Basic Formulary
This Preferred Drug List (PDL) is a guide to care- and cost-effective medications covered on the QualChoice Basic Formulary.
This list is not all-inclusive nor a guarantee of coverage. Plan benefit design is the final determinate of coverage.
Certain medications may be subject to Quantity Limits (QL), Prior Authorization (PA) or Step Therapy (ST).
The use of generic drugs can save both you and your health plan money. This list is subject to change at any time without notice.
Please check www.qualchoice.com for the most up-to-date information.
Asterisk (*) denotes a generic equivalent is available.
Effective January 1, 2012
14983QCABASICDL1011
Drug Category tier 1 tier 2 tier 3 tier 4
anti-infective agents
cefaclor, cefadroxil, cefdinir,
Ceftin*, Cefzil*, Keflex*,
antibiotics-Cephalosporins cefprozil, cefuroxime,
Spectracef*, Suprax*
cephalexin
ciprofloxacin, Avelox, Cipro*, Cipro XR*,
antibiotics-Fluoroquinolones
ciprofloxacin ER, Levaquin*
azithromycin, clarithromycin, Biaxin*, Biaxin XL*, Ery-Tab,
antibiotics-Macrolides
erythromycin PCE, Zithromax*, Zmax
amoxicillin, amoxicillin with
Augmentin*, Augmentin XR*,
antibiotics-Penicillins potassium clavulanate,
Moxatag ER
ampicillin, penicillin
doxycycline, minocycline, Adoxa*, Doryx, Ketek, Oracea,
antibiotics-other
tetracycline Solodyn, Zyvox
fluconazole (QL),
antifungals Diflucan*, Lamisil*, Sporanox*,
itraconazole, ketoconazole,
Vfend
terbinafine
antivirals-Flu amantadine, rimantadine Tamiflu (QL) Relenza
acyclovir, famciclovir,
antivirals-Herpes Famvir*, Valtrex*, Zovirax*
valacyclovir
antivirals-HiV
All products
Cardiovascular agents
benazepril, benazepril/hctz, Accupril*, Accuretic*,
captopril, enalapril, Aceon*, Altace*, Capoten*,
aCe inhibitors &
enalapril/hctz, fosinopril, Monopril*, Monopril HCT*,
aCe inhibitor Combinations
lisinopril, lisinopril/hctz, Prinivil*, Prinzide*, Vasotec*,
quinapril, ramipril Zestoretic*, Zestril*
Atacand, Atacand HCT,
Avalide, Avapro, Benicar,
angiotensin ii receptor
losartan (ST), Benicar HCT, Cozaar*, Diovan,
antagonists (arBs) &
losartan/hctz (ST) Diovan HCT, Hyzaar*, Micardis,
Combinations
Micardis HCT, Teveten,
Teveten HCT
Altoprev, Crestor, Lescol/XL,
antihyperlipidemics atorvastatin, lovastatin,
Lipitor, Mevacor*, Pravachol*,
(Statins) pravastatin, simvastatin
Zocor*
Advicor, Antara, Caduet,
cholestyramine, colestipol, Lovaza, Niaspan, Questran,
antihyperlipidemics-other
fenofibrate, gemfibrozil Simcor, Tricor, Trilipix, Welchol,
Vytorin, Zetia
antihypertensive
Azor, Caduet, Exforge, Exforge
Combinations amlopidine/benazepril
HCT, Lotrel, Twynsta, Valturna
Aldactone*, Bidil, Caduet,
antihypertensives-other spironolactone
Inspra, Tekturna, Tekturna HCT
BASIC FormulAry (Cont.)
Drug Category tier 1 tier 2 tier 3 tier 4
cilostazol, dipyridamole, Aggrenox, Brilinta, Effient,
antiplatelet agents
ticlopidine Plavix, Ticlid*
acebutolol, atenolol, Coreg*, Coreg CR, Inderal*,
Beta Blockers bisoprolol, carvedilol, Innopran XL, Lopressor*,
metoprolol, propranolol Tenormin*, Toprol XL*
amlodipine, diltiazem,
Cardizem CD*, Cardizem LA*,
Calcium Channel Blockers felodipine, nifedipine,
Dynacirc CR, Norvasc*, Sular*
verapamil
Central Nervous System agents
Adderall*, Adderall XR*,
amphetamine salts,
Concerta, Dexedrine*,
amphetamine-
aDHD Medications Focalin XR, Intuniv, Metadate
dextroamphetamine SR,
CD, Metadate ER*, Nuvigil,
dextroamphetamine,
Provigil, Ritalin LA, Ritalin SR*,
methylphenidate, pemoline
Strattera, Vyvanse
Aricept*, Aricept ODT, Exelon,
alzheimers
galantamine, donepezil Namenda, Razadyne*,
Razadyne ER*
codeine-apap, hydrocodone Actiq*, Avinza, Conzip,
combinations, meperidine, Duragesic*, Fentora, Kadian,
analgesics-Narcotic
morphine sulfate, oxycodone Nucynta, Nucynta ER, Opana,
combinations, propoxyphene, Opana ER*, OxyContin*,
propoxyphene-N Ryzolt, Trezix
diclofenac, etodolac,
Arthrotec, Celebrex, Duexis,
ibuprofen, indomethacin,
analgesics-NSaiDs Flector, Naprelan, Vimovo,
meloxicam, naproxen,
Zipsor
piroxicam, sulindac
Aricept*, Aricept ODT, Exelon,
anti-alzheimer's agents donepezil, galantamine Namenda, Razadyne*,
Razadyne ER*
alprazolam, diazepam, Ativan*, Valium*, Xanax*,
antianxiety
lorazepam Xanax XR*
Depakote ER*, Dilantin,
carbamazepine, divalproex
Gabitril, Gralise, Horizant,
sodium, gabapentin,
anticonvulsants Keppra*, Keppra XR, Lamictal*,
lamotrigine, levetiracetam,
Lamictal XR, Lyrica, Topamax*,
oxcarbazepine, phenytoin
Trileptal*
Cymbalta, Effexor*,
antidepressants-SNris venlafaxine, venlafaxine XR
Effexor XR*, Pristiq
citalopram, fluoxetine, Celexa*, Lexapro, Paxil*,
antidepressants-SSris paroxetine, paroxetine ER, Paxil CR*, Prozac*,
sertraline Prozac Weekly*, Zoloft*
amitriptyline, bupropion Wellbutrin*, Wellbutrin SR*,
immediate-release, Wellbutrin XL*
antidepressants-other bupropion SR, bupropion XL,
desipramine, imipramine,
mirtazapine, nortriptyline
Azilect, Comtan, Mirapex*,
carbidopa/levodopa, Mirapex ER, Requip*, Requip
anti-Parkinson's agents
pramipexole, ropinirole XL, Sinemet*, Sinemet CR*,
Stalevo, Tasmar
Abilify, Clozaril*, Geodon,
antipsychotic agents Risperdal M*, Seroquel,
clozapine, risperidone
Seroquel XR, Symbyax,
Zyprexa, Zyprexa Zydis
Amerge, Axert, Frova, Maxalt,
Migraine Products naratriptan (QL),
Maxalt-MLT, Migranal, Relpax,
sumatriptan (QL)
Treximet, Zomig, Zomig ZMT
flurazepam, temazepam, Ambien*, Ambien CR, Lunesta,
Sedative Hypnotics
triazolam, zaleplon, zolpidem Rozerem, Sonata*
carisoprodol,
Flexeril*, Lioresal*, Skelaxin*,
Skeletal Muscle relaxants cyclobenzaprine,
Soma*, Zanaflex*
metaxolone, tizanidine
Actoplus-Met, Avandamet, Avandaryl,
Diabetes-Combinations glyburide/metformin
Actoplus-Met XR Duetact, Glucovance, Metaglip
Humalog, Humulin, Levemir
Apidra, Novolin, NovoLog,
Diabetes-insulin
Lantus
endocrine agents
Amaryl*, Diabeta*, Diabinese*,
chlorpropamide, glimepiride,
Diabetes- Glucotrol*, Glucotrol XL*,
glipizide, glyburide,
insulin-Secreting agents Micronase*, Prandin, Starlix*,
nateglinide, tolazamide
Tolinase*
Avandia, Fortamet,
Diabetes-
metformin, metformin XR Actos Glucophage*,
insulin-Sensitizing agents
Glucophage XR*, Glumetza
Diabetes-Non-insulin
injectable antihyperglycemic Byetta, Symlin, Victoza
agents
Glyset, Janumet, Januvia,
Diabetes-other Medications acarbose Precose*, Tradjenta
Onglyza
Diabetic Supplies Accu-Chek, OneTouch All other test strips
thyroid agents levothyroxine, Levoxyl Synthroid
gastrointestinal/ urinary agents
Creon, Pancrease,
Digestive aids pancrelipase
Ultrase, Viokase, Zenpep
gallstone-Solubilizing
ursodiol Urso*
agents
Detrol, Detrol LA, Ditropan XL*,
genitourinary Medications oxybutynin Enablex, Oxytrol, Sanctura,
Vesicare
cimetidine, famotodine,
H-2 antagonists nizatadine, ranitidine, Axid*,
Pepcid*, Tagamet*, Zantac*
Hyperparathyroid agents calcitriol Hectorol, Roxaltrol, Zemplar
Apriso, Asacol, Asacol HD,
balsalazide, mesalamine,
Inflammatory Bowel Canasa, Lialda, Pentasa,
sulfasalazine
Rowasa*
lansoprazole, pantoprazole,
Proton Pump inhibitors* omeprazole Aciphex, Dexilant, Nexium,
Prevacid, Prilosec*, Protonix
Men’s Health
Caverject, Cialis, Levitra,
erectile Dysfunction
Muse, Viagra
Hormone replacement AndroGel (PA) Androderm, Testim
doxazosin, tamsolusin, Avodart, Flomax*, Proscar*,
Prostate Health
terazosin Rapaflo, Uroxatral*
respiratory agents
cetirizine, fexofenadine,
fexofenadine-D, Allegra,
antihistamines
Allegra-D*, Clarinex,
Clarinex-D, Xyzal
asthma-Beta agonists-
Foradil Arcapta, Perforomist, Serevent
Long-acting
Alupent*, Maxair Autohaler,
asthma-Beta agonists- albuterol sulfate,
ProAir HFA Proventil HFA, Ventolin HFA,
Short-acting metaproterenol
Xopenex
asthma-Leukotriene
Singulair (CT) Accolate, Zyflo
Modulators
Aerobid-M, Asmanex,
asthma-Steroid inhalants budesonide Flovent
Azmacort, Pulmicort, QVAR
Astelin, Astepro,
Beconase AQ, Flonase*,
azelastine, flunisolide, Nasacort AQ*, Nasarel*,
Nasal Products
fluticasone Nasonex, Omnaris,
Rhinocort AQ, Veramyst
Advair, Atrovent,
respiratory-other ipratropium/albuterol Combivent, Spiriva,
Symbicort
BASIC FormulAry (Cont.)
topical agents
antipyrine/benzocaine, Auralgan, Ciprodex, Cipro HC,
ears
ofloxacin Floxin otic*
Acular*, Acuvail, Alamast,
cromolyn, diclofenac, Alocril, Alomide, Bepreve,
eye-allergy
ketotifen fumarate Bromday, Elestat, Emadine,
Optivar*, Pataday, Patanol
acetazolamide, brimonidine, Alphagan-P, Azopt, Betimol,
dorzolamide, dorzolamide/ Betoptic S, Combigan,
eye-glaucoma
timolol, latanoprost, Cosopt*, Lumigan, Travatan,
levobunolol, timolol Travatan Z, Trusopt*, Xalatan*
Alrex, Lotemax, Natacyn,
ciprofloxacin, erythromycin,
eye-Miscellaneous Quixin, Vigamox, Voltaren*,
gentamicin
Zymar, Zymaxid
benzoyl peroxide, Benzaclin*, Benzamycin*,
Skin-acne
clindamycin, clindamycin Cleocin T*, Differin*,
(generics only)
phosphate-benzoyl peroxide Duac Gel, Retin A*
Aldara, Altabax, Bactroban,
Desonate Gel, Diprolene,
Diprolene AF, Elidel, Elocon,
Ertaczo, Eurax, Finacea,
Skin-all betamethasone,
Halonate, Lidoderm, Locoid
(generics only) mometasone
Lipocream, Lotrixone,
Mentax, Pramosone, Protopic,
Rosadan, Ulesfia, Venelex
Ointment, Veregen, Zoderm
Women’s Health
Beyaz, Estrostep Fe*,
Generess Fe, Lo LoestrinlFe,
Loestrin 24 Fe, Loestrin Fe*,
Contraceptives All oral generics Loseasonique, Mircette*,
Ortho Evra, Ortho Tri-Cyclen
Lo, Seasonale*, Seasonique,
Yasmin*, Yaz
Combination Hormone Activella, Climara Pro,
estradiol/norethindrone Premphase, Prempro
replacement therapy CombiPatch, Femhrt, Prefest
Alora, Climara, Enjuvia, Esclim,
Hormone replacement Cenestin, Vagifem, Estrace, Estraderm, Estring,
estradiol
therapy Vivelle-Dot Estrogel Pump, Femring,
Menest, Premarin, Prometrium
osteoporosis - Actonel, Boniva, Fosamax*,
alendronate
Calcium regulators Fosamax Plus D, Miacalcin
osteoporosis - Hormone
Evista
receptor Modulators
Vaginal Products clindamycin, metronidazole, Clindesse, Gynazole-1,
(generics only) terconazole Metrogel Vaginal, Terazol*
Miscellaneous agents
antiemetics granisetron (QL), Anzemet, Emend, Kytril*,
ondansetron (QL) Sancuso pads, Zofran*
gout allopurinol, colchicine Uloric, Zyloprim*
azathioprine, cyclosporine,
Cellcept*, Myfortic*, Prograf*,
immunosuppressive agents mycophenolate mofetil,
Rapamune, Simulect, Zenapax
tacrolimus
Brand-names are the property of their respective manufacturers. DL 01 1498 1011
For information on drugs not listed, call Catalyst Rx at 1-877-629-3118.
For information on your prescription benefit program, please visit www.qualchoice.com.