Generic Premium

Member education
Generic Premium
With Generic Premium, you have coverage
for low-cost generic drugs, plus some of
the most common brand drugs. That means
you can get the medicine you need, while
saving money.
Member education
What is Generic Premium?
Generic Premium can help you lower your prescription costs
by covering most generic drugs. Some brand drugs are
covered by Generic Premium too. They include drugs that
treat common conditions like high blood pressure, diabetes,
high cholesterol, ulcers and more. So you can choose from a
wide range of quality drugs.
How does Generic Premium work?
Talk to your doctor before you switch or stop taking any
drugs. If you and your doctor agree that a covered drug is a
good option, you’ll need a new prescription. You can choose
to fill the prescription through home delivery or at a local
pharmacy.
* Required by the U.S. Food and Drug Administration (FDA).
Generics can help you save
Generic Premium encourages you to use generic drugs.
Why? Generics and their brand versions have the same
active ingredient, strength and dose. Generics must meet
the same high standards for purity, quality, safety and
strength.* Plus, generics normally cost 30 to 60% less than
the brand versions. With generics, you get the same quality
for less money.
Drug coverage at a glance
The Generic Premium drug list includes products used for
the health needs and conditions below, plus many more.
See the next pages for a list of covered drugs.
• Attention deficit hyperactivity
disorder (ADHD)
• Arthritis
• Asthma
• Birth control
• Depression
• Diabetes drugs and supplies
• Enlarged prostate
• Glaucoma
• High blood pressure
2 | Generic Premium
• High cholesterol
• Infections
• Osteoporosis
• Overactive bladder
• Pain
• Prenatal vitamins
• Seizures
• Sleep aids
• Ulcers
Generic drugs are listed in all
lowercase letters.
Brand drugs are listed with a first
capital letter.
TIER 1
amlodipine besylate (Norvasc)*
DO QL
contraceptives – all prescription
strength, self administered generic
contraceptives
amlodipine besylate/atorvastatin
(Caduet)*
cough and cold preparations –
all prescription strength, self
administered, generic cough and
cold preparations
pancreatic enzymes – all prescription
strength, self administered, generic
pancreatic enzymes
amlodipine besylate/benazepril
(Lotrel)*
amoxapine (Asendin)*
amoxicillin trihydrate (Amoxil,
Trimox, various)*
amoxicillin trihydrate/potassium
clavulanate, ER (Augmentin, XR)*
PKU – all prescription strength, self
administered, generic PKU formulas
amphetamine salt combo
(Adderall)*
vitamins – all prescription strength,
self administered, generic vitamins
ampicillin trihydrate (Principen)*
Tier 2 drugs have a medium copay
and offer a good value.
Tier 3 drugs have the highest
copay. Many of these drugs treat
complex, ongoing conditions and
may require special handling.
PA = Prior authorization is needed.
In this case, you must receive
approval before the drug
is covered.
anagrelide hcl (Agrylin)*
antipyrine/benzocaine/glycerin
(Auralgan)*
acarbose (Precose)*
aspirin/codeine phosphate
acebutolol hcl (Sectral)*
atovaquone/proguanil
(Malarone)*
acetaminophen/caffeine/butalbital
(Fioricet)* QL
Tier 1 drugs have the lowest
copay. Many Tier 1 drugs are
generics.
QL = Quantity limits are needed.
Some drugs have limits on the
amount you receive for each
prescription or each month.
ST = Step therapy is needed.
You may need to try another drug
before we’ll provide coverage for
the medicine.
DO = Dose optimization is needed.
This usually means that you take
the drug once a day instead of
twice a day.
* Generic versions of these drugs
are covered. The brand name in
parenthesis is only for reference.
^ These drugs often require your
doctor to carefully monitor your
dose to make sure the drug
works best for you. In general,
you shouldn’t switch between
the brand and generic versions
of these drugs. Your plan covers
both the brand and generic
versions.
†
Once a generic is available,
the brand version will not
be covered.
Key
atenolol (Tenormin)*
acetaminophen/codeine (Tylenol w/
Codeine)* QL
atenolol/chlorthalidone
(Tenoretic)*
bromfenac (Xibrom)*
carvedilol (Coreg)*
acetaminophen/Phenyltoloxamine
(Dologesic, various)*
atorvastatin (Lipitor)* DO, QL
budesonide EC (Entocort EC)*
cefaclor (Ceclor, Ceclor CD)*
atropine sulfate (Isopto Atropine)*
bromocriptine mesylate (Parlodel)*
cefadroxil hydrate (Duricef)*
azathioprine (Imuran)*
bumetanide (Bumex)*
cefdinir (Omnicef)*
azelastine (Optivar)* QL
buprenorphine (Subutex)* QL
cefpodoxime proxetil (Vantin)*
azelastine (Astelin Nasal)* QL
bupropion hcll (Wellbutrin,
cefprozil (Cefzil)*
azithromycin (Zithromax)* QL
Wellbutrin SR)*
cefuroxime axetil (Ceftin)*
bacitracin/polymyxin b sulfate
(Polysporin Ointment)*
bupropion HCl (Wellbutrin XL)* DO, QL
(XL only)
cephalexin monohydrate (Keflex)*
baclofen (Lioresal)*
buspirone HCl (Buspar)*
chlordiazepoxide hcl (Librium)*
balsalazide disodium
butalbital/acetaminophen/caffeine
(Esgic-Plus)*
chlorhexidine gluconate (Peridex)*
acetazolamide (Diamox)*
acetic acid (VoSol)*
acetic acid/aluminum acetate
(Domeboro)*
acetic acid/hydrocortisone
(VoSol HC)*
acetylcysteine (Mucomyst)*
acyclovir (Zovirax)*
adapalene (Differin)*
albuterol sulfate (Proventil)*
belladonna alkaloids/phenobarbital
(Donnatal)*
albuterol/ipratropium nebulizer soln
(Duoneb)*
benazepril hcl (Lotensin)*
butorphanol (Stadol)*
benazepril/hydrochlorothiazide
(Lotensin HCT)*
cabergoline (Dostinex)*
alclometasone dipropionate
(Aclovate)*
alendronate (Fosamax)* QL
alfuzosin (Uroxatral)*
allopurinol (Zyloprim)*
alprazolam, ER (Xanax, Xanax XR)*
benzonatate (Tessalon Perles)*
benzoyl peroxide (Benzagel,
Benzac AC, various)*
benztropine mesylate (Cogentin)*
butalbital/aspirin/caffeine (Fiorinal)*
calcipotriene (Dovonex Oint.)*
captopril (Capoten)*
captopril/hydrochlorothiazide
(Capozide)*
chloral hydrate (Somnote)*
chloroquine phosphate (Aralen)*
chlorothiazide (Diuril)*
chlorpromazine hcl (Thorazine)*
chlorpropamide (Diabinese)*
chlorthalidone (Hygroton)*
chlorzoxazone (Parafon Forte DSC)*
cholestyramine/aspartame
carbamazepine (Carbatrol, Tegretol,
Epitol)^
(Questran Light)*
carbamazepine, ER (Tegretol XR)*
cholestyramine/sucrose (Questran)*
amantadine hcl (Symmetrel)*
betamethasone dipropionate
(Diprosone, Diprolene, Diprosone)*
amcinonide (Cyclocort)*
betamethasone valerate (Betatrex)*
carteolol (Ocupress)*
choline salicylate/magnesium
salicylate (Tricosal)*
amiloride (Midamor)*
betametheasone dipropionate/
propylene glycol (Diprolene AF)*
carbidopa/levodopa (Sinemet,
ciclopirox (Loprox Shampoo)*
Sinemet CR)*
ciclopirox (Penlac)*
cilostazol (Pletal)*
amiloride/hydrrocholorthiazide
(Moduretic)*
betaxolol hcl (Betoptic)*
aminophylline
bethanechol chloride (Urecholine)*
carbidopa/levodopa/entacapone
(Stalevo)*
amiodarone hcl (Cordarone,
Pacerone)^
bisoprol/hydrochlorothiazide (Ziac)*
carisoprodol (Soma)*
bisoprolol fumarate (Zebeta)*
carisoprodol/aspirin (Soma
Compound)*
amitriptyline hcl (Elavil)*
brimonidine tartrate (Alphagan)*
cimetidine – prescription only
(Tagamet)*
ciprofloxacin hcl (Cipro)* QL
ciprofloxacin hcl drops (Ciloxan)*
Generic Premium | 3
citalopram hydrobromide
(Celexa)* DO, QL
desoximetasone (Topicort)*
erythromycin base (Ilotycin)*
dexamethasone (Decadron)*
citric acid/potassium citrate
(Polycitra - K)*
dexamethasone sodium phosphate
(Decadron)*
erythromycin base/benzoyl peroxide
(Benzamycin)*
citric acid/sodium citrate (Bicitra)*
fluoxetine hcl 10, 20, 40mg only
(Prozac)* DO, QL
fluphenazine hcl (Prolixin)*
erythromycin base/ethanol (A/T/S)*
flurazepam hcl (Dalmane)*
erythromycin base/ethanol (Erycette)*
flurbiprofen (Ansaid)*
clarithromycin, ER (Biaxin, Biaxin XL)*
dextroamphetamine sulfate, ER
(Dexedrine, Dextrostat)*
erythromycin ethylsuccinate (E.E.S.)*
flurbiprofen sodium (Ocufen)*
clidinium/chlordiazepoxide (Librax)*
diazepam (Valium)*
erythromycin
fluticasone nasal spray (Flonase)* QL
clindamycin hcl (Cleocin HCl)*
diazepam rectal (Diastat)^
fluticasone propionate (Cutivate)*
clindamycin phosphate (Cleocin T)*
diclofenac potassium (Cataflam)*
ethylsuccinate/sulfisoxazole
(Pediazole)*
clindamycin/benzoyl peroxide
(Benzaclin)*
diclofenac sodium (Voltaren, Voltaren
Ophth.)*
escitalopram (Lexapro)* DO, QL
fluvoxamine maleate (Luvox)* DO
estazolam (ProSom)*
clobetasol propionate (Clobex Lotion,
Shampoo)*
dicloxacillin sodium (Dynapen)*
folic acid (Folvite)*
estradiol (Estrace)*
dicyclomine hcl (Bentyl)*
fosinopril sodium (Monopril)*
clobetasol propionate (Cormax)*
estradiol (Climara)*
diflorasone diacetate (Psorcon)*
clobetasol propionate (Temovate)*
estradiol/norethindrone (Activella)*
fosinopril/hydrochlorothiazide
(Monopril HCT)*
diflunisal (Dolobid)*
clobetasol propionate/emollient
(Temovate-E)*
estrogen, esterified/
methyltestosterone (Syntest D.S.)*
furosemide (Lasix)*
digoxin (Lanoxin)*
clomipramine hcl (Anafranil)*
dihydroergotamine mesylate
(D.H.E.45, Migranal)*
estrogen, esterified/
methyltestosterone (Syntest H.S.)*
galantamine (Razadyne, ER)*
clonazepam (Klonopin)*
diltiazem hcl (Cardizem,
estropipate (Ogen)*
clonidine hcl (Catapres)*
Cardizem LA, Tiazac, Cardizem SR,
Cardizem CD)* DO
ethambutol hcl (Myambutol)*
diphenhydramine – prescription
strength (Benadryl)*
etidronate (Didronel)*
diphenoxylate hcl/atropine sulfate
(Lomotil)*
famciclovir (Famvir)*
clonidine patch (Catapres-TTS)*
clopidogrel (Plavix)* QL
clorazepate dipotassium
(Tranxene T-Tab)*
clotrimazole (Mycelex)*
ethosuximide (Zarontin)^
etodolac (Lodine)*
fluvastatin (lescol)* DO
gabapentin (Neurontin)*
gemfibrozil (Lopid)*
gentamicin sulfate (Garamycin)*
gianvi (Yaz)*
glimepiride (Amaryl)*
glipizide, ER (Glucotrol, Glucotrol XL)*
glipizide/metformin hcl (Metaglip)*
glyburide (DiaBeta, Micronase)*
dipyridamole (Persantine)*
felbamate (Felbatol)^
disopyramide phosphate (Norpace,
Norpace CR)*
felodipine (Plendil)* DO, QL
glyburide, micronized/metformin hcl
(Glucovance)*
fenofibrate, micronized (Lofibra)*
glycopyrrolate
codeine phosphate/carisoprodol/
asprin (Carisoprodol CompoundCodeine)*
disulfiram (Antabuse)*
fenoprofen (Nalfon)*
griseofulvin, microsize (Griseofulvin)*
divalproex sodium (Depakote)^
fentanyl (Duragesic)* QL
donepizil 5, 10mg only (Aricept)*
fentanyl citrate (Actiq)* PA, QL
guaifenesin/codeine phosphate
(Robitussin AC)*
codeine sulfate
dorzolamide (Trusopt)*
dorzolamide/timolol (Cosopt)*
ferrous fumarate/folic acid
(Nephro-Fer RX)*
guaifenesin/phenylephrine hcl
codeine/butalbital/aspirin/caffeine
(Fiorinal w/Codeine)*
ferrous fumerate/docusate sodium/
folic acid
guanfacine hcl (Tenex)*
clotrimazole/betamethasone
(Lotrisone)*
clozapine (Clozaril)^
colestipol hcl (Colestid)*
cortisone cetate
cromolyn sodium (Intal)*
doxazosin mesylate (Cardura)*
doxepin hcl (Sinequan)*
doxycycline hyclate (Doryx,
Vibramycin, Vibra-Tabs)*
fexofenadine hcl (Allegra)* QL
finasteride (Proscar)*
(Entex LA)*
halobetasol propionate (Ultravate)*
haloperidol (Haldol)*
doxycycline monohydrate
(Adoxa, Monodox)*
flavoxate hcl (Urispas)*
homatropine hbr (Isopto
Homatropine)*
flecainide acetate (Tambocor)*
hyaluronate sodium
dronabinol (Marinol)*
fluconazole (Diflucan)*
hydralazine hcl (Apresoline)*
flucytosine (Ancobon)*
cyclopentolate HCl (Cyclogyl 1%, 2%)*
drospirenone/ethinyl estradiol
(Yasmin)*
hydrochlorothiazide (HydroDIURIL)*
fludrocortisone acetate (Florinef)*
danazol
econazole nitrate (Spectazole)*
flunisolide (Nasalide)*
dantrolene sodium (Dantrium)*
enalapril maleate (Vasotec)*
demeclocycline hcl (Declomycin)*
desipramine hcl (Norpramin)*
enalapril/hydrochlorothiazide
(Vaseretic)*
fluocinolone acetonide (DermaSmoothe-FS, Dermotic Oil, Synalar)*
hydrocodone/acetaminophen
(Vicodin, Lortab, Vicodin ES, various)*
QL
desmopressin acetate (DDAVP)*
epinastine (Elestat)*
fluocinonide/emollient (Lidex-E)*
desogestrel/ethinyl estradiol
eprosartan mesylate (Teveten)*
fluorometholone (FML, Flarex)*
desonide (DesOwen)*
ergotamine/caffeine (Cafergot)*
fluorouracil (Efudex)*
cromolyn sodium (Opticrom)* QL
cyanocobalamin/folic acid/pyridoxine
cyclobenzaprine, ER (Amrix ER,
Fexmid, Flexeril)*
4 | Generic Premium
fluocinonide (Lidex)*
hydrocodone/chlorpheniramine
(Tussionex)*
hydrocodone/homatropine
(Hycodan)*
hydrocodone/ibuprofen
(Vicoprofen)* QL
hydrocortisone (Hytone, Locoid)*
lancets
methocarbamol (Robaxin)*
hydrocortisone acetate (Anucort-HC,
Anusol-HC, various)*
lansoprazole (Prevacid)* QL
methscopolamine bromide (Pamine)*
latanoprost (Xalatan)*
methylergonovine (Methergine)*
hydrocortisone acetate/pramoxine
hcl (Analpram-HC)*
leflunomide (Arava)*
methyldopa (Aldomet)*
hydrocortisone acetate/pramoxine
hcl (Pramosone)*
levalbuterol (Xopenex)*
levetiracetam, ER (Keppra, XR)^
methyldopa/hydrochlorothiazide
(Aldoril)*
neomycin sulfate/polymyxin b/
dexamethasone (Maxitrol)*
neomycin sulfate/polymyxin b/
hydrocortisone (Cortisporin)*
nicardipine, ER (Cardene, SR)* DO
nifedipine (Adalat, Procardia, Adalat
CC, Procardia XL)* DO QL
hydrocortisone valerate (Westcort)*
levobunolol hcl (Betagan)*
hydrocortisone/pramoxine/
chloroxylenol (Cortane-B)*
levocetirizine (Xyzal)* QL
methylphenidate hcl (Metadate ER,
Methylin ER, Methylin, Ritalin, Ritalin
LA, various)*
levofloxacin (Levaquin)* QL
methylprednisolone (Medrol)*
hydromorphone hcl (Dilaudid)*
levofloxacin ophthalmic (Quixin)*
metipranolol (OptiPranolol)*
nitrofurantoin macrocrystal
(Macrodantin, Macrobid)*
hydroxychloroquine sulfate
(Plaquenil)*
levonorgestrel (Plan B)*
metoclopramide hcl (Reglan)*
nitroglycerin (Nitrostat)*
levonorgestrel/ethinyl estradiol
metolazone (Zaroxolyn)*
nizatidine – prescription only (Axid)*
hydroxyzine hcl (Atarax)*
levothyroxine sodium (Synthroid,
various)^
metoprolol succinate (Toprol XL)*
norethindrone (Ortho Micronor)*
metoprolol tartrate (Lopressor)*
norethindrone acetate (Aygestin)*
metronidazole (Flagyl)*
norethindrone acetate/ethinyl
estradiol/ferrouse fumarate
hydroxyzine pamoate (Vistaril)*
hyoscyamine sulfate (Cystospaz,
Levsin, Nulev, Levsinex, Levbid)*
lidocaine hcl (Xylocaine, various)*
ibandronate (Boniva)* QL
lisinopril (Prinivil, Zestril*)
ibuprofen (Motrin)*
ibuprofen/oxycodone hcl
lisinopril/hydrochlorothiazide
(Prinzide, Zestoretic)*
(Combunox)* QL
lithium carbonate (Eskalith)^
minocycline hcl (Dynacin, Minocin)*
imipramine hcl (Tofranil)*
lithium citrate
minoxidil (Loniten)*
imiquimod (Aldara)* QL
lorazepam (Ativan)*
indapamide (Lozol)*
losartan (Cozaar)* DO, QL
mirtazapine (Remeron, Remeron
Sol Tab)*
indomethacin (Indocin)*
losartan/hctz (Hyzaar)* DO, QL
insulin syringes
lovastatin (Mevacor)* DO, QL
ipratropium bromide
loxapine succinate (Loxitane)*
(Atrovent, Nasal)* QL
maprotiline (Ludiomil)*
moexipril/hydrochlorothiazide
(Uniretic)*
irbesartan (Avapro)* DO, QL
mebendazole (Vermox)*
mometasone furoate (Elocon)*
irbesartan/hctz (Avalide)* DO, QL
mefenamic acid (Ponstel)*
iron, carbonyl/vitamin C/vitamin
B12/folic acid
medroxyprogesterone acetate
(Provera)*
morphine sulfate (Kadian, MS Contin,
Oramorph SR, RMS-Suppository)* QL
isometheptene/acetaminophen/
dichloralphenazone (Midrin)*
mefloquine hcl (Lariam)*
isoniazid
meperidine hcl (Demerol, Meperitab)*
isosorbide dinitrate (Isordil)*
meperidine hcl/prometh hcl
(Meprozine)*
isosorbide mononitrate (ISMO,
Imdur)*
liothyronine (Cytomel)*
meloxicam (Mobic)* QL
metronidazole (Metrogel Vaginal)*
mexiletine hcl (Mexitil)*
midodrine hcl (ProAmatine)*
nimodipine (Nimotop)* DO
nisoldipine (Sular)* DO, QL
norgestimate/ethinyl estradiol
norgestrel/ethinyl estradiol
nortriptyline hcl (Pamelor)*
nystatin (Mycostatin)*
nystatin/triamcinolone (Mycolog II)*
ofloxacin (Floxin)* QL
misoprostol (Cytotec)*
ofloxacin (Ocuflox)*
modafinil (Provigil)* DO, QL, PA
olanzapine (Zyprexa, Zydis)*
moexipril hcl (Univasc)*
omeprazole – prescription only
(Prilosec)* QL
multivitamin combination/ferrous
fumarate/polysaccharide iron
complex/folic acid
mupirocin (Bactroban)*
nabumetone (Relafen)*
nadolol (Corgard)*
meprobamate (Miltown)*
naltrexone hcl (ReVia)*
isotretinoin (Accutane)*
mesalamine (Rowasa)*
naproxen (Naprosyn)*
isradipine (DynaCirc)* DO
metaproterenol sulfate (Alupent)*
itraconazole (Sporanox)* PA
metaxolone (Skelaxin)*
naproxen sodium (Anaprox,
Naprelan)*
ketoconazole (Nizoral, Extina)*
metformin, ER (Fortamet, Glucophage,
Glucophage XR)*
orphenadrine/aspirin/caffeine
(Norgesic)*
oxandrolone
oxaprozin (Daypro)*
oxazepam (Serax)*
oxcarbazepine tab (Trileptal tab)*
oxybutynin chloride (Ditropan,
Ditropan XL)*
oxycodone hcl (Roxicodone,
OxyFAST)*
oxycodone hcl/acetaminophen
(Percocet, Tylox)* QL
oxycodone/aspirin (Percodan)*
oxymorphone, ER (Opana, ER)* QL
naratriptan (Amerge)* QL
pantoprazole (Protonix)* QL
nateglinide (Starlix)*
paromomycin sulfate (Humatin)*
nefazodone (Serzone)*
(Toradol)* QL
methadone hcl (Dolophine HCl,
Methadone Intensol, Methadose)*
paroxetine hcl (Paxil, Paxil CR)* DO,
QL
ketorolac soln (Acular, LS)*
methamphetamine (Desoxyn)*
labetalol hcl (Normodyne)*
methazolamide (Neptazane)*
neomycin sulfate/gramicidin/
polymyxin b (Neosporin)*
lactulose (Cephulac, Chronulac)*
methenamine mandelate
(Mandelamine)*
neomycin sulfate/polymyxin b/
hydrocortisone (Cortisporin)*
ketoprofen (Orudis)*
ketorolac tromethamine
lamotrigine (Lamictal)^
methimazole (Tapazole)*
neomycin sulfate
peg 3350/sodium sulfate/sodium
bicarbonate/sodium chloride/
penicillin v potassium (Pen-Vee K)*
pentoxifylline (Trental)*
perindopril (Aceon)*
Generic Premium | 5
permethrin (Elimite)*
quinapril hcl (Accupril)*
terbinafine hcll (Lamisil)*
ursodiol (Actigall)*
perphenazine (Trilafon)*
terbutaline sulfate (Brethine)*
valacyclovir (Valtrex)*
phenazopyridine hcl (Pyridium)*
quinapril/hydrochlorothiazide
(Accuretic)*
terconazole (Terazol)*
valproate sodium (Depakene)^
phenelzine (Nardil)*
quinidine gluconate (Quinaglute)*
tetracycline hcl (Achromycin V)*
vancomycin (Vancocin capsule)*
phenobarbital
quinidine sulfate (Quinidex)*
theophylline anhydrous (Theo-24)^
venlafaxine hcl, ER (Effexor, XR)*
phenylephrine hcl (Neo-Synephrine)*
ramipril (Altace)*
thioridazine hcl (Mellaril)*
phenytoin (Dilantin)^
ranitidine hcl – prescription only
(Zantac)*
thiothixene (Navane)*
verapamil hcl, ER (Calan, Verelan,
Verelan PM, Calan SR, Isoptin S.R.)*
thyroid (Armour Thyroid)^
voriconazole (Vfend)*
thyroid, pork (Nature-Throid)*
warfarin sodium (Coumadin)^
ticlopidine hcl (Ticlid)*
zafirlukast (Accolate)*
timolol maleate (Timoptic,
zaleplon (Sonata)* QL
Timoptic-XE)*
ziprasidone (Geodon)*
tinidazole (Tindamax)*
zolpidem, ER (Ambien, CR)* QL
tizanidine hcl (Zanaflex)*
zonisamide (Zonegran)*
pilocarpine hcl (Isopto Carpine)*
pindolol (Visken)*
piroxicam (Feldene)*
polymyxin b sulfate/trimethoprim
(Polytrim)*
rifampin (Rifadin)*
rimantadine hcl (Flumadine)*
risperidone (Risperdal)*
rivastigmine (Exelon)*
potassium bicarbonate/potassium
citrate (K-Lyte)*
ropinirole, ER (Requip, XL)*
potassium chloride (GoLYTELY)*
salsalate (Disalcid)*
potassium chloride (K-Dur, Klor-Con,
Slow-K, various)*
selegiline hcl (Eldepryl)*
potassium chloride/potassium
bicarbonate (K-Lyte/Cl)*
sertraline hcl (Zoloft)* DO, QL
tobramycin sulfate drops
(Tobrex)*
silver sulfadiazine (Silvadene)*
tolazamide (Tolinase)*
simvastatin (Zocor)* DO, QL,
tolbutamide (Orinase)*
PA – 80 mg only
topiramate (Topamax)^
sodium citrate/potassium citrate
torsemide (Demadex)
prazosin hcl (Minipress)*
sodium citrate (Polycitra)*
prednicarbate (Dermatop)*
sodium fluoride (Luride)*
tramadol, ER 100, 200, 300mg (Ultram,
ER, Ryzolt ER)* QL
sodium polystyrene sulfonate
(Kayexalate)*
tramadol hcl/acetaminophen
(Ultracet)* QL
Accu-Chek Test Strips QL
prednisolone (Prelone)*
sotalol hcl (Betapace, Betapace AF)*
trandolapril (Mavik)*
Actos† QL
spironolact/hydrochlorothiazide
(Aldactazide)*
trandolapril/verapamil (Tarka)*
Advair Diskus QL
trazodone hcl (Desyrel)*
Advair HFA QL
spironolactone (Aldactone)*
triamcinolone acetonide
Armour Thyroid
prednisone (Deltasone)*
stannous fluoride
(Kenalog)*
Byetta ST, QL
primidone (Mysoline)*
sucralfate (Carafate)*
Carbatrol
probenecid (Probenecid)*
sulfacetamide sodiujm/sulfur/urea
triamcinolone acetonide nasal
(Nasacort AQ)* QL
procainamide hcl (Pronestyl)*
sulfacetamide sodium (Bleph-10)*
Clozaril
prochlorperazine maleate
sulfacetamide sodium (Ovace)*
triamterene/hydrochlorothiazide
(Dyazide, Maxzide)*
(Compazine, Compro)*
sulfacetamide sodium/
prednisolone
potassium citrate (Urocit K)*
pramipexole (Mirapex)*
pravastatin sodium (Pravachol)* DO,
QL
prednisolone acetate (Pred Forte)*
prednisolone sodium phosphate
(Pediapred)*
prednisolone sodium phosphate
(Inflamase Forte)*
progesterone (Prometrium)*
promethazine containing products
(Phenergan, various)*
propafenone hcl (Rythmol)*
proparacaine hcl (Ophthetic)*
propranolol hcl (Inderal, Inderal LA,
Innopran XL)*
propranolol/hydrochlorothiazide
(Inderide)*
salicylic acid
selenium sulfide (Selsun Rx)*
tobramycin/dexamethasone susp
(TobraDex)*
triazolam (Halcion)*
trifluoperazine hcl (Stelazine)*
TIER 2
Pancreatic Enzymes – all prescription
strength, self administered, brand
pancreatic enzymes
PKU – all prescription strength, self
administered, brand PKU formulas
Abilify
Abilify Discmelt
Actoplus Met QL
Celebrex ST, QL
Cordarone
Coumadin
Creon
sodium phosphate (Vasocidin)*
trifluridine (Viroptic)*
sulfacetamide sodium/sulfur
(Sulfacet-R)*
trihexyphenidyl hcl (Artane)*
sulfadiazine
trimethoprim (Proloprim)*
sulfamethoxazole/trimethoprim
(Bactrim, Bactrim DS)*
trimipramine (Surmontil)*
sulfasalazine (Azulfidine)*
trospium (Sanctura)*
sulindac (Clinoril)*
Droxia
trimethobenzamide hcl (Tigan)*
tropicamide (Mydriacyl)*
Depakene
Depakote ER
Diastat
Dilantin
Dilantin-125
Diovan† DO, QL
Diovan HCT† DO, QL
propylthiouracil (Propylthiouracil)*
sumatriptan (Imitrex)* QL
trypsin/balsam peru/castor oil
(Granulex)*
pyrazinamide
tamsulosin (Flomax)*
urea (Aluvea 39% cream, Carmol 40)*
Duetact QL
pyridostigmine bromide (Mestinon)*
temazepam (Restoril)*
Elixophyllin
quetiapine (Seroquel)*
terazosin hcl (Hytrin)*
urine test strips (Urine Acetone, Urine
Glucose, Urine Gluc-Acet Comb, Urine
Multiple)*
6 | Generic Premium
Epipen
Epipen Jr
Qvar QL
Emtriva
ondansetron (Zofran/ODT)* QL
Eskalith CR
Relenza QL
Enbrel PA, QL
Pegasys PA, QL
Felbatol
Relion Novolin 70-30 Innolet
enoxaparin (Lovenox)*
Prezista
Flovent Diskus QL
Relion Novolin N Innolet
Epivir HBV
Procrit PA
Flovent HFA QL
Serevent QL
Epzicom
Rapamune
Flumadine
Seroquel XR
Erivedge PA
Rebif PA
Gabitril†
Singulair† QL
etoposide (VePesid)*
Rescriptor
Glucagen
Symbicort QL
exemestane (Aromasin)*
Revlimid PA, QL
Glucagon
Synthroid
Fareston
Reyataz
Glyset
Tamiflu QL
flutamide (Eulexin)*
Ribavirin (generics)
heparin (>5,000U/ml)
Tegretol
fondaparinux (Arixtra)*
Saizen PA QL
Humalog Mix
Tegretol XR
Fuzeon
Sandimmune
Humalog
Theo-24
ganciclovir (Cytovene)*
Selzentry
Humulin 70/30
Topamax
Gengraf
Serostim PA QL
Humulin N
Twinject
Gleevec PA
Sprycel PA
Humulin R
Ultrase, MT
granisetron hcl (Kytril)* QL
stavudine (Zerit)*
Janumet QL
Uniphyl
Hexalen
Sustiva
Januvia QL
Vesicare
hydroxyurea (Hydrea)*
Sutent PA
Keppra, XR
Viokase
Inlyta PA
tacrolimus (Prograf)*
Kombiglyze XR QL
Vyvanse
Intron-A PA
tamoxifen citrate (Nolvadex)*
Lamictal, ODT
Zarontin
Invirase
Tarceva PA
Lanoxin
Zenpep
Iressa
Targretin PA
Lantus
Kaletra
Tasigna PA
Lantus Solostar
lamivudine (Epivir)*
Temodar† PA
Levemir
TIER 3
lamivudine/zidovudine (Combivir)*
Thalomid PA
Lithobid
Actimmune
letrozole (Femara)*
tretinoin (Vesanoid)*
Lumigan
Alferon N
leucovorin calcium
Trexall
Megace ES
Alkeran
Leukeran
Trizivir
Nexium QL
Aminocaproic Acid (Amicar)*
leuprolide acetate (Lupron)* PA
Truvada
Novolin 70/30
anastrozole (Arimidex)*
Lexiva
Tykerb PA
Novolin N
Atripla
Lysodren
Valcyte
Novolin R
Avonex PA
Matulane
Videx
Novolog Mix
Azasan
megestrol acetate (Megace)*
Viracept
Novolog
azathioprine (Imuran)*
mercaptopurine (Purinethol)*
Viramune XR
One Touch Test Strips QL
Betaseron PA
Mesnex
Virazole
Onglyza DO, QL
bicalutamide (Casodex)*
methotrexate sodium (Rheumatrex)*
Viread
Oxycontin QL
Ceenu
mycophenolate (Cellcept)^
Xeloda PA
Pancrecarb
Cellcept
Myleran
Ziagen
Pancrelipase
Copaxone PA
Neoral
zidovudine (Retrovir)*
Phenytek
Crixivan
Neumega PA
Zolinza PA
Prandin
Neupogen PA
Premarin
cyclophosphamide (Cytoxan,
Neosar)*
Premarin Vaginal Cream
cyclosporine (Sandimmune)^
Nexavar PA
Premphase
cyclosporine, modified (Neoral,
Gengraf)^
Nilandron
Prempro
Proair HFA QL
Pulmicort Flexhaler QL
didanosine (Videx EC)*
Eligard PA
Emcyt PA
nevirapine (Viramune)*
Norvir
Nutropin AQ PA, QL
Nutropin PA, QL
Generic Premium | 7
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans
of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits
underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO
Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for
the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or
administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue
Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
15823ANMENABS Rev. 6/12