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

2 W/ LANSOPRAZOLEAMPHETAMINE SULFATEAMPHETAMINE-DEXTROAMPHETAMINEAMPH OTERICIN BAMPICILLINAMPICILLIN & SULBACTAM SODIUMAMPICILLIN SODIUMANAGRELIDE HCLANASTROZOLEANTICOAGULANT CITRATE DEXTROSE SOLUTION AANTICOAGULANT SODIUM CITRATEANTIVENIN LATRODECTUS MACTANSANTIVENIN MICRURUS FULVIUSAPRACLONIDINE HCLAPREPITANTARGATROBANARGATROBAN 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)

3 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)

4 BUSPIRONE HCLBUTALBITAL-ACETAMINOPHENBUTALBITAL-AC ETAMINOPHEN-CAFFEINECABERGOLINECALCIPOTR IENECALCIPOTRIENE-BETAMETHASONE DIPROPIONATECALCITONIN (SALMON)CALCITRIOLCALCIUM ACETATE (PHOSPHATE BINDER)CALCIUM CHLORIDE (DIHYDRATE)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)

5 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)

6 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)

7 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)DESOGESTREL-ETHINYL ESTRADIOL (TRIPHASIC)

8 DESONIDEDESOXIMETASONEDESVENLAFAXINE 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)

9 DISOPYRAMIDE PHOSPHATEDISPOSABLE GLOVESDIVALPROEX SODIUMDOBUTAMINE HCLDOBUTAMINE IN D5 WDONEPEZIL HYDROCHLORIDEDOPAMINE HCLDOPAMINE IN D5 WDORIPENEMDORZOLAMIDE HCLDORZOLAMIDE HCL-TIMOLOL MALEATEDOXAZOSIN MESYLATEDOXEPIN HCLDOXEPIN HCL (SLEEP)DOXYCYCLINE (MONOHYDRATE)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)

10 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 SODI