Quick Reference Preferred Drug List - Molina Healthcare
Quick Reference Preferred Drug List - Molina Healthcare
Quick Reference Preferred Drug List - Molina Healthcare
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<strong>Quick</strong> <strong>Reference</strong><br />
<strong>Preferred</strong> <strong>Drug</strong> <strong>List</strong><br />
Effective 07-13-2009<br />
A<br />
ABILIFY<br />
ACANYA PA<br />
ACCOLATE<br />
ACCUPRIL<br />
ACCUTANE ST<br />
ACI-JEL<br />
ACIPHEX PA<br />
ACLOVATE, cream<br />
ACTIFED<br />
ACTOS<br />
ACULAR<br />
ACULAR -LS<br />
ADALAT-CC<br />
ADDERALL<br />
ADDERALL XR<br />
ADVAIR ST<br />
ADVICOR PA<br />
AEROBID<br />
AEROCHAMBER,<br />
E-Z Spacer<br />
AGGRENOX PA<br />
AKINETON<br />
AK-TRACIN<br />
ALAVERT<br />
ALCOHOL SWABS<br />
ALDACTONE<br />
ALDOMET<br />
ALESSE<br />
ALEVE<br />
ALKERAN<br />
ALL ORAL HIV<br />
DRUGS COVERED<br />
ALLEGRA<br />
ALLEGRA-D PA<br />
ALOMIDE PA<br />
ALOXI PA<br />
ALPHAGAN<br />
ALTABAX PA<br />
ALTACE PA<br />
ALTOCOR PA<br />
ALTOPREV PA<br />
ALUPENT<br />
ALUPENT INHALER<br />
AMARYL<br />
AMBIEN<br />
AMBIEN CR PA<br />
AMERGE PA<br />
ANAFRANIL<br />
AMITIZA PA<br />
ANZEMET PA<br />
ASMANEX<br />
ANAPROX<br />
ANAPROX DS<br />
ANSAID<br />
ANTABUSE<br />
ANTIVERT<br />
ANUSOL HC SUPP<br />
APRESOLINE<br />
AQUASOL<br />
ARICEPT<br />
ARIMIDEX<br />
ARMOUR THYROID<br />
AROMASIN<br />
ARTANE<br />
ASACOL<br />
ASCENDIN<br />
ASPIRIN<br />
ASTELIN<br />
ATARAX<br />
ATACAND PA<br />
ATACAND/HCTZ PA<br />
ATIVAN<br />
ATROVENT<br />
AUGMENTIN<br />
AURALGAN<br />
AVALIDE PA<br />
AVANDAMET PA<br />
AVANDIA PA<br />
AVANDARYL PA<br />
AVAPRO PA<br />
AVINZA PA<br />
AVODART PA<br />
AXERT PA<br />
AVANDAMET<br />
AVANDIA<br />
AYGESTIN<br />
AZMACORT<br />
AZULFIDINE<br />
B<br />
BACITRACIN<br />
BACTRIM<br />
BACTROBAN<br />
BANZEL PA<br />
BECONASE AQ PA<br />
BENADRYL<br />
BENEMID<br />
BENICAR<br />
BENTYL<br />
BENZOYL PEROXIDE<br />
BETAGAN<br />
BETAPACE-AF<br />
BETOPTIC<br />
BIAXIN-XL<br />
BIRTH CONTROL PILLS<br />
BLEPH 10<br />
BLEPHAMIDE<br />
BLOCADREN<br />
BRETHINE<br />
BRONCHO SALINE<br />
BUMEX<br />
BUSPAR<br />
BYSTOLIC PA<br />
C<br />
CAFERGOT<br />
CADUET PA<br />
CALAMINE LOTION<br />
CALAN<br />
CALAN SR<br />
CALCIFEROL<br />
CALCIUM GLUCONATE<br />
CAPOTEN<br />
CAPOZIDE<br />
CARAFATE<br />
CARDIZEM SR<br />
CARDURA<br />
CARNITOR<br />
CASODEX<br />
CATAPRES (tabs only)<br />
CECLOR<br />
CEDAX PA<br />
CEENU<br />
CEFACLOR ER PA<br />
CEFZIL<br />
CELEBREX PA<br />
CELEXA<br />
CELLCEPT<br />
CENESTIN PA<br />
CERUMENEX<br />
CHLOROPTIC<br />
CHLOR-TRIMETON<br />
CILOXAN PA<br />
CIPRO (not-XR)<br />
CIPRODEX<br />
CLARINEX PA<br />
CLARINEX-D PA<br />
CLARITIN<br />
CLEOCIN<br />
CLINDAMYCIN 300mg PA<br />
CLINORIL<br />
CLODERM PA<br />
CLOZARIL<br />
COGENTIN<br />
CO-GESIC<br />
COGNEX<br />
COLACE<br />
COLCHICINE<br />
COLYTE, FLAVORED<br />
COMBIPATCH<br />
COMBIVENT<br />
COMPAZINE<br />
CONDOMS<br />
CONDYLOX gel<br />
CONTAC 12 HR<br />
CORDARONE<br />
CORDRAN PA<br />
COREG<br />
COREG CR PA<br />
CORGARD<br />
CORTEF<br />
CORTISPORIN<br />
CORTISPORIN OTIC<br />
COTAZYM, CREON<br />
COUMADIN<br />
COZAAR PA<br />
CRESTOR 5 & 10mg PA<br />
CYMBALTA PA<br />
CYCLOGYL<br />
CYTOTEC<br />
CYTOVENE<br />
CYTOXAN<br />
D<br />
DALMANE<br />
DANOCRINE<br />
DARAPRIM<br />
DARVOCET-N<br />
DAYPRO<br />
DAYTRANA PA<br />
DDAVP<br />
DEBROX<br />
DECADRON<br />
DEPAKENE<br />
DEPAKOTE,<br />
DEPAKOTE ER<br />
DEPO-PROVERA<br />
DERMATOP PA<br />
DESQUAM<br />
All forms<br />
DESYREL<br />
DETROL, LA<br />
DEXEDRINE<br />
DHT, HYTAKEROL<br />
DIABETA<br />
DIABINESE<br />
DIAMOX<br />
DIAPHRAGMS<br />
DIFLUCAN<br />
DIFFERIN PA<br />
DILACOR XR<br />
DILANTIN<br />
DILATRATE SR<br />
DIMETAPP<br />
DIOVAN<br />
DIOVAN HCT<br />
DIPROLENE<br />
DIPROSONE<br />
DISALCID<br />
DITROPAN<br />
DITROPAN XL PA<br />
DOLOPHINE<br />
DONNATAL<br />
DORYX PA<br />
DOVONEX<br />
DRITHOCREME<br />
DRYSOL<br />
DULCOLAX<br />
DUPHALAC<br />
DURAGESIC PA<br />
DURICEF<br />
DYAZIDE<br />
DYNACIN<br />
DYNACIRC,-CR<br />
DYNAPEN<br />
E<br />
E.E.S.<br />
EASIVENT,<br />
MICROCHAMBER<br />
EFFEXOR<br />
EFFEXOR XR<br />
EFUDEX 5%<br />
ELAVIL<br />
ELDEPRYL<br />
ELIDEL AGE<br />
ELIMITE<br />
ELOCON<br />
EMCYT<br />
EMSAM<br />
ENABLEX PA<br />
ENTEX PSE<br />
EPIFOAM<br />
EPIFRIN<br />
EPIPEN<br />
EPIVIR HBV<br />
ERGAMISOL<br />
ERY-TAB<br />
ERYTHROCIN<br />
ESKALITH, ESKALITH CR<br />
ESTRACE<br />
ESTRADERM, patch<br />
ESTROGEL PA<br />
ESTROSTEP<br />
EULEXIN<br />
EVISTA<br />
EXCEDRIN MIGRAINE<br />
EVOXAC PA<br />
EXELON<br />
EXTINA FOAM<br />
F<br />
FAMVIR PA<br />
FARESTON<br />
FELDENE<br />
FEMARA<br />
FEMHRT<br />
FEMRING PA<br />
FEMSTAT-3<br />
FEOSOL<br />
FERGON<br />
FIORICET<br />
FIORINAL<br />
FLAGYL<br />
FLAGYL ER PA<br />
FLECTOR PATCH PA<br />
FLEETS PREP KIT<br />
FLEXERIL<br />
FLOMAX<br />
FLONASE<br />
FLORINEF<br />
FLORONE, FLORONE E<br />
FLOVENT HFA<br />
FLOXIN OTIC<br />
FML, FML FORTE<br />
FOLIC ACID<br />
FORADIL<br />
FOSAMAX AGE<br />
FOSRENOL PA<br />
FROVA PA<br />
FULVICIN<br />
FURADANTIN SUSP<br />
G<br />
GABAPENTIN<br />
GABITRIL<br />
GANTRISIN<br />
GARAMYCIN<br />
GENOPTIC<br />
GEODON<br />
GLEEVEC<br />
GLUCAGON KIT<br />
GLUCOPHAGE<br />
GLUCOSE METERS /<br />
TEST STRIPS – ALL MEMBERS<br />
MUST USE TRUE-TRACK<br />
GLUCOTROL<br />
GLUCOTROL XL<br />
GLYNASE<br />
GYNE-LOTRIMIN<br />
H<br />
HALCION<br />
HALDOL<br />
HELIDAC<br />
HEXALEN<br />
HISTUSSIN HC,<br />
HISTINEX HC<br />
HUMALOG MIX<br />
HUMALOG<br />
HUMIBID DM<br />
HUMULIN<br />
HYDREA<br />
THIS IS A QUICK REFERENCE LIST OF THE MOST COMMONLY PRESCRIBED MEDICATIONS,<br />
FOR A COMPLETE FORMULARY, PLEASE VISIT OUR WEBSITE AT: www.<strong>Molina</strong><strong>Healthcare</strong>.com<br />
HYDROCHLOROTHIAZIDE<br />
HYGROTON<br />
HYTONE<br />
HYTRIN<br />
HYZAAR PA<br />
I<br />
ILOTYCIN<br />
IMDUR, MONOKET<br />
IMITREX QL<br />
IMODIUM<br />
IMURAN<br />
INDERAL<br />
INDOCIN<br />
INNOPRAN XL<br />
INSULIN PEN DEVICE<br />
All forms including needles<br />
INTAL<br />
INVEGA PA<br />
ISMO<br />
ISO HYOSCINE<br />
ISONIAZID<br />
ISOPTO ATROPINE<br />
ISOPTO HOMATROPINE<br />
ISORDIL<br />
K<br />
KADIAN<br />
KAOPECTATE<br />
KAPIDEX PA<br />
K-DUR<br />
KEFLEX<br />
KEFLEX 750mg PA<br />
KENALOG<br />
KEPPRA<br />
KLONOPIN<br />
KLOTRIX, K-TABS<br />
K-LYTE/CI<br />
KYTRIL PA<br />
L<br />
LAMICTAL<br />
LAMISIL<br />
LANCETS<br />
LANOXIN<br />
LANTUS<br />
LARODOPA<br />
LASIX<br />
LATISSE PA<br />
LESCOL<br />
LESCOL XL PA<br />
LEUKERAN<br />
LEVONORGESTREL<br />
LEVAQUIN<br />
LEVATOL<br />
LEVOXYL, SYNTHROID<br />
LEVSIN,<br />
LEVSINEX<br />
LEXAPRO PA<br />
LIBRAX
LIBRIUM<br />
LIDEX<br />
LIDODERM PATCH PA<br />
LIORESAL<br />
LIPITOR (10, 20, 40mg) PA<br />
LITHONATE<br />
LODINE,-XL<br />
LOESTRIN<br />
LOMOTIL<br />
LONITEN<br />
LO-OVRAL, OVRAL<br />
LOPID<br />
LOPRESSOR<br />
LOTENSIN<br />
LOTREL<br />
LOTRISONE<br />
LOTRONEX ST<br />
LOXITANE<br />
LUMIGAN<br />
LUNESTA PA<br />
LURIDE<br />
LYRICA PA<br />
LYSODREN<br />
M<br />
MAALOX<br />
MACROBID<br />
MACRODANTIN<br />
MARPLAN<br />
MATULANE<br />
MAXAIR AUTOHALER<br />
MAXALT/ODT PA<br />
MAXIDE<br />
MEDROL<br />
MEGACE<br />
MELLARIL<br />
MENEST<br />
MEPHYTON<br />
MESTINON<br />
METADATE CD<br />
METHADONE<br />
METHERGINE<br />
METHOTREXATE<br />
METROGEL-VAGINAL<br />
MEVACOR<br />
MEXITIL<br />
MIACALCIN AGE<br />
MICARDIS/HCTZ<br />
MICRONOR<br />
MIDRIN<br />
MIGRANAL<br />
MINOCIN<br />
MINIPRESS<br />
MIRCETTE<br />
MIRTAZAPINE/STB PA<br />
MOBAN<br />
MODICON<br />
MONISTAT<br />
MOTRIN<br />
MOXATAG PA<br />
MS CONTIN<br />
MSIR<br />
MYAMBUTOL<br />
MYCELEX<br />
MYCOLOG<br />
MYCOSTATIN<br />
MYDRIACIL<br />
MYLANTA<br />
MYLERAN<br />
MYLICON<br />
MYSOLINE<br />
N<br />
NAMENDA<br />
NAPHCON<br />
NAPROSYN<br />
NARDIL<br />
NASACORT AQ PA<br />
NASALCROM<br />
NASONEX PA<br />
NATACYN<br />
NAVANE<br />
NEOMYCIN<br />
NEOSPORIN<br />
NEOSYNEPHRINE<br />
NEPHROCAPS<br />
NEPTAZANE<br />
NEURONTIN<br />
NEXIUM PA<br />
NIACIN, SLO-NIACIN<br />
NIASPAN<br />
NICODERM CQ<br />
NICORETTE GUM<br />
NICOTROL INH PA<br />
NICOTROL NASAL SPRAY PA<br />
NIFEREX-150 FORTE<br />
NITRO-BID<br />
NITRO-DUR<br />
NITROL OINT<br />
NITROLINGUAL SPRAY<br />
NITROSTAT<br />
NIX<br />
NIZORAL<br />
NOCTEC<br />
NOLAHIST<br />
NOLVADEX<br />
NORDETTE<br />
NORFLEX<br />
NORGESIC/FORTE PA<br />
NORMODYNE<br />
NORPACE,-CR<br />
NORPRAMIN<br />
NOVOLIN<br />
NOVOLOG<br />
NUVARING<br />
O<br />
OCUFEN<br />
OCUFLOX<br />
OMNARIS PA<br />
OMNICEF<br />
ONE-A-DAY<br />
OPANA<br />
OPTICHAMBER /<br />
INSPIREASE<br />
OPTICROM<br />
ORAMORPH SR<br />
ORAPRED<br />
ORTHO EVRA PATCH<br />
ORTHO TRI-CYCLEN<br />
ORTHO-CEPT<br />
ORTHO-CYCLEN<br />
ORTHO-NOVUM<br />
ORTHO-PREFEST PA<br />
ORUVAIL<br />
OS-CAL, TUMS<br />
OVCON<br />
OVIDE ST<br />
OVRETTE<br />
OXYCONTIN<br />
(120 tabs/30 days) QL > PA<br />
OXYTROL PATCH PA<br />
P<br />
PAMELOR<br />
PARLODEL<br />
PARNATE<br />
PATANASE<br />
PATANOL<br />
PAXIL (not-CR)<br />
PEDIACARE<br />
PEDIALYTE<br />
PEDIAZOLE<br />
PENTASA<br />
PEPCID<br />
PEPTO BISMOL<br />
PERCOCET<br />
PERCODAN<br />
PERIACTIN<br />
PERSANTINE<br />
PEXEVA PA<br />
PHENERGAN<br />
All forms<br />
PHENOBARBITAL<br />
PHOSLO<br />
PILOCAR<br />
PLAQUENIL<br />
PLAVIX<br />
PLENDIL<br />
POLY PRED SUSP<br />
POLY-HISTINE<br />
POLYSPORIN OINTMENT<br />
POLYTRIM<br />
POLY-VI-FLOR<br />
POTASSIUM CHLORIDE<br />
PRANDIN<br />
PRECOSE<br />
PRED MILD, PRED FORTE<br />
PRED-G DROPS<br />
PRED-G S.O.P. OINT<br />
PREDNISOLONE<br />
PREDNISONE<br />
PRELONE<br />
PREMARIN<br />
PREMPRO, PREMPHASE<br />
PRENATAL VITAMINS<br />
PREVACID PA<br />
PRILOSEC CR 40mg PA<br />
PRIMAQUINE<br />
PRINCIPEN<br />
PRISTIQ PA<br />
PRO-AIR HFA<br />
PRO-BANTHINE<br />
PROCANBID<br />
PROCTOCREAM HC<br />
PROCTOFOAM HC<br />
PROGRAF<br />
PROLIXIN<br />
PRONESTYL<br />
PROPINE<br />
PROSOM<br />
PROTONIX<br />
PROTOPIC<br />
PROVENTIL<br />
PROVENTIL HFA<br />
PROVERA, CYCRIN<br />
PROVIGIL PA<br />
PROZAC<br />
PROZAC WKLY PA<br />
PSORCON<br />
PSORCON E PA<br />
PTU<br />
PULMICORT RESPULES AGE<br />
PULMICORT FLEXHALER<br />
PURINETHOL<br />
PYRAZINAMIDE<br />
PYRIDIUM<br />
Q<br />
QUESTRAN<br />
QUINAGLUTE<br />
QUINIDEX<br />
QUINIDINE SULFATE<br />
QVAR<br />
R<br />
RAPAMUNE<br />
REGLAN<br />
RELAFEN<br />
RELPAX<br />
REMERON<br />
REMERON SLTB PA<br />
REQUIP XL PA<br />
RESTORIL<br />
RESTASIS PA<br />
RETIN-A<br />
RHEUMATREX<br />
RHINOCORT AQUA PA<br />
RYHTHMOL SR<br />
RID, A-200<br />
RIFADIN<br />
RISPERDAL<br />
RITALIN<br />
ROBITUSSIN<br />
ROCALTROL<br />
RONDEC<br />
ROZEREM PA<br />
S<br />
SANDIMMUNE, NEORAL<br />
SANCTURA PA<br />
SANCUSO PA<br />
SANSERT<br />
SELSUN SHAMPOO<br />
SEMPREX-D<br />
SEPTRA<br />
SERAX<br />
SEREVENT<br />
SEROQUEL<br />
PA NON-PSYCHIATRIST<br />
SEROQUEL XR<br />
SERZONE<br />
SILVADENE<br />
SINEMET<br />
SINEQUAN<br />
SINGULAIR ST<br />
SKELAXIN PA<br />
SLO-BID GYROCAPS<br />
SODIUM SULAMYD<br />
SOLARAZE PA<br />
SOMA<br />
SOMA COMPOUND<br />
SONATA<br />
SPORANOX<br />
STALEVO<br />
STRATTERA<br />
SUMYCIN<br />
SUPRAX<br />
SYMBICORT PA<br />
SYMMETREL<br />
SYNALAR<br />
SYNAREL<br />
T<br />
TAGAMET<br />
TAMBOCOR<br />
TAPAZOLE<br />
TARCEVA ST<br />
TARGRETIN<br />
TARKA PA<br />
TAVIST<br />
TAZORAC ST<br />
TEGRETOL<br />
TEGRETOL XR<br />
TEMOVATE<br />
TENEX<br />
TENORMIN<br />
TESSALON PERLES<br />
TESTOSTERONE<br />
SUPPLEMENTS PA<br />
THEO-DUR<br />
THIAMINE-OTC<br />
THIOGUANINE<br />
THORAZINE<br />
TIAZAC<br />
TIGAN<br />
TILADE INHALER<br />
TIMOPTIC<br />
TIMOPTIC-XE GEL<br />
TINACTIN<br />
TOBRA-DEX<br />
TOBREX<br />
TOFRANIL<br />
TOFRANIL PM PA<br />
TOLBUTAMIDE<br />
TOLINASE<br />
TOPAMAX<br />
TOPICORT<br />
TOPICORT LP<br />
TOPROL XL<br />
TORADOL<br />
TRANSDERM SCOP PA<br />
TRAVATAN PA<br />
TRENTAL<br />
TRICOR PA<br />
TRIDESILON<br />
TRILAFON<br />
TRILEPTAL<br />
TRILIPIX PA<br />
TRIMOX<br />
TRIMPEX<br />
TRIPHASIL<br />
TRIPLE ANTIBIOTIC<br />
TRIPLE SULFA<br />
TRI-VI-FLOR<br />
All forms<br />
TRUE TRACK<br />
Meter & Strips<br />
TRUE RESULT Meter<br />
TRUE TEST Strips<br />
All Other Meters &Strips PA<br />
TRUSOPT<br />
T-STAT<br />
TUMS<br />
TUSSI-ORGANIDIN<br />
TUSSIONEX PA<br />
TYLENOL<br />
TYLENOL/CODEINE<br />
U<br />
ULORIC PA<br />
ULTRAM<br />
ULTRAM ER PA<br />
ULTRAVATE PA<br />
UNIPHYL<br />
URECHOLINE<br />
UROXATRAL<br />
V<br />
VAGIFEM<br />
VALCYTE<br />
VALISONE<br />
VALIUM<br />
VALTREX PA<br />
VAPORIZER<br />
VASOCON A<br />
VEETIDS<br />
VELOSEF<br />
VENTOLIN HFA PA<br />
VEPESID<br />
VERAMYST PA<br />
VERMOX<br />
VESICARE PA<br />
VFEND<br />
VIBRAMYCIN<br />
VICODIN<br />
All forms<br />
VIGAMOX<br />
VIROPTIC<br />
VISTARIL<br />
VITAMIN B-6<br />
VIVELLE<br />
THIS IS A QUICK REFERENCE LIST OF THE MOST COMMONLY PRESCRIBED MEDICATIONS,<br />
FOR A COMPLETE FORMULARY, PLEASE VISIT OUR WEBSITE AT: www.<strong>Molina</strong><strong>Healthcare</strong>.com<br />
VOLMAX<br />
VOLTAREN<br />
VOSOL<br />
VOSOL HC OTIC<br />
VUSION OINT PA<br />
VYTORIN PA<br />
VYVANSE PA<br />
W<br />
WELLBUTRIN<br />
WELLBUTRIN XL<br />
WESTCORT<br />
X<br />
XALATAN<br />
XANAX<br />
XANAX XR PA<br />
XIFAXAN PA<br />
XOPENEX HFA PA<br />
XOPENEX NEB SOL.<br />
XYLOCAINE VISCOUS<br />
XYZAL PA<br />
Y<br />
YASMIN<br />
YAZ<br />
Z<br />
ZADITOR<br />
ZANTAC<br />
ZANTAC 300mg PA<br />
ZARONTIN<br />
ZAROXOLYN<br />
ZEBETA<br />
ZEGERID PA<br />
ZELNORM PA<br />
ZESTORETIC<br />
ZESTRIL<br />
ZETIA<br />
ZIAC<br />
ZITHROMAX<br />
ZOFRAN<br />
ZOLOFT<br />
ZOMIG QL<br />
ZOVIRAX<br />
ZYBAN<br />
ZYLOPRIM<br />
ZYMAR<br />
ZYPREXA<br />
ZYRTEC OTC<br />
ZYVOX ST
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