Washtenaw Health Plan B Quick Drug List

Washtenaw Health Plan B Quick Drug List
Brand names (in parentheses) are listed for reference only. If available, only the generic product is covered.
Please check the WHP Plan A and B Drug Formulary for a complete listing of dosages and medications.
Prescription copays are listed on the health plan card
This list may change at any time. This is a partial listing. For the latest list go to http://whp.ewashtenaw.org
For medications marked:
“NC $4 program”: Drug is not covered by the WHP but is available at the $4 pharmacy program
·“OTC”: Available over the counter; prescription is required
·“QL”: Quantity is limited
“PA Req’d”: Contact WHP Nurse Coordinator
ANALGESIC
Antiarthritic
· allopurinol (Zyloprim); NC $4 program
·· methotrexate sodium (methotrexate)
· salsalate (Disalcid)
Anti-Migraine
· sumatriptan (Imitrex) QL
Muscle Relaxants
· baclofen (Lioresal); NC $4 program
· carisoprodol (Soma)
· cyclobenzaprine hcl (Flexeril); NC $4 program
· methocarbamol (Robaxin)
Non narcotic
· acetaminophen/butalbital/caffeine (Fioricet)
· asa/butalbital/caffeine (Fiorinal)
· chol sal/mg (Trilisate)
· diflunisal (Dolobid)
· tramadol (Ultram)
Narcotic QL=180tabs/mo or 960 ml/mo liquid
· acetaminophen w/codeine (Tylenol #2,3,4)QL
· hydrocodone/acetaminophen (Vicodin, Lorcet, Norcro) QL
· hydrocodone/ibuprofen (Vicoprofen) QL
· hydromorphone (Dilaudid) QL
· meperidine hcl (Demerol) QL
· methadone (Dolophine) QL 30mg/day
· morphine sulfate ER (MS Contin) --PA Req’d if >
60mg/day
· morphine sulfate IR (MSIR) QL
· oxycodone hcl (Oxycodone) 5 mg tab only QL
· oxycodone/Acetaminopehen (Percocet) QL
· oxycodone/Aspirin (Percodan) QL
·Non Steroidal
· diclofenac sodium (Voltaren); NC $4 program
· ibuprofen (Motrin) NC $4 program
· indomethacin (Indocin)
· ketoprofen (Orudis)
. naproxen (Anaprox)
· naproxen (Naprosyn) ; NC $4 program
· sulindac (Clinoril)
ANTI-INFECTIVE
Antibacterial
· metronidazole (Flagyl)
·Antifungal
· fluconazole (Diflucan) ; NC $4 program
· griseofulvin microsize (GrifulvinV) 125 mg/5 ml only
· nystatin (Mycostatin) ; NC $4 program
Antimalarial
· hydroxychloroquine (Plaquenil)
Antiviral
· acyclovir (Zovirax); 400 and 800 mg tab only
Cephalosporin
· ceflacor (Ceclor)
· cefadroxil (Duricef)
· cephalexin (Keflex) ; NC $4 program
Macrolide
· azithromycin (Zithromax) QL
· clarithromycin (Biaxin)
· erythromycin (E.E.S. or Erythrocin)
·
Updated 9/15//2012
Miscellaneous
. clindamycin (Cleocin) 150 mg only
Penicillin
· amoxicillin (Amoxil) ; NC $4 program
· amox/potassium clavulanate (Augmentin)
Quinolone
· ciprofloxacin (Cipro) ; NC $4 program
. levofloxacin (Levaquin)
Sulfonamide
· sulfamethoxazole/trimethoprim (Bactrim/Bactrim DS) ; NC $4
program
· sulfasalazine (Azulfidine)
· sulfisoxazole (Gantrisin)
TB
· isoniazid (INH) ; NC $4 program
Tetracycline
doxycycline hyclate (Vibramycin) ; NC $4 program
minocycline (Minocin)
tetracycline (Sumycin) ; NC $4 program
Urinary Tract
Nitrofurantoin (Macrodantin)
BRONCHIAL
Antihistamine
· clemastine fumarate (Tavist)
· cyproheptadine (Periactin)
· hydroxyzine (Atarax)
· hydroxyzine pamoate (Vistaril)
promethazine (Phenergan); suppositories only are covered
Asthma/COPD
. aerochamber (Spacer) QL
· albuterol (Pro Air HFA) inhaler/solution QL
· beclomethasone dipropionate (QVAR) QL
· aminophylline (Aminophylline)
· cromolyn sodium (Intal) solution
· fluticasone propionate (Flovent) inhaler 110 mcg only ; PA
Req’d for 220 mcg
· ipratropium (Atrovent HFA) inhaler/solution
· metaproterenol (Alupent) solution/tab
. montelukast (Singulair)
· theophylline (Theo-Dur)
Bronchodilators
· epinephrine (Epipen and Epipen JR) QL
Cough and Cold
· benzonatate (Tessalon Perle) 100 mg cap only
· codeine/promethazine (Phenergen w/codeine)
· dextromethorphan (Phenergen DM)
· d-methorphan/p-ephedrine (Cardec-DM)
. guaifenesin/codeine (Robitussin AC)
· guaifenesin/p-ephedrine (Entex PSE)
· guaifenesin/p-ephedrine (Duratuss HD, Robitussin DAC))
· hydrocodone/homatrop (Hycodan)
· phenylephrine/codeine (Phenergan VC w/codeine)
· phenylephrine/pyrila (Rynatan)
Nasal Steroids
· fluticasone (Flonase)
CARDIOVASCULAR
Angiotensin-Converting Enzyme (ACE) Inhibitor
· captopril (Capoten) ; NC $4 program
· enalapril maleate (Vasotec) ; NC $4 program
· lisinopril (Zestril) ; NC $4 program
.
Appendix C
Quick Drug List
ACE + Diuretic
· lisinopril/HCTZ (Zestoretic) ; NC $4 program
Angiotensin II Receptor Blocker
.losartan (Cozaar)
Angiotensin II Receptor Blocker/Diuretic
. losartan/HCTZ (Hyzaar)
Alpha Blocker
· doxazosin (Cardura) ; NC $4 program
· terazoxin (Hytrin) ; NC $4 program
Antiarrhythmic
· amiodarone (Cordarone)
· disopyramide (Norpace)
· mexiletine (Mexitil)
· procainamide (Procainamide
Anticoagulant
· warfarin (Coumadin); NC $4 program
Antihypertensives-Misc.
· clonidine (Catapres) ; NC $4 program
· guanabenz acetate (Wytensin)
· guanfacine hcl (Tenex) ; NC $4 program
. hydralazine Apresoline)
· methyldopa (Aldomet) ; NC $4 program
· minoxidil (Loniten)
Antiplatelet
. clopidogrel (Plavix)
Beta Blocker
· atenolol (Tenormin) ; NC $4 program
· carvedilol (Coreg) ; NC $4 program
· metoprolol tartrate (Lopressor) ; NC $4
program
· propranolol (Inderal LA only)
Beta Blocker + Diuretic
· atenolol/chlorthalidone (Tenoretic) ; NC $4
program
Calcium Channel Blocker
· diltiazem (Cardizem and Cardizem CD)
· nifedipine (Procardia and Procardia XL)
· verapamil (Calan)
Diuretics
· bumetanide (Bumex) ; NC $4 program
. chlorthalidone (Hygroton)
· furosemide (Lasix) ; NC $4 program
· hydrochlorthiazide (Hydrodiuril) ; NC $4
program
· hydrochlorothiazide/triamterene
(Dyazide, Maxzide) ; NC $4 program
· spironolactone (Aldactone)
Lipid Lowering Agent
· cholestyramine (Questran/Questran Light)
· gemfibrozil (Lopid)
· lovastatin (Mevacor)
· simvastin (Zocor)
Potassium Supplement
· potassium bicarbonate (K-Lyte)
· potassium chloride (K Tab, Micro K) 10 meq only
· potassium chloride (Slow K 8 meq tab)
Coronary Vasodilator
· isosorbide dinitrate (Isordil)
· isosorbide mononitrate (Imdur; NC $4 program)
· nitroglycerin (Nitrostat)
· nitroglycerin ( Nitro-Bid 2% Ointment)
· nitroglycerin (Transderm -Nitro Patch)

Digitalis Glycoside
· digoxin (Lanoxin)
Peripheral Vasodilator
·isoxsuprine (Vasodilan)
·papaverine ( Pavabid)
DERMATOLOGIC
Anti-Infective
· bacitracin ointment; NC $4 program
· erythromycin base (A/T/S 2%) gel/solution
· clindamycin (Cleocin T 1%) solution
metronidazole 0.75% gel,cream,lotion
· silver sulfadiazine (Silvadene 1%) cream; NC $4
program
Antifungal
· betramethasone/clotrimazole (Lotrisone)
·· nystatin/triamcin (Mycolog II) cream/ointment
· nystatin (Mycotastin); suspension only
Antiparasitic
· permethrin (Elimite) 5% cream
Corticosteroid topical
· Betamethasone (Valisone)
· clobetasol (Temovate)
· desonide/L.S.B (Des-Owen) ointment/cream
· desoximetasone (Topicort)
· fluocinolone (Synalar)
· fluocinide (Lidex E)
· hydrocortisone (Hydorcortisone 1%); NC $4 program
· triamcinolone (Aristocort/Kenalog-Orabase) ; NC $4
program
Miscellaneous
· podofilox (Condylox 0.5%)
· selenium sulfide (Selsun 2.5%) shampoo
.
DIABETES
Oral Drugs
· chlorpropamide (Diabinese) ; NC $4 program
· glipizide (Glucotrol) ; NC $4 program
· glyburide (Diabeta/Micronase) ; NC $4 program
· metformin (Glucophage) ; NC $4 program
Insulins- vials only, QL 3 vials/month
· Humalog 100 U/ML QL
· Humalog Mix 75/25 QL
· Humulin 50/50 and 70/30 QL
· Humulin L,N,R 100 U/ML QL
· Lantus 100 IU/ML QL
· Novolin 70/30 QL
· Novolin N 100 U/ML QL
· Novlog 100 U/ML QL
Supplies
· glucagon emergency kit QL
· glucometer (Ascensia Breeze and Contour)
· lancets and syringes
· test strips (Ascensia Breeze and Contour only) QL
*WHP members may get a free Ascensia Breeze or Contour
Glucometer by calling Bayer at 1-877-229-3777
GASTROINTESTINAL
Antidiahhrea
· diphenoxylate (Lomotil)
Anti-inflammatory
· sulfasalazine (Azulfidine)
Anti-nausea
· meclizine (Antivert)
· metoclopramide (Reglan) ; NC $4 program
· prochlorperazine (Compazine) tablets; NC $4 program
· promethazine (Phenergen)suppositories only; tablets
NC $4 program
Antispasmotic
· belladonna (Donnatal) elixir only
· clidinium (Librax)
· dicyclomine (Bentyl) ; NC $4 program
· hyoscyamine sulfate (Levsin/Levsinex)
· propantheline (Pro-Banthine)
Anti-Ulcer
· Sucralfate (Carafate)
Antagonist 2
· famotidine (Pepcid/) ; NC $4 program
· ranitidine (Zantac) ; NC $4 program
Laxative
·· lactulose (Cephulac) syrup
· peg 3350/electrolyte solution (Colyte)
Proton Pump Inhibitor
· omeprazole (Prilosec)
Rectal Prep
· hydrocortisone (Anucort HC) suppository
OPHTHALMIC
Anti-Infective
· erythromycin base (Ilotycin) ointment
· gentamicin (Garamycin) ; NC $4 program
· neomycin/bacitracin (Cortisporin/Neomycin) drops/oint.
· ofloxacin (Ocuflox) 0.3%
· sulfacetamide (Sod Sulamyd 10%)
· tobramycin (Tobrex) ; NC $4 program
Anti-Inf/NSAID
· flurbiprofen (ocufen) 0.03%
Anti-Inf/Steroid
· neomycin/polymixin/d (Maxitrol) ointment
Corticosteroid
· dexamethason (Decadron 0.1%) drops
· fluorometholone (FML Liquifilm 0.1%) drops
· prednisolone (Pred Forte 1%)
Dilator
· atropine (Isopto Atropine) ; NC $4 program
Glaucoma
· acetazolamide (Diamox) 125 & 250mg tabs
. lantanoprost (Xalatan) 0.005% drops
· levobunolol (Betagan)
· pilocarpine (Pilocarpine; NC $4 program)
· timolol maleate (Timoptic 0.25% & 0.5%) drops/ocudose;
NC $4 program
OTIC (EAR)
Anti-Infective
· acetic acid (Vosol) solution
. ciprofloxacin/dexamethasone (Ciprodex)0.3% susp.
Anti-Inf/Steroid
· Acetic/hydrocortisone (Vosol HC) drops
· neomycin/polymysixB/hydrocortisone (Cortisporin)
suspension/solution
Miscellaneous
· acetic acid/aluminum (Domeboro) drops
PSYCHOTHERAPEUTIC/CNS
Anti-Anxiety;
· alprazolam (Xanax)
· buspirone (Buspar) ; NC $4 program
· chlordiazepoxide hcl (Librium)
· clorazepate (Tranxene)
· diazepam (Valium)
· lorazepam (Ativan)
Anticonvulsant
· carbamazepine (Tegretol) ; NC $4 program
· clonazepam (Klonopin)
· divalproex sodium (Depakote)
. gabapentin (Neurontin) max 3600 mg/day
. lamotrigine (Lamictal) max 500 mg/day
. levetiracetam (Keppra) max 3000 mg/day
· phenobarbital (Phenobarbital)
· phenytoin (Dilantin)
· primidone (Mysoline)
· valproic acid (Depakene)
Antidepressants
· amitrip/perphen (Triavil)
· amitriptyline (Elavil) ; NC $4 program
· amitriptyline/cl (Limbitrol)
· bupropion SR (Wellbutrin)
· citalopram (Celexa) ; NC $4 program
· desipramine (Norpramin)
· doxepin (Sinequan)
· fluoxetine (Prozac) ; NC $4 program ·
imipramine (Tofranil)
· mirtazapine (Remeron)
· nortriptyline (Pamelor) ; NC $4 program
· paroxetine (Paxil) ; NC $4 program
· sertraline hydrochloride (Zoloft)
· trazadone (Desyrel) ; NC $4 program
Antimanic
· lithium carbonate (Lithotabs);
Antiparkinson
· amantadine hcl (Symmetral)
· benztropine mesylate (Cogentin) ; NC $4 program
· carbidopa/levodopa (Sinemet)
· trihexyphenidyl (Artane)
Antipsychotics
· chlorpromazine hcl (Thorazine)
· fluphenazine (Prolixin)tablets; NC $4 program
· haloperidol (Haldol) ; NC $4 program
· loxapine succinate (Loxitane)
· perphenazine (Trilafon)
. risperidone (Risperdal)
· thiothixene (Navane)
· trifluoperazine hcl (Stelazine)
CNS Stimulant
· methylphenidate (Ritalin and SR)
Sedative/Hypnotic
· flurazepam hcl (Dalmane)
· temazepam (Restoril)
· triazolam (Halcion)
· zolpidem tartrate (Ambien) QL
Substance Abuse
· disulfiram (Antabuse)
WOMEN’S HEALTH
Antifungal
· fluconazole (Diflucan) (150 mg tab only) ; NC $4 program
· miconazole nitrate (Monistat 3)suppositories
· metronidazole 0.75% vaginal gel
Estrogen
· estradiol (Estrace; NC $4 program)
· estropipate (Ogen)
Progesterone
Medroxyprogesterone (Provera) ; NC $4 program
VITAMIN SUPPLEMENT
· ergocal (Vitamin D 50000 IU)capsule
· folic acid (Folic Acid) ; NC $4 program
· iron/multivits/min (B-Complex Vitamin Plus Tab)
· prenatal vit w/Fe Fumarate, FA (Prenatal Rx) tablet; NC $4
program
·
MISCELLANEOUS
Anesthetic
· lidocaine(Xylocaine Viscous 2%) solution
Anti-Thyroid
· methimazole (Tapazole)
· propylthiouracil (Propylthiouracil)
Corticosteroid
· dexamethasone (Decadron)
· methylprednisolone (Medrol Dosepak)
· prednisone (Prednisone) ; NC $4 program
· prednisolone (Orapred)
mmunosuppressive
· azathioprine (Imuran)
Osteoporosis
· alendronote sodium (Fosamax) 70 mg only QL
Thyroid
· levothyroxine (Synthroid) ; NC $4 program
· thyroid (Armour Thyroid)
Urinary Tract
· oxybutinin (Ditropan) ; NC $4 program
· phenazopyridine (Pyridium) ; NC $4 program
·
WHP Formulary Contact Numbers
WHP Nurse Coordinator: (734) 544-3034
Customer Service: toll free (866) 291-8691
Updated 9/15/2012