| Non-Preferred Brand Name Drug |
Non-Preferred Brand Tier
(4-1-05) |
Alternative
Drug Name(s) |
Alternative Drug Tier |
| Augmentin ES-600 suspension |
3 |
amoxicillin/clavulanate (generic equivalent) |
1 |
| Bactroban |
3 |
mupirocin (generic equivalent) |
1 |
| Depo-Provera injection |
2 |
medroxyprogesterone acetate injection (generic equivalent) |
1 |
| Diflucan |
3 |
fluconazole(generic equivalent) |
1 |
| Eskalith CR |
3 |
lithium carbonate extended-release(generic equivalent) |
1 |
| Halcion |
3 |
triazolam(generic equivalent) |
1 |
| Lasix |
3 |
furosemide(generic equivalent) |
1 |
| Lescol |
3 |
lovastatin, |
1 |
| Crestor, Lipitor, Pravachol |
2 |
| Lescol XL |
3 |
lovastatin, |
1 |
| Crestor, Lipitor, Pravachol |
2 |
| Lexapro |
3 |
citalopram, fluoxetine, paroxetine |
1 |
| Zoloft |
2 |
| Lithobid |
3 |
lithium carbonate extended-release |
1 |
| MiraLax |
3 |
polyethylene glycol 3350(generic equivalent) |
1 |
| Neurontin |
3 |
gabapentin(generic equivalent) |
1 |
| Nizoral 2% shampoo & cream |
3 |
ketoconazole 2% shampoo(generic equivalent) |
1 |
| NuLytely solution |
3 |
peg 3350/sodium bicarbonate/sodium chloride/potassium chloride(generic equivalent) |
1 |
| Provera |
3 |
medroxyprogesterone acetate(generic equivalent) |
1 |
| Rowasa enema |
3 |
mesalamine enema(generic equivalent) |
1 |
| Sulfacet-R |
3 |
sulfacetamide/sulfur(generic equivalent) |
1 |
| Temovate |
3 |
clobetasol(generic equivalent) |
1 |
| Tridesilon |
3 |
desonide(generic equivalent) |
1 |
