County Health Plan

ANTIMICROBIALS Antibacterials 1 amoxicillin* 1 ampicillin* 1 penicillin VK* 1 erythromycin* 1 E.E.S.* 1 tetracycline* 1 Vibramycin/Vibratabs* 1 SMZ/TMP DS* 2 Keflex* (not 750mg) 2 Cleocin* 2 Flagyl* 2 Macrodantin* 2 Minocin 50*, 100mg* 2 Macrobid* 2 Ceclor* 2 Cipro* 2 Zithromax 250mg and 500mg* 2 Zithromax Z Pak 250mg* 2 Zithromax Tri-Pak 500mg* 2 Augmentin 500mg and 875mg* Antifungals 1 Mycostatin* 1 Nizoral 200mg* 1 Diflucan 100mg* 2 Diflucan 150mg* Antivirals 1 Zovirax* NSAIDS 1 OTC APAP/Ibuprofen/Naproxen 1 ibuprofen* 1 Indocin* 1 Naprosyn* 1 Lodine* 1 Clinoril* 1 Anaprox/Anaprox DS* 1 Feldene* 1 Orudis* 1 Indocin SR* 1 Voltaren* (not gel) 1 Relafen* ORAL ANTIHYPERGLYCEMICS 1 Diabinese* 1 Tolinase* 1 Glucotrol* 1 Orinase* 1 Micronase* 1 Glucophage* RESPIRATORY Antihistamines 1 Benadryl* 1 Phenergan* 1 Tavist 2.68 mg* 1 Claritin OTC*# 1 Atarax/Vistaril* Antihist/Deconges 1 Claritin-D OTC*# INHALED AGENTS Miscellaneous 1 Atrovent solution 1 Intal solution* Sympathomimetics 1 Alupent soln/tablet 1 Proventil nebulizer* soln 1 ProAir HFA ANTILIPEMICS 1 Questran* 1 Atromid-S* 2 Lopid* 2 Zocor* HORMONE REPLACEMENT 1 Estrace* 1 Provera* 1 Ogen* DIABETIC AGENTS 1 Humalog Insulins 1 Humulin Insulins 1 Novolin Insulins 1 Novolog Insulins

County Health Plan Drug Formulary Selected Drug Category Reference, December 2010
1. Consider for 1 line therapy
GASTROINTESTINAL AGENTS 1 OTC imodium AD, pepto bismol, kaopectate 1 Tagamet* 1 Reglan* 1 Zantac* 1 Carafate* 1 Omeprazole 20mg OTIC PREPARATIONS 1 Domeboro otic drops* 1 Vosol otic, Vosol HC* 1 Cortomycin otic soln* 2 Cortisporin ear susp* OPHTHALMIC PREPARATIONS 1 Bacitracin* 1 Betagan* 1 Bleph-10* 1 Cortisporin* 2 Garamycin* 2 Neosporin* ACE INHIBITORS 1 Capoten* 1 Vasotec* 1 Zestril/Prinivil* 1 Accupril* BETA BLOCKERS 1 Coreg* (not CR) 1 Corgard* 1 Inderal* 1 Lopressor* 1 Sectral* 1 Tenormin* 1 Visken* CA++ BLOCKERS 1 Calan* 1 Cardizem* 1 Calan SR* 1 Dilacor XR* 1 Cardizem SR* 1 Cardizem CD* 1 Adalat CC* 1 Cardene* 1 Norvasc* OTHER HYPOTENSIVES 1 Aldomet* 1 Apresoline* 1 Minipress* 1 Hytrin* 1 Cardura* 1 Tenex* 2 Loniten* DIURETICS 1 Hygroton* 1 Hydro-Diuril* 1 Lasix* 1 Moduretic* 1 Maxzide* 1 Aldactone (25mg)* 1 Aldactazide* 1 Dyazide* 1 Bumex* 1 Lozol* 2 Demadex* BEHAVIORAL HEALTH See note in next column ANTICONVULSANTS 1 Dilantin* 1 Phenobarbital 1 Depakene* 1 Depakote* (not ER) 2 Tegretol* 2 Mysoline* 2 Klonopin*# 2 Neurontin*
st

2. Alternative therapy

* generic

BEHAVIORAL HEALTH Note: For Plan A, behavioral health meds are covered through MiHealth (First Health). For Plan B, behavioral health meds are covered through HealthPlus, as listed on the CHP Formulary. SEDATIVES/ANTI-ANXIETY 1 Dalmane*# 1 Restoril* (15mg and 30mg only)# 1 Ativan*# 1 Librium*# 2 Serax*# 2 Valium*# 2 Xanax* (not XR)# 2 Tranxene*# ANTIPSYCHOTICS 1 Haldol* 1 Prolixin* 1 Navane* 1 Thorazine* 1 Mellaril* 2 Stelazine* 2 Trilafon* ANTIDEPRESSANTS 1 Elavil* 1 Tofranil* 1 Sinequan* 1 Norpramin* 1 Desyrel* 1 Wellbutrin* 2 Pamelor* 2 Anafranil* 2 Wellbutrin SR 100mg* 2 Wellbutrin SR 150mg * 2 Wellbutrin SR 200mg* SSRIs 1 Prozac* 2 Paxil* 2 Zoloft*

Medications that are NOT covered by CHP include: Contraceptive agents, fertility agents, medications for weight loss or cosmetic purposes, smoking cessation, and brand products when a generic is available. # Not covered for Plan B This is not a complete list but a summary of select categories. If you need a copy of the complete County Health Plan Drug Formulary, please call (800) 332-9161.

This program is administered by HealthPlus Options. Questions should be directed to (800) 332-9161.