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EmblemHealth Pharmacy Benefit Services
2013 Select Formulary Summary
(Effective July 1, 2013)
This is a list of the most commonly prescribed preferred drugs for members with the Select Formulary. Make sure to ask your doctor to prescribe generic drugs whenever appropriate; this may lower NOTE: Not all drugs listed are covered by all pharmacy benefit programs, so coverage is not guaranteed. Check your benefit materials for the copay and any other responsibilities you may have under your pharmacy benefit. For additional questions about your prescription drug coverage, please call the phone number on the back of your ID card.
chlorthalidone
diflunisal
flunisolide (QLL)
abacavir
bacitracin
chlorzoxazone
fluocinolone acetonide
acarbose
bacitracin-polymyxin
cholestyramine
dihydroergotamine nasal
fluocinonide
ipratropium bromide (QLL)
acebutolol hcl
baclofen
choline mag trisalicylate
flucytosine
ipratropium-albuterol
acetaminophen-codeine
fluorometholone
balsalazide disodium
ciclopirox
diltiazem/er
fluorouracil
irbesartan/hctz (QLL)
acetazolamide
cilostazol
diltiazem 24hr er
fluoxetine hcl (QLL)
cimetidine
fluphenazine hcl (QLL)
isoniazid
benazepril hcl
diphenhydramine hcl
flurazepam hcl
isosorbide
benazepril-hctz
ciprofloxacin er
diphenoxylate-atropine
flurbiprofen
isosorbide dinitrate
ciprofloxacin hcl
dipyridamole
fluticasone propionate
isotretinoin
acyclovir
benzonatate
ciprofloxacin otic
disulfiram
itraconazole
adapalene
benzoyl peroxide
citalopram (QLL)
divalproex sodium/er
fluvastatin (QLL)
benztropine mesylate
citalopram hbr (QLL)
donepezil hcl
fluvoxamine maleate/ER
betamethasone
clarithromycin/er
dorzolamide hcl (QLL)
dipropionate
dorzolamide-timolol
folic acid
betamethasone valerate
clindamycin hcl
doxazosin mesylate
albuterol sulfate (QLL)
bethanechol chloride
clindamycin phosphate
doxepin hcl (QLL)
jevantique
alclometasone
bicalutamide
clobetasol propionate
doxycycline hyclate
dipropionate
bisoprolol fumarate
clomiphene citrate (PA)
doxycycline monohydrate
fosinopril sodium
alendronate sodium (QLL)
bisoprolol-hctz
clomipramine hcl
dronabinol
fosinopril- hctz
jolivette
allopurinol
bp-wash 10% liquid
clonazepam
junel/fe
bp-wash 8% treatment pk
clonidine
brimonidine tartrate
clonidine hcl
econazole nitrate
bromocriptine mesylate
clopidogrel (QLL)
alprazolam
budesonide (QLL)
clorazepate dipotassium
furosemide
alprazolam er
bumetanide
clotrimazole
alprazolam xr
buprenorphine/nalox (QLL)
clotrimazole-
amantadine
bupropion hcl
betamethasone
kelnor 1-35
enalapril maleate
gabapentin
amethia/lo
bupropion hcl sr
clozapine/ODT
ketoconazole
enalapril- hctz
galantamine hbr
amiloride hcl
bupropion xl (QLL)
ketoprofen
gemfibrozil
amiodarone hcl
buspirone hcl
colestipol hcl
ketorolac tromethamine
endocet (QLL)
gentamicin sulfate (PA)
amitriptyline hcl
butalbital compound-
enoxaparin sodium (PA)
amlodipine-atorvastatin
enpresse
glimepiride
amlodipine besylate (QLL)
butalbital-aspirin-caffeine
entacapone
glipizide/er
amlodipine-benazepril
butorphanol tartrate (QLL)
glipizide-metformin
glyburide
amoxicillin
epinephrine auto inject
glyburide micronized
labetalol hcl
amoxicillin- clavulanate
glyburide-metformin hcl
lactulose
amoxicillin-clavulanate er
calcipotriene
granisetron hcl (QLL)
lamivudine
amphetamine salt combo
calcitonin nasal spray
eplerenone
griseofulvin
lamivudine-zidovudine
eprosartan mesylate
ultramicrosize
lamotrigine/ER
anagrelide hcl
cromolyn sodium (QLL)
calcitriol
guaifenesin-codeine
anastrozole
cryselle
calcium acetate
guanfacine hcl
lansoprazole (QLL)
cyclobenzaprine hcl
erythromycin
antipyrine-benzocaine
cyclopentolate hcl
erythromycin-benz
anucort-hc
peroxide
leflunomide (QLL)
cyproheptadine hcl
candesartan
escitlopram
aranelle
halobetasol propionate
candesartan-hctz
estazolam
arbinoxa
haloperidol
captopril
leucovorin calcium (PA)
heparin sodium (PA)
captopril- hctz
estradiol (QLL)
leuprolide acetate (PA)
carbamazepine
estradiol/noreth acetate
levalbuterol solution
hydrochlorothiazide
carbidopa-levodopa
hydrocodone bit-ibuprofen
carbidopa-levodopa-
methyltestosterone
levetiracetam
hydrocodone-acetamin
entacapone
desipramine hcl
estropipate
levetiracetam er
atenolol
carisoprodol (QLL)
desloratadine/ODT
etidronate disodium
levobunolol hcl
atenolol-chlorthalidone
hydrocortisone
cartia xt (QLL)
desmopressin acetate
etodolac
levocarnitine (PA)
atorvastatin calcium (QLL)
hydrocortisone acetate
carvedilol
desonide
levocetirizine
hydrocortisone butyrate
cefaclor er
desoximetasone
dihydrochloride
atropine sulfate
hydrocortisone valerate
cefadroxil
levora-28
hydromorphone hcl (QLL)
cefdinir
dexamethasone
levothyroxine sodium
hydroxychloroquine
cefpodoxime proxetil
dexamethasone sod phos
famciclovir
cefprozil
lidocaine hcl (PA)
famotidine
hydroxyurea
cefuroxime
dexmethylphenidate hcl
lidocaine-prilocaine
felbamate
hydroxyzine
dextroamphetamine
lisinopril
felodipine er (QLL)
hyoscyamine sulfate
lisinopril- hctz
fenofibrate
cephalexin
dextroamphet-
lithium carbonate
fentanyl
amphetamine
loperamide
fentanyl citrate loz (QLL)
cevimeline
diazepam (QLL)
ibandronate (QLL)
lorazepam (QLL)
finasteride
diclofenac/misoprostol
ibuprofen
losartan potassium (QLL)
azathioprine
flecainide acetate
chlordiazepoxide hcl
diclofenac potassium
imipramine hcl
losartan- hctz
azithromycin
chlordiazepoxide-
diclofenac sodium
lovastatin (QLL)
clidinium
dicloxacillin sodium
indapamide
low-ogestrel
fluconazole (QLL)
chlorpromazine hcl
dicyclomine hcl
indomethacin
fludrocortisone acetate
EmblemHealth Pharmacy Benefit Services
2013 Select Formulary Summary
nisoldipine
pindolol
nitrofurantoin
pioglitazone (QLL)
timolol maleate
zaleplon (QLL)
nitrofurantoin mono-
pioglitazone-glimepiride
tinidazole
zamicet (QLL)
pioglitazone-metformin
reprexain
tizanidine hcl
mafenide acetate
nitroglycerin
zenchent
meclizine hcl
nitroglycerin patch
piroxicam
tobramycin sulfate
zidovudine
medroxyprogesterone
podofilox
tobramycin-
ziprasidone
acetate (PA/QLL)
nizatidine
polymyxin b sul-
ribapak (PA)
dexamethasone
zolmitriptan/ODT (QLL)
mefloquine hcl
trimethoprim
rifampin
topiramate
zolpidem tartrate (QLL)
megestrol acetate
tolterodine
zonisamide
meloxicam (QLL)
potassium chloride (QLL)
risperidone (QLL)
torsemide
zovia 1-35e
mercaptopurine
potassium citrate
rivastigmine
tramadol hcl
zovia 1-50e
metaproterenol sulfate
norethindrone acetate
rizatriptan (QLL)
tramadol hcl-acetamin
pramipexole
ropinirole hcl/ER
metaxalone
nortriptyline hcl (QLL)
dihydrochloride
roxicet (QLL)
trandolapril
metformin hcl
tranexemic acid
metformin hcl er (QLL)
novarel (PA)
pravastatin sodium (QLL)
tranylcypromine sulfate
methadone hcl (QLL)
prazosin hcl
salsalate
travoprost
methimazole
selenium sulfide
trazodone hcl
methocarbamol
tretinoin
methotrexate (PA)
prednisolone
methyldopa
prednisolone acetate
triamcinolone acetonide
methylphenidate er/sr/cd
prednisolone sod
sertraline hcl (QLL)
methylphenidate hcl (QLL)
phosphate
silver sulfadiazine
triamterene-hctz
methylprednisolone
nystatin
prednisone
triazolam
metoclopramide hcl
nystatin-triamcinolone
simvastatin (QLL)
trifluoperazine hcl
metolazone
sodium fluoride
trifluridine
metoprolol succinate
sodium sulfacetamide-
trihexyphenidyl hcl
metoprolol tartrate
tri-legest fe
metoprolol- hctz
ofloxacin
previfem
trilyte with flavor packets
ogestrel
trimethoprim
metronidazole
olanzapine/odt
primidone
spinosad
trinessa
microgestin
olanzapine-fluoxetine
probenecid
tri-previfem
microgestin fe
omeprazole (QLL)
prochlorperazine maleate
spironolactone
tri-sprintec
minocycline hcl
omeprazole-sodium
proctosol-hc
spironolactone-hctz
trivora-28
minoxidil
bicarbonate
proctozone-hc
sprintec
trospium/ER
mirtazapine
ondansetron hcl (QLL)
misoprostol
ondansetron odt (QLL)
modafanil
progesterone in oil (PA)
moexipril hcl
orphenadrine citrate
progesterone caps
moexipril- hctz
sucralfate
ursodiol
mometasone furoate
promethazine hcl
sulfacetamide sodium
mononessa
oxaprozin
promethazine vc-codeine
sulfamethoxazole-TMP
montelukast (QLL)
oxazepam
promethazine-codeine
sulfasalazine
valacyclovir
morphine sulfate (QLL)
oxcarbazepine
promethazine-dm
sulindac
valproic acid
oxybutynin chloride/er
promethegan
sumatriptan (QLL)
valsartan-hctz (QLL)
mupirocin
oxycodone hcl (QLL)
propafenone hcl
vancomycin caps
oxycodone-acetamin
propranolol hcl
vandazole
propylthiouracil
oxymorphone/ER (QLL)
venlafaxine hcl/er
nabumetone
naltrexone hcl
verapamil
pantoprazole sodium (QLL)
pyridostigmine bromide
tamoxifen citrate
veripred 20
naproxen
paroxetine hcl
tamsulosin hcl
naproxen sodium
peg 3350-electrolyte
naratriptan hcl (QLL)
nateglinide
quasense
penicillin v potassium
quetiapine
temazepam
nefazodone hcl
pentoxifylline
quinapril hcl
terazosin hcl
neomycin-bacitracin-
permethrin
quinapril- hctz
terbinafine hcl
polymyxin
perphenazine
terconazole
neomycin-polymyxin-
phenazopyridine hcl
tetracycline hcl
dexameth
phenobarbital
ramipril
warfarin sodium
neomycin-polymyxin-hc
phentermine hcl (PA)
theophylline
nevirapine
ranitidine hcl
theophylline anhydrous
nifediac cc (QLL)
phenytoin sodium
thioridazine hcl
nifedical xl (QLL)
extended
thiothixene
nifedipine er (QLL)
pilocarpine hcl
reclipsen
tiagabine hcl
See Key on next page.
EmblemHealth Pharmacy Benefit Services
2013 Select Formulary Summary
Key:
Capital letters
Lowercase bold letters Generic drug (PA) Prior Authorization – Prescriber needs to obtain EmblemHealth approval for coverage of this drug (as outlined in the member’s plan).
Quantity Level Limit – Quantities dispensed may be limited.
Step Therapy – Drug is part of a program where drug options are organized in a series of steps (as outlined in the member’s plan).
For the member:
Generic medications contain the same active ingredients as the corresponding brand name medications, but may differ in color or shape. They have been FDA approved For the physician:
Please prescribe preferred products and allow generic substitutions when medically appropriate.
THIS FORMULARY SUMMARY IS EFFECTIVE JANUARY 1, 1013 TO DECEMBER 31, 2013, AND IS SUBJECT TO CHANGE.
You can get more information about our formularies and our Pharmacy Services program at www.emblemhealth.com.
Formulary Disclaimer
Please refer to your benefit materials for specific coverage information. Your benefit design determines what is covered for you and what your copayment will be. The presence of a medication on
this formulary does not guarantee that you as a plan member will be covered for that drug. Additionally, these medications may be subject to Prior Authorization. Coverage for some drugs may be
limited to specific dosage forms and/or strengths. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EmblemHealth’s Pharmacy Benefit
Services. As new generics become available, the corresponding brand name drug will no longer be considered a preferred agent.
Group Health Incorporated (GHI), GHI HMO Select, Inc. (GHI HMO), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies EGH_MB_OTH_12756_ 2013_SELECT_Formualry_WEB 7/13

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