allopurinol Zyloprim

Colchicine Colcrys Appetite Stimulants

Dronabinol Marinol

Megestrol Megace Antimicrobials/antifungals/antiparasitics

Albendazole Albenza

Amikacin Amikin Amoxicillin Amoxil

Amoxicillin/Clavulanate Augmentin Atovaquone Mepron

Azithromycin Zithromax Capreomycin Capastat

Cefdinir Omnicef

Cephalexin Keflex Chloroquine Phosphate Aralen

Ciprofloxacin Cipro Clarithromycin Biaxin

Clindamycin Cleocin

Clotrimazole Troche Mycelex Troche Cycloserine Seromycin

Dapsone Aczone Dicloxacillin Dycill, Pathocil

Doxycycline V”Pibramycin, Vibratab

Erythromycin Base Erythromycin Base Ethambutol Myambutol

General Revenue Prescription Drug Formulary

Updated January 2021

General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,

whichever is less expensive at the time of dispensing.

2

Fluconazole Diflucan

Hydroxychloroquine Plaquenil Isonicotinic acid hydrazide Isoniazid, INH

Itraconazole Sporanox

Ivermectin Stromectol Levofloxacin Levaquin

Linezolid Zyvox Metronidazole Flagyl

Minocycline Minocin Nitazoxanide Alinia

Nitrofurantoin Macrobid

Nystatin Mycostatin, Nystop Paromomycin Humatin

Penicillin G Benzathine/Penicillin G Procaine

Bicillin

Penicillin V Potassium Pen VK

Primaquine Phosphate Primaquine Probenecid Benemid

Pyrazinamide Pyrazinamide

Pyrimethamine Daraprim Rifabutin Mycobutin

Rifampin Rifadin Rifapentine Priftin

Streptomycin Streptomycin

Sulfadiazine Sulfadiazine Sulfamethoxazole/ Trimethoprim

Bactrim, Septra

Terbinafine Lamisil

Voriconazole Vfend

Antivirals Acyclovir Zovirax

Famciclovir Famvir Oseltamivir Tamiflu

Valacyclovir Valtrex Valganciclovir Valcyte

Antiepileptics

Carbamazepine Tegretol Gabapentin Neurontin

Lacosamide Vimpat Lamotrigine Lamictal

Levetiracetam Keppra

Oxcarbazepine Trileptal Phenobarbital Phenobarbital

Phenytoin Dilantin Topiramate Topamax

Valproic acid Divalproex, Depakote Anti-migraine

General Revenue Prescription Drug Formulary

Updated January 2021

General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,

whichever is less expensive at the time of dispensing.

3

Butalbital/Acetaminophen/ caffeine

Capacet, Fioricet

Naratriptan Amerge

Rizatriptan Maxalt Sumatriptan Imitrex

Anti-neoplastic

Anastrozole Arimidex Tamoxifen Soltamox, Nolvadex

Antiretrovirals Abacavir Ziagen

Abacavir/Dolutegravir/ Lamivudine

Triumeq

Abacavir/Lamivudine Epzicom Abacavir/Lamivudine/ Zidovudine

Trizivir

Atazanavir Reyataz

Atazanavir/Cobicistat Evotaz

Bictegravir/Emtricitabine/ TAF

Biktarvy

Cobicistat Tybost Darunavir Prezista

Darunavir/Cobicistat Prezcobix Darunavir/Cobicistat/ Emtricitabine/TAF

Symtuza

Delavirdine Rescriptor

Didanosine Videx Dolutegravir Tivicay

Dolutegravir/Rilpivirine Juluca

Doravirine Pifeltro Doravirine/Lamivudine/ TDF Delstrigo

Efavirenz Sustiva Efavirenz/Emtricitabine/ TDF Atripla

Efavirenz/Lamivudine/ TDF Symfi, Symfi Lo Elvitegravir/Cobicistat/ Emtricitabine/TAF

Genvoya

Elvitegravir/Cobicistat/ Emtricitabine/TDF

Stribild

Emtricitabine Emtriva

Emtricitabine/Rilpivirine/ TAF

Odefsey

Emtricitabine/Rilpivirine/ TDF

Complera

Emtricitabine/Tenofovir Alafenamide

Descovy

Emtricitabine/Tenofovir Disoproxil Fumarate

Truvada

Enfuvirtide Fuzeon

Etravirine Intelence

General Revenue Prescription Drug Formulary

Updated January 2021

General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,

whichever is less expensive at the time of dispensing.

4

Fosamprenavir Lexiva

Fostemsavir Rukobia Indinavir Crixivan

Lamivudine Epivir

Lamivudine/Dolutegravir Dovato Lamivudine/Tenofovir Disoproxil Fumarate

Cimduo

Lamivudine/Zidovudine Combivir

Lopinavir/Ritonavir Kaletra Maraviroc Selzentry

Nelfinavir Viracept Nevirapine Viramune

Raltegravir Isentress

Rilpivirine Edurant Ritonavir Norvir

Saquinavir Invirase Stavudine Zerit

Tenofovir Disoproxil Fumarate

Viread

Tipranavir Aptivus

Zidovudine Retrovir Cardiac

Amiloride Amiloride Amlodipine Norvasc

Amlodipine/Atorvastatin Caduet

Amlodipine/Benazepril Lotrel Atenolol Tenormin

Benazepril Lotensin

Bumetanide Bumex Candesartan Atacand

Candesartan/HCTZ Atacand HCT Carvedilol Coreg

Chlorthalidone Thalitone Clonidine Catapres

Digoxin Lanoxin

Diltiazem Cardizem Doxazosin Cardura

Enalapril/HCTZ Vaseretic Epinephrine EpiPen 2-Pak

Flecainide Flecainide

Furosemide Lasix Hydralazine Apresoline

Hydrochlorothiazide HydroDiuril Isosorbide Dinitrate Isordil

Isosorbide Mononitrate Imdur Labetalol Trandate

Lisinopril Zestril, Prinivil

Lisinopril/HCTZ Prinzide, Zestoretic

General Revenue Prescription Drug Formulary

Updated January 2021

General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,

whichever is less expensive at the time of dispensing.

5

Losartan Cozaar

Losartan/HCTZ Hyzaar Methyldopa Aldomet

Metoprolol Succinate Toprol XL

Metoprolol Tartrate Lopressor Minoxidil Minoxidil

Nadolol Corgard Nifedipine Adalat CC, Nifediac CC,

Afeditab CR, Procardia, Procardia XL

Nitroglycerin Nitrostat, NitroQuick Olmesartan Benicar

Prazosin Minipress Ranolazine Ranexa

Sacubitril/Valsartan Entresto

Simvastatin Zocor Spironolactone Aldactone

Spironolactone/HCTZ Aldactazide Triamterene/HCTZ Dyazide, Maxzide

Valsartan/HCTZ Diovan HCT

Verapamil Calan, Verelan Contraceptives

Ethinyl Estradiol and Desogestrel

Ethinyl Estradiol and Desogestrel

Ethinyl Estradiol and Drospirenone

Ethinyl Estradiol and Drospirenone

Ethinyl Estradiol and Etonogestrel

Nuvaring

Ethinyl Estradiol and Levonorgestrel

Ethinyl Estradiol and Levonorgestrel

Ethinyl Estradiol and Norethindrone

Ethinyl Estradiol and Norethindrone

Ethinyl Estradiol and Norethindrone and FE

Ethinyl Estradiol and Norethindrone and FE

Ethinyl Estradiol and Norgestimate

Ethinyl Estradiol and Norgestimate

Ethinyl Estradiol and Norgestrel

Ethinyl Estradiol and Norgestrel

Medroxyprogesterone Depo-Provera

Medroxyprogesterone Provera Norethindrone Norethindrone

Corticosteroids

Dexamethasone Dexamethasone Fludrocortisone Fludrocortisone

Methylprednisolone Medrol DosePak Prednisolone Orapred, Prelone

Prednisone Prednisone Dental

General Revenue Prescription Drug Formulary

Updated January 2021

General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,

whichever is less expensive at the time of dispensing.

6

Chlorhexidine Gluconate Peridex

Sodium Fluoride 1.1% PreviDent 5000 Dry Mouth Toothpaste

Diabetes Canagliflozin Invokana

Canagliflozin/Metformin Invokamet, Invokamet XR

50% Insulin Lispro protamine /50% Insulin Lispro

Humalog Mix 50/50

70% human insulin isophane/ 30% human insulin

Humulin 70/30, Novolin 70/30

70% Insulin Aspart protamine /30% Insulin Aspart

Novolog Mix 70/30

75% Insulin Lispro protamine/25% Insulin Lispro

Humalog Mix 75/25

Empagliflozin Jardiance Exenatide ER Bydureon

Glipizide Glucotrol Glipizide/Metformin Glipizide/Metformin

Glyburide Diabeta, Micronase

Glyburide/Metformin Glucovance

Insulin Aspart Novolog, Novolog Flexpen

Insulin Glargine Lantus, Lantus Solostar Insulin Lispro Humalog, Humalog

Kwikpen Insulin NPH Humulin N, Novolin N

Insulin Regular Humulin R, Novolin R

Liraglutide Saxenda, Victoza Metformin Glucophage

Pioglitazone Actos Sitagliptin Januvia

Sitagliptin/Metformin Janumet Gastrointestinal/Urinary

Aprepitant Emend

Atropine/Diphenoxylate Lomotil Bisacodyl Dulcolax

Calcium Polycarbophil Calcium Polycarbophil Clidinium/Chlordiazepoxide Librax

Dicyclomine Bentyl

Diphenhydramine Elixir, Nystatin Oral Suspension, Lidocaine 2% Viscous

Magic Mouthwash

Docusate Colace

General Revenue Prescription Drug Formulary

Updated January 2021

General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,

whichever is less expensive at the time of dispensing.

7

Electrolyte Solution Golytely

Enema Fleet Enema Esomeprazole Nexium

Famotidine Pepcid

Hydrocortisone Suppository

Anusol HC Suppository

Lactobacillus acidophilus Culturelle Lactulose Enulose

Loperamide Imodium Mesalamine Asacol HD, Delzicol

Methylcellulose Citrucel Metoclopramide Reglan

Ondansetron Zofran

Oxybutynin Ditropan Pantoprazole Protonix

Paregoric Camphorated Tincture of Opium

Phentermine Adipex-P, Lomaira Polyethylene glycol 3350 MiraLax

Pramoxine/Hydrocortisone Proctofoam HC

Psyllium Metamucil, Konsyl Rifaximin Xifaxan

Sennosides Senna Sodium Bicarbonate Neut

Solifenacin Succinate Vesicare

Tamsulosin Flomax Tolterodine Detrol

Ursodiol Actigall

Hematology Apixaban Eliquis

Aspirin Aspirin Cilostazol Pletal

Clopidogrel Plavix Dabigatran Pradaxa

Eltrombopag Promacta

Enoxaparin Lovenox Epoetin Alfa Procrit

Filgrastim Neupogen Hydroxyurea Hydrea

Peg-filgrastim Neulasta

Prasugrel Effient Rivaroxaban Xarelto

Warfarin Coumadin Hormones

Conjugated Estrogens Premarin Danazol Danocrine

Estradiol Estrace

Estradiol Patch Climara

General Revenue Prescription Drug Formulary

Updated January 2021

General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,

whichever is less expensive at the time of dispensing.

8

Estradiol Valerate Delestrogen

Finasteride Proscar Testosterone Androderm,

Depo-Testosterone, Androgel

Hyperlipidemia Atorvastatin Lipitor

Ezetimibe Zetia

Fenofibrate Tricor Gemfibrozil Lopid

Omega-3-Acid-Ethyl Esters Lovaza Pravastatin Pravachol

Rosuvastatin Crestor Mental Health

Alprazolam Xanax

Amitriptyline Elavil Amphetamine/ dextroamphetamine

Adderall, Adderall XR

Aripiprazole Abilify

Atomoxetine Strattera

Benztropine Cogentin

Bupropion Wellbutrin

Buspirone Buspar Carbidopa/ Levodopa Rytary, Sinemet

Chlorpromazine Chlorpromazine

Citalopram Celexa Clonazepam Klonopin

Desvenlafaxine Khedezla, Pristiq

Donepezil Aricept Doxepin Silenor

Duloxetine Cymbalta Escitalopram Lexapro

Eszopiclone Lunesta Fluoxetine Prozac

Haloperidol Haldol

Hydroxyzine Vistaril Imipramine Tofranil

Lithium Eskalith Lorazepam Ativan

Melatonin Melatonin

Methylphenidate Ritalin Mirtazapine Remeron

Nortriptyline Pamelor Olanzapine Zyprexa

Paliperidone Invega Paroxetine Paxil

Pregabalin Lyrica

Prochlorperazine Compazine

General Revenue Prescription Drug Formulary

Updated January 2021

General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,

whichever is less expensive at the time of dispensing.

9

Propranolol Inderal

Quetiapine Seroquel Risperidone Risperdal

Ropinirole Requip

Sertraline Zoloft Temazepam Restoril

Trazodone Desyrel Venlafaxine Effexor

Vilazodone Viibryd Ziprasidone Geodon

Zolpidem Ambien

Ophthalmic Acetazolamide Diamox

Atropine Sulfate 1% Isopto Atropine Bacitracin Bacitracin

Brimonidine Alphagan

Brimonidine/Timolol Combigan Cyclopentolate Cyclogyl

Dexamethasone Sod Phosphate 0.1%

Maxidex

Dorzolamide Trusopt Dorzolamide Hydrochloride-Timolol Maleate

Cosopt

Erythromycin Base Ophthalmic

Erythromycin Base Ophthalmic

Gentamycin Sulfate Gentak

Hydrocortisone/Neomycin/Polymyxin B

Hydrocortisone/Neomycin/Polymyxin B

Ketorolac Acular Latanoprost Xalatan

Methazolamide Neptazane

Moxifloxacin Vigamox Neomycin/Polymyxin/Dexamethasone 0.1%

Maxitrol

Olopatadine Pataday, Patanol, Pazeo

Polymyxin B Sulfate/TMP drops

Polytrim

Prednisolone Acetate 1% Pred Forte Sulfacetamide Sodium Sulfacetamide Sodium

Timolol Timoptic Tobramycin Sulfate 0.3% Tobrex

Osteoporosis

Alendronate Fosamax Otic

Hydrocortisone/Neomycin/Polymyxin B Solution

Cortisporin

Ofloxacin Floxin Otic

General Revenue Prescription Drug Formulary

Updated January 2021

General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,

whichever is less expensive at the time of dispensing.

10

Renal

Calcitriol Rocaltrol Calcium Acetate Phoslo

Cinacalcet Sensipar

Lanthanum Fosrenol Sevelamer Renagel, Renvela

Sodium Citrate and Citric Acid

Bicitra

Sodium Polystyrene Sulfonate

Kayexalate

Respiratory/Asthma/Allergy Albuterol Sulfate Proventil, Ventolin

Albuterol/Ipratropium Combivent Azelastine Astepro

Beclomethasone QVAR

Budesonide Rhinocort Budesonide/Formoterol Symbicort

Cetirizine Zyrtec Cetirizine/ Pseudoephedrine

Zyrtec D

Cyproheptadine Periactin

Diphenhydramine Benadryl

Fexofenadine Allegra Fluticasone Flonase

Fluticasone/ Salmeterol Advair, AirDuo, Wixela

Fluticasone/ Vilanterol Breo Ellipta Guaifenesin with Codeine Robitussin AC

Guaifenesin with Dextromethorphan

Robitussin DM

Hydroxyzine Vistaril, Atarax

Ipratropium Atrovent Loratadine Claritin

Loratadine/ Pseudoephedrine

Claritin D

Mometasone Asmanex, Nasonex Mometasone/ Formoterol Dulera

Montelukast Singulair Olopatadine Patanase

Salmeterol Serevent Diskus

Tiotropium Bromide Spiriva Skeletal Muscle Relaxant

Baclofen Lioresal Cyclobenzaprine Flexeril

Thyroid

Levothyroxine Synthroid Liothyronine Cytomel

Methimazole Tapazole Propylthiouracil (PTU) Propylthiouracil (PTU)

General Revenue Prescription Drug Formulary

Updated January 2021

General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,

whichever is less expensive at the time of dispensing.

11

Substance Abuse

Buprenorphine Buprenex, Butrans Buprenorphine/Naloxone Suboxone

Disulfiram Antabuse

Naloxone Narcan Spray Naltrexone Vivitrol, oral Naltrexone

Nicotine Nicoderm, Nicorette Topical

Ammonium Lactate 12% Lac-Hydrin Betamethasone Valerate/Dipropionate

Diprolene, Celestone

Clindamycin/Benzoyl Peroxide

Clindamycin/Benzoyl Peroxide

Clobetasol Propionate Clobetasol Propionate

Clotrimazole Lotrimin

Clotrimazole/ Betamethasone

Lotrisone

Dry Mouth Moisturizing Spray

Biotene

Fluocinolone Fluocinolone Fluocinonide Fluocinonide

Fluorouracil topical Efudex Hydrocortisone Hydrocortisone

Hydrocortisone/ Pramoxine Procort, Proctofoam HC

Hydrophor Aquaphor

Hydroquinone Nuquin HP Imiquimod 5% Aldara

Ketoconazole Nizoral

Metronidazole Metrogel Miconazole Monistat

Mupirocin 2% Bactroban Nystatin Mycostatin

Permethrin 5% Elimite Podofilox Condylox

Selenium Sulfide Selenium Sulfide

Silver Sulfadiazine 1% Silvadene Tacrolimus (topical only) Protopic

Terconazole Terazol Tretinoin Retin-A

Triamcinolone Acetonide Triamcinolone Acetonide

Nutrition/Vitamins

Calcium Carbonate + Vitamin D

Calcium Carbonate + Vitamin D

Cholecalciferol Vitamin D3 Doxercalciferol Hectorol

Ergocalciferol Vitamin D2 Ferrous Sulfate Ferrous Sulfate

General Revenue Prescription Drug Formulary

Updated January 2021

General Revenue funded prescription drug service providers MUST use the most cost-effective product, either brand or generic,

whichever is less expensive at the time of dispensing.

12

Folic Acid Folic Acid

Folinic Acid Leucovorin Magnesium Oxide Magnesium Oxide

Multivitamin Multivitamin

Multivitamin-Renal Rena-Vite Potassium Chloride Potassium Chloride

Prenatal Vitamins Prenatal Vitamins UltraMeal Advance Protein Powder

UltraMeal Advance Protein Powder

Vitamin B-1 (Thiamine) Vitamin B-1 (Thiamine)

Vitamin B-12 (Cyanocobalamin)

Vitamin B-12 (Cyanocobalamin)

Vitamin B-6 (Pyridoxine) Vitamin B-6 (Pyridoxine)

Vitamin D3 Vitamin D3

Medical Equipment Lancets

Lancing Device

Syringes/Needles True Track/True Metrix Glucometer

True Track/True Metrix Test Strips