GHC-SCW Formulary by Drug Class

GHC-SCW Standard Drug Formulary (drug class version)
This Drug Formulary identifies which medications are covered under the standard GHC-SCW
Outpatient Prescription Drug benefit. We strive to make this document as accurate as possible.
Actual benefits are determined by the member’s insurance contract documents.
How to read this document
• This version of the Drug Formulary is organized by drug class. Another version, organized
alphabetically by drug name, is also available at www.ghcscw.com.
• Some medications show information about limitations specific to that medication. In this
regard, QL = quantity limits, and PA = prior authorization required.
• Medications are identified as brand or generic by the symbol B or g. Medications listed with
“g” are covered in generic form. A brand name may be listed as the alternative name for
informational purposes only. In many benefit plans, asking for a branded version of this
medication will result in your cost including the difference in cost between the brand and
generic version, in addition to your co-pay amount.
• Information about excluded medications can be found at the bottom of this introduction.
• Use the binoculars icon on the left to begin a search for a specific drug name.
Notes
• Member’s co-payment or co-insurance varies depending on your benefit plan. Because this
varies, it is impractical to list co-payment amounts in this document.
• We use the Medispan Drug Database to determine if the medication is a brand or generic at the
time the prescription is filled. That will supersede the generic status shown in this document.
• The Drug Formulary may be revised from time to time. New medications (additional coverage)
may be added at any time. Medications removed from the Drug Formulary will not have
coverage deleted until after they have been published in Housecalls, and have been removed
from the Drug Formulary currently available on the website www.ghcscw.com.
• GHC-SCW’s Formulary Committee evaluates medications for addition or deletion to the Drug
Formulary. This is a group of pharmacists and practicing health care providers.
• Use the binoculars icon on the left to begin a search for a search for a specific drug name.
Formulary Exclusions
• The listed drugs and drug classes are excluded from coverage under the GHC-SCW Standard
Formulary.
• Benefit Certificate Exclusions:
Infertility medications; sexual dysfunction medications (e.g. Viagra, Cialis, Levitra);
medications for weight control (e.g. phentermine, phendimetrazine, diethylpropion); dental
(e.g. topical florides, Periostat); medications resulting from a non-covered service (e.g. LASIK,
cosmetic surgery); medications for cosmetic purposes (e.g. Vaniqua, Renova, Propecia);
prescription products which are classified as medical foods instead of prescription drugs.
• Specific Formulary Committee Exclusions:
Acanya, Adoxa, Beyaz, Edular, Evoclin, Metazolv ODT, Oracea, Soladyn, Soma 250mg, Veltin,
Vimovo, Ziana.
Members and Providers may contact Pharmacy Benefit Administration with questions or
comments at 608-828-4811. Alternatively you may call GHC-SCW Member Services at 608-828-
4853 or if out of area, at 1-800-605-4327.
Analgesics & Anesthetics
Analgesic-Narcotic
Formulary Drug Name B/g Alternate Drug Name
Acetaminophen-Codeine #2, #3, #4, Soln g Tylenol w/Codeine #2, #3, #4, Soln
Acetaminophen-Hydrocodone 325/10mg g Norco
Acetaminophen-Hydrocodone 325/5mg g Norco
Acetaminophen-Hydrocodone 325/7.5mg g Norco
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Group Health Cooperative of
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Acetaminophen-Hydrocodone 500/10mg g Lortab
Acetaminophen-Hydrocodone 500/5mg g Vicodin
Acetaminophen-Hydrocodone 500/7.5mg g Lortab
Codeine Phosphate (Soln), Codeine Sulfate g Codeine
Fentanyl Patch g Duragesic Patch
Hydromorphone HCL g Dilaudid
Levorphanol Tartrate g LevoDromoran
Methadone HCL g Dolophine
Morphine Sulfate, Morphine CR g Morphine, MS Contin
Naltrexone g Revia
Oxycodone HCL (Immediate release tab) g Roxicodone
Oxycodone-Acetaminophen 5/325mg g Roxicet
Roxicet (Soln) B Percocet
Tramadol (immediate release only) g Ultram
Analgesic-Non Narcotic
Antirheumatic
Formulary Drug Name B/g Alternate Drug Name
Acetaminophen-Butalbital g Phrenilin
Butalbital-APAP-Caffeine (tabs only) g Fioricet
Butalbital-ASA-Caffeine (tabs only) g Fiorinal
Salsalate g Disalcid
Formulary Drug Name B/g Alternate Drug Name
Diclofenac Sodium (oral only) g Voltaren Oral
Etodolac g Lodine
Ibuprofen g Motrin
Indomethacin, Indomethacin CR g Indocin
Ketoprofen (immediate release only) g Orudis
Ketorolac (QL 20) g Toradol
Meloxicam g Mobic
Nabumetone g Relafen
Naproxen g Naprosyn
Naproxen Sodium g Anaprox, Naprosyn
Oxaprozin g Daypro
Ridaura B Auranofin
Sulindac g Clinoril
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Gout
Migraine Products
Formulary Drug Name B/g Alternate Drug Name
Allopurinol g Zyloprim
Colchicine g Colchicine
Colchicine-Probenecid g ColBenemid
Probenecid g Benemid
Uloric (Requires PA) B Febuxostat
Formulary Drug Name B/g Alternate Drug Name
APAP-Isometheptene-Dichloral g Midrin
Dihydroergotamine Mesylate g DHE Injection
Divalproex Sodium Extended Release g Depakote ER
Ergotamine-Caffeine g Cafergot
Methergine B Methylergonovine Maleate
Migranal B Dihydroergotamine Nasal Soln
Naratriptan (QL 1 pkg) g Amerge (QL 1 pkg)
Relpax (QL 1 Pkg) B Eletriptan Hydrobromide (QL 1 Pkg)
Sprix (QL 1 bx of 5 btls) B Ketorolac nasal
Sumatriptan g Imitrex
Anti-Infective Agents
Aminoglycosides
Antifungals
Antihelmintic
Formulary Drug Name B/g Alternate Drug Name
Neomycin Sulfate g Neomycin
Formulary Drug Name B/g Alternate Drug Name
Fluconazole g Diflucan
Grifulvin V B Griseofulvicin
GrisPEG B Griseofulvin
Ketoconazole g Nizoral
Terbinafine (Tabs) g Lamisil
Formulary Drug Name B/g Alternate Drug Name
Albenza B Albendazole
Ivermectin B Stromectol
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Group Health Cooperative of
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Antimalarial
Antimycobacterial
Antiviral
Mebendazole g Vermox
Formulary Drug Name B/g Alternate Drug Name
Atovaquone-Proguanil HCL g Malarone
Chloroquine Phosphate g Aralen
Hydroxychloroquine Sulfate g Plaquenil
Malarone B Atovaquone-Proguanil
Mefloquine HCL g Lariam
Formulary Drug Name B/g Alternate Drug Name
Ethambutol HCL g Myambutol
Isoniazid g INH
Mycobutin B Rifabutin
Pyrazinamide g Pyrazinamide
Rifabutin B Mycobutin
Rifampin g Rimactane
Formulary Drug Name B/g Alternate Drug Name
Acyclovir (Oral Forms Only) g Zovirax
Atripla B Efavirenz-Emtricitabine-Tenofovir
Combivir B Lamivudine-Zidovudine
Crixivan B Indinavir Sulfate
Didanosine A/R g Videx EC
Emtriva B Emtricitabine
Epivir, Epivir HBV B Lamivudine
Hepsera B Adefovir Dipivoxil
Hivid B Zalcitabine
Invirase B Saquinavir
Isentress B Raltegravir
Kaletra B Lopinavir-Ritonavir
Lexiva B Fosamprevnavir
Norvir B Ritonavir
Prezista B Darunavir
Relenza B Zanamivir
Rescriptor B Delavirdine
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Group Health Cooperative of
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Cephalosporins
Fluoroquinolones
Reyataz B Atazanavir
Macrolide Antibiotics
Misc Anti-Infectives
Rimantadine g Flumadine
Selzentry B Maraviroc
Stavudine g Zerit
Sustiva B Efavirenz
Tamiflu B Oseltamivir
Trizivir B Abacavir+Lamivudine+Zidovudine
Valacyclovir g Valtrex
Valcyte B Valganciclovir HCL
Viracept B Nelfinavir Mesylate
Viramune B Nevirapine
Viread B Tenofovir
Ziagen B Abacavir Sulfate
Zidovudine g Retrovir
Formulary Drug Name B/g Alternate Drug Name
Cefdinir g Omnicef
Cefpodoxime Proxetil g Vantin
Cefprozil (tabs & suspension) g Cefzil
Cefuroxime Axetil g Ceftin
Cephalexin Monohydrate g Keflex
Formulary Drug Name B/g Alternate Drug Name
Avelox B Moxifloxacin HCL
Ciprofloxacin HCL g Cipro
Levofloxacin g Levaquin
Formulary Drug Name B/g Alternate Drug Name
Azithromycin g Zithromax
Clarithromycin g Biaxin, Biaxin XL
Ery-tab B Erythromycin Base EC
Erythromycin Ethyl Succinate g Erythromycin, EES
Formulary Drug Name B/g Alternate Drug Name
Alinia (Ped. Susp. Only) B Nitazoxanide
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Group Health Cooperative of
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Penicillins
Tetracyclines
Clindamycin HCL g Cleocin
Dapsone B Dapsone
Erythromycin-Sulfisoxazole g Pediazole
Mepron B Atovaquone
Metronidazole g Flagyl
SMZ-TMP, SMZ-TMP DS g Bactrim, Bactrim DS
Sulfamethoxazole-Trimethoprim, Sulfameth-TM g Bactrim, Bactrim DS
Trimethoprim g Trimpex
Vancocin HCL B Vancomycin HCL
Formulary Drug Name B/g Alternate Drug Name
Amoxicillin g Amoxil
Amoxicillin-Pot Clavulanate g Augmentin, Augmentin ES
Dicloxacillin Sodium g Dynapen
Penicillin V Potassium g Beepen VK
Formulary Drug Name B/g Alternate Drug Name
Doxycycline Hyclate g Vibramycin, Doxycycline
Doxycycline Monhydrate (susp. Only) g Vibramycin, Doxycycline
Minocycline HCL g Minocin
Tetracycline HCL g Acromycin V, Sumycin
Antineoplastic Agents
Antineoplastics
Formulary Drug Name B/g Alternate Drug Name
Alkeran B Melphalan
Anastrozole (18 yrs or older only) g Arimidex
Bicalutamide g Casodex
CeeNU B Lomustine
Cyclophosphamide g Cytoxan
Emcyt B Estramustine
Ergamisol g Levamisole
Etoposide g Toposar, VePesid
Fareston B Toremifene Citrate
Flutamide g Eulexin
Gleevec B Imatinib Mesylate
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Group Health Cooperative of
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Hexalen B Altretamine
Letrozole g Femara
Leucovorin Calcium g Wellcovorin
Leukeran B Chlorambucil
Megestrol Acetate g Megace
Mercaptopurine g Purinethol
Methotrexate, Methotrexate Sod LPF g Rheumatrex
Myleran B Busulfan
Nilandron B Nilutamide
Sprycel B Dasatinib
Tamoxifen Citrate g Nolvadex
Tarceva B Erlotinib
Targretin B Bexarotene
Temodar B Temozolomide
Thioguanine B Thioguanine
Tykerb B Lapatinib Ditosylate
Vesanoid B Tretinoin
Xeloda B Capecitabine
Zortress B Everolimus
Cardiovascular Agents
Antianginal Agents
Antiarrhythmic
Formulary Drug Name B/g Alternate Drug Name
Isosorbide Dinitrate, Isosorbide CR g Isordil
Isosorbide Mononitrate CR g Imdur
Nitro-Bid B Nitroglycerin
Nitroglycerin g Nitroglyn, Nitro Derm, Nitrodur
Formulary Drug Name B/g Alternate Drug Name
Amiodarone HCL g Cordarone
Disopyramide g Norpace, Norpace CR
Flecainide Acetate g Tambocor
Mexiletine HCL g Mexitil
Propafenone HCL g Rythmol
Quinidine Gluconate CR g Quinidine
Tikosyn B Dofetilide
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Group Health Cooperative of
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Antihyperlipidemic
Antihypertensive
Formulary Drug Name B/g Alternate Drug Name
Advicor B Niacin-Lovastatin
Atorvastatin g Lipitor
Cholestyramine, Cholestyramine Light g Questran
Colestipol HCL g Colestid
Crestor (10, 20, 40 mg) B Rosuvastatin
Fenofibrate g Lofibra
Gemfibrozil g Lopid
Lovastatin g Mevacor
Niaspan B Niacin CR
Pravastatin g Pravachol
Simcor B Simvastatin-Niacin SR
Simvastatin g Zocor
Zetia B Ezetimibe
Formulary Drug Name B/g Alternate Drug Name
Benazepril, Benazepril-HCTZ g Lotensin, Lotensin-HCTZ
Captopril, Captopril-HCTZ g Capoten, Capozide
Clonidine HCL (Tablets Only) g Catapres
Dibenzyline B Phenoxybenzamine
Doxazosin Mesylate g Cardura
Dutoprol B Metoprolol XL-hydrochlorothiazide
Edarbi B azilsartan medoxomil
Edarbyclor B azilsartan medoxomil-HCTZ
Enalapril Maleate, Enalapril-HCTZ g Vasotec, Vaseretic
Guanabenz Acetate g Wytensin
Guanfacine HCL g Tenex
Hydralazine HCL g Apresoline
Lisinopril, Lisinopril-HCTZ g Zestril, Zestoretic
Losartan Potassium g Cozaar
Losartan-HCTZ g Hyzaar
Methyldopa g Aldomet
Minoxidil g Loniten
Prazosin HCL g Minipres
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Group Health Cooperative of
South Central Wisconsin

Beta Blockers
Propranolol-HCTZ B Inderide
Quinapril HCL g Accupril
Ramipril g Altace
Terazosin HCL g Hytrin
Trandolapril g Mavik
Formulary Drug Name B/g Alternate Drug Name
Acebutolol HCL g Sectral
Atenolol g Tenormin
Atenolol-chlorthalidone g Tenoretic
Bystolic B nebivolol
Carvedilol g Coreg
Coreg CR B Carvedilol CR
Innopran XL B Propranolol
Labetalol HCL g Normodyne
Metoprolol Succinate SR g Toprol XL
Metoprolol Tartrate g Lopressor
Nadolol g Corgard
Pindolol g Visken
Propranolol HCL, Propranolol LA g Inderal
Sotalol HCL, Sotalol AF g Betapace, Betapace AF
Calcium Channel Blockers
Cardiotonics
Cardiovascular
Formulary Drug Name B/g Alternate Drug Name
Amlodipine g Norvasc
Diltiazem HCL, Diltiazem CD g Cardizem, Cardizem CD
Nifedipine, Nifedipine CR g Procardia, Adalat CC
Verapamil HCL, Verapamil SR (tabs only) g Calan, Isoptin, Calan SR
Formulary Drug Name B/g Alternate Drug Name
Digoxin g Lanoxin
Formulary Drug Name B/g Alternate Drug Name
Papaverine HCL Capsules g Pavabid
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Group Health Cooperative of
South Central Wisconsin

Diuretics
Pressors
Formulary Drug Name B/g Alternate Drug Name
Acetazolamide g Diamox
Acetazolmide SR g Diamox Sequels
Amiloride g Midamor
Amiloride-HCTZ g Moduretic
Bumetanide g Bumex
Chlorothiazide g Diuril
Chlorthalidone g Hygroton
Dyrenium B Triamterene
Furosemide g Lasix
Hydrochlorothiazide g HydroDiuril
Indapamide g Lozol
Methazolamide g Neptazane
Metolazone g Zaroxolyn
Spironolactone, Spironolactone-HCTZ g Aldactone, Aldactazide
Triamterene-HCTZ g Dyazide, Maxzide
Formulary Drug Name B/g Alternate Drug Name
Epipen, Epipen Jr B Epinephrine
Midodrine HCL g ProAmatine
Central Nervous System Drug
Antianxiety Agents
Antidementia
Formulary Drug Name B/g Alternate Drug Name
Alprazolam g Xanax
Buspirone HCL g Buspar
Chlordiazepoxide HCL g Librium
Clorazepate Dipotassium g Tranxene
Diazepam g Valium
Hydroxyzine HCL g Atarax
Lorazepam g Ativan
Meprobamate g Equanil
Formulary Drug Name B/g Alternate Drug Name
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Group Health Cooperative of
South Central Wisconsin

Antidepressants
Antipsychotics
Donepezil g Aricept
Exelon Patches B Rivastigmine
Namenda B Memantine
Rivastigmine Caps g Exelon
Formulary Drug Name B/g Alternate Drug Name
Amitriptyline HCL g Elavil
Bupropion HCL, SR, XL g Wellbutrin, Wellbutrin SR, XL
Citalopram Hydrobromide g Celexa
Clomipramine HCL g Anafril
Cymbalta 20mg & 30mg (QL 30/month) B Duloxetine
Cymbalta 60mg (QL 60/month) B Duloxetine
Desipramine HCL g Norpramin
Doxepin HCL g Sinequan
Escitalopram g Lexapro
Fluoxetine g Prozac (not Prozac Weekly)
Imipramine HCL g Tofranil
Mirtazapine g Remeron, Remeron Solutab
Nortriptyline HCL g Pamelor
Paroxetine HCL g Paxil
Phenelzine g Nardil
Sertraline g Zoloft
Surmontil B Trimipramine
Trazodone HCL g Desyrel
Venlafaxine & Venlafaxine ER g Effexor & Effexor XR
Formulary Drug Name B/g Alternate Drug Name
Abilify B Aripiprazole
Chlorpromazine HCL g Thorazine
Clozapine g Clozaril
Fluphenazine g Prolixin
Haloperidol g Haldol
Lithium Carbonate, Lithium Citrate g Lithium
Loxapine Succinate g Loxitane
Olanzapine g Zyprexa
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Group Health Cooperative of
South Central Wisconsin

Hypnotics
Perphenazine g Trilafon
Prochlorperazine g Compazine
Quetiapine g Seroquel
Risperidone (not Risperidone ODT) g Risperdal
Seroquel XR B Quetiapine
Thioridazine HCL g Mellaril
Thiothixene g Navane
Trifluoperazine HCL g Stelazine
Ziprasidone g Geodon
Formulary Drug Name B/g Alternate Drug Name
Estazolam g Prosom
Flurazepam HCL g Dalmane
Temazepam g Restoril
Triazolam g Halcion
Zaleplon g Sonata
Zolpidem Tartrate (immediate release) g Ambien
Misc Psychotherapeutic
Stimulants
Formulary Drug Name B/g Alternate Drug Name
Antabuse B Disulfiram
Campral B Acamprosate Calcium
Ergoloid Mesylates g Hydergine
Orap B Pimozide
Savella B Milnacipran
Suboxone B Buprenophine - Naloxone
Formulary Drug Name B/g Alternate Drug Name
Adderall XR B Amphetamine-Dextroamphetamine XR
Amphetamine-Dextroamphetamine g Adderall (immediate release)
Concerta B Methylphenidate
Desoxyn B Methamphetamine
Dextroamphetamine CR, Dextroamphet Sulfate g Dextrostat, Dexedrine
Kapvay B Clonidine
Metadate CD (tabs only) B Methylphenidate CD
Methylphenidate HCL, CR g Ritalin, Methylin, Metadate ER
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Group Health Cooperative of
South Central Wisconsin

Methylphenidate LA g Ritalin LA
Methylphenidate LA 10mg B Ritalin LA
Strattera B Atomoxetine
Vyvanse (qty limit -30/month) B Lisdexamfetamine Dimesylate
Endocrine & Metabolic Drugs
Androgen-Anabolic
Antidiabetic
Formulary Drug Name B/g Alternate Drug Name
Androderm B Testosterone
Androgel B Testosterone
Danocrine g Danazol
Testoderm B Testosterone
Testosterone g Testosterone Enanthate, Cypionate
Testosterone Injection B Androderm, Testosterone Inj
Formulary Drug Name B/g Alternate Drug Name
Acarbose g Precose
Actoplus Met, Actoplus Met XR B Pioglitazone-metformin
Actos B Pioglitazone
Duetact B Glimepiride - Pioglitazone
Glimepiride g Amaryl
Glipizide, Glipizide ER g Glucotrol
Glucagon Emergency Kit B Glucagon
Glyburide g Diabeta
Glyburide-Metformin g Glucovance
Humalog Mix pen B Lispro+Lispro Protamine
Humalog Mix vial g Lispro+Lispro Protamine
Humalog pen B Lispro
Humalog vial g Lispro
Humulin 70/30 pen B Regular+Isophane (NPH)
Humulin 70/30 vial g Regular+Isophane (NPH)
Humulin N pen B Isophane (NPH)
Humulin N vial g Isophane (NPH)
Humulin R vial (U100 only) g Regular
Janumet, Janumet XR B Sitagliptin-Metformin
Januvia B Sitagliptin phosphate
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Group Health Cooperative of
South Central Wisconsin

Contraceptives
Corticosteroids
Lantus Insulin Pen B Glargine
Lantus Insulin vial g Glargine
Metformin HCL, Metformin ER g Glucophage
Formulary Drug Name B/g Alternate Drug Name
Camila g Micronor, NorQD, Errin
Cryselle g Lo/Ovral, Low-Ogestrel
Ella B Ulipristal Acetate
Enpresse g Tri-Levlen, Triphasil, Trivora
Jolessa g Seasonale, Quasense, Levonorgestrel
Junel FE (1/20 , 1.5/30) g Loestrin FE, Microgestin FE
Kariva g Mircette
Leena g TriNorinyl
Levora g Levlen, Nordette, Portia
Necon 1/50 (28) g OrthoNovum, Norinyl
Next Choice g Levonorgestrel
Nortrel (1/35, 0.5/35) g Brevicon, Modicon, Necon, Norinyl, Ort
Nortrel (7/7/7) g Ortho Novum 7/7/7, Necon 7/7/7
Nuvaring B Nuvaring (Vaginal Ring)
Plan B One-Step (QL 1 Pkg) B Levonorgestrel
Reclipsen g Desogen, Orthocept, Apri, Solia
Sprintec g Ortho Cyclen, Mononessa
Sronyx g Aviane, Levlite, Lessina, Lutera
Tri-Legest Fe g Estrostep FE, Tilia FE
Tri-Sprintec g TriNessa, Ortho Tri-Cyclen
Velivet g Cylessa, Cesia
Zovia g Demulen
Formulary Drug Name B/g Alternate Drug Name
Dexamethasone g Decadron, Dexameth. Intensol
Fludrocortisone Acetate g Florinef
Methylprednisolone g Medrol
Prednisolone g Prelone, Pediapred
Prednisolone Sod Phosphate g Orapred Solution
Prednisone g Orasone, Deltasone
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Group Health Cooperative of
South Central Wisconsin

Estrogens
Misc Endocrine
Progestins
Thyroid
Formulary Drug Name B/g Alternate Drug Name
Activella B Estradiol/Norethindrone
Combipatch B Estradiol-Norethindrone
Estraderm B Estradiol TD Patch
Estradiol g Climara, Estraderm, Estrace
Estropipate g Ogen
FemHRT B Norethindrone/Ethinyl Estradiol
Premarin B Conjugated Estrogens
Premphase B Conjugated Estrogen-Medroxyprogest A
Prempro B Conjugated Estrogen-Medroxyprogest A
Syntest g Estratest
Formulary Drug Name B/g Alternate Drug Name
Alendronate g Fosamax
Cabergoline g Dostinex
Calcitonin Nasal Soln g Miacalcin
Clomiphene Citrate g Clomid
Desmopressin Acetate g DDVAP
Evista B Raloxifene
Formulary Drug Name B/g Alternate Drug Name
Medroxyprogesterone Acetate g Provera
Prometrium B Progesterone Micronized
Formulary Drug Name B/g Alternate Drug Name
Cytomel B Liothyronine
Levothroid g Levothyroxine
Methimazole g Tapazole
Propylthiouracil g PTU
Thyroid g Armour Thyroid
Gastrointestinal Agents
Antidiarrheals
Formulary Drug Name B/g Alternate Drug Name
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Group Health Cooperative of
South Central Wisconsin

Antiemetics
Laxatives
Misc GI
Ulcer Drugs
Diphenoxylate-Atropine g Lomotil, Lonox
Loperamide HCL g Imodium
Formulary Drug Name B/g Alternate Drug Name
Anzemet B Dolasetron
Dronabinol g Marinol
Granisetron tabs g Kytril
Meclizine HCL g Antivert
Ondansetron g Zofran
Transderm-Scop (QL 5 patches) B Scopolamine
Trimethobenzamide HCL g Tigan
Formulary Drug Name B/g Alternate Drug Name
Glycolax g Miralax
Moviprep B PEG 3350
PEG Bowel Prep g Golytely
Prepopik B Sodium Cosulfate/Magnesium Oxide
Suprep B Sodium/Potassium Bowel Prep
Formulary Drug Name B/g Alternate Drug Name
Asacol, Asacol HD B Mesalamine
Balsalazide g Colazal
Calcium Acetate g Phoslo
Canasa B Mesalamine
Lactulose g Cholac, Enulose
Metoclopramide HCL g Reglan
Pentasa B Mesalamine
Renagel B Sevelamer Hydrochloride
Renvela B Sevelamer Carbonate
Sulfasalazine g Azulfidine
Ursodiol g Actigall
Formulary Drug Name B/g Alternate Drug Name
Axid OS (children only) B Nizatidine Oral Solution
Belladona Alkaloids-Opium g B & O Suppository
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Group Health Cooperative of
South Central Wisconsin

Cimetidine HCL g Tagamet
Dexilant (requires PA, QL 60) B Dexlansoprazole
Dicyclomine HCL g Bentyl
Famotidine g Pepcid
Glycopyrrolate g Robinul, Robinul-Forte
Hyoscyamine Sulfate, CR, SL g Levsin
Lansoprazole (QL 60) g Prevacid
Lansoprazole ODT (infants/toddlers) g Prevacid Solu-Tabs
Misoprostol g Cytotec
Omeprazole 10, 20, 40mg g Prilosec
Pantoprazole (QL 60) g Protonix
Phenobarbital-Belladonna Alk g Donnatal
Propantheline Bromide g ProBanthine
Ranitidine HCL g Zantac
Sucralfate g Carafate
Genitourinary Products
Misc Genitourinary Products
Formulary Drug Name B/g Alternate Drug Name
Alfuzosin g Uroxatral
Avodart B Dutesteride
Finasteride (5 mg only) g Proscar (not Propecia)
Phenazopyridine HCL g Pyridium
Potassium Citrate g Polycitra-K
Tamsulosin g Flomax
Urinary Anti-Infectives
Formulary Drug Name B/g Alternate Drug Name
Furadantin B Nitrofurantoin
Methenamine Hippurate g Hiprex
Nitrofurantoin Macro & Mono/Macro g Macrodantin, Macrobid
Urinary Antispasmodics
Formulary Drug Name B/g Alternate Drug Name
Bethanechol Chloride g Urecholine
Flavoxate g Urispas
Oxybutynin Chloride g Ditropan (Immediate Release Only)
Oxybutynin XL g Ditropan XL
Monday, December 03, 2012 Page 17 of 27
Group Health Cooperative of
South Central Wisconsin

Vaginal Products
Formulary Drug Name B/g Alternate Drug Name
Clotrimazole 3 Day (Vaginal) g Gyne-Lotrimin 3
Clotrimazole-7 Vag Cream g Gyne-Lotrimin
Estrace Vaginal Cream B Estradiol Vaginal
Estring B Estradiol Vaginal Ring
Metronidazole (Vaginal) g Metrogel Vaginal
Miconazole 3 g Monistat 3
Nystatin Vaginal g Mycostatin Vaginal
Progesterone Vaginal Suppositories g First-Progesterone
Terconazole 0.4% Vag Cream g Teraconazole 7-day
Vagifem B Estradiol
Hematological Agents
Anticoagulants
Hematopoietic Agents
Hemostatics
Misc Hematological
Formulary Drug Name B/g Alternate Drug Name
Enoxaparin g Lovenox
Fragmin B Dalteparin
Heparin Lock Flush g Heparin Flush
Warfarin Sodium g Coumadin
Formulary Drug Name B/g Alternate Drug Name
Folic Acid g Folvite
Hydroxyurea g Hydrea
Formulary Drug Name B/g Alternate Drug Name
Aminocaproic Acid g Amicar
Lysteda B Tranexamic acid
Formulary Drug Name B/g Alternate Drug Name
Anagrelide g Agrylin
Cilostazol g Pletal
Clopidogrel g Plavix
Dipyridamole g Persantine
Pentoxifylline CR g Trental
Monday, December 03, 2012 Page 18 of 27
Group Health Cooperative of
South Central Wisconsin

Miscellaneous Products
Antiseptics & Disinfectants
Assorted Classes
Diagnostic Products
Medical Devices
Formulary Drug Name B/g Alternate Drug Name
Phisohex B Hexachlorophene
Formulary Drug Name B/g Alternate Drug Name
Azathioprine g Imuran
Cyclosporine g Sandimmune
Cyclosporine Modified g Neoral, Gengraf
Mycophenolate Mofetil g Cellcept
Myfortic B Mycophenolate
Penicillamine g Cuprimine
Rapamune B Sirolimus
Sodium Polystyrene Sulfonate g Kayexalate
Tacrolimus g Prograf
Thalomid B Thalidomide
Formulary Drug Name B/g Alternate Drug Name
Keto-Diastix VI Urine Glucose Ketones
Formulary Drug Name B/g Alternate Drug Name
Alcohol Pads Alcohol Pads
FreeStyle Freedom Lite Monitor FreeStyle Freedom Lite
FreeStyle Lancets FreeStyle Lancets
FreeStyle Lite Monitor FreeStyle Lite
FreeStyle Lite Test Strips FreeStyle Lite Test Strips
FreeStyle Test Strips FreeStyle Test Strips
Insulin Pen Needle Insulin Pen Needle
Insulin Syringe-Needle U-100 Insulin Syringe-Needle U-100
Lancing Device Lancing Device
Needle (Disp) 18, 19, 21, 22, 23, 25, 27, 30g Needle (Disp)
Optichamber Mask Optichamber/Mask
Ortho Diaphragm All-Flex Ortho Diaphragm
Peak Flow Meter Inh Assist Kit, Low & Univ Ra Peak Flow Meter
Monday, December 03, 2012 Page 19 of 27
Group Health Cooperative of
South Central Wisconsin

Precision Xtra Prescision Xtra
Precision Xtra Test Strips Precision Xtra Test Strips
Softclix Lancets Softclix Lancets
Space Chamber Spacer
Syringe (Disposable) Disposable Syringe
Pharmaceutical Adjuvants
Formulary Drug Name B/g Alternate Drug Name
Sorbitol B Sorbitol
Neuromuscular Drugs
Anticonvulsant
Antiparkinson's
Formulary Drug Name B/g Alternate Drug Name
Carbamazepine, XR g Tegretol, Tegretol XR
Carbatrol B Carbamazepine XR
Celontin B Methsuximide
Clonazepam g Klonopin
Diastat B Diazepam
Dilantin, Dilantin Infatabs B Phenytoin
Divalproex Sodium Enteric Coated g Depakote
Ethosuximide g Zarontin
Gabapentin g Neurontin
Gabitril B Tiagabine
Lamotrigine (not starter pack or SR) g Lamictal
Levetiracetam g Keppra
Oxcarbazepine g Trileptal
Phenobarbital g Phenobarbital
Phenytoin (Infatabs Require PA) g Dilantin
Primidone g Mysoline
Topiramate g Topamax
Valproic Acid g Depakene
Zonisamide g Zonegran
Formulary Drug Name B/g Alternate Drug Name
Amantadine HCL g Symmetrel
Benztropine Mesylate g Cogentin
Bromocriptine Mesylate g Parlodel
Monday, December 03, 2012 Page 20 of 27
Group Health Cooperative of
South Central Wisconsin

Carbidopa-Levodopa, Carbidopa-Levodopa CR g Sinemet
Comtan B Entacapone
Pramipexole Dihydrochloride g Mirapex
Ropinirole g Requip
Selegiline tabs & caps g Eldepryl
Stalevo B Carbidopa-Levodopa-Entacapone
Tasmar B Tolcapone
Trihexyphenidyl HCL g Artane
Neuromuscular Blockers
Formulary Drug Name B/g Alternate Drug Name
Rilutek B Riluzole
Skeletal Muscle Relaxants
Formulary Drug Name B/g Alternate Drug Name
Baclofen g Lioresal
Carisoprodol (350 mg only) g Soma
Cyclobenzaprine HCL g Flexeril
Dantrolene Sodium g Dantrium
Methocarbamol g Robaxin
Tizanidine (Tablets only) g Zanaflex
Nutritional Products
Minerals & Electrolytes
Multivitamins
Nutrients
Formulary Drug Name B/g Alternate Drug Name
Fluoride g Fluoride Chewable, Drops
K-Phos B Potassium Acid Phosphate
K-Phos-Neutral B Potassium Phosphate/Sodium Phospha
Potassium Chloride, Potassium Chloride CR g K-Tab, K-DUR
Sodium Fluoride g Fluoride
Formulary Drug Name B/g Alternate Drug Name
Dialyvite g B-Complex w/ C & Folic Acid
Prenatal Plus g NatalCare Plus
Formulary Drug Name B/g Alternate Drug Name
Levocarnitine g Carnitor
Monday, December 03, 2012 Page 21 of 27
Group Health Cooperative of
South Central Wisconsin

Vitamins
Ultra Omega-3 g Fish oil
Respiratory Agents
Antiasthmatic
Antihistamines
Formulary Drug Name B/g Alternate Drug Name
Calcitriol g Rocaltrol
Ergocalciferol g Drisdol
Mephyton g Phytonadione
Niacin g Niacin (Immediate Release Only)
Formulary Drug Name B/g Alternate Drug Name
Advair Diskus/HFA B Salmeterol+Fluticasone
Albuterol Sulfate (Osmotic) g Vospire
Albuterol Sulfate Nebulizer Soln g Albuterol Neb Soln
Albuterol-Ipratropium Nebulizer Soln g Duoneb
Asmanex B Mometasone Furoate
Atrovent HFA B Ipratropium Bromide
Budesonide Nebs g Pulmicort Respules
Combivent B Ipratropium+Albuterol
Cromolyn (Nebulizer) g Intal Neb Solution
Flovent HFA B Fluticasone Propionate HFA
Flovent Rotadisk B Fluticasone Inh
Foradil Aerolizer B Formoterol
Ipratropium Bromide (Nebulizer) g Atrovent
Montelukast g Singulair
Proventil HFA B Albuterol HFA
Pulmicort Flexhaler B Budesonide
Serevent Diskus B Salmeterol
Spiriva (Requires PA, COPD Only) B Tiotropium Bromide Monohydrate
Symbicort B Budesonide, Formoterol
Theophylline, Theophylline CR g Theodur
Ventolin HFA B Albuterol HFA
Formulary Drug Name B/g Alternate Drug Name
Cetirizine (excludes chewables) g Zyrtec
Chlorpheniramine, Clorpheniramine CR g Chlor-Trimeton
Monday, December 03, 2012 Page 22 of 27
Group Health Cooperative of
South Central Wisconsin

Cough/Cold
Decongestants
Topical Products
Anorectal
Dermatological
Cyproheptadine HCL g Periactin
Loratadine g Claritin
Promethazine HCL g Phenergan, Phenadoz
Formulary Drug Name B/g Alternate Drug Name
Benzonatate g Tessalon
Cheratussin AC g Robitussin AC
Guaifenesin AC, Guaifenesin DAC g Robitussin AC, Robitussin DAC
Promethazine Plain/Codeine g Phenergan/Codeine
Promethazine VC/Codeine g Phenergan VC/Codeine
Sodium Chloride Inhalant g Sodium Chloride solution
Formulary Drug Name B/g Alternate Drug Name
Astepro B Azelastine
Azelastine Nasal Soln g Astelin Nasal Spray
Flunisolide (Nasal) g Nasalide
Fluticasone Nasal g Flonase
Ipratropium Bromide (Nasal) g Atrovent
Nasonex B Mometasone Furoate
Patanase Nasal Spray B Olopatadine
Veramyst B Fluticasone Furoate
Formulary Drug Name B/g Alternate Drug Name
Hemorrhoidal-HC g Anusol HC
Proctofoam HC B Hydrocortisone-Ace-Pramoxine
Formulary Drug Name B/g Alternate Drug Name
Aczone B Dapsone
Adapalene (Gel and Cream Only) g Differin
Aluminum Chloride Hexahydrate g Drysol
Ammonium Lactate g AmLactin
Aug. Betamethasone (Crm AF/Oint/Lot) g Diprolene
Azelex B Azelaic Acid
Monday, December 03, 2012 Page 23 of 27
Group Health Cooperative of
South Central Wisconsin

Bactroban cream B Mupirocin
Benzoyl Peroxide Gel (5% & 10%) g Benzac AC
Benzoyl Peroxide Wash (5% & 10%) g Benzac W
Betamethasone Dipropionate (Crm, Lotn, Oint) g Diprosone
Betamethasone Valerate g Betaval
Biafine B Emulsion Wound Dressing
Calcipotriene g Dovonex
Ciclopirox g Loprox, Penlac
Clindamycin Phosphate (Topical) g Cleocin T
Clobetasol foam g Olux foam
Clobetasol Propionate g Temovate
Clotrimazole-Betamethasone (crm & lotion) g Diprolene
Cordran Tape B Flurandrenolide Tape
Derma-Smoothe FS Oil B Fluocinolone Acetonide
Desonide g Desowen
Econazole Nitrate g Spectazole
Elidel B Pimecrolimus
Erythromycin (Acne Aid) g T-Gel
Finacea 15% Gel B Azelaic Acid 15% Gel
Fluocinolone Acetonide (Crm/Oint/Sol) g Synalar
Fluocinonide, Fluocinonide-E g Lidex, Lidex-E
Fluorouracil g Fluoroplex, Efudex
Fluticasone Propionate (Crm/Oint) g Cutivate
Halobetasol Propionate (Crm/Oint) g Ultravate
Hydrocortisone g Hydrocortisone, Hytone
Hydrocortisone Iodoquinol g Vytone
Imiquimod g Aldara
Isotretinoin g Accutane, Claravis, Sotret
Lidocaine 4% cream g Xylocaine
Lidocaine HCL g Lidocaine
Metrogel B Metronidazole
Metronidazole 0.75% (Topical) g Metrolotion, Metrocream
Miconazole Nitrate g Micatin
Mometasone Furoate (Crm/Oint) g Elocon
Mupirocin oint g Bactroban oint
Naftin B Naftifine
Monday, December 03, 2012 Page 24 of 27
Group Health Cooperative of
South Central Wisconsin

Intrarectal Steroids
Noritate B Metronidazole
Nystatin g Mycostatin
Nystatin-Triamcinolone (cream & oint) g Mytrex, Mycolog
Oxsoralen Ultra B Methoxsalen
Panretin B Alitretinoin
Permethrin g Elimite, Acticin
Podofilox g Condylox
Pramoxine-HC g Pramosone
Protopic B Tacrolimus
Santyl B Collagenase
Selenium Sulfide g Selenium Sulfide
Silver Sulfadiazine g Silvadene, SSD
Sodium Sulfacetamide-Sulfur g Sulfacetamide-Sulfur
Soriatane B Acitretin
Sulfacetamide sodium 10% lotion g Klaron
Sulfacetamide sodium-sulfur wash g Plexion
Tazorac B Tazarotene
Tretinoin g Retin-A
Triamcinolone Acetonide (Topical Oint 0.5%) B Triamcinolone
Triamcinolone Acetonide (Topical) g Kenalog, Azmacort
Ulesfia 5% lotion B benzyl alcohol
Urea 40% (cream, lotion) g Carmol, Keralac
Vectical B Calcitriol
Voltaren gel (qty limit - 500gm) B Diclofenac gel
Formulary Drug Name B/g Alternate Drug Name
Hydrocortisone (Intrarectal) g Hydrocortisone Enema
Mouth & Throat (Local)
Formulary Drug Name B/g Alternate Drug Name
Chlorhexidine Gluconate g Peridex
Clotrimazole g Mycelex Troche
Evoxac B Cevimeline
Lidocaine Viscous g Lidocaine
Pilocarpine g Salagen
Monday, December 03, 2012 Page 25 of 27
Group Health Cooperative of
South Central Wisconsin

Ophthalmic
Formulary Drug Name B/g Alternate Drug Name
Alphagan P B Brimonidine
Alrex B Loteprednol Etabonate
Atropine Sulfate (Eye) g Atropine
Azopt B Brinzolamide
Bacitracin (Eye) g Bacitracin
Bacitra-Neomycin-Polymyxin-HC (Eye) g Cortisporin OP Oint
Betoptic-S B Betaxolol
Blephamide B Sulfacetamide Sod-Pred
Brimonidine g Alphagan P
Carbachol (Eye) g Miostat
Carteolol HCL g Ocupress
Ciprofloxacin HCL (Eye) g Ciloxan
Combigan B Brimonidine-Timolol
Cromolyn (Eye) g Opticrom
Cyclopentolate HCL g Cyclogyl
Diclofenac g Voltaren (eye)
Dorzolamide g Trusopt
Dorzolamide+Timolol g Cosopt
Erythromycin (Eye) g Erythromycin
Fluorometholone (Eye) g FML-S Liquifilm, FML
FML Forte, FML S.O.P B Fluorometholone
Gentamicin Sulfate (Eye) g Garamycin
Homatropine HBR g Homatropine
Ketorolac Ophthalmic g Acular
Ketotifen g Zaditor
Latanoprost g Xalatan
Levobunolol HCL g Betagan
Lotemax B Loteprednol Etabonate
Neomycin-Bacitracin-Polymyxin g Neosporin
Neomycin-Polymyxin-Dexameth g Maxitrol
Neomycin-Polymyxin-Gramicid g Neosporin
Neomycin-Polymyxin-HC (Eye) g Cortisporin
Ofloxacin (Eye) g Ocuflox
Pataday B Olopatadine
Monday, December 03, 2012 Page 26 of 27
Group Health Cooperative of
South Central Wisconsin

Otic
Patanol B Olopatadine
Phospholine Iodide B Echothiophate Iodide
Pilocarpine HCL (Eye) g Pilocar
Prednisolone Acetate (Eye) g Predforte
Sulfacetamide Sodium g Sodium Sulamyd
Timolol Maleate (Eye) g Timoptic
Tobramycin Sulfate (Eye) g Tobramycin
Tobramycin+Dexamethasone g Tobradex
Trifluridine g Viroptic
Trimethoprim-Polymyxin B g Polytrim
Vigamox B Moxifloxacin
Zirgan B ganciclovir
Zylet B Loteprednol Etabonate-Tobramycin
Formulary Drug Name B/g Alternate Drug Name
A/B Otic g Auralgan
Ciprodex B Ciprofloxacin-Dexamethasone
Neomycin-Polymyxin-HC (Ear) g Cortisporin Otic
Ofloxacin Otic g Floxin Otic
Monday, December 03, 2012 Page 27 of 27
Group Health Cooperative of
South Central Wisconsin