Printer Friendly

Therapeutic Class List

dotted line

This list can assist you in choosing a generic or preferred/formulary medication.

  • Generic medications are listed in lower case bold. Example: fluconazole.
    • Brand name medications listed in parenthesis after a generic are:
      • Non-preferred/non-formulary.
      • Only listed as a reference for a generically available medication. Example: fluconazole (Diflucan®)
  • Brand name medications start with a capital letter and are followed by the (®) symbol. Example: Ancobon®.

dotted line

Additional Information:

  • Preferred/formulary medications are limited to the dosage form and strength listed; if no strength is listed, all strengths for the listed dosage form are preferred/formulary.
  • Sustained action/release (SA/SR), extended release (ER/XR), long-acting (LA), and enteric coated (EC) are only preferred/formulary if listed.
  • Occasionally, preferred/formulary medications may be contract exclusions and therefore are not covered.
  • Some medications may require prior authorization or have quantity limits.
  • Please note that this list may change.

dotted line

Antifungals
Anti-Infectives
Antineoplastics
Anti-Virals//HIV/AIDS
Behavior Modification
Blood Modifiers
Bone & Joint
Cardiovascular
Cholesterol Lowering
Diabetes
Diabetic Supplies
Ear/Nose/Throat
Gastrointestinal
Hormone/Endocrine
Immunosuppresants
Mental Health
Muscle Relaxants
Neurological
Ophthalmic
Pain & Inflammatory Disease
Respiratory
Skin/Topical
Urology
Women's Health
Self-Injected
Other

ANTIFUNGALS (Systemic)
clotrimazole troche (Mycelex® Troche)
fluconazole tablet, oral suspension
(Diflucan®)
grifulvin V tablet
griseofulvin microsize oral suspension

ketoconazole tablet
itraconazole capsule (Sporanox®)*
nystatin suspension, tablet
terbinafine HCL tablet (Lamisil®)*
voriconazole tablet (Vfend®)
Ancobon® capsule
Gris-Peg® tablet
Vfend® oral suspension

ANTI-INFECTIVES

amoxicillin capsule, suspension, tablet, chews, drops (Amoxil®)
amoxicillin/pot. clavulanate tabs, chews, suspension (Augmentin®)
atovaquone-proguanil tablet (Malarone®)
azithromycin tablet, packet, suspension (Zithromax®)
cefaclor capsule, suspension (Ceclor®)
cefadroxil capsule, tablet (Duricef®)
cefdinir capsule, suspension (Omnicef®)
cefditoren tablet (Spectracef®)
cefprozil tablet, suspension (Cefzil®)
cefuroxime tablet (Ceftin®)
cephalexin capsule (Keflex®)
chloroquine tablet (Aralen®)
ciprofloxacin ER tablet (Cipro XR®)
ciprofloxacin tablet, suspension (Cipro®)
clarithromycin tablet (Biaxin®)
clarithromycin ER tablet (Biaxin XL®)
clindamycin capsule (Cleocin®)
dapsone tablet
doxycycline hyclate tablet (Periostat®)
doxycycline capsule, tablet (Vibramycin®)
erythrocin stearate tablet
erythromycin base EC tablet (Emycin®)
erythromycin ethylsuc tablet, suspension (E.E.S.®)
erythromycin/sulfisoxazole suspension
ethambutol tablet (Myambutol®)
hydroxychloroquine tablet (Plaquenil®)
isoniazid tablet
mebendazole chewtabs (Vermox®)
metronidazole tablet (Flagyl®)
minocycline capsule (Minocin®)
minocycline ER tablet (Solodyn®)
nitrofurantoin capsule (Macrodantin®, Macrobid®)
nitrofurantoin oral suspension (Furadantin®)
ofloxacin tablet
penicillin V potassium tablet, suspension (Veetids®)
primaquine phosphate tablet
pyrazinamide tablet
rifampin/isoniazid capsule (Rifamate®)
rifampin capsule (Rifadin®)
sulfamethoxazole/trimethoprim tablet, suspension (Bactrim®, Septra®)
sulfadiazine tablet
tetracycline capsule
trimethoprim tablet
Albenza® tablet
Alinia® tablet, suspension
Avelox® tablet
Biltricide® tablet
Coartem® tablet
Daraprim® tablet
Mepron® oral suspension
Mycobutin® capsule
Seromycin® capsule
Stromectal® tablet
Yodoxin® tablet
Zyvox® tablet, oral suspension

ANTINEOPLASTICS++

anastrozole tablet (Arimidex®)
bicalutamide tablet (Casodex®)
cyclophosphamide tablet
etoposide capsule (Toposar®, Vepesid®)
exemestane tablet (Aromasin®)
flutamide capsule
hydroxyurea capsule (Hydrea®)
letrozole tablet (Femara®)
leucovorin tablet
megestrol tablet, syrup (Megace®)
tamoxifen tablet (Nolvadex®)
tretinoin capsule (Vesanoid®)
Alkeran® tablet
CeeNu® capsule
Droxia® capsule
Emcyt® capsule
Fareston® tablet
Gleevec® tablet, capsule
Hexalen® capsule
Leukeran® tablet
Lysodren® tablet
Matulane® capsule
Mesnex® tablet
Myleran® tablet
Nexavar® tablet
Purinethol® tablet
Revlimid® capsule
Sprycel® tablet
Sutent® capsule
Tabloid® tablet
Tarceva® tablet
Tasigna® capsule
Temodar® capsule
Xeloda® tablet
Zelboraf® tablet
Zytiga™ tablet

ANTI-VIRALS/HIV/AIDS

acyclovir tablet, capsule, suspension (Zovirax®)
amantadine capsule, syrup
didanosine capsule (Videx® EC)
famciclovir tablet (Famvir®)
ganciclovir capsule
ribavirin capsule (Rebetol®)
ribavirin tablet (Copegus®)
rimantadine HCL tablet (Flumadine®)
stavudine capsule, oral solution (Zerit®)
valacyclovir HCL tablet (Valtrex®)
zidovudine capsule, tablet, syrup (Retrovir®)
Atripla® tablet
Baraclude® tablet
Combivir® tablet
Crixivan® capsule
Emtriva® capsule
Epivir® tablet, oral solution
Epivir HBV® tablet, oral solution
Epzicom ® tablet
Hepsera® tablet
Incivek™ tablet
Intelence® tablet
Invirase® capsule
Invirase® tablet
Isentress tablet
Kaletra® tablet, solution
Lexiva® tablet, oral suspension
Norvir®
Prezista® tablet
Rebetol® oral solution
Rescriptor® tablet
Reyataz® capsule
Selzentry tablet
Sustiva® capsule, tablet
Tamiflu® capsule, suspension
Trizivir® tablet
Truvada® tablet
Valcyte® tablet, solution
Victrelis™ capsule
Videx® solution
Viracept® tablet, powder for oral solution
Viramune® tablet, oral suspension
Viread® tablet
Ziagen® tablet, oral solution

BEHAVIOR MODIFICATION
dextroamphetamine SR capsule (Dexedrine Spansule®)
dextroamphetamine tablet (Dexedrine®)
disulfiram tablet (Antabuse®)
methylphenidate tablet
(Ritalin®)
methylphenidate ER tablet 10 mg, 20mg (Ritalin® SR)
Adderall XR™ capsule
Metadate® CD capsule
Suboxone® SL film
Vyvanse® capsule

BLOOD MODIFIERS
cilostazol tablet (Pletal®)
dipyridamole tablet
(Persantine®)
pentoxifylline tablet (Trental®)
ticlopidine tablet
warfarin tablet (Coumadin®)
Agrylin® capsule
Coumadin® tablet
Mephyton® tablet
Plavix® tablet
Pradaxa® capsule
Xarelto® tablet

BONE & JOINT

alendronate sodium tablet (Fosamax®)
allopurinol tablet
(Zyloprim®)
calcitonin-salmon nasal spray (Fortical®, Miacalcin®)
colchicine tablet
etidronate disodium
(Didronel®)
ibandronate tablet
(Boniva®)
methotrexate tablet
(Rheumatrex®)
probenecid tablet (Benemid®)
sulfasalazine tablet (Azulfidine® EN-tabs®)
Actonel® tablet
Atelvia™ tablet
Colcrys® tablet
Cuprimine® capsule
Depen® tablet
Evista® tablet
Fosamax® oral solution
Ridaura® capsule
Uloric® tablet

CARDIOVASCULAR

acebutolol capsule (Sectral®)
amiloride tablet (Midamor®)
amiloride/HCTZ tablet
aminocaproic acid tablet (Amicar®)
amiodarone tablet (Cordarone®)
amlodipine besylate/benazepril (Lotrel®)
amlodipine besylate tablet (Norvasc®)
atenolol tablet (Tenormin®)
atenolol/chlorthalidone tablet (Tenoretic®)
benazepril HCL tablet (Lotensin®)
betaxolol tablet
(Kerlone®)
bumetanide tablet (Bumex®)
captopril tablet
captopril/HCTZ tablet
carvedilol tablet (Coreg®)
chlorothiazide tablet
chlorthalidone tablet
clonidine patch (Catapres-TTS®)
clonidine tablet (Catapres®)
digoxin tablet, elixir (Lanoxin®)
diltiazem tablet (Cardizem®)
diltiazem SR capsule (Cardizem® SR)
diltiazem SR capsule (Cardizem® CD)
diltiazem SR capsule (Dilacor® XR)
disopyramide & ER capsule (Norpace®, Norpace CR®)
doxazosin tablet (Cardura®)
enalapril tablet (Vasotec®)
enalapril/HCTZ tablet (Vaseretic®)
felodipine tablet
flecainide tablet (Tambocor®)
fosinopril tablet
furosemide tablet (Lasix®)
guanfacine tablet (Tenex®)
hydralazine tablet (Apresoline®)
hydralazine/HCTZ tablet (Apresazide®)
hydrochlorothiazide tablet
indapamide tablet
isradipine (DynaCirc®)
isosorbide dinitrate & ER tablet (Isordil® & Dilatrate® SR)
isosorbide mononitrate & ER tablet (Ismo® & Imdur®)
labetalol tablet (Trandate®)
lisinopril tablet (Zestril®, Prinivil®)
lisinopril/HCTZ tablet (Zestoretic®)
losartan tablet (Cozaar®)
losartan/hctz tablet (Hyzaar®)
methyclothiazide tablet
methyldopa tablet (Aldomet®)
metolazone tablet (Zaroxolyn®)
metoprolol tablet (Lopressor®)
metoprolol succinate tablet (Toprol XL®)
methazolamide tablet
mexiletine capsule
minoxidil tablet
moexipril HCL tablet (Univasc®)
moexipril/HCTZ tablet (Uniretic®)
nadolol tablet (Corgard®)
nicardipine capsule (Cardene®)
nifedipine capsule (Procardia®)
nifedipine SA tablet (Adalat® CC)
nimodipine capsule (Nimotop®)
nisoldipine tablet
(Sular®)
nitroglycerin patch
(Minitran®, Nitro-Dur®)
nitroglycerin capsule (NitroTime®)
pindolol tablet
potassium chloride tablet
potassium chloride CR capsule
prazosin capsule (Minipress®)
propafenone tablet (Rythmol®)
propranolol tablet
propranolol HCL SA capsule (Inderal® LA)
propranolol/HCTZ tablet
quinidine gluconate tablet
quinidine sulfate tablet
ramipril capsule (Altace®)
sotalol tablet (Betapace®)
spironolactone tablet (Aldactone®)
spironolactone/HCTZ tablet (Aldactazide®)
terazosin capsule
timolol maleate tablet
trandolapril tablet (Mavik®)
trandolapril/verapamil tablet
(Tarka®)
triamterene/HCTZ tablet
(Maxzide®)
verapamil tablet (Calan®)
Benicar® tablet
Benicar HCT® tablet
K-Tab® tablet
Lanoxin® tablet, elixir
Micardis® tablet
Micardis HCT® tablet
Norpace® CR capsule
Tikosyn® capsule

CHOLESTEROL LOWERING

atorvastatin tablet (Lipitor®)
cholestyramine/sucrose powder (Questran®)
colestipol HCL granules, tablet (Colestid®)
fenofibrate capsule, tablet
gemfibrozil capsule (Lopid®)
lofibra capsule, tablet
lovastatin tablet (Mevacor®)
pravastatin tablet (Pravachol®)
simvastatin tablet (Zocor®)
Colestid® packet
Crestor® tablet
Niaspan® tablet

DIABETES
acarbose tablet (Precose®)
chlorpropamide tablet
glipizide tablet (Glucotrol®)
glipizide ER tablet (Glucotrol® XL)
glyburide tablet (Diabeta®)
glyburide, micronized tablet (Glynase®)
metformin tablet (Glucophage®)
metformin ER tablet (Glucophage® XR)
nateglinide tablet (Starlix®)
tolazamide tablet
tolbutamide tablet
ACTOplus met® tablet
Actos® tablet
Byetta® injection
Duetact® tablet
Glucagon® injection
Humalog® insulins
Humulin® insulins
Janumet® tablet
Januvia® tablet
Juvisync™ tablet
Lantus® insulin
Lantus® SoloSTAR® insulin
Levemir® insulin
Novolin® insulins
Novolog® insulins
Prandin® tablet
Proglycem® oral suspension

DIABETIC SUPPLIES
Please check if these are covered by your prescription benefit:
  • Bayer® test strips*
  • Bayer Breeze® 2 test strips*
  • Bayer Contour® test strips*
  • Lancets, needles, syringes (all products)
  • EAR/NOSE/THROAT
    acetic acid otic (Acetasol®)
    acetic acid/hydrocortisone otic (Acetasol®-HC)
    azelastine nasal spray (Astelin®)
    benzocaine/antipyrine otic
    (Aurodex®)
    benzonatate capsule (Tessalon®)
    bromhist oral syrup
    clemastine tablet (Tavist®)
    flunisolide nasal spray
    fluticasone propionate nasal spray (Flonase®)
    hydrocort/polymyx/neomycin otic (Cortisporin® Otic)
    ipratropium nasal spray (Atrovent®)
    levocetirizine tablet (Xyzal®)
    triamcinolone nasal spray (Nasacort AQ®)
    Cipro® HC otic suspension
    Ciprodex® otic suspension

    GASTROINTESTINAL

    cimetidine tablet, liquid (Tagamet®)
    compro rectal suppository
    dicyclomine capsule, tablet (Bentyl®)
    diphenoxylate/atropine tablet (Lomotil®)
    dronabinol capsule (Marinol®)
    famotidine tablet (Pepcid®)
    granisetron HCL tablet, solution (Kytril®)
    lactulose solution
    lansoprazole capsule (Prevacid®)
    lansoprazole ODT tablet (Prevacid® solutab)
    loperamide capsule
    meclizine tablet (Antivert®)
    mesalamine enema (Rowasa®)
    metoclopramide tablet, syrup
    (Reglan®)
    misoprostil tablet (Cytotec®)
    omeprazole capsule (Prilosec®)
    omeprazole-sodium bicarbonate capsule (Zegerid®)
    ondansetron HCL tablet, oral solution (Zofran®)
    ondansetron ODT tablet (Zofran ODT®)
    opium tincture
    pantoprazole tablet (Protonix®)
    peg-3350/kcl sol/sodium (Nulytely®)
    polyethylene glycol/electrolyte solution
    prochlorperazine tablet

    promethazine tablet, suppository
    ranitidine tablet, syrup (Zantac®)
    sucralfate tablet (Carafate®)
    sulfasalazine tablet (Azulfidine® EN-tabs®)
    trimethobenzamide capsule (Tigan®)
    ursodiol capsule (Actigall®)
    ursodiol tablet (Urso 250®, Urso Forte®)
    Analpram HC® rectal cream, rectal lotion
    Asacol® tablet, oral solution
    Asacol® HD tablet
    Canasa® rectal suppository
    Cortifoam® rectal foam
    Creon® capsule
    Dexilant™ capsule (formerly Kapidex)
    Dipentum® capsule
    Emend® capsule
    Epifoam® topical foam
    Helidac® combopak
    Kristalose® packet
    Pancreaze™ capsule
    Pancrecarb MS® capsule
    Pentasa® capsule
    PrevPac®
    ProctoFoam®-HC rectal foam
    Ultrase® capsule
    Ultrase® MT capsule
    Viokase® tablet
    Visicol® tablet
    Zenpep® capsule

    HORMONE/ENDOCRINE (also see WOMEN'S HEALTH)
    calcitriol capsule (Rocaltrol®)
    cortisone acetate tablet (Cortone®)
    desmopressin tablet, nasal spray, nasal solution (DDAVP®)
    dexamethasone intensol oral solution
    dexamethasone tablet, elixir
    fludrocortisone tablet
    folic acid tablet
    levothyroxine sodium tablet
    liothyronine sodium tablet (Cytomel®)
    methimazole tablet
    (Tapazole®)
    methylprednisolone tablet (Medrol®)
    prednisolone 15mg/5ml syrup (Prelone®)
    prednisone intensol oral concentrate
    prednisone tablet, solution
    propylthiouracil tablet
    thyroid dessicated tablet
    triamcinolone tablet

    unithroid tablet
    Androgel® gel
    Armour® Thyroid tablet
    DDAVP® nasal solution, nasal spray
    Levothroid® tablet
    Levoxyl® tablet
    Methitest® tablet
    Nilandron® tablet
    Orapred® oral solution
    Stimate® nasal spray
    Synthroid® tablet
    Testred® tablet
    Thyrolar® tablet

    IMMUNOSUPPRESSANTS

    azathioprine tablet (Imuran®)
    cyclosporine, modified capsule, solution (Neoral®)
    cyclosporine capsule, solution (Sandimmune®)
    mycophenolate mofetil capsule, tablet (CellCept®)
    tacrolimus capsule (Prograf®)
    CellCept® suspension
    Myfortic® ER tablet
    Rapamune® tablet, solution

    MENTAL HEALTH

    alprazolam tablet (Xanax®)
    alprazolam ER tablet (Xanax XR®)
    amitriptyline tablet
    amoxapine tablet (Asendin®)
    budeprion SR tablet (Wellbutrin SR®)
    budeprion XL tablet (Wellbutrin XL®)
    bupropion SR tablet (Wellbutrin SR®)
    bupropion XL tablet (Wellbutrin XL®)
    buspirone tablet (BuSpar®)
    chloral hydrate capsule
    chlordiazepoxide capsule
    chlorpromazine tablet
    citalopram tablet (Celexa®)
    clomipramine capsule (Anafranil®)
    clonazepam tablet (Klonopin®)
    clorazepate tablet (Tranxene®)
    clozapine tablet (Clozaril®)
    desipramine tablet (Norpramin®)
    diazepam tablet, solution (Valium®)
    doxepin capsule
    escitalopram tablet (Lexapro®)
    estazolam tablet
    fluoxetine capsule (Prozac®)
    fluphenazine tablet
    flurazepam capsule
    fluvoxamine tablet (Luvox®)
    haloperidol tablet, solution
    hydroxyzine HCL tablet (Atarax®)
    hydroxyzine pamoate capsule (Vistaril®)
    imipramine tablet (Tofranil®)
    lithium carbonate capsule, tablet
    lithium citrate syrup
    lorazepam intensol oral concentrate
    lorazepam tablet (Ativan®)
    loxapine succinate capsule (Loxitane®)
    maprotiline tablet
    mirtazapine tablet (Remeron®)
    nefazodone tablet
    nortriptyline capsule (Pamelor®)
    olanzapine tablet (Zyprexa®)
    olanzapine ODT tablet (Zyprexa Zydis®)
    oxazepam capsule
    paroxetine tablet (Paxil®)
    perphenazine tablet
    phenelzine tablet (Nardil®)
    phenobarbital tablet, elixir
    protriptyline tablet (Vivactil®)
    risperidone tablet, solution (Risperdal®)
    risperidone M-tab (Riperdal® M-Tab™)
    sertraline tablet (Zoloft®)
    temazepam capsule (Restoril®)
    thioridazine tablet, solution
    thiothixene capsule (Navane®)
    tranylcypromine sulfate tablet (Parnate®)
    trazodone tablet
    triazolam tablet (Halcion®)
    trifluoperazine tablet
    venlafaxine ER capsule, tablet (Effexor XR®)
    venlafaxine HCL tablet (Effexor®)
    zaleplon capsule (Sonata®)
    zolpidem tartrate ER tablet (Ambien CR®)
    zolpidem tartrate tablet (Ambien®)
    Abilify® tablet, solution
    Abilify Discmelt® tablet
    Geodon® capsule
    Lithobid® tablet
    Moban® tablet
    Orap® tablet
    Seroquel® tablet
    Seroquel XR tablet

    MUSCLE RELAXANTS
    baclofen tablet
    carisoprodol tablet (Soma®)
    carisoprodol/ASA tablet
    cyclobenzaprine ER capsule (Amrix®)
    cyclobenzaprine tablet (Flexeril®)
    dantrolene capsule (Dantrium®)
    metaxalone tablet (Skelaxin®)
    methocarbamol tablet (Robaxin®)

    NEUROLOGICAL

    benztropine tablet (Cogentin®)
    bromocriptine tablet (Parlodel®)
    carbamazepine capsule (Carbatrol®)
    carbamazepine tablet, chews, suspension (Tegretol®)
    carbidopa/levodopa tablet (Sinemet®)
    divalproex sodium tablet (Depakote®)
    divalproex sodium ER tablet (Depakote® ER)
    divalproex sodium sprinkle capsule (Depakote Sprinkle®)
    donepezil tablet (Aricept®)
    donepezil ODT tablet (Aricept ODT®)
    epitol tablet
    ethosuximide syrup (Zarontin®)
    galantamine HBR tablet, oral solution (Razadyne™)
    lamotrigine (Lamictal®)
    levetiracetam tablet, solution (Keppra®)
    oxcarbazepine tablet (Trileptal®)
    pramipexole tablet (Mirapex®)
    phenytoin sodium capsule (Dilantin®)
    primidone tablet (Mysoline®)
    rivastigmine capsule (Exelon®)
    ropinirole HCL tablet (Requip®)
    selegiline tablet, capsule (Eldepryl®)
    topiramate capsule
    (Topamax® Sprinkle)
    topiramate tablet
    (Topamax®)
    trihexyphenidyl tablet (Artane®)
    valproic acid capsule, syrup (Depakene®)
    Aricept® 23 mg tablet
    Azilect® tablet
    Celontin® tablet, capsule
    Comtan® tablet
    Diastat® rectal gel
    Dilantin® capsule, chews, suspension
    Exelon® solution, patch
    Felbatol® tablet, oral suspension
    Gabitril® tablet
    Mebaral® tablet
    Mestinon® tablet, syrup
    Mysoline® tablet
    Neurontin® capsule, tablet, solution
    Parlodel® capsule only
    Phenytek® capsule
    Reminyl® tablet, solution
    Rilutek® tablet
    Stalevo® tablet
    Tegretol® XR tablet
    Zarontin® capsule, syrup
    Zonegran® capsule

    OPHTHALMIC

    acetazolamide SR capsule (Diamox Sequels®)
    acetazolamide tablet

    apraclonidine ophthalmic solution (Iopidine®)
    atropine ophthalmic solution

    bacitracin/polymyxin ophthalmic ointment
    bacitracin ophthalmic solution
    betaxolol ophthalmic solution
    brimonidine ophthalmic solution
    (Alphagan®)
    bromfenac ophthalmic solution (Xibrom®)
    carteolol ophthalmic solution
    ciprofloxacin HCL ophthalmic solution
    (Ciloxan®)
    cromolyn ophthalmic solution
    (Crolom®)
    dexamethasone sod phos ophthalmic suspension
    diclofenac sod ophthalmic solution

    dorzolamide HCL ophthalmic solution (Trusopt®)
    dorzolamide-timolol ophthalmic solution (Cosopt®)
    epinastine ophthalmic solution
    (Elestat®)
    erythromycin base ophthalmic ointment
    fluorometholone ophthalmic suspension
    (Fluor-Op®)
    flurbiprofen ophthalmic solution (Ocufen®)
    gentamicin ophthalmic solution
    homatropine ophthalmic solution
    isopto homatropine ophthalmic solution
    ketorolac 0.5% ophthalmic solution (Acular®)
    ketorolac 0.4% ophthalmic solution (Acular LS®)
    ketotifen fumarate ophthalmic solution (Zaditor®)
    latanoprost ophthalmic solution (Xalatan®)
    levobunolol ophthalmic solution(Betagan®)
    levofloxacin ophthalmic solution (Quixin®)
    metipranolol ophthalmic solution (OptiPranolol®)
    naphazoline ophthalmic solution

    neo/polymyx/dexamethasone ophthalmic suspension,
    ointment
    ofloxacin ophthalmic solution
    (Ocuflox®)
    phenylephrine ophthalmic solution
    pilocarpine ophthalmic solution
    (Isopto Carpine®)
    prednisolone acetate ophthalmic suspension (Pred Forte®)
    prednisolone sod phosphate ophthalmic solution
    sulfacetamide/prednisolone ophthalmic suspension (Blephamide®)
    sulfacetamide ophthalmic solution (Bleph®-10)
    timolol maleate ophthalmic solution (Timoptic®)
    timolol maleate ophthalmic gel solution (Timoptic-XE®)
    tobramycin ophthalmic solution (Tobrex®)
    tobramycin/dexamethasone ophthalmic suspension (Tobradex®)
    trifluridine ophthalmic solution (Viroptic®)
    Alocril® ophthalmic solution
    Alphagan® P ophthalmic solution
    Alrex® ophthalmic suspension
    Azopt® ophthalmic suspension
    Betimol® ophthalmic solution
    Betoptic S® ophthalmic suspension
    Blephamide® S.O.P. ophthalmic ointment
    Ciloxan® ophthalmic ointment
    Cyclogyl® ophthalmic solution
    FML® S.O.P. ophthalmic ointment
    Isopto® Atropine ophthalmic solution
    Lotemax® ophthalmic suspension
    Lumigan® ophthalmic solution
    Pataday™ ophthalmic solution
    Patanol® ophthalmic solution
    Pilopine HS® ophthalmic gel
    Pred-Mild® ophthalmic suspension
    TobraDex® ophthalmic suspension, ointment
    Travatan Z® ophthalmic solution

    PAIN & INFLAMMATORY DISEASE

    choline mag trisalicylate tablet
    codeine/APAP tablet (Tylenol® #3)
    diclofenac tablet
    diflunisal tablet
    ergotamine/caffeine tablet, suppository (Cafergot®)
    etodolac capsule, tablet
    fenoprofen tablet
    fentanyl patch(Duragesic®)
    flurbiprofen tablet (Ansaid®)
    hydrocodone/APAP tablet (Vicodin®)
    hydrocodone/chlorpheniramine suspension (Tussionex® Pennkinetic)
    hydrocodone/homatropine tablet, syrup
    hydromorphone tablet (Dilaudid®)
    ibuprofen tablet (Motrin®)
    indomethacin capsule
    ketoprofen capsule
    ketoprofen ER capsule
    meclofenamate capsule
    mefenamic acid capsule (Ponstel®)
    meperidine tablet, syrup (Demerol®)
    methadone tablet, solution, concentrate (Dolophine®)
    morphine SR tablet (MS Contin®)
    nabumetone tablet
    naproxen tablet (Naprosyn®)
    naratriptan tablet (Amerge®)
    oxaprozin tablet (Daypro®)
    oxycodone capsule
    oxycodone/APAP tablet (Percocet®)
    oxycodone/ASA tablet (Percodan®)
    oxymorphone tablet (Opana®)
    piroxicam capsule (Feldene®)
    salsalate tablet
    sulindac tablet (Clinoril®)
    sumatriptan succinate injection, tablet (Imitrex®)
    sumatriptan nasal spray (Imitrex®)
    tolmetin tablet
    tramadol tablet (Ultram®)
    tramadol/APAP tablet (Ultracet®)
    tramadol ER tablet (Ultram ER®)
    tramadol ER biphasic tablet (Ryzolt®)
    Ergomar® tablet
    Maxalt® tablet
    Maxalt®-MLT tablet
    Migranal® nasal spray
    Phrenalin® with caffeine/codeine capsule
    Relpax® tablet

    RESPIRATORY
    acetylcysteine solution
    albuterol inhalation solution, tablet, syrup (Proventil®)
    aminophylline tablet, liquid
    cromolyn sodium solution

    dyphylline tablet (Lufyllin®)
    ipratropium bromide solution (Atrovent®)
    ipratropium-albuterol inhalation solution (Duoneb®)
    metaproterenol tablet, syrup, inhalation solution (Alupent®)
    theophylline tablet, capsule, elixir
    zafirlukast tablet (Accolate®)
    Advair Diskus® oral inhaler
    Advair® HFA oral inhaler
    Alvesco® oral inhaler
    Atrovent HFA® oral inhaler
    Cayston® inhalation solution
    Combivent® oral inhaler
    Dulera® oral inhaler
    Flovent® Diskus® oral inhaler
    Flovent® HFA oral inhaler
    Foradil® oral inhaler
    Letairis tablet
    Nebupent® powder for inhalation
    Peak Flow Meters
    ProAir® HFA oral inhaler
    Pulmicort Respules®
    Pulmicort® oral inhaler
    Pulmozyme® inhalation solution
    QVAR® oral inhaler
    Serevent Diskus® oral inhaler
    Singulair® tablet, granules, chews
    Spacer devices
    Spiriva® oral inhaler
    Tobi® oral inhalation solution
    Tracleer® tablet
    Ventolin® HFA oral inhaler

    SKIN/TOPICAL

    adapalene cream (Differin®)
    amcinonide cream, ointment, lotion

    betamethasone dipropionate cream, gel, lotion, ointment (Diprolene®)
    betamethasone dipropionate augmented cream (Diprolene® AF cream)
    betamethasone valerate liquid, lotion (Beta-val®)
    betamethasone/clotrimazole cream (Lotrisone®)
    calcipotriene solution (Dovonex®)
    centany ointment
    ciclopirox cream, gel, shampoo, topical suspension
    (Loprox®)
    ciclopirox topical solution
    (Penlac®)
    clindamycin topical gel, lotion, solution (Cleocin®)
    clindamycin/benzoyl peroxide (BenzaClin®)
    clobetasol propionate cream, lotion, ointment
    (Temovate®)
    desonide cream
    desoximetasone gel, cream, ointment (Topicort®, Topicort LP®)
    diflorasone diacetate ointment, cream
    erythromycin base/benzoyl peroxide gel (Benzamycin®)
    fluocinolone acetonide cream, ointment
    fluocinolone acetonide oil (Derma-Smoothe/FS® oil)
    fluocinonide cream, ointment, solution, gel
    fluorouracil cream, solution (Efudex®)
    gentamicin cream, ointment
    halobetasol propionate cream, ointment (Ultravate®) hydrocortisone cream, ointment, lotion (Ala-cort®)
    imiquimod (Aldara®)
    isotretinoin (claravis, sotret, amnesteem) capsule
    (Accutane®)
    ketoconazole shampoo
    lidocaine viscous solution (Xylocaine®)
    lindane lotion, shampoo
    malathion lotion (Ovide®)
    metronidazole cream (MetroCream®)
    metronidazole lotion (MetroLotion®)
    mometasone cream, lotion, ointment (Elocon®)
    mupirocin ointment (Bactroban®)
    prednicarbate cream, ointment (Dermatop®)
    permethrin 5% cream (Elimite®)
    silver sulfadiazine cream (Silvadene®)
    sulfacetamide sodium topical suspension (Klaron®)
    tretinoin cream, gel, lotion (Retin A®)*
    triamcinolone acetonide cream, ointment
    Aclovate® cream, ointment
    Azelex® cream
    Bactroban® cream
    Bactroban® nasal ointment
    Capex® shampoo
    Carac® cream
    Cloderm® cream
    Condylox® gel, solution
    Cordran® lotion, tape, ointment, cream
    Cutivate® cream, lotion, ointment
    Differin® gel
    Eurax® cream, lotion
    Fluoroplex® cream
    Locoid® cream, ointment, solution
    Luxiq® foam
    MetroGel®
    Natroba™ topical suspension
    Noritate® cream
    Phisohex® liquid
    Retin A Micro® gel*
    Soriatane® capsule
    Soriatane® CK kit
    Tazorac® cream, gel
    Ulesfia lotion

    UROLOGY

    alfuzosin tablet (Uroxatral®)
    citric acid/sodium citrate solution (Bicitra®)
    bethanechol tablet (Urecholine®)
    finasteride tablet (Proscar®)
    methenamine hippurate tablet (Hiprex®)
    methenamine mandelate tablet
    oxybutynin tablet (Ditropan®)
    oxybutynin chloride ER (Ditropan XL®)
    phenazopyridine tablet (Pyridium®)
    tamsulosin capsule (Flomax®)
    trospium tablet (Sanctura®)
    Avodart® capsule
    Detrol® LA capsule
    Elmiron® capsule
    Jalyn™ capsule
    Toviaz® tablet

    WOMEN’S HEALTH

    altavera tablet* (Nordette®)
    amethia tablet* (Seasonique®)
    amethyst tablet*
    (Lybrel®)
    apri tablet*
    (Ortho Cept®)
    aranelle tablet* (Tri-Norinyl®)
    aviane tablet*
    azurette tablet*
    (Mircette®)
    balziva tablet
    * (Ovcon-35®)
    briellyn tablet* (Ovcon-35®)
    camila tablet
    * (Ortho Micronor®)
    camrese tablet* (Seasonique®*)
    caziant tablet
    * (Cyclessa®)
    clomiphene citrate tablet
    (Clomid®)*
    cryselle tablet* (Lo/Ovral-28®)
    cyclafem tablet* (Ortho Novum®)
    danazol capsule
    emoquette tablet* (Ortho Cept®)
    enpresse tablet* (Triphasil®)
    errin tablet* (Ortho Micronor®)
    estradiol-norethindrone tablet (Activella®)
    estradiol tablet (Estrace®)
    estradiol transdermal patch (Climara®)
    estropipate tablet

    gianvi tablet* (Yaz®)*
    gildess fe tablet* (Loestrin Fe®)
    introvale tablet* (Seasonale®)
    jolessa tablet* (Seasonale®)*
    jolivette tablet* (Ortho Micronor®)
    junel tablet* (Loestrin®)
    junel fe tablet* (Loestrin Fe®)
    kariva tablet* (Mircette®)
    kelnor tablet*
    leena tablet* (Tri-Norinyl®)
    lessina tablet*
    levora-28 tablet* (Nordette®)
    loryna tablet* (Yaz®)
    low-ogestrel tablet* (Lo/Ovral-28®)
    lutera tablet*
    marlissa tablet* (Nordette®)
    medroxyprogesterone acetate tablet
    methylergonovine tablet (Methergine®)
    microgestin tablet* (Loestrin®)
    microgestin fe tablet* (Loestrin® Fe)
    mimvey tablet (Activella®)
    mononessa tablet* (Ortho-Cyclen®)
    necon tablet*
    next choice tablet* (Plan B®)
    nora-BE tablet* (Ortho Micronor®)
    nortrel tablet* (Modicon®)
    ocella tablet (Yasmin®)*
    ogestrel tablet*
    orsythia tablet*
    portia tablet* (Nordette®)
    previfem tablet* (Ortho Cyclen®)
    quasense tablet* (Seasonale®)*
    reclipsen tablet* (Ortho Cept®)
    solia tablet* (Ortho Cept®)
    sprintec tablet* (Ortho Cyclen®)
    sronyx tablet*
    syeda tablet* (Yasmin®)
    tilia FE tablet (Estrostep® FE)
    tri-legest FE tablet (Estrostep® FE)
    trinessa tablet* (Ortho Tri-Cyclen®)
    tri-previfem tablet* (Ortho Tri-Cyclen®)
    tri-sprintec tablet* (Ortho Tri-Cyclen®)
    trivora-28 tablet* (Triphasil®)
    velivet tablet* (Cyclessa®)
    vestura tablet* (Yaz®*)
    viorele tablet* (Mircette®)
    zarah tablet* (Yasmin®)
    zenchent fe chew tab* (Femcon Fe®)
    zenchent tablet* (Ovcon-35®)
    zeosa chew tab* (Femcon Fe®)
    zovia tablet*
    Alora® patch
    Desogen® tablet*
    Diaphragms*
    Divigel®
    Enjuvia® tablet
    Estraderm® patch
    FemHRT® tablet
    Loestrin® tablet*
    Loestrin® Fe tablet*
    Lo/Ovral-28® tablet*
    MetroGel-Vaginal®
    Micronor® tablet*
    Modicon® tablet*
    Nora-BE® tablet*
    Nordette® tablet*
    Norinyl® tablet*
    Nor-QD® tablet*
    Ortho Cept® tablet*
    Ortho Cyclen® tablet*
    Ortho Evra® patch*
    Ortho Micronor® tablet*
    Ortho Novum® tablet*
    Ortho Tri-Cyclen® tablet*
    Ortho Tri-Cyclen® Lo tablet*
    Prefest® tablet
    Premarin® tablet
    Premarin® vaginal cream
    Premphase® tablet
    Prempro® tablet
    Serophene® tablet*
    Terazol® vaginal cream
    Tri-Norinyl® tablet*
    Triphasil® tablet*
    Vagifem® vaginal tablet
    Vivelle-DOT® patch

    SELF-INJECTED

    calcitonin salmon injection
    cyanocobalamin injection
    enoxaparin injection
    (Lovenox®)
    fondaparinux injection
    (Arixtra®)
    heparin sodium injection
    leuprolide non-depot injection

    octreotide acetate injection (Sandostatin®)
    Apokyn® injection
    Aranesp® injection
    Avonex® injection
    Copaxone® injection
    Enbrel® injection
    Epipen® injection
    Epipen® Jr injection
    Epogen® injection
    Firazyr® injection
    Fragmin® injection
    Fuzeon® injection
    Humira® injection
    Intron® A injection
    Leukine® injection
    Miacalcin® injection
    Neupogen® injection
    Nutropin AQ® injection*•
    Nutropin® injection*•
    Omnitrope® injection*•
    Pegasys® injection
    Peg-Intron® injection
    Procrit® injection
    Protropin® injection*•
    Rebif® injection
    Simponi® injection

    OTHER

    calcium acetate capsule (PhosLo®)
    chlorhexidine gluconate oral rinse
    (Peridex®)
    fluoride drops
    periogard oral liquid
    Buphenyl® tablet, powder
    Carnitor® tablet, liquid
    Chemet® capsule
    Cystadane® oral powder
    Dialyvite® tablet
    Eliphos™ tablet
    Evoxac® tablet
    Galzin® capsule
    Salagen® tablet
    Syprine® capsule
    Viagra® tablet

    * May not be a covered benefit under some plans.
    • Obtain from designated Specialty Pharmacy.
    ++ Regence BlueCross BlueShield of Oregon members may have a different copay/coinsurance amount for cancer related medications. Please check your prescription benefit.

    Effective May 3, 2012
    Updated May 10, 2012