USH&L MANAGED FORMULARY Formulary Alternatives for Common Non-Covered Drugs POSSIBLE THERAPEUTIC ALTERNATIVES
The Formulary Alternatives list represents possible options to Not Covered drugs. These alternative medications can generally be prescribedwithout approval from the plan and can be dispensed with normal copayments for members. Therapeutic alternatives may represent a differentdrug class, contain different ingredients, or may be available in different strengths or dosage forms than the prescribed branded products.
Some medications are produced by more than one pharmaceutical manufacturer under different brand names. However, in some cases, onlyone of the brand-name products is listed in the USH&L Managed Formulary. The other brands are considered Not Covered. Providers areencouraged to select the preferred product.
Listed below are examples of therapeutic alternatives a patient’s physician may consider when determining appropriate treatment for the patient. USH&L Managed Formulary Alternatives for Common Non-Covered Drugs Not Covered Formulary Alternative Not Covered Formulary Alternative
etc.), Benicar*, or Micardis* PLUSNorvasc(g)
Cardizem(g), Cardizem CD(g),Cardizem SR(g)
Lodine(g), Mobic(g), Motrin(g),Naprosyn(g), Voltaren(g), etc.
Naprosyn(g), Voltaren(g), etc. plusCytotec(g)
Climara(g), Vivelle-DOT, orEstraderm plus a progestin
Prozac(g), Wellbutrin, SR, XL(g);Lexapro*, Effexor XR*
(g) Use generic equivalent<s> Specialty Drug* Prior Authorization or Step Therapy may be required. Not Covered Formulary Alternative Not Covered Formulary Alternative
Ultra OTC, Monistat-Derm(g),Nizoral cream, Spectazole (g)
Climara(g), Estrace(g), Ogen(g),Vivelle-DOT, Estraderm
Climara(g), Estrace(g), Ogen(g),Vivelle-DOT, Estraderm
COMMIT LOZENGE OTC Generic nicotine lozenge, patch or
Lotrel(g), Generic ACE Inhibitor(lisinopril, benazepril, etc.),Benicar*, or Micardis* PLUSNorvasc(g)
DONNATAL EXTENTABS Bentyl(g), Donnatal(g), Robinul(g)
Topical OTC analgesic balms, i.e. trolamine salicylate
Ambien(g), Halcion(g), Prosom(g),Restoril(g), Sonata(g)
(g) Use generic equivalent<s> Specialty Drug* Prior Authorization or Step Therapy may be required. Not Covered Formulary Alternative Not Covered Formulary Alternative
Lotrimin(g), Monistat-Derm(g),Nizoral cr(g), Spectazole(g)
Androxy(g), Depo-Testosterone(g),Oxandrin(g), Androderm, Delatestryl
NAPRELAN 375MG Mobic(g), Motrin(g), Naprosyn,
Long-acting nitrate, plus abeta-blocker or calcium channelblocker
Ceclor(g), Ceftin(g), Duricef(g),Keflex(g), Omnicef(g)
RHINOCORT AQUA Flonase(g), Nasalide(g), Nasarel(g),
Ambien(g), Halcion(g), Prosom(g),Restoril(g)
Prempro/Premphase, or Estradiolplus progestin
Clozaril(g), Risperdal(g), Abilify,Geodon, Zyprexa, Seroquel(IR)
(g) Use generic equivalent<s> Specialty Drug* Prior Authorization or Step Therapy may be required. Not Covered Formulary Alternative Not Covered Formulary Alternative
Ceclor(g), Ceftin(g), Duricef(g),Keflex(g), Omnicef(g)
Adderall(g), Focalin(g), Ritalin(g),Adderall XR, Concerta, MetadateCD
Androxy(g), Depo-testosterone(g),Oxandrin(g), Androderm, Delatestryl
SULAR 8.5, 17, 25.5, Sular(g), Cardene(g), Norvasc(g),34mg
tabs, Omeprazole (RX) caps; plusNaprosyn(g)
Prilosec OTC*, Omeprazole DRTabs, Omeprazole (Rx) Caps
Individual agents: Cleocin topical(g)and Retin-A(g)
Lortab(g), Tylenol with Codeine(g),Vicodin(g),
(g) Use generic equivalent<s> Specialty Drug* Prior Authorization or Step Therapy may be required. Not Covered Formulary Alternative Not Covered Formulary Alternative
Diprolene(g), Psorcon(g),Temovate(g), Ultravate(g)
Flonase(g), Nasalide(g),Nasarel(g), Nasacort AQ*
Elocon(g), Locoid(g), Synalarsolution(g), Capex
Topical OTC analgesic balms, i.e. trolamine salicylate
(g) Use generic equivalent<s> Specialty Drug* Prior Authorization or Step Therapy may be required.
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1. When you have headaches, how often is the pain severe? 2. How often do headaches limit your ability to do usual daily activities including household work, 3. When you have a headache, how often do you wish you could lie down? 4. In the past 4 weeks, how often have you felt too tired to do work or daily activities because of 5. In the past 4 weeks, how often have you felt fed up or irrit