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Author: Admin | 2025-04-28
Similar effectiveness, quality and safety. When pharmacies fill prescriptions with preferred alternatives, the generic equivalents are dispensed, if available. Additional coverage requirements may apply for preferred alternatives, such as prior authorization. Drugs that won’t be covered Affected drug lists Common use or drug class Preferred alternatives Anucort-HC®, Anusol-HC®, Hemorrex-HC®, Proctocort® suppository All Topical anti-inflammatory Generic hydrocortisone suppository Ergomar® Clinical, Custom, Preferred Migraine Generic dihydroergotamine injection, nasal spray (Migranal®); ergotamine-caffeine Generic metronidazole capsule All Antibacterial Generic metronidazole tablet Levemir® Clinical, Custom, Custom Select Long-acting insulin Lantus®, Toujeo® Mar-Cof BP® Clinical, Custom, Preferred Cough and cold Generic guaifenesin/codeine syrup Renacidin® All Urinary tract irrigant Discuss treatment options with members. Restasis MultiDose® All Dry eye disease Generic cyclosporin ophthalmic emulsion (Restasis®) Rydex® Clinical, Custom, Preferred Cough and cold Generic brompheniramine/ pseudoephedrine/ dextromethorphan syrup Vyvanse® (brand) Custom Select, Preferred CNS stimulant, ADHD Generic methylphenidate (such as Ritalin® LA, Concerta®), generic dexmethylphenidate (such as Focalin® XR), generic amphetamine/ dextroamphetamine (such as Adderall® XR), lisdexamphetamine (Vyvanse®) Drugs that will have a higher copayment The brand-name drugs that will have a higher copayment are listed along with the covered preferred alternatives we suggest that have similar effectiveness, quality and safety. When pharmacies fill prescriptions with preferred alternatives, the generic equivalents are dispensed, if available. Additional coverage requirements may apply for preferred alternatives. Drugs that will have a higher copayment** Affected drug lists Common use or drug class Preferred alternatives Albuterol nebulization solution (brand) All Bronchospasm Generic albuterol sulfate nebulization solution Apexicon E® Clinical, Custom, Preferred Topical anti-inflammatory
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