Tier 1 Drug List - Friday Health Plans

1 ACARBOSEACEBUTOLOL HCLACETAZOLAMIDEACETAZOLAMIDE SODIUMACETIC ACIDACETIC ACID (OTIC)ACETYLCYSTEINEACITRETINACYCLOVIRAC YCLOVIR SODIUMACYCLOVIR TOPICALADAPALENEADAPALENE-BENZOYL PEROXIDEADENOSINEADENOSINE (DIAGNOSTIC)ALBENDAZOLEALBUMIN, HUMANALBUTEROL SULFATEALCLOMETASONE DIPROPIONATEALCOHOLALCOHOL, RUBBINGALENDRONATE SODIUMALFUZOSIN HCLALISKIREN FUMARATEALLOPURINOLALLOPURINOL SODIUMALOSETRON HCLALPHA-LIPOIC ACID (THIOCTIC ACID)ALPRAZOLAMALPROSTADILAMANTADINE HCLAMIKACIN SULFATEAMILORIDE & HYDROCHLOROTHIAZIDEAMILORIDE HCLAMINO ACID ELECTROLYTE INFUSIONAMINO ACID INFUSIONAMINOCAPROIC ACIDAMINOPHYLLINEAMIODARONE HCLAMITRIPTYLINE HCLTier 1 Drug ListAMLODIPINE BESYLATEAMLODIPINE BESYLATE-ATORVASTATIN CALCIUMAMLODIPINE BESYLATE-BENAZEPRIL HCLAMLODIPINE BESYLATE-OLMESARTAN MEDOXOMILAMLODIPINE BESYLATE-VALSARTANAMLODIPINE-VALSARTAN-H YDROCHLOROTHIAZIDEAMOXAPINEAMOXICILLINAM OXICILLIN & POT CLAVULANATEAMOXICILLIN-CLARITHROMYCIN W/ LANSOPRAZOLEAMPHETAMINE SULFATEAMPHETAMINE-DEXTROAMPHETAMINEAMPH OTERICIN BAMPICILLINAMPICILLIN & SULBACTAM SODIUMAMPICILLIN SODIUMANAGRELIDE HCLANASTROZOLEANTICOAGULANT CITRATE DEXTROSE SOLUTION AANTICOAGULANT SODIUM CITRATEANTIVENIN LATRODECTUS MACTANSANTIVENIN MICRURUS FULVIUSAPRACLONIDINE HCLAPREPITANTARGATROBANARGATROBAN

2 IN SODIUM CHLORIDEARIPIPRAZOLEARMODAFINILASCORBIC ACIDASPIRIN-DIPYRIDAMOLEATENOLOLATENOLOL & CHLORTHALIDONEATOMOXETINE HCLATORVASTATIN CALCIUMATOVAQUONEATOVAQUONE-PROGUANIL HCLATROPINE SULFATEATROPINE SULFATE (OPHTHALMIC)AZATHIOPRINEAZATHIOPRINE SODIUMAZELASTINE HCLAZELASTINE HCL (OPHTH)AZELASTINE HCL-FLUTICASONE PROPIONATEAZITHROMYCINAZTREONAMBACITRACI NBACITRACIN-POLY-NEOMYCIN-HCBACITRACIN-P OLYMYXIN B (OPHTH)BACLOFENBACTERIOSTATIC SODIUM CHLORIDEBALSALAZIDE DISODIUMBENAZEPRIL HCLBENZHYDROCODONE HCL-ACETAMINOPHENBENZOIN COMPOUNDBENZONATATEBENZOYL PEROXIDEBENZOYL PEROXIDE-ERYTHROMYCINBENZPHETAMINE HCLBENZTROPINE MESYLATEBETAMETHASONE DIPROPIONATE (TOPICAL)BETAMETHASONE DIPROPIONATE AUGMENTEDBETAMETHASONE SOD PHOSPHATE & ACETATEBETAMETHASONE VALERATEBETAXOLOL HCLBETAXOLOL HCL (OPHTH)BETHANECHOL CHLORIDEBICALUTAMIDEBISACODYL-PEG 3350-POT CHLORIDE-SOD BICARB-SOD CHLORIDEBISOPROLOL & HYDROCHLOROTHIAZIDEBISOPROLOL FUMARATEBIVALIRUDIN TRIFLUOROACETATEBIVALIRUDIN TRIFLUOROACETATE-SODIUM CHLORIDEBLOOD COLLECTION NEEDLE 20 GBLOOD COLLECTION NEEDLE 21 GBLOOD COLLECTION NEEDLE 22 GBRETYLIUM TOSYLATEBRIMONIDINE TARTRATEBUDESONIDEBUDESONIDE (INHALATION)BUMETANIDEBUPIVACAINE HCLBUPIVACAINE IN DEXTROSEBUPIVACAINE W/ EPINEPHRINEBUPROPION HCLBUPROPION HCL (SMOKING DETERRENT)BUSPIRONE HCLBUTALBITAL-ACETAMINOPHENBUTALBITAL-AC ETAMINOPHEN-CAFFEINECABERGOLINECALCIPOTR IENECALCIPOTRIENE-BETAMETHASONE DIPROPIONATECALCITONIN (SALMON)CALCITRIOLCALCIUM ACETATE (PHOSPHATE BINDER)CALCIUM CHLORIDE (DIHYDRATE)

3 CALCIUM GLUCONATECALCIUM GLUCONATE-DEXTROSECALCIUM GLUCONATE-SODIUM CHLORIDECANDESARTAN CILEXETILCANDESARTAN CILEXETIL-HYDROCHLOROTHIAZIDECAPTOPRIL & HYDROCHLOROTHIAZIDECARBAMAZEPINECARBIDOP ACARBIDOPA-LEVODOPACARBIDOPA-LEVODOPA-EN TACAPONECARBINOXAMINE MALEATECARDIOPLEGIC SOLNCARISOPRODOLCARISOPRODOL W/ ASPIRINCARISOPRODOL W/ ASPIRIN & CODEINECARTEOLOL HCL (OPHTH)CARVEDILOLCASPOFUNGIN ACETATECEFACLORCEFACLOR MONOHYDRATECEFADROXILCEFAZOLIN SODIUMCEFAZOLIN SODIUM IN SODIUM CHLORIDECEFAZOLIN SODIUM-DEXTROSECEFDINIRCEFDITOREN PIVOXILCEFEPIME HCLCEFEPIME HCL-DEXTROSECEFIXIMECEFOTAXIME SODIUMCEFOTETAN DISODIUMCEFOTETAN DISODIUM AND DEXTROSECEFOXITIN SODIUMCEFOXITIN SODIUM AND DEXTROSECEFPODOXIME PROXETILCEFPROZILCEFTAZIDIMECEFTAZIDIME- DEXTROSECEFTRIAXONE SODIUMCEFTRIAXONE SODIUM AND DEXTROSECEFTRIAXONE SODIUM IN DEXTROSECEFUROXIME AXETILCEFUROXIME SODIUMCELECOXIBCEPHALEXINCEVIMELINE HCLCHLORAMPHENICOL SODIUM SUCCINATECHLORDIAZEPOXIDE HCLCHLORDIAZEPOXIDE HCL-CLIDINIUM BROMIDECHLORDIAZEPOXIDE-AMITRIPTYLINECHL ORHEXIDINE GLUCONATE (MOUTH-THROAT)

4 CHLOROPROCAINE HCLCHLOROQUINE PHOSPHATECHLOROTHIAZIDECHLOROTHIAZIDE SODIUMCHLORPHENIRAMINE MALEATECHLORPROMAZINE HCLCHLORPROPAMIDECHLORTHALIDONECHLORZOXA ZONECHOLESTYRAMINECHOLESTYRAMINE LIGHTCHOLINE & MAG SALICYLATECHOLINE FENOFIBRATECHROMIC CHLORIDECICLOPIROXCICLOPIROX OLAMINECILOSTAZOLCIMETIDINECIMETIDINE HCLCIPROFLOXACINCIPROFLOXACIN HCLCIPROFLOXACIN HCL (OPHTH)CIPROFLOXACIN HCL (OTIC)CIPROFLOXACIN IN D5 WCIPROFLOXACIN-CIPROFLOXACIN HCLCIPROFLOXACIN-FLUOCINOLONE ACETONIDECITALOPRAM HYDROBROMIDECLARITHROMYCINCLEMASTINE FUMARATECLINDAMYCIN HCLCLINDAMYCIN PALMITATE HYDROCHLORIDECLINDAMYCIN PHOSPHATECLINDAMYCIN PHOSPHATE (TOPICAL)CLINDAMYCIN PHOSPHATE IN D5 WCLINDAMYCIN PHOSPHATE IN NACLCLINDAMYCIN PHOSPHATE VAGINALCLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDECLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE (REFRIGERATE)CLOBAZAMCLOBETASOL PROPIONATECLOBETASOL PROPIONATE EMOLLIENT BASECLOMIPRAMINE HCLCLONAZEPAMCLONIDINE HCLCLONIDINE HCL (ANALGESIA)CLOPIDOGREL BISULFATECLORAZEPATE DIPOTASSIUMCLOTRIMAZOLECLOTRIMAZOLE W/ BETAMETHASONECLOZAPINECOLCHICINECOLCHICI NE W/ PROBENECIDCOLESEVELAM HCLCOLISTIMETHATE SODIUMCONCEPTION ASSISTANCE SUPPLIESCOSYNTROPINCROMOLYN SODIUMCROMOLYN SODIUM (MASTOCYTOSIS)CROMOLYN SODIUM (OPHTH)CROTAMITONCUPRIC CHLORIDECYANOCOBALAMINCYCLOBENZAPRINE HCLCYCLOPENTOLATE HCLCYCLOPHOSPHAMIDECYCLOSERINECYPROHEPTA DINE HCLDANAZOLDANTROLENE SODIUMDAPSONEDAPTOMYCINDARIFENACIN HYDROBROMIDEDEFEROXAMINE MESYLATEDEMECLOCYCLINE HCLDESIPRAMINE HCLDESLORATADINEDESMOPRESSIN ACETATEDESMOPRESSIN ACETATE SPRAYDESMOPRESSIN ACETATE SPRAY REFRIGERATEDDESOGESTREL & ETHINYL ESTRADIOLDESOGESTREL-ETHINYL ESTRADIOL (BIPHASIC)

5 DESOGESTREL-ETHINYL ESTRADIOL (TRIPHASIC)DESONIDEDESOXIMETASONEDESVENL AFAXINE SUCCINATEDEXAMETHASONEDEXAMETHASONE ACETATEDEXAMETHASONE ACETATE & SOD PHOSPHATEDEXAMETHASONE SODIUM PHOSPHATEDEXAMETHASONE SODIUM PHOSPHATE (OPHTH)DEXAMETHASONE SODIUM PHOSPHATE-SODIUM CHLORIDEDEXMEDETOMIDINE HCLDEXMETHYLPHENIDATE HCLDEXTROAMPHETAMINE SULFATEDEXTROSEDEXTROSE IN LACTATED RINGERSDEXTROSE W/ SODIUM CHLORIDEDIAZEPAMDIAZEPAM (ANTICONVULSANT)DIAZOXIDEDICLOFENAC POTASSIUMDICLOFENAC SODIUMDICLOFENAC SODIUM (OPHTH)DICLOFENAC SODIUM (TOPICAL)DICLOFENAC W/ MISOPROSTOLDICLOXACILLIN SODIUMDICYCLOMINE HCLDIETHYLPROPION HCLDIFLUNISALDIGOXINDIHYDROERGOTAMINE MESYLATEDILTIAZEM HCLDILTIAZEM HCL COATED BEADSDILTIAZEM HCL EXTENDED RELEASE BEADSDILTIAZEM HCL IN DEXTROSEDILTIAZEM HCL IN SODIUM CHLORIDEDIMENHYDRINATEDIPHENHYDRAMINE HCLDIPHENHYDRAMINE-ZINC ACETATEDIPHENOXYLATE W/ ATROPINEDIPHTHERIA-TETANUS TOXOIDS (DT)DIPYRIDAMOLEDIPYRIDAMOLE (DIAGNOSTIC)DISOPYRAMIDE PHOSPHATEDISPOSABLE GLOVESDIVALPROEX SODIUMDOBUTAMINE HCLDOBUTAMINE IN D5 WDONEPEZIL HYDROCHLORIDEDOPAMINE HCLDOPAMINE IN D5 WDORIPENEMDORZOLAMIDE HCLDORZOLAMIDE HCL-TIMOLOL MALEATEDOXAZOSIN MESYLATEDOXEPIN HCLDOXEPIN HCL (SLEEP)DOXYCYCLINE (MONOHYDRATE)

6 DOXYCYCLINE HYCLATEDOXYLAMINE-PYRIDOXINEDRONABINOLDR OPERIDOLDROSPIRENONE-ETHINYL ESTRADIOLDROSPIRENONE-ETHINYL ESTRADIOL-LEVOMEFOLATE CALCIUMDULOXETINE HCLDUTASTERIDEDUTASTERIDE-TAMSULOSIN HCLECONAZOLE NITRATEEDETATE CALCIUM DISODIUMELECTROLYTE-48 IN DEXTROSEELECTROLYTE-M IN DEXTROSEELETRIPTAN HYDROBROMIDEENALAPRIL MALEATEENALAPRIL MALEATE & HYDROCHLOROTHIAZIDEENALAPRILATENTERAL NUTRITION SUPPLIESEPHEDRINE SULFATE (PRESSORS)EPINASTINE HCL (OPHTH)EPINEPHRINEEPINEPHRINE (ANAPHYLAXIS)EPINEPHRINE HCL-DEXTROSEEPINEPHRINE HCL-SODIUM CHLORIDEEPINEPHRINE-DEXTROSEEPINEPHRINE- SODIUM CHLORIDEEPROSARTAN MESYLATEEPTIFIBATIDEERGOCALCIFEROLERGOLO ID MESYLATESERGOTAMINE W/ CAFFEINEERYTHROMYCIN (ACNE AID)ERYTHROMYCIN (OPHTH)ERYTHROMYCIN BASEERYTHROMYCIN ETHYLSUCCINATEESCITALOPRAM OXALATEESMOLOL HCLESMOLOL HCL-SODIUM CHLORIDEESOMEPRAZOLE MAGNESIUMESOMEPRAZOLE SODIUMESTAZOLAMESTERIFIED ESTROGENS & METHYLTESTOSTERONEESTRADIOLESTRADIOL & NORETHINDRONE ACETATEESTRADIOL VAGINALESTROPIPATEESZOPICLONEETHACRYNATE SODIUMETHAMBUTOL HCLETHOSUXIMIDEETHYL CHLORIDEETHYNODIOL DIACET & ETH ESTRADETIDRONATE DISODIUMETODOLACETOMIDATEETONOGESTREL-ET HINYL ESTRADIOLEXEMESTANEEZETIMIBEEZETIMIBE-SI MVASTATINFAMCICLOVIRFAMOTIDINEFAMOTIDINE IN NACLFAT EMULSION PLANT BASEDFE FUMARATE-VITAMIN C-VITAMIN B12-FOLIC ACIDFEBUXOSTATFELBAMATEFELODIPINEFENOFIB RATEFENOFIBRATE MICRONIZEDFENOPROFEN CALCIUMFERROUS FUMARATE-IRON POLYSACCHARIDE COMPLEX-FOLIC ACID-C-B3 FILTER NEEDLESFINASTERIDEFLAVOXATE HCLFLECAINIDE ACETATEFLUCONAZOLEFLUCONAZOLE IN DEXTROSEFLUCONAZOLE IN

7 NACLFLUCYTOSINEFLUDROCORTISONE ACETATEFLUMAZENILFLUNISOLIDE (NASAL)FLUOCINOLONE ACETONIDEFLUOCINOLONE ACETONIDE (OTIC)FLUOCINONIDEFLUOCINONIDE EMULSIFIED BASEFLUORESCEIN SODIUM INJECTIONFLUOROMETHOLONE (OPHTH)FLUOROURACIL (TOPICAL)FLUOXETINE HCLFLUOXETINE HCL (PMDD)FLUPHENAZINE DECANOATEFLUPHENAZINE HCLFLURAZEPAM HCLFLURBIPROFENFLURBIPROFEN SODIUMFLUTAMIDEFLUTICASONE PROPIONATEFLUTICASONE-SALMETEROLFLUVOXAM INE MALEATEFOLIC ACIDFOMEPIZOLEFORMALDEHYDEFOSINOPRIL SODIUMFOSINOPRIL SODIUM & HYDROCHLOROTHIAZIDEFOSPHENYTOIN SODIUMFUROSEMIDEFUROSEMIDE IN SODIUM CHLORIDEGABAPENTINGADOTERATE MEGLUMINEGALANTAMINE HYDROBROMIDEGEMFIBROZILGENTAMICIN IN SALINEGENTAMICIN SULFATEGENTAMICIN SULFATE (OPHTH)GENTAMICIN SULFATE (TOPICAL)GLIMEPIRIDEGLIPIZIDEGLIPIZIDE-M ETFORMIN HCLGLUCAGON HCL (DIAGNOSTIC)GLUTARALGLYBURIDEGLYBURIDE MICRONIZEDGLYBURIDE-METFORMINGLYCINE (GU IRRIGANT)GLYCINE DILUENTGLYCOPYRROLATEGRANISETRON HCLGRISEOFULVIN MICROSIZEGUAIFENESIN-CODEINEGUANFACINE HCLGUANFACINE HCL (ADHD)GUANIDINE HCLHALCINONIDEHALOBETASOL PROPIONATEHALOPERIDOLHALOPERIDOL DECANOATEHALOPERIDOL LACTATEHEPARIN (PORCINE) IN SODIUM CHLORIDEHEPARIN SOD (PORCINE) IN D5 WHEPARIN SODIUM (PORCINE)HEPARIN SODIUM (PORCINE) LOCK FLUSHHEPARIN SODIUM (PORCINE) LOCK FLUSH & NACL LOCK FLUSHHETASTARCH IN SODIUM CHLORIDEHOMATROPINE HBRHYDRALAZINE HCLHYDROCHLOROTHIAZIDEHYDROCODONE BITARTRATEHYDROCODONE POLISTIREX-CHLORPHENIRAMINE POLISTIREXHYDROCODONE W/ HOMATROPINEHYDROCODONE-ACETAMINOPHENHYDR OCODONE-GUAIFENESINHYDROCORTISONEHYDROCO RTISONE (INTRARECTAL)HYDROCORTISONE (RECTAL)HYDROCORTISONE (TOPICAL)HYDROCORTISONE ACETATE (RECTAL)

8 HYDROCORTISONE ACETATE W/ PRAMOXINEHYDROCORTISONE BUTYRATEHYDROCORTISONE VALERATEHYDROCORTISONE W/ACETIC ACIDHYDROXOCOBALAMIN ACETATEHYDROXYCHLOROQUINE SULFATEHYDROXYUREAHYDROXYZINE HCLHYDROXYZINE PAMOATEHYOSCYAMINE SULFATEHYPROMELLOSE (INTRAOCULAR)IBANDRONATE SODIUMIBUPROFENIBUTILIDE FUMARATEIMIPENEM-CILASTATINIMIPRAMINE HCLIMIPRAMINE PAMOATEIMIQUIMODINDAPAMIDEINDOCYANINE GREENINDOMETHACININDOMETHACIN SODIUMIODINE (TOPICAL)IODINE STRONG (LUGOL'S)IODOQUINOL-HCIPRATROPIUM BROMIDEIPRATROPIUM BROMIDE (NASAL)IPRATROPIUM-ALBUTEROLIRBESARTANIR BESARTAN-HYDROCHLOROTHIAZIDEIRRIGATION SOLUTIONS, PHYSIOLOGICALISOFLURANEISONIAZIDISOSORBI DE DINITRATEISOSORBIDE MONONITRATEISOTRETINOINISOXSUPRINE HCLISRADIPINEITRACONAZOLEIVERMECTINIVERM ECTIN (ROSACEA)KETAMINE HCLKETOCONAZOLEKETOCONAZOLE (TOPICAL)KETOPROFENKETOROLAC TROMETHAMINEKETOROLAC TROMETHAMINE (OPHTH)KETOTIFEN FUMARATE (OPHTH)LABETALOL HCLLABETALOL HCL-DEXTROSELACTATED RINGER'SLACTATED RINGER'S (IRRIGATION)LACTIC ACID (AMMONIUM LACTATE)LACTULOSELACTULOSE (ENCEPHALOPATHY)LAMOTRIGINELANOLIN ANHYDROUSLANSOPRAZOLELANTHANUM CARBONATELATANOPROSTLEFLUNOMIDELETROZOLE LEUCOVORIN CALCIUMLEVALBUTEROL HCLLEVETIRACETAMLEVETIRACETAM IN SODIUM CHLORIDELEVOBUNOLOL HCLLEVOCARNITINE (METABOLIC MODIFIERS)LEVOFLOXACINLEVOFLOXACIN (OPHTH)LEVOFLOXACIN IN D5 WLEVONORGESTREL & ETH ESTRADIOLLEVONORGESTREL-ETH ESTRADIOL (TRIPHASIC)LEVONORGESTREL-ETHINYL ESTRADIOL (91-DAY)LEVONORGESTREL-ETHINYL ESTRADIOL (CONTINUOUS)LEVOTHYROXINE SODIUMLIDOCAINE HCLLIDOCAINE HCL (CARDIAC)LIDOCAINE HCL (LOCAL ANESTH.)

9 LIDOCAINE HCL (MOUTH-THROAT)LIDOCAINE HCL-SODIUM CHLORIDELIDOCAINE IN D5 WLIDOCAINE IN DEXTROSELIDOCAINE W/ EPINEPHRINELIDOCAINE-HYDROCORTISONE ACETATE (RECTAL)LIDOCAINE-PRILOCAINELINCOMYCIN HCLLINEZOLIDLINEZOLID IN SODIUM CHLORIDELIOTHYRONINE SODIUMLISINOPRILLISINOPRIL & HYDROCHLOROTHIAZIDELITHIUMLITHIUM CARBONATELORAZEPAMLORAZEPAM-DEXTROSELORA ZEPAM-SODIUM CHLORIDELOSARTAN POTASSIUMLOSARTAN POTASSIUM & HYDROCHLOROTHIAZIDELOTEPREDNOL ETABONATELOVASTATINLOXAPINE SUCCINATELULICONAZOLEMAGNESIUM SULFATEMAGNESIUM SULFATE IN DEXTROSEMAGNESIUM SULFATE-LACTATED RINGERSMAGNESIUM SULFATE-SODIUM CHLORIDEMANGANESE CHLORIDEMANNITOLMAPROTILINE HCLMECLIZINE HCLMEDROXYPROGESTERONE ACETATEMEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE)MEFLOQUINE HCLMEGESTROL ACETATEMEGESTROL ACETATE (APPETITE)MELATONINMELOXICAMMELPHALANMEM ANTINE HCLMEPIVACAINE HCLMEPROBAMATEMERCAPTOPURINEMEROPENEMMER OPENEM & SODIUM CHLORIDEMESALAMINEMETAPROTERENOL SULFATEMETAXALONEMETFORMIN HCLMETHADONE HCLMETHAZOLAMIDEMETHENAMINE HIPPURATEMETHENAMINE MANDELATEMETHENAMINE-HYOSC-METHYLENE BLUE-BENZOIC ACID-PHENYL SALMETHENAMINE-HYOSC-METHYLENE BLUE-SOD PHOS-PHENYL SALMETHENAMINE-HYOSCAMINE-M