Core Formulary

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Asuris Northwest Health 528 East Spokane Falls Blvd, Suite 301 Spokane, WA 99202

© 2021 Asuris Northwest Health

PHARMACY SERVICES

High-Cost Drug ExclusionsThe high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at the lowest cost, consider talking with your doctor about one of the therapeutically equivalent (similar safety and efficacy) or over-the-counter (OTC) alternatives listed below. We encourage you to talk to your doctor about whether one of these options is right for you. Coverage of alternatives will vary.

These high cost medications may be considered medically necessary when ALL of the alternatives in the table below have been ineffective, not tolerated or all are contraindicated, unless otherwise specified. If your doctor believes that the listed alternatives are not right for you, your doctor may request an exception by contacting Customer Service. Please visit your health plan’s website or contact Customer Service at the number listed on the back of your member ID card for more information about medication coverage.

Questions?

Call the Customer Service number on your member ID card.

High-Cost Drug Exclusion List Effective 5/1/2021

Core Formulary

Drug Alternatives

Absorica Amnesteem, Claravis, isotretinoin, Myorisan, Zenatane

Absorica LD Amnesteem, Claravis, isotretinoin, Myorisan, Zenatane

Acanya

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

Acticlate doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

acyclovir 5% cream (generic Zovirax) acyclovir 5% ointment

Aczone

At least three of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

adapalene 0.1% pads, solution (generic Differin)

adapalene 0.1% cream, adapalene 0.1% gel, and at least two of the following lower cost products: adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

AirDuo Digihaler fluticasone-salmeterol (generic AirDuo), Advair Diskus, Advair HFA

Aklief cream tretinoin cream, tretinoin 0.01% and 0.025% gel

Ala-Scalp desoximetasone 0.25% cream, fluocinonide 0.05% solution, hydrocortisone 2.5% lotion

Alkindi Sprinkle hydrocortisone tablet

Allzital

At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen-caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325-40mg capsule or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule

almotriptan (generic Axert)

At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet

Altoprev atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

amcinonide cream, lotion, ointment

betamethasone dipropionate 0.05% cream, desoximetasone 0.25% ointment, fluocinonide 0.05% cream, fluocinonide 0.05% gel, fluocinonide 0.05% ointment, fluticasone propionate 0.005% ointment, triamcinolone 0.5% cream, triamcinolone 0.5% ointment

Amerge

generic naratriptan and at least one of the following lower cost triptan medications: eletriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet

amlodipine-atorvastatin tablet (generic Caduet)

amlodipine in combination with atorvastatin, amlodipine in combination with rosuvastatin or simvastatin

Amrix

cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

Amzeeq

At least three of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

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Core Formulary

Drug Alternatives

Antara

At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule

ApexiCon E desoximetasone 0.05% cream, fluocinonide 0.05% cream, triamcinolone 0.5% cream

Arazlo

tazarotene 0.1% cream and at least two of the following lower cost products: adapalene 0.1% cream/gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/gel/lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel

ArmonAir Digihaler Arnuity Ellipta, Asmanex HFA, Asmanex Twisthaler, Flovent Diskus, Flovent HFA

Atelvia alendronate, ibandronate, risedronate IR (immediate-release)

Belsomra eszopiclone, zaleplon, zolpidem

benzonatate 150mg capsule

benzonatate 100mg and 200mg capsule, guaifenesin-codeine 100-10mg/5ml solution, promethazine-codeine 6.25-10mg/5ml syrup, promethazine-dm 6.25-15mg/5ml syrup

betamethasone valerate 0.12% external foam (generic Luxiq)

betamethasone dipropionate 0.05% cream, betamethasone valerate 0.1% ointment, mometasone furoate 0.1% solution (lotion), triamcinolone 0.5% cream

Bijuva estradiol in combination with progesterone, Fyavolv, Jevantique Lo, Jinteli

Binosto alendronate tablet, alendronate solution

Bryhali betamethasone dipropionate augmented 0.05% lotion, betamethasone valerate 0.1% ointment, clobetasol propionate 0.05% lotion

Bupap

At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen-caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325-40mg capsule or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule

butalbital-acetaminophen 25-325mg tablet

At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen-caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325-40mg capsule or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule

butalbital-acetaminophen 50-300mg capsule (generic Bupap)

At least two of the following lower cost butalbital-containing medications: butalbital-acetaminophen 50-325mg tablet, butalbital-acetaminophen-caffeine 50-300-40mg capsule, butalbital-acetaminophen-caffeine 50-325-40mg capsule or tablet, butalbital-aspirin-caffeine 50-325-40mg capsule

Caduet amlodipine in combination with atorvastatin, amlodipine in combination with rosuvastatin or simvastatin

Cafergot At least one of the following lower cost ergot-containing medications: generic ergotamine/ caffeine tablet, generic dihydroergotamine injection

calcipotriene 0.005% foam (generic Sorilux) calcipotriene 0.005% cream/ ointment/ solution, tazarotene 0.1% cream calcitriol 3mcg/gm ointment (generic Vectical) calcipotriene 0.005% cream/ ointment/ solution, tazarotene 0.1% cream

Cambia packets

diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac

Capex fluocinolone 0.01% oil (scalp oil), fluocinolone 0.01% solution

Carac fluorouracil 5% cream, fluorouracil 2% solution, fluorouracil 5% solution

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Core Formulary

Drug Alternatives

Centany mupirocin 2% ointment

Chenodal ursodiol 300mg capsule, 250mg tablet, 500mg tablet chlorzoxazone 250mg, 375mg, 750mg tablet (generic Lorzone)

chlorzoxazone 500mg tablet at least two of the following lower cost products: baclofen, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

Cleocin-T

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

Clindacin-P

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

Clindacin ETZ

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

Clindagel

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

clindamycin 1% topical gel (generic Clindagel)

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

clindamycin foam (generic Evoclin)

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

clindamycin swab (generic Clindacin-P, Clindacin ETZ)

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

clindamycin-benzoyl peroxide 1.2-2.5% (generic Acanya)

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

clindamycin-tretinoin topical gel (generic Veltin, Ziana)

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

clobetasol foam (generic Olux)

At least two lower cost forms of clobetasol propionate including cream, gel, lotion, ointment, and solution

clobetasol emulsion foam (generic Olux-E)

At least two lower cost forms of clobetasol propionate including cream, gel, lotion, ointment, and solution

clobetasol spray (generic Clobex)

At least two lower cost forms of clobetasol propionate including cream, gel, lotion, ointment, and solution

Clobex At least two lower cost forms of clobetasol propionate including cream, gel, lotion, ointment, and solution

clocortolone 0.1% cream (generic Cloderm)

fluocinolone 0.025% ointment, mometasone 0.1% cream, triamcinolone 0.1% cream

Page 4 of 15

Core Formulary

Drug Alternatives

Cloderm cream, pump fluocinolone 0.025% ointment, mometasone 0.1% cream, triamcinolone 0.1% cream

Conjupri amlodipine and at least two additional calcium channel blockers, such as diltiazem, felodipine, nifedipine, or verapamil

Consensi amlodipine in combination with celecoxib

Cordran tape fluocinonide 0.05% ointment, hydrocortisone 1% ointment, triamcinolone 0.1% ointment

Cordran 0.05% cream, ointment

desonide 0.05% cream and lotion, fluocinonide 0.05% ointment, hydrocortisone 1% ointment, triamcinolone 0.1% ointment, triamcinolone 0.025% lotion and ointment

CoreMino doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

Cuprimine penicillamine 250mg tablet (generic Depen Titratabs)

Cutivate betamethasone dipropionate 0.05% lotion, fluocinolone 0.025% cream, triamcinolone 0.1% lotion

cyclobenzaprine 7.5mg tablet (generic Fexmid)

cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

cyclobenzaprine ER (extended-release) capsule [generic Amrix]

cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

dapsone 5% and 7.5% gel (generic Aczone)

At least three of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

Dayvigo eszopiclone, zaleplon, zolpidem

Desonate gel At least two lower cost forms of desonide including cream, lotion and ointment desonide 0.05% gel (generic Desonate) At least two lower cost forms of desonide including cream, lotion and ointment desoximetasone 0.05% gel (generic Topicort gel)

betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment

desoximetasone 0.05% ointment (generic Topicort ointment)

betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment

desoximetasone spray (generic Topicort spray)

betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment

Dexabliss dexamethasone tablet dexamethasone dose pack (generic Dexpak) dexamethasone tablet

Dexpak dexamethasone tablet

D.H.E. 45 At least one of the following lower cost ergot-containing medications: generic ergotamine/ caffeine tablet, generic dihydroergotamine injection

diclofenac 35mg capsule (generic Zorvolex)

diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac

Page 5 of 15

Core Formulary

Drug Alternatives diclofenac topical patch (generic Flector)

diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution (generic Pennsaid 1.5%), over-the-counter Voltaren gel

Differin 0.1% lotion

adapalene 0.1% gel, adapalene 0.1% cream and at least one of the following lower cost products: adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

diflorasone cream, ointment (generic Psorcon)

desoximetasone 0.05% cream, fluocinonide 0.05% cream, ointment and solution, triamcinolone 0.5% cream and ointment

dihydroergotamine mesylate nasal spray (generic Migranal)

At least one of the following lower cost ergot-containing medications: generic ergotamine/ caffeine tablet, generic dihydroergotamine injection

doxepin 5% cream (generic Prudoxin, Zonalon)

At least two of the following lower cost products: betamethasone 0.05% cream, clobetasol propionate 0.05% cream, desoximetasone 0.25% cream, pimecrolimus 1% cream, tacrolimus 0.03% ointment, tacrolimus 0.1% ointment, triamcinolone 0.5% cream

Doryx, Doryx MPC (modified polymer coat)

doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

doxycycline hyclate DR (delayed-release) tablet [generic Doryx, Doryx MPC]

doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

doxycycline 40mg ER (extended-release) capsule (for rosacea) [generic Oracea]

doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

doxycycline hyclate 50mg, 75mg, 150mg tablet (generic Acticlate, Targadox)

doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

doxycycline monohydrate capsule

doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

Duaklir Pressair Anoro Ellipta, Stiolto Respimat

Duetact pioglitazone in combination with glimepiride

Duobrii halobetasol propionate 0.05% cream, tazarotene 0.1% cream

Durlaza clopidogrel bisulfate 75mg tablet in combination with over-the-counter aspirin 81mg

dutasteride-tamsulosin (generic Jalyn)

dutasteride in combination with tamsulosin and at least two of the following lower cost products: alfuzosin ER (extended-release) tablet, doxazosin, dutasteride, finasteride, tamsulosin, terazosin

Dutoprol metoprolol in combination with hydrochlorothiazide

Dxevo dexamethasone tablet

Ecoza econazole nitrate 1% cream

Edarbi irbesartan, losartan, olmesartan, telmisartan, valsartan

Edarbyclor chlorothiazide, indapamide, irbesartan-hydrochlorothiazide (HCTZ), losartan-HCTZ, metolazone, olmesartan-HCTZ, telmisartan-HCTZ, valsartan-HCTZ

Edluar eszopiclone, zaleplon, zolpidem

Elepsia XR levetiracetam IR (immediate-release) tablet, levetiracetam ER (extended-release) tablet

Emflaza methylprednisolone, prednisolone syrup, prednisone oral solution, prednisone tablet

Page 6 of 15

Core Formulary

Drug Alternatives

Ergomar At least one of the following lower cost ergot-containing medications: generic ergotamine/ caffeine tablet, generic dihydroergotamine injection

Ertaczo

At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the-counter terbinafine cream

Evoclin

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

Exelderm 1% cream, solution

At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the-counter terbinafine cream

Extina ketoconazole 2% cream, ketoconazole 2% shampoo ezetimibe-simvastatin tablet (generic Vytorin)

ezetimibe in combination with simvastatin, ezetimibe in combination with atorvastatin or rosuvastatin

Fabior

tazarotene 0.1% cream and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel

fenofibrate 40mg tablet, 120mg tablet (generic Fenoglide)

At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule

fenofibrate 50mg and 150mg capsule (generic Lipofen)

At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule

fenofibrate 160mg tablet (generic Triglide)

At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule

fenofibric acid 35mg, 105mg tablet (generic Fibricor)

At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule

Fenoglide

At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule

fenoprofen capsule (generic Fenortho)

fenoprofen calcium 600mg tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac

Fenortho

fenoprofen calcium 600mg tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac

Fexmid

cyclobenzaprine 5mg, cyclobenzaprine 10mg tablet, and at least one of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

Fibricor

At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule

Flector diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution (generic Pennsaid 1.5%), over-the-counter Voltaren gel

Fluoroplex fluorouracil 2% solution, fluorouracil 5% solution fluorouracil 0.5% cream (generic Carac) fluorouracil 5% cream, fluorouracil 2% solution, fluorouracil 5% solution

Page 7 of 15

Core Formulary

Drug Alternatives flurandrenolide 0.05% ointment (generic Cordran)

fluocinonide 0.05% ointment, hydrocortisone 1% ointment, triamcinolone 0.1% ointment

fluticasone propionate 0.05% lotion (generic Cutivate)

betamethasone dipropionate 0.05% lotion, fluocinolone 0.025% cream, triamcinolone 0.1% lotion

fluvastatin capsule (generic Lescol) atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin fluvastatin ER (extended-release) tablet [generic Lescol XL] atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Fortamet metformin, metformin ER (extended-release) [non-osmotic, non-modified release]

Fosamax D alendronate in combination with over-the-counter vitamin D

Frova

At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet

frovatriptan (generic Frova)

At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet

Gimoti metoclopramide IR (immediate-release) tablet, metoclopramide solution

Glumetza metformin, metformin ER (extended-release) [non-osmotic, non-modified release]

glycopyrrolate 1.5mg tablet (generic Glycate) glycopyrrolate 1mg tablet, glycopyrrolate 2mg tablet

Gocovri amantadine capsule/syrup/ tablet, rasagiline, selegiline

Gralise amitriptyline tablet, gabapentin capsule/solution/ tablet, pregabalin capsule/ solution

halcinonide 0.1% cream (generic Halog)

betamethasone AF 0.05% cream, desoximetasone 0.25% cream, fluocinonide 0.05% cream

halobetasol 0.05% foam (generic Lexette) halobetasol cream, halobetasol ointment

Halog cream betamethasone AF 0.05% cream, desoximetasone 0.25% cream, fluocinonide 0.05% cream

Halog ointment betamethasone dipropionate 0.05% ointment, desoximetasone 0.25% ointment, fluocinonide 0.05% ointment

Halog solution betamethasone AF 0.05% cream, desoximetasone 0.25% cream, fluocinonide 0.05% cream, fluocinonide 0.05% solution

Hemady dexamethasone tablet

Hidex dexamethasone tablet

Horizant amitriptyline tablet, gabapentin capsule/solution/ tablet, pregabalin capsule/ solution

hydrocortisone butyrate 0.1% lotion (generic Locoid)

betamethasone dipropionate 0.05% lotion, fluticasone propionate 0.05% cream, triamcinolone 0.1% lotion

hydrocortisone butyrate hydrophilic lipo base 0.1% cream (generic Locoid Lipocream)

betamethasone valerate 0.1% cream, fluticasone propionate 0.05% cream, hydrocortisone valerate 0.2% cream

imiquimod 3.75% cream (generic Zyclara pump) imiquimod 5% cream

Page 8 of 15

Core Formulary

Drug Alternatives

Imitrex injection

generic sumatriptan injection and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, zolmitriptan tablet/ orally disintegrating tablet

Imitrex nasal spray

generic sumatriptan nasal spray and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, zolmitriptan tablet/ orally disintegrating tablet

Imitrex tablet

generic sumatriptan and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, zolmitriptan tablet/ orally disintegrating tablet

Impeklo 0.05% lotion At least two lower cost forms of clobetasol propionate including cream, gel, lotion, ointment, and solution

Impoyz betamethasone 0.05% ointment, desoximetasone 0.25% cream, fluocinonide 0.05% cream

Inderal XL propranolol tablet and solution, propranolol ER (extended-release) capsule [generic Inderal LA], nadolol tablet, timolol tablet

Indocin ibuprofen suspension 100mg/5ml, indomethacin 25mg capsule, indomethacin 50mg capsule, over-the-counter Voltaren gel

indomethacin 20mg capsule (generic Tivorbex)

indomethacin 25mg capsule, indomethacin 50mg capsule, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac

InnoPran XL propranolol tablet and solution, propranolol ER (extended-release) capsule [generic Inderal LA], nadolol tablet, timolol tablet

Intermezzo eszopiclone, zaleplon, zolpidem

Isordil Titradose 40mg tablet isosorbide dinitrate tablet isosorbide tablet 40mg (generic Isordil Titradose) isosorbide dinitrate tablet

Istalol (once daily) eye drops timolol maleate (twice daily) eye drops [generic Timoptic]

Jalyn

dutasteride in combination with tamsulosin and at least two of the following lower cost products: alfuzosin ER (extended-release) tablet, doxazosin, dutasteride, finasteride, tamsulosin, terazosin

Kenalog triamcinolone 0.025% cream, triamcinolone 0.1% cream, triamcinolone 0.025% ointment, triamcinolone 0.1% ointment

ketoconazole 2% foam (generic Extina) ketoconazole 2% cream, ketoconazole 2% shampoo

ketodan (generic Extina) ketoconazole 2% cream, ketoconazole 2% shampoo

ketoprofen 25mg capsule

ketoprofen 50mg capsule and at least three of the following lower cost NSAID products: celecoxib, etodolac, ketoprofen ER (extended-release) 200mg capsule, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac

ketorolac nasal spray (generic Sprix)

At least four of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac

Klisyri fluorouracil 2% solution, fluorouracil 5% solution, fluorouracil 5% cream, imiquimod 5% cream, diclofenac 3% gel

lactulose oral crystal packet lactulose solution, polyethylene glycol 3350 oral powder

Lescol atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Lescol XL atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Page 9 of 15

Core Formulary

Drug Alternatives

Lexette halobetasol cream, halobetasol ointment

Licart diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution (generic Pennsaid 1.5%), over-the-counter Voltaren gel

lidocaine-tetracaine 7-7% cream (generic Pliaglis)

lidocaine-prilocaine cream, lidocaine ointment, patch and solution, over-the-counter lidocaine gel

Lipofen

At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule

Livalo atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Locoid lotion betamethasone 0.05% lotion, fluticasone propionate 0.05% cream, triamcinolone 0.1% lotion

Locoid Lipocream betamethasone valerate 0.1% cream, fluticasone propionate 0.05% cream, hydrocortisone valerate 0.2% cream

Lorzone

chlorzoxazone 500mg tablet at least two of the following lower cost products: baclofen, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

Luxiq betamethasone dipropionate 0.05% cream, betamethasone valerate 0.1% ointment, mometasone furoate 0.1% solution (lotion), triamcinolone 0.5% cream

luliconazole cream (generic Luzu)

At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the-counter terbinafine cream

Luzu

At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the-counter terbinafine cream

Maxalt

generic rizatriptan and at least one of the following lower cost triptan medications: eletriptan, naratriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet

Maxalt ODT (orally disintegrating tablet)

generic rizatriptan orally disintegrating tablet and at least one of the following lower cost triptan medications: eletriptan, naratriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet

Medrol tablet methylprednisolone tablet, prednisolone syrup, prednisone oral solution, prednisone tablet

meloxicam capsule (generic Vivlodex)

generic meloxicam tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, nabumetone, naproxen, sulindac

metaxalone 400mg tablet

metaxalone 800mg tablet and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, methocarbamol tablet, tizanidine tablet

metformin ER (extended-release) modified release [generic Glumetza]

metformin, metformin ER (extended-release) [non-osmotic, non-modified release]

metformin ER (extended-release) osmotic release [generic Fortamet]

metformin, metformin ER (extended-release) [non-osmotic, non-modified release]

metoclopramide ODT (orally disintegrating tablet) [generic Metozolv ODT] metoclopramide IR (immediate-release) tablet, metoclopramide solution metoprolol-hydrochlorothiazide ER (extended-release) tablet [generic Dutoprol] metoprolol in combination with hydrochlorothiazide

Page 10 of 15

Core Formulary

Drug Alternatives miconazole-zinc oxide-petroleum ointment (generic Vusion)

At least two previous generic antifungals such as clotrimazole 1% cream, ketoconazole 2% cream, nystatin cream, ointment and powder, over-the-counter terbinafine cream, over-the-counter miconazole cream

Migergot At least one of the following lower cost ergot-containing medications: generic ergotamine/ caffeine tablet, generic dihydroergotamine injection

Migranal At least one of the following lower cost ergot-containing medications: generic ergotamine/ caffeine tablet, generic dihydroergotamine injection

Millipred, Millipred DP methylprednisolone tablet, prednisolone syrup, prednisone oral solution, prednisone tablet

minocycline IR (immediate-release) tablet

doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

minocycline ER (extended-release) tablet [generic Solodyn]

doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

minocycline ER (extended-release) capsule [generic Ximino]

doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

Minolira doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

Mondoxyne NL doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

mupirocin calcium cream (generic Bactroban) mupirocin 2% ointment, over-the-counter bacitracin ointment

Mytesi over-the-counter Bismuth, diphenoxylate-atropine, loperamide, opium tincture 1%, paregoric tincture 2mg/5ml

naftifine gel (generic Naftin) naftifine 1% cream, naftifine 2% cream

Naftin gel naftifine 1% cream, naftifine 2% cream

Nalfon

fenoprofen calcium 600mg tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac

Naprelan

naproxen EC (enteric-coated), naproxen DR (delayed-release), naproxen sodium and at least one of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, sulindac

naproxen ER (extended-release) [generic Naprelan]

naproxen EC (enteric-coated), naproxen DR (delayed-release), naproxen sodium and at least one of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, sulindac

Nascobal cyanocobalamin 1000mcg/mL injection

Nexletol atorvastatin, ezetimibe, rosuvastatin, simvastatin

Nexlizet atorvastatin, ezetimibe, rosuvastatin, simvastatin niacin (antihyperlipidemic) [generic Niacor] niacin ER (extended-release) [generic Niaspan], over-the-counter niacin

Niacor niacin ER (extended-release) [generic Niaspan], over-the-counter niacin

Nocdurna

bethanechol, desmopressin nasal spray, desmopressin tablet, flavoxate, oxybutynin, tolterodine ER (extended-release), tolterodine IR (immediate-release), trospium IR

Page 11 of 15

Core Formulary

Drug Alternatives

Noctiva

bethanechol, desmopressin nasal spray, desmopressin tablet, flavoxate, oxybutynin, tolterodine ER (extended-release), tolterodine IR (immediate-release), trospium IR

Norgesic Forte

orphenadrine ER (extended-release) and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

Noritate metronidazole 0.75% cream, metronidazole 0.75% gel, metronidazole 1% gel, metronidazole 0.75% lotion

Okebo doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

Olux, Olux-E At least two lower cost forms of clobetasol propionate including cream, gel, lotion, ointment and solution

Onexton

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

Onzetra Xsail

At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet

Oracea doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

Orapred ODT (orally disintegrating tablet)

methylprednisolone, prednisolone syrup, prednisone oral solution, prednisone tablet

Oravig clotrimazole lozenge, clotrimazole troche, nystatin suspension orphenadrine-aspirin-caffeine tablet (generic Norgesic Forte)

orphenadrine ER (extended-release) and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

Orphengesic Forte

orphenadrine ER (extended-release) and at least two of the following lower cost products: baclofen, chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

Oxistat 1% lotion

At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, oxiconazole cream, terbinafine tablet, over-the-counter terbinafine cream

Ozobax oral solution

baclofen tablets and at least two of the following lower cost products: chlorzoxazone 500mg tablet, cyclobenzaprine 5mg and 10mg tablet, metaxalone 800mg tablet, methocarbamol tablet, tizanidine tablet

Pandel cream betamethasone valerate 0.1% cream, fluocinolone 0.025% cream, hydrocortisone butyrate 0.1% cream

penicillamine capsule (generic Cuprimine) penicillamine tablet (generic Depen Titratabs)

Pennsaid 2% diclofenac 1% topical gel (generic Voltaren), diclofenac 1.5% solution (generic Pennsaid 1.5%), over-the-counter Voltaren gel

pioglitazone-glimepiride tablet (generic Duetact) pioglitazone in combination with glimepiride

Pliaglis 7-7% cream, kit lidocaine-prilocaine cream, lidocaine ointment, patch and solution, over-the-counter lidocaine gel

prednisolone ODT (orally disintegrating tablet) [generic Orapred ODT]

methylprednisolone tablet, prednisolone syrup, prednisone oral solution, prednisone tablet

Prestalia perindopril in combination with amlodipine

Page 12 of 15

Core Formulary

Drug Alternatives

ProAir Digihaler albuterol sulfate HFA (generic ProAir HFA and generic Proventil HFA), Ventolin HFA

Prudoxin

At least two of the following lower cost products: betamethasone 0.05% cream, clobetasol propionate 0.05% cream, desoximetasone 0.25% cream, pimecrolimus 1% cream, tacrolimus 0.03% ointment, tacrolimus 0.1% ointment, triamcinolone 0.5% cream

Psorcon cream desoximetasone 0.05% cream, fluocinonide 0.05% cream, ointment and solution, triamcinolone 0.5% cream and ointment

Pylera metronidazole 250mg tablets in combination with tetracycline capsules and over-the-counter (OTC) bismuth

Qmiiz ODT (orally disintegrating tablet)

ibuprofen 100mg/5ml suspension, meloxicam tablet, over-the-counter Voltaren gel

ramelteon tablet (generic Rozerem) eszopiclone, zaleplon, zolpidem

Rayos dexamethasone tablet, methylprednisolone tablet, prednisolone syrup and solution, prednisone tablet and solution

Relafen DS 1000mg tablet

generic nabumetone and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, naproxen, sulindac

Relpax

generic eletriptan and at least one of the following lower cost triptan medications: naratriptan, rizatriptan, sumatriptan, zolmitriptan tablet/ orally disintegrating tablet

Reltone ursodiol 300mg capsule, 250mg tablet, 500mg tablet

Renagel 800mg tablet sevelamer carbonate 800mg tablet, sevelamer carbonate packet

Retin-A tretinoin cream, tretinoin 0.01% and 0.025% gel risedronate DR (delayed-release) tablet [generic Atelvia] alendronate, ibandronate, risedronate IR (immediate-release)

Roszet ezetimibe in combination with rosuvastatin, ezetimibe in combination with atorvastatin or simvastatin

Rozerem eszopiclone, zaleplon, zolpidem

Sernivo spray At least two lower cost forms of betamethasone including cream, lotion, and ointment

sevelamer hydrochloride 800mg tablet (generic Renagel) sevelamer carbonate 800mg tablet, sevelamer carbonate packet

Seysara doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

Sitavig clotrimazole troches, nystatin suspension

Solodyn doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

Sprix

At least four of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac

sulconazole 1% cream, solution (generic Exelderm)

At least two previous generic antifungals such as clotrimazole 1% cream, econazole 1% cream, ketoconazole 2% cream, terbinafine tablet, over-the-counter terbinafine cream

sumatriptan-naproxen (generic Treximet) sumatriptan in combination with naproxen

Page 13 of 15

Core Formulary

Drug Alternatives

Synera lidocaine-prilocaine cream, lidocaine ointment, lidocaine patch, lidocaine solution

Taclonex calcipotriene-betamethasone dipropionate 0.005-0.064% suspension

Talicia rifabutin in combination with amoxicillin and over-the-counter (OTC) omeprazole

Taperdex dexamethasone tablet, prednisone tablet therapy pack

Targadox doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

Tazorac

tazarotene 0.1% cream and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel

Texacort fluocinolone 0.025% cream, hydrocortisone 1% ointment, triamcinolone 0.1% ointment

timolol maleate (once daily) eye drops [generic Istalol] timolol maleate (twice daily) eye drops [generic Timoptic]

Timoptic Ocudose timolol maleate (twice daily) eye drops [generic Timoptic]

Tivorbex

indomethacin 25mg, indomethacin 50mg capsule, and at least two of the following lower cost NSAID products: celecoxib, etodolac, meloxicam tablet, nabumetone, naproxen, sulindac

Tolsura itraconazole capsule, itraconazole solution

Tolak fluorouracil 2% solution, fluorouracil 5% solution

Topicort 0.05% gel

betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment

Topicort 0.05% ointment

betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment

Topicort spray

betamethasone 0.05% ointment, desoximetasone 0.25% cream, 0.25% ointment, and 0.05% cream, fluocinonide 0.05% gel and solution, fluticasone propionate 0.005% ointment, triamcinolone 0.5% ointment

Tosymra

generic sumatriptan nasal spray and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, zolmitriptan tablet/ orally disintegrating tablet

Tovet calcipotriene 0.005% cream, ointment, and solution, tazarotene 0.1% cream

Trexall generic methotrexate tablets, methotrexate injection

Treximet sumatriptan in combination with over-the-counter naproxen triamcinolone 0.05% ointment (generic Trianex) triamcinolone 0.025% ointment, triamcinolone 0.1% ointment triamcinolone topical aerosol spray (generic Kenalog)

triamcinolone 0.025% cream, triamcinolone 0.1% cream, triamcinolone 0.025% ointment, triamcinolone 0.1% ointment

Trianex ointment triamcinolone 0.025% ointment, triamcinolone 0.1% ointment

Triglide

At least two of the following lower cost fenofibrate products: choline fenofibrate; fenofibrate 48mg, 54mg, 145mg, and 160mg tablet; fenofibrate micronized 43mg, 67mg, 130mg, 134mg, and 200mg capsule

Page 14 of 15

Core Formulary

Drug Alternatives

TussiCaps hydrocodone-chlorpheniramine suspension, promethazine-codeine 6.25-10mg/5ml syrup, promethazine-dm 6.25-15mg/5ml syrup

Ultravate 0.05% lotion halobetasol 0.05% cream, halobetasol 0.05% ointment vancomycin oral solution (reconstituted) Firvanq

Vectical calcipotriene 0.005% cream/ ointment/ solution, tazarotene 0.1% cream

Veltin

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel, and at least one of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream

Verdeso foam At least two lower cost other forms of desonide including cream, lotion, and ointment

Vivlodex

generic meloxicam tablet and at least three of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, nabumetone, naproxen, sulindac

Vusion

At least two previous generic antifungals such as clotrimazole 1% cream, ketoconazole 2% cream, nystatin cream, ointment and powder, over-the-counter terbinafine cream, over-the-counter miconazole cream

Vytorin ezetimibe in combination with simvastatin, ezetimibe in combination with atorvastatin or rosuvastatin

Winlevi

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T) and at least two of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream, tretinoin cream, tretinoin 0.01% and 0.025% gel

Wynzora cream betamethasone 0.05% lotion, calcipotriene 0.005% ointment, calcipotriene-betamethasone dipropionate 0.005-0.064% suspension

Xerese acyclovir ointment in combination with hydrocortisone 1% cream

Ximino doxycycline IR (immediate-release) [generic Adoxa, Monodox, and Vibramycin capsule], minocycline IR capsule

Xolegel ketoconazole 2% cream, ketoconazole 2% shampoo

Zembrace SymTouch

generic sumatriptan injection and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan tablet, zolmitriptan tablet/ orally disintegrating tablet

Ziana

clindamycin phosphate 1% solution/ gel/ lotion (generic Cleocin-T), tretinoin cream, tretinoin 0.01% and 0.025% gel, and at least one of the following lower cost products: adapalene 0.1% cream/ gel, adapalene 0.3% gel, tazarotene 0.1% cream

zileuton ER (extended-release) [generic Zyflo CR] montelukast tablet, montelukast chew tablet, zafirlukast tablet

Zilxi azelaic acid 15% gel, metronidazole 0.75% cream, metronidazole 0.75% gel, metronidazole 1% gel, metronidazole 0.75% lotion, Soolantra

Zipsor

diclofenac potassium 50mg tablet, diclofenac sodium DR (delayed-release) tablet, and at least two of the following lower cost NSAID products: celecoxib, etodolac, indomethacin 25mg and 50mg capsule, meloxicam tablet, nabumetone, naproxen, sulindac

zolmitriptan nasal spray (generic Zomig nasal spray)

At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan (also available as a nasal spray), zolmitriptan tablet/ orally disintegrating tablet

zolpidem sublingual tablet (generic Intermezzo) eszopiclone, zaleplon, zolpidem

Page 15 of 15

Core Formulary

Drug Alternatives

Zolpimist eszopiclone, zaleplon, zolpidem

Zomig nasal spray

At least two of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan (also available as a nasal spray), zolmitriptan tablet/ orally disintegrating tablet

Zomig ZMT (orally disintegrating tablet)

generic zolmitriptan orally disintegrating tablet and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan (also available as an orally disintegrating tablet), sumatriptan

Zomig tablet generic zolmitriptan tablet and at least one of the following lower cost triptan medications: eletriptan, naratriptan, rizatriptan, sumatriptan

Zonalon

At least two of the following lower cost products: betamethasone 0.05% cream, clobetasol propionate 0.05% cream, desoximetasone 0.25% cream, pimecrolimus 1% cream, tacrolimus 0.03% ointment, tacrolimus 0.1% ointment, triamcinolone 0.5% cream

Zorvolex

Zovirax cream acyclovir 5% ointment

Ztlido lidocaine ointment, lidocaine patch, lidocaine solution

Zuplenz granisetron, ondansetron, ondansetron ODT (orally disintegrating tablet)

Zyclara imiquimod 5% cream

Zyflo (immediate-release) montelukast tablet, montelukast chew tablet, zafirlukast tablet

Zyflo CR (extended-release) montelukast tablet, montelukast chew tablet, zafirlukast tablet

Zypitamag atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin