drug coverage criteria â new and therapeutic equivalent medications

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Medication/DrugFormulary Alternative(s)losartan/hydrochlorothiazide (generic Hyzaar); amlodipine(generic Norvasc) plus Benicar HCT orMicardis HCT; amlodipine (generic Norvasc) plus DiovanHCTFenofibrate 48mg, 145mg (generic Fenofibrate 54mg, 160mg (generic Tricor, Antara, LipofenTricor)FlectorVoltaren GelFlo-PredPrednisolone (generic Prelone), Orapred, PediapredForfivo XLBupropion (generic Wellbutrin), bupropion SR (WellbutrinSR), buproprion XL (generic Wellbutrin XL)FortestaTestimGeneress FEGildess FE, Junel FE, Microgestin FE (generic for LoestrinFE),Giazobalsalazide (generic Colazal), sulfasalazine (genericAzulfidine), Apriso, LialdaGraliseGabapentin (generic Neurontin)HorizantGabapentin (generic Neurontin)IlevroDiclofenac ophthalmic solution (generic Voltaren), ketorolacophthalmic solution (Acular), NevanacIntermezzoZolpidem (generic Ambien), zaleplon (generic Sonata)Jalyn Avodart (requires precertification if
Medication/DrugFormulary Alternative(s)Otic CareAntipyrine/benzocaine solutionOxtellar XROxcarbazepine (generic Trileptal)Pacnex HPOTC benzoyl peroxidePacnex LPOTC benzoyl peroxidePatadayAzelastine, Bepreve, Optivar, OTC ketotifenPatanolAzelastine, Bepreve, Optivar, OTC ketotifenPediaderm AFnystatin creamPediaderm TAtriamcinolone 0.1% creamPedipirox-4Ciclopirox (generic Penlac)Pennsaid DropsVoltaren GelPertzye (lipase/protease/amylse) PancreazePramosone EHydrocortisone/pramoxine (generic Pramosone)Procort Hydrocortisone/pramoxine (generic Analpram E)Promiseb Complete KitPromisebQuillivant XRMethylphenidate solution (generic Methylin),methylphenidate extended-release (generic Ritalin LA),Adderall XR, VyvanseRayosprednisoneRequip XLRopinirole (Generic for Requip)Ropinirole extended release (Requip Ropinirole (generic Requip)XL)Rosadan Kit CreamMetronidazole cream (Metrocream)Rosadan Kit GelMetronidazole gel 0.75% (Metrogel)Rybix ODTtramadolRyzoltTramadol ER (generic for Ultram ER)SafyralYasmin + folic acidSancusoGranisetron (generic for Kytril)SilenordoxepinSkelaxin (br<strong>and</strong> only)chlorzoxazone (generic Parafon Forte DSC),cyclobenzaprine (generic Flexeril), metaxalone (genericSkelaxin), methocarbamol (generic Robaxin)SoltamoxTamoxifen (generic Nolvadex)Soma 250mg / carisoprodol 250mg Carisprodol 350mg (generic for Soma)Sorilux (calcipotriene)calcipotriene (Dovonex)SSS 10-4Sulfacetamide sodium/sulfurSubsysMorphine sulfate (generic MS IR), fentanyl citrate (genericActiq)SumadanSulfacetamide, sodium/sulfur (generic for Sulfatol)Sumaxin CPSulfacetamide sodium/sulfur (generic Sulfatol)Sumaxin TSsulfacetamide sodium/sulfurSuprax Chewable TabletsSuprax Oral SuspensionSynalarFluocinolone (generic Synalar)Synalar KitFluocinolone (generic Synalar)Synalar TSFluocinolone (generic Synalar)TekamloAmlodipine plus TekturnaTerbinexTerbinafine (generic for Lamisil)Tobradex STTobramycin/dexamethasone ophthalmic drops (generic forTobradex)Tramadol extended-release (generic Tramadol IR or Tramadol ERryzolt)TreximetSumatriptan plus naproxen.TrianexTriamcinolone ointment (generic Aristocort)Tribenzoramlodipine plus hydrochlorothiazide plus Benicar (or)Benicar HCT plus amlodipine (or) Azor plusDrug Coverage Criteria - New <strong>and</strong> Therapeutic Equivalent Medications: Clinical Policy (Effective 04/01/2013)©1996-2013, Oxford Health Plans, LLC5
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drug coverage criteria â new and therapeutic equivalent medications