Drug Formulary (Appendix A)

Complimentary State Formulary Access

Drug ClassGeneric NameInnovator brandNoteGeneric (GE)Status
Drug ClassGeneric NameInnovator brandNoteGeneric (GE)Status
AnticoagulantsApixabanEliquis ®No
Y
AnticoagulantsDabigatranPradaxa ®No
Y
AnticoagulantsEnoxaparinLovenox ®Yes
Y
AnticoagulantsRivaroxabanXarelto ®No
Y
AntidepressantsAmitriptylineElavil ®For mental disordersYes
Y
AntidepressantsBupropion Wellbutrin ®For mental disordersYes
Y
AntidepressantsBupropion Wellbutrin ®For pain treatmentYes
N
AntidepressantsCitalopramCelexa ®For mental disordersYes
N
AntidepressantsDesvenlafaxinePristiq ®For mental disordersYes
Y
AntidepressantsDuloxetineCymbalta ®For mental disordersYes
Y
AntidepressantsEscitalopram Lexapro ®For mental disordersYes
Y
AntidepressantsEscitalopram Lexapro ®For pain treatmentYes
N
AntidepressantsFluoxetine Prozac ®For mental disordersYes
Y
AntidepressantsFluoxetine Prozac ®For pain treatmentYes
N
AntidepressantsFluvoxamine Luvox ®For mental disordersYes
N
AntidepressantsMilnacipranSavella/Ixel ®For mental disordersYes
N
AntidepressantsMirtazapine Remeron ®For pain treatmentYes
N
AntidepressantsMirtazapine Remeron ®For mental disordersYes
Y
AntidepressantsNortriptylinePamelor ™For mental disordersYes
Y
AntidepressantsParoxetinePaxil ®For mental disordersYes
Y
AntidepressantsParoxetinePaxil ®For pain treatmentYes
N
AntidepressantsSertralineZoloft ®For mental disordersYes
Y
AntidepressantsSertralineZoloft ®For pain treatmentYes
N
AntidepressantsVenlafaxineEffexor ®For mental disordersYes
Y
AntidiabeticsAcarbosePrecoseYes
N
AntidiabeticsExenatideByettaNo
N
AntidiabeticsGlimepirideAmarylYes
N
AntidiabeticsGlipizideGlucotrolYes
N
AntidiabeticsGlyburideGlynaseYes
N
AntidiabeticsInsulinHumalogNo
Y
AntidiabeticsInsulinHumulinNo
N
AntidiabeticsInsulinNovolinNo
N
AntidiabeticsInsulinNovoLogNo
Y
AntidiabeticsMetforminGlucophageYes
Y
AntidiabeticsMiglitolGlysetYes
N
AntidiabeticsNateglinideStarlixYes
N
AntidiabeticsPioglitazoneActosYes
N
AntidiabeticsRepaglinidePrandinYes
N
AntidiabeticsRosiglitazoneAvandiaYes
N
AntidiabeticsSaxagliptinOnglyzaNo
N
AntidiabeticsSitagliptinJanuviaNo
N
AntiemeticsOndansetronZofran ®Yes
N
AntiemeticsOndansetronZuplenz ®No
N
Anti-epilepsy drugs (AEDs)CarbamazepineTegretol ®Yes
Y
Anti-epilepsy drugs (AEDs)GabapentinNeurontin ®, Gabarone ™Yes
Y
Anti-epilepsy drugs (AEDs)Gabapentin ERGralise ®No
N
Anti-epilepsy drugs (AEDs)Gabapentin ERHorizant ®No
N
Anti-epilepsy drugs (AEDs)LacosamideVimpat ®Yes
N
Anti-epilepsy drugs (AEDs)LamotrigineLamictal ®Yes
N
Anti-epilepsy drugs (AEDs)LevetiracetamKeppra ®Yes
N
Anti-epilepsy drugs (AEDs)OxcarbazepineTrileptal ®Yes
Y
Anti-epilepsy drugs (AEDs)PhenytoinDilantin ®Yes
N
Anti-epilepsy drugs (AEDs)PregabalinLyrica ® IRNo
Y
Anti-epilepsy drugs (AEDs)TiagabineGabitril ®Yes
N
Anti-epilepsy drugs (AEDs)TopiramateTopamax ®Yes
N
Anti-epilepsy drugs (AEDs)ZonisamideZonegran ®Yes
N
AntihypertensivesAliskirenTekturnaNo
N
AntihypertensivesAmlodipineNorvascYes
Y
AntihypertensivesAtenololTenorminYes
Y
AntihypertensivesBenazeprilLotensinYes
Y
AntihypertensivesCaptoprilCapotenYes
Y
AntihypertensivesClonidineCatapresYes
N
AntihypertensivesDoxazosinCarduraYes
N
AntihypertensivesEnalaprilVasotecYes
Y
AntihypertensivesHydralazineApresolineYes
N
AntihypertensivesHydrochlorothiazideHCTZYes
Y
AntihypertensivesLisinoprilZestrilYes
Y
AntihypertensivesLosartanCozaarYes
Y
AntihypertensivesMetoprololLopressorYes
Y
AntihypertensivesMinoxidilLonitenYes
N
AntihypertensivesNadololCorgardYes
Y
AntihypertensivesNicardipineCardeneYes
Y
AntihypertensivesNifedipineProcardiaYes
Y
AntihypertensivesOlmesartanBenicarYes
Y
AntihypertensivesPrazosinMinipressYes
N
AntihypertensivesPropranololInderalYes
Y
AntihypertensivesRamiprilAltaceYes
Y
AntihypertensivesSpironolactoneAldactoneYes
N
AntihypertensivesTerazosinHytrinYes
N
AntihypertensivesValsartanDiovanYes
Y
Anti-infectivesAmoxicillinAmoxilYes
Y
Anti-infectivesAmoxicillin-ClavulanateAugmentinYes
Y
Anti-infectivesAzithromycinZithromaxYes
Y
Anti-infectivesCefadroxilDuricefYes
Y
Anti-infectivesCefdinirOmnicefYes
Y
Anti-infectivesCefprozilCefzilYes
Y
Anti-infectivesCefuroximeCeftinYes
Y
Anti-infectivesCephalexinKeflexYes
Y
Anti-infectivesCiprofloxacinCiproYes
Y
Anti-infectivesClarithromycinBiaxinYes
Y
Anti-infectivesClindamycinCleocinYes
Y
Anti-infectivesDicloxacillinDynapenYes
Y
Anti-infectivesDoxycyclineVibramycin, DoryxYes
Y
Anti-infectivesLevofloxacinLevaquinYes
Y
Anti-infectivesLinezolidZyvoxYes
Y
Anti-infectivesMetronidazoleFlagylYes
Y
Anti-infectivesMinocyclineMinocin, DynacinYes
Y
Anti-infectivesMoxifloxacinAveloxYes
Y
Anti-infectivesPenicillinVeetidsYes
Y
Anti-infectivesSulfamethoxazole-TrimethoprimBactrim, SeptraYes
Y
Asthma medicationsAlbuterol oral tabletAlbuterolYes
N
Asthma medicationsBeclomethasoneQvar ®No
Y
Asthma medicationsCiclesonideAlvesco ®No
Y
Asthma medicationsCromolynCromolyn ®Yes
N
Asthma medicationsFluticasone inhalationFlovent ®No
Y
Asthma medicationsFormoterolForadil ®No
N
Asthma medicationsBudesonideSymbicort ®No
Y
Asthma medicationsMometasoneDulera ®No
Y
Asthma medicationsIndacaterolArcapta ®No
N
Asthma medicationsMometasoneAsmanex ®No
Y
Asthma medicationsMontelukastSingulair ®Yes
N
Asthma medicationsOmalizumabXolair ®No
N
Asthma medicationsPirbuterolMaxairNo
Y
Asthma medicationsSalmeterolSerevent ®No
N
Asthma medicationsSalmeterol/FluticasoneAdvair ®No
Y
Asthma medicationsTheophyllineSlo-Bid ®Yes
N
Asthma medicationsZafirlukastAccolate ®Yes
N
Asthma medicationsZileutonZyflo ®No
N
Atypical antipsychoticsAripiprazoleAbilifyYes
N
Atypical antipsychoticsQuetiapineSeroquelYes
N
Atypical antipsychoticsOlanzapineZyprexaYes
N
Atypical antipsychoticsRisperidoneRisperdalYes
N
BenzodiazepinesAlprazolamXanaxYes
N
BenzodiazepinesChlordiazepoxideLibriumYes
N
BenzodiazepinesClonazepamKlonopinYes
N
BenzodiazepinesClorazepateTranxeneYes
N
BenzodiazepinesDiazepamValiumYes
N
BenzodiazepinesEstazolamProSomYes
N
BenzodiazepinesFlurazepamDalmaneYes
N
BenzodiazepinesLorazepamAtivanYes
N
BenzodiazepinesMidazolamVersedYes
N
BenzodiazepinesOxazepamSeraxYes
N
BenzodiazepinesQuazepamDoralNo
N
BenzodiazepinesTemazepamRestorilYes
N
BenzodiazepinesTriazolamHalcion Yes
N
BisphosphonatesAlendronateFosamax ®Yes
Y
BisphosphonatesEtidronateDidronel ®Yes
Y
BisphosphonatesIbandronateBoniva ®Yes
Y
BisphosphonatesRisedronateActonel ®, Atelvia ®Yes
Y
Botulinum toxinBotulinum toxinBotox ®No
N
Botulinum toxinBotulinum toxinDysportNo
N
Botulinum toxinBotulinum toxinMyobloc ®No
N
Botulinum toxinBotulinum toxinXeominNo
N
CannabinoidsMarijuana/dronabinolMarinol ®Yes
N
CannabinoidsNabiloneCesamet ®No
N
CannabinoidsTetrahydrocannabinolTHC dronabinol MarinolYes
N
Central adrenergic agonistsClonidine, intrathecalDuraclon ®Yes
N
Dopamine agonistsAmantadineSymmetrelYes
Y
Dopamine agonistsCarbidopa/LevodopaSinemet ®Yes
Y
Gout medicationsColchicineColchicineYes
N
H2-receptor antagonistsCimetidineTagamet ®Y-OTC
Y
H2-receptor antagonistsFamotidinePepcid ®Y-OTC
Y
H2-receptor antagonists ibuprofen and famotidineDuexis ®No
N
H2-receptor antagonistsRanitidineZantac ®Y-OTC
Y
LaxativesLubiprostoneAmitiza ®No
N
LaxativesMethylnaltrexoneRelistor ®No
N
LaxativesNaloxegolMovantik ®No
N
LaxativesOTC LaxativesvariousY-OTC
Y
Muscle relaxantsBaclofenLioresal ®Yes
Y
Muscle relaxantsCarisoprodolSoma ®Yes
N
Muscle relaxantsChlorzoxazoneParafon Forte ®, Paraflex ®, Relax™DS, Remular S™Yes
Y
Muscle relaxantsChlorzoxazoneLorzone ®No
N
Muscle relaxantsCyclobenzaprineFlexeril ®, Fexmid ™Yes
Y
Muscle relaxantsCyclobenzaprine ERAmrix ®No
N
Muscle relaxantsDantroleneDantrium ®Yes
N
Muscle relaxantsMeprobamateMiltownYes
N
Muscle relaxantsMetaxaloneSkelaxin ®Yes
Y
Muscle relaxantsMethocarbamolRobaxin ®, Relaxin ™Yes
Y
Muscle relaxantsOrphenadrineNorflex®, Banflex®, Antiflex™, Mio-Rel™, OrphenateYes
N
Muscle relaxantsTizanidineZanaflex ®Yes
Y
Nonprescription analgesicsAcetaminophenTylenol ®Y-OTC
Y
Nonprescription analgesicsAspirinBayer ®Y-OTC
Y
Nonprescription analgesicsIbuprofenAdvil ®Y-OTC
Y
Nonprescription analgesicsNaproxenAleve ®Y-OTC
Y
NSAIDsCelecoxibCelebrex ®Yes
Y
NSAIDsDiclofenac sodiumVoltaren ®Yes
Y
NSAIDsDiclofenacZorvolex ®No
N
NSAIDsDiclofenac/ misoprostolArthrotec ®Yes
N
NSAIDsDiclofenac epolamineFlector patch ®No
N
NSAIDsDiclofenac PotassiumCataflam ®Yes
Y
NSAIDsDiclofenac PotassiumZipsorYes
N
NSAIDsDiclofenac sodium ERVoltaren-XR ®Yes
N
Topical analgesicsDiclofenac sodium gelVoltaren ® GelYes
Y
NSAIDsDiclofenac sodiumDylojectNo
N
NSAIDsDiclofenac sodium topicalPennsaid ®Yes
N
NSAIDsDiflunisalDolobid ®Yes
Y
NSAIDsEtodolacLodine ®Yes
Y
NSAIDsEtodolac ERLodine XL ®Yes
Y
NSAIDsFenoprofenNalfon ®Yes
Y
NSAIDsFlurbiprofenAnsaid ®Yes
Y
NSAIDsIbuprofenAdvil ®Y-OTC
Y
NSAIDsIbuprofenMotrin ®Yes
Y
NSAIDsIndomethacinIndocin ®Yes
N
NSAIDsIndomethacinTivorbexNo
N
NSAIDsIndomethacin ERIndocin SR ®Yes
N
NSAIDsKetoprofenKetoprofenYes
Y
NSAIDsKetoprofenKetoprofen ERYes
Y
NSAIDsKetorolacToradol ®Yes
N
NSAIDsKetorolac injectionToradol ®Yes
Y
NSAIDsKetorolac nasal spraySprixNo
N
NSAIDsMefenamic AcidPonstel ®Yes
Y
NSAIDsMeloxicamMobic ®Yes
Y
NSAIDsMeloxicamVivlodex ®No
N
NSAIDsNabumetoneRelafen ®Yes
Y
NSAIDsNaproxenAleve ®Y-OTC
Y
NSAIDsNaproxenNaprosyn ®Yes
Y
NSAIDsNaproxen EREC-Naprosyn ®Yes
Y
NSAIDsNaproxenAnaprox ®Yes
Y
NSAIDsNaproxenAnaprox DS ®Yes
Y
NSAIDsNaproxen ERNaprelan ®Yes
N
NSAIDsOxaprozinDaypro ®Yes
Y
NSAIDsPiroxicamFeldene ®Yes
N
NSAIDsSulindacClinoril ®Yes
Y
NSAIDsTolmetinTolectin ®Yes
Y
NSAIDsTolmetinTolectin ®/Tolectin DS Yes
Y
OpioidsBuprenorphine buccal filmBelbuca ™No
N
OpioidsBuprenorphineBuprenex ®Injection for detoxYes
Y
OpioidsBuprenorphineBuprenex ®Injection for painYes
N
OpioidsBuprenorphine implantProbuphineNo
N
OpioidsBuprenorphineBupren SL tab for detoxYes
Y
OpioidsBuprenorphineBupren SL tab for painYes
N
OpioidsBuprenorphine transdermalButrans ™No
N
OpioidsBuprenorphineBunavail ®For detoxNo
Y
OpioidsBuprenorphineBunavail ®For pain treatmentNo
N
OpioidsBuprenorphineSuboxone ®For detoxNo
Y
OpioidsBuprenorphineSuboxone ®For pain treatmentNo
N
OpioidsBuprenorphine/Naloxone SL tabBupren/NaloxFor detoxYes
Y
OpioidsBuprenorphine/Naloxone SL tabBupren/NaloxFor pain treatmentYes
N
OpioidsBuprenorphineZubsolv For detoxNo
Y
OpioidsBuprenorphineZubsolv For pain treatmentNo
N
OpioidsButalbitalFioricet ®(combos) BarbituratesYes
N
OpioidsCodeineCodeineYes
Y
OpioidsCodeine/AcetaminTylenol #3 4Yes
Y
OpioidsDihydrocodeineTrezix Synalgos-DCNo
N
OpioidsFentanyl buccalFentora ®Yes
N
OpioidsFentanyl buccal filmOnsolis ™No
N
OpioidsFentanyl lollipopActiq ®Yes
N
OpioidsFentanyl nasal sprayLazanda ®No
N
OpioidsFentanyl sublingual spraySubsys ® No
N
OpioidsFentanyl transdermalDuragesic ®Yes
N
OpioidsFentanyl transmucosalAbstral No
N
OpioidsHydrocodone ERHysingla No
N
OpioidsHydrocodone ERZohydro No
N
OpioidsHydrocodoneLortab ®Yes
Y
OpioidsHydrocodone bitartrateVantrela ER ®No
N
OpioidsHydrocodone/IbuprofenVicoprofen ®Yes
N
OpioidsHydromorphoneDilaudid ®Yes
Y
OpioidsHydromorphone ERExalgo Yes
N
OpioidsLevorphanolLevo-Dromoran ®Yes
N
OpioidsMeperidineDemerol ®Yes
N
OpioidsMethadone Methadose ®Yes
N
OpioidsMorphineMorphine Yes
Y
OpioidsMorphine ERAvinza ®Yes
N
OpioidsMorphine ERKadian ®Yes
N
OpioidsMorphine ERMS-Contin Yes
N
OpioidsMorphine ER / NaltrexoneEmbeda No
N
OpioidsMorphine sulfateArymo ER ®No
N
OpioidsMorphine sulfateMorphabond ER ®No
N
OpioidsNaloxone Evzio ®Injection deviceNo
N
OpioidsNaloxoneNarcan ®IntranasalNo
Y
OpioidsNaloxoneNaloxoneInjectableYes
Y
OpioidsOxycodoneOxyIR ®Yes
Y
OpioidsOxycodoneOxaydo ®No
N
OpioidsOxycodone EROxyContin ®No
N
OpioidsOxycodoneXartemis XR ®No
N
OpioidsOxycodoneTarginiq ER ®No
N
OpioidsOxycodone/acetaminophenPercocet ®Yes
Y
OpioidsOxycodone/aspirin IRPercodan ®Yes
N
OpioidsOxycodone/ibuprofen IRCombunox Yes
N
OpioidsOxycodoneTroxyca ER ®No
N
OpioidsOxycodone HCLRoxyBond ™No
N
OpioidsOxymorphone IROpana ®Yes
N
OpioidsOxymorphone EROpana ER No
N
OpioidsPentazocine lactateTalwin Yes
N
OpioidsPentazocine/NaloxoneTalwin NX Yes
N
OpioidsPropoxyphene hclDarvon ®Yes
N
OpioidsPropoxyphene/acetaminDarvocet ®Yes
N
OpioidsPropoxyphene napsylateDarvon-N ®No
N
OpioidsTapentadolNucynta ™No
N
OpioidsTramadolUltram ®Yes
Y
OpioidsTramadol ERUltram ER ®Yes
Y
OpioidsTramadol ER, biphasic ConZip/RyzoltNo
N
OpioidsTramadol/AcetaminophenUltracet ®Yes
Y
OpioidsZiconotidePrialt ®Morphine pumpNo
N
Oral corticosteroidsMethylprednisoloneMedrolYes
Y
Oral corticosteroidsPrednisonePrednisoneYes
Y
PPI (Proton Pump Inhibitor)Dexlansoprazole Dexilant ®No
N
PPI (Proton Pump Inhibitor)EsomeprazoleNexium ®Y-OTC
Y
PPI (Proton Pump Inhibitor)NaproxenVimovo ®Yes
N
PPI (Proton Pump Inhibitor)LansoprazolePrevacid ®Y-OTC
Y
PPI (Proton Pump Inhibitor)OmeprazolePrilosec ®Y-OTC
Y
PPI (Proton Pump Inhibitor)PantoprazoleProtonix ®Yes
N
PPI (Proton Pump Inhibitor)RabeprazoleAciphex ®Yes
N
ProstaglandinsMisoprostolCytotecYes
Y
Sedative-hypnoticsEszopicoloneLunesta ™Yes
Y
Sedative-hypnoticsPromethazine PhenerganYes
N
Sedative-hypnoticsRamelteonRozerem ™Yes
Y
Sedative-hypnoticsTrazodoneDesyrelYes
N
Sedative-hypnoticsZaleplonSonata ®Yes
Y
Sedative-hypnoticsZolpidemAmbien ®Yes
Y
Sedative-hypnoticsZolpidem ERAmbien CRYes
N
Sedative-hypnoticsZolpidemEdluar SLYes
N
StimulantsArmodafinilNuvigilYes
N
StimulantsModafinilProvigil ®Yes
N
StimulantsSodium oxybateXyremYes
N
Topical analgesicsCapsaicinQutenzaNo
N
Topical analgesicsDimethylsulfoxideDMSOYes
N
Topical analgesicsKetamineKetamineYes
N
Topical analgesicsLidocaineLidoderm ®Yes
N
Topical analgesicsSalicylate Ben-GayY-OTC
Y
TriptansRizatriptanMaxalt ®Yes
Y
TriptansSumatriptanImitrex ®Yes
Y
Tumor necrosis factor (TNF) modifiersAdalimumabHumira ®Yes
N
Tumor necrosis factor (TNF) modifiersEtanerceptEnbrel ®Yes
N
Tumor necrosis factor (TNF) modifiersInfliximabRemicade ®Yes
N
Asthma medicationsAlbuterol inhalationProventil ®/Ventolin ®Not meteredYes
Y
Asthma medicationsAlbuterol/IpratropiumCombivent ®Not meteredYes
Y
Asthma medicationsBudesonide inhalationPulmicort ®Not meteredYes
Y
Asthma medicationsIpratropiumAtrovent ®Not meteredYes
N
Asthma medicationsLevalbuterolXopenex ®Not meteredYes
Y
Dopamine agonistsPramipexoleMirapex ®Not ERYes
N
Dopamine agonistsRopiniroleRequip ®Not ERYes
N
AntidepressantsVenlafaxine EREffexor XR ®Yes
Y
Sedative-hypnoticsDiphenhydramine BenadrylFor insomniaY-OTC
N
OpioidsHydrocodone/acetaminVicodin® /Lortab ®Yes
Y
HIV AntiretroviralsAtazanavirReyataz ®Yes
Y
HIV AntiretroviralsDarunavirPrezista ®No
Y
HIV AntiretroviralsDidanosine ERVidex ® ECYes
N
HIV AntiretroviralsEmtricitabineEmtriva ™No
Y
HIV AntiretroviralsEmtricitabine/TenofovirTruvada ®Yes
Y
HIV AntiretroviralsEtravirineIntelence ®No
Y
HIV AntiretroviralsLamivudineEpivir ®Yes
Y
HIV AntiretroviralsLamivudine/ZidovudineCombivir ®Yes
Y
HIV AntiretroviralsLopinavir/RitonavirKaletra ®Yes
Y
HIV AntiretroviralsNelfinavirViracept ®No
N
HIV AntiretroviralsNevirapineViramune ®Yes
N
HIV AntiretroviralsNevirapine ERViramune XRYes
N
HIV AntiretroviralsRaltegravirIsentress ®No
Y
HIV AntiretroviralsRilpivirineEdurant ®No
Y
HIV AntiretroviralsRitonavirNorvir ®Yes
Y
HIV AntiretroviralsTenofovirViread ®Yes
Y
HIV AntiretroviralsTipranavirAptivus ®No
N
HIV AntiretroviralsZidovudineRetrovir ™Yes
Y
Human Immune globulinsHepatitis B Immune GlobulinHepaGam BNo
Y
Human Immune globulinsHepatitis B Immune GlobulinHyperhep BNo
Y
Human Immune globulinsHepatitis B Immune GlobulinNabi-HBNo
Y
Human Immune globulinsHepatitis B Immune GlobulinHepaGamB NovaPlussNo
Y
HIV AntiretroviralsDidanosineVidex ®No
N
Anti-epilepsy drugs (AEDs)PregabalinLyrica® CRNo
N
OpioidsSufentanilDsuviaSublingualNo
N
Compound drugsN/AN/ANo
N
OpioidsOxycodoneXtampza ERNo
N
Topical analgesicsMethyl salicylate Thera-Gesic Crème Y-OTC
Y
Topical analgesicsMentholBiofreeze gelY-OTC
Y
Calcitonin gene-related peptide receptor (CGRP-R) antagonistErenumabAimovigNo
N
AntidepressantsEsketamineSpravato™Nasal sprayNo
N

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