ARE YOUR PRESCRIPTION MEDICINES COVERED BY YOUR HEALTH PLAN? - MYPRIME
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Are your prescription medicines
covered by your health plan?
If you use a non‑covered drug, you may
pay the full price.
Talk to your doctor about
switching to one of the
alternative drugs listed
on the formulary.
SourceRx 1.0 is your formulary — a list of covered drugs
Prime Therapeutics (Prime) is trusted by your employer or health plan to help you get the
medicine you need to feel better and live well. Our pharmacy experts work hard to make
medicine more affordable for everyone.
SourceRx 1.0 is the list of drugs covered by your health plan. It was designed to push back against
today’s high costs for medicine. SourceRx 1.0 works by offering alternatives to more expensive
drugs. This helps people get the right medicine at the best cost.
Some drugs will not be listed on the SourceRx 1.0 formulary
If a drug is not on the formulary, it will not be covered by your health plan. This publication lists
many of the non‑covered drugs along with alternative drugs that are covered. The list is divided
into four sections:
1 Non‑covered with preferred alternatives
Alternatives to non‑covered drugs — potential options at better costs.
2 Standard non‑covered drugs
Lists reasons why these drugs are not covered.
4 Non‑covered due to high costs
Safe, effective alternatives are available at lower costs.
Additionally, some health plans or groups may choose not to cover drugs for the
following reasons:
3 Non‑covered with over‑the‑counter alternatives
For prescriptions drugs that have an effective medicine available from your pharmacy.
The formulary guide represents changes (non‑covered and covered alternatives) that may not be effective until January 1, 2020.
The formulary is reviewed quarterly and changes are made to ensure clinical appropriateness of the formulary while giving
members access to lower cost alternatives. Notifications are sent out each quarter to affected members of new non‑covered drugs.1 Non‑covered with preferred alternatives
Generics and preferred Non‑preferred
Drug class Non‑covered brand alternatives brand alternatives
Acne and rosacea agents CLINDAGEL, CLINDAMYCIN GEL, azelaic acid gel, clindamycin gel,
FINACEA FOAM, RHOFADE clindamycin lotion, clindamycin
solution, metronidazole cream,
metronidazole gel, metronidazole
lotion, SOOLANTRA
Allergic reaction (anaphylaxis) AUVI-Q, EPINEPHRINE SOLUTION EPINEPHRINE SOLUTION AUTO-
therapy AUTO-INJECTOR (authorized generic INJECTOR (authorized generic of
of ADRENACLICK), EPIPEN-JR EPIPEN-JR), epinephrine solution auto-
injector (generic of EPIPEN), SYMJEPI
Antibiotic: SOLOSEC clindamycin vaginal cream,
bacterial vaginosis metronidazole tablet, metronidazole
vaginal gel
Anticoagulants SAVAYSA ELIQUIS, XARELTO PRADAXA
Antirheumatics RASUVO methotrexate injection, methotrexate
tablet, OTREXUP
Antivirals: VEMLIDY tenofovir disoproxil fumarate
hepatitis B agents
Antivirals: DAKLINZA, EPCLUSA, HARVONI, LEDIPASVIR/SOFOSBUVIR TABLET
hepatitis C agents TECHNIVIE, VIEKIRA PAK, ZEPATIER (authorized generic of HARVONI),
MAVYRET, SOFOSBUVIR/VELPATASVIR
TABLET (authorized generic of
EPCLUSA), SOVALDI, VOSEVI
Asthma: AEROSPAN, ALVESCO, ARMONAIR, ARNUITY, ASMANEX, FLOVENT, QVAR
inhaled steroids PULMICORT INHALER
Asthma: ALBUTEROL HFA (authorized generics PROAIR, PROAIR RESPICLICK, VENTOLIN
short-acting beta agonists of PROAIR, PROVENTIL and VENTOLIN),
LEVALBUTEROL HFA, PROVENTIL,
XOPENEX HFA
Asthma/COPD: AIRDUO, BEVESPI, fluticasone ADVAIR, ANORO, BREO, DULERA, COMBIVENT
combination agents propionate/salmeterol diskus, FLUTICASONE PROPIONATE/
UTIBRON, wixela SALMETEROL AEROSOL (authorized
generic of AIRDUO), STIOLTO,
SYMBICORT, TRELEGY
Asthma/COPD: PERFOROMIST NEBULIZATION BROVANA NEBULIZATION SOLUTION, ARCAPTA
long-acting beta agonists SOLUTION SEREVENT, STRIVERDI
Attention deficit hyperactivity ADZENYS ER SUSP, ADZENYS XR-ODT, ADDERALL XR, amphetamine/
disorder (ADHD) amphetamine/dextroamphetamine dextroamphetamine, CONCERTA,
ER, APTENSIO XR, COTEMPLA XR-ODT, dextroamphetamine solution,
DAYTRANA PATCH, DYANAVEL XR dextroamphetamine, methylphenidate,
SUSP, methylphenidate ER, MYDAYIS, VYVANSE
QUILLICHEW ER, QUILLIVANT XR SUSP
Biologic agents: SIMPONI HUMIRA, STELARA CIMZIA, XELJANZ
Inflammatory Bowel Disease
Biologic agents: SILIQ, SIMPONI, TALTZ COSENTYX, ENBREL, HUMIRA, OTEZLA,
plaque psoriasis and SKYRIZI, STELARA, TREMFYA
psoriatic arthritis
Biologic agents: KEVZARA, KINERET, OLUMIANT, ENBREL, HUMIRA ACTEMRA, CIMZIA
rheumatoid arthritis ORENCIA, SIMPONI, XELJANZ XR
Bladder incontinence darifenacin ER, GELNIQUE, TOVIAZ MYRBETRIQ, oxybutynin, oxybutynin ER,
solifenacin tablet, tolterodine,
tolterodine ER, trospium ER
2 continued1 Non‑covered with preferred alternatives (continued)
Generics and preferred Non‑preferred
Drug class Non‑covered brand alternatives brand alternatives
COPD: LONHALA, SEEBRI, TUDORZA, YUPELRI INCRUSE, SPIRIVA ATROVENT
inhaled anticholinerigics
Diabetes: SYMLINPEN OZEMPIC, TRULICITY, VICTOZA BYDUREON
amylin analogs
Diabetes: ALOGLIPTIN/METFORMIN, ALOGLIPTIN/ glipizide/metformin, glyburide/ QTERN, SEGLUROMET,
combination agents PIOGLITAZONE, JENTADUETO, metformint, GLYXAMBI, INVOKAMET, XIGDUO XR
JENTADUETO XR, KAZANO, OSENI, INVOKAMET XR, JANUMET, JANUMET
STEGLUJAN XR, KOMBIGLYZE XR, pioglitazone/
metformin, SYNJARDY, SYNJARDY XR
Diabetes: ALOGLIPTIN, NESINA, TRADJENTA JANUVIA, ONGLYZA
dipeptidyl peptidase (DPP-4)
inhibitors
Diabetes: ADLYXIN, BYETTA OZEMPIC, TRULICITY, VICTOZA BYDUREON
glucagon-like peptide-1 (glp-1)
agonists
Diabetes: Abbott (FreeStyle, Precision), Lifescan Bayer/Ascensia (Breeze, Contour)
glucose test strips (OneTouch), Roche (Accu-Chek), Nipro
(TRUtest, TRUEtrack)
Diabetes: SOLIQUA, XULTOPHY LANTUS, OZEMPIC, TOUJEO, TRESIBA,
injectable combination agents TRULICITY, VICTOZA
Diabetes: BASAGLAR, HUMULIN N HUMULIN R U-500, LANTUS, LEVEMIR,
intermediate and long-acting insulins NOVOLIN N, TOUJEO, TRESIBA
Diabetes: HUMALOG MIX, HUMULIN 70/30 NOVOLIN 70/30, NOVOLOG MIX
mixed insulins
Diabetes: ADMELOG, AFREZZA, APIDRA, FIASP, NOVOLIN R, NOVOLOG
short-acting insulins HUMALOG, HUMULIN R, INSULIN
LISPRO
Glaucoma: VYZULTA latanoprost solution
ophthalmic prostaglandins
Glaucoma: ALPHAGAN P, IOPIDINE SOLUTION apraclonidine solution, brimonidine
opthalmic alpha 2 agonists & solution, SIMBRINZA
combinations
Glaucoma: RHOPRESSA, ROCKLATAN latanoprost solution
ophthalmic rho kinase inhibitors
Gout COLCHICINE (authorized generic of MITIGARE
COLCRYS), COLCHICINE (authorized
generic of MITIGARE), COLCRYS
Growth hormones GENOTROPIN, HUMATROPE, NORDITROPIN
NUTROPIN AQ, OMNITROPE, SAIZEN,
SEROSTIM, ZOMACTON, ZORBTIVE
Hemophilia A JIVI ADVATE, ADYNOVATE, AFSTYLA,
ELOCTATE, NOVOEIGHT, NUWIQ,
RECOMBINATE, XYNTHA
Hereditary angioedema (HAE) agents TAKHZYRO HAEGARDA
High cholesterol: PRALUENT REPATHA
PCSK-9 inhibitors
3 continued1 Non‑covered with preferred alternatives (continued)
Generics and preferred Non‑preferred
Drug class Non‑covered brand alternatives brand alternatives
HIV DOVATO, PIFELTRO, SYMTUZA Talk to your doctor about clinically
appropriate alternatives. Examples of
covered alternatives include: BIKTARVY,
efavirenz, INTELENCE, GENVOYA,
nevirapine, STRIBILD.
Inflammatory bowel agents budesonide ER, DIPENTUM, GIAZO, APRISO, balsalazide capsule,
PENTASA budesonide capsule, DELZICOL,
mesalamine enema, mesalamine DR
tablet, sulfasalazine tablet
Laxatives: CLENPIQ, GOLYTELY, MOVIPREP, gavilyte-g solution, peg 3350/ SUPREP
bowel prep OSMOPREP TABLET, PLENVU, PREPOPIK electrolytes solution, peg-3350/nacl/
na bicarbonate/kcl solution
Laxatives: AMITIZA, LINZESS, MOTEGRITY, SYMPROIC, TRULANCE
CIC, IBS-C, OIC MOVANTIK, RELISTOR
Migraine products: AJOVY AIMOVIG, EMGALITY
CGRP inhibitors
Migraine products: DIHYDROERGOTAMINE NASAL dihydroergotamine injection solution
ergotamines (authorized generic of MIGRANAL),
MIGRANAL
Migraine products: ONZETRA XSAIL, ZEMBRACE eletriptan, rizatriptan, SUMATRIPTAN
triptans SYMTOUCH, ZOMIG NASAL SYRINGE, sumatriptan, zolmitriptan
Multiple sclerosis COPAXONE, EXTAVIA, glatopa AUBAGIO, AVONEX, BETASERON,
GILENYA, glatiramer (generic
COPAXONE by Mylan), MAVENCLAD,
MAYZENT, PLEGRIDY, REBIF, TECFIDERA
Ophthalmic: TOBREX OINTMENT BACITRACIN OINTMENT, erythromycin
anti-infectives ointment, moxifloxacin solution,
NATACYN, ofloxacin solution,
tobramycin solution
Ophthalmic: TOBRADEX OINTMENT neomycin/polymyxin/bacitracin/
steroid combinations hydrocortisone ointment, neomycin/
polymyxin/dexamethasone ointment,
neomycin/polymyxin/dexamethasone
suspension, tobramycin/
dexamethasone suspension
Ophthalmic: DUREZOL, FML FORTE, FML OINTMENT, ALREX, DEXAMETHASONE SOLUTION,
steroids INVELTYS, PRED FORTE, PRED MILD fluorometholone suspension,
LOTEMAX, prednisolone suspension
Osteoporosis agents FORTEO TYMLOS
Otic anti-infectives, steroids and CIPRO HC neomycin/polymyxin/hydrocortisone CIPRODEX
combinations solution, neomycin/polymyxin/
hydrocortisone suspension, ofloxacin
solution
Ovulatory stimulants GONAL-F, OVIDREL CHORIONIC GONADOTROPIN SOLUTION,
FOLLISTIM AQ, MENOPUR, NOVAREL,
PREGNYL
Pain: ARYMO ER, MORPHABOND ER, fentanyl patch, hydromorphone tablet, XTAMPZA ER
narcotic analgesics ROXYBOND morphine ER, oxycodone, OXYCONTIN
Pain: LYRICA CR gabapentin, pregabalin
nerve pain
Pancreatic enzymes PANCREAZE, PERTZYE, VIOKACE CREON, ZENPEP
4 continued1 Non‑covered with preferred alternatives (continued)
Generics and preferred Non‑preferred
Drug class Non‑covered brand alternatives brand alternatives
Sleep aid: ROZEREM eszopiclone, zaleplon, zolpidem,
melatonin receptor agonists zolpidem ER
Testosterone products ANDRODERM, AVEED, NATESTO NASAL, testosterone gel (generic ANDROGEL),
STRIANT, VOGELXO, XYOSTED testosterone solution, testosterone
cypionate solution, testosterone
enanthate solution, testosterone
topical solution (generic AXIRON)
Topical: LEVULAN diclofenac gel (3%), fluorouracil cream
actinic keratosis (AK) agents (5%)
Topical: DICLOFENAC PATCH (authorized generic diclofenac gel (1%), diclofenac
anti inflammatory agents of FLECTOR PATCH), FLECTOR PATCH, solution (1.5%)
PENNSAID SOLUTION (2%)
Topical: IMPOYZ CREAM clobetasol cream, clobetasol ointment,
corticosteroids hydrocortisone cream, triamcinolone
cream, triamcinolone ointment
Topical: FABIOR FOAM tazarotene cream, TAZORAC
retinoids
Topical: TACLONEX ENSTILAR
steroid combination agents
Vaginal: CLEOCIN SUPPOSITORY clindamycin vaginal cream, CLINDESSE CREAM,
anti-infectives metronidazole vaginal gel NUVESSA GEL
Vaginal: estradiol vaginal tablet, IMVEXXY, estradiol vaginal cream, ESTRING RING,
estrogen products yuvafem vaginal tablet PREMARIN CREAM, VAGIFEM TABLET FEMRING RING
Vaginal: CRINONE ENDOMETRIN
progestin products
Vitamins: NASCOBAL cyanocobalamin injection
vitamin b12
5 continued2 Standard non‑covered drugs
Other standard non‑covered
drugs strategies Rationale
Brand drug, when generic Brand name medications are not covered when a generic equivalent product is available. Please talk to your
equivalent is available doctor or pharmacist about a generic version of your medication.
(e.g., ACTOS, CRESTOR, NEXIUM)
Bulk powders Compound drugs are prepared by mixing ingredients together to create an individualized medication for a
(e.g., testosterone powder) specific patient. A common ingredient in compounds are bulk powders. Bulk powders are not approved by the
Food and Drug Administration (FDA). Drugs marketed without required FDA approval may not meet standards
for safety, effectiveness and quality. Therefore, bulk powders are not covered under your drug benefit. Please
talk to your doctor or pharmacist about FDA-approved drugs available for your condition.
Drugs deemed not safe and/or These medications have been determined not safe or not effective by Prime’s Pharmacy and Therapeutics
effective Committee. Please talk to your doctor or pharmacist about other medications available for your condition.
(e.g., carisoprodol, KETEK, ZYFLO)
General exclusions These products are no longer covered under your drug benefit. These products may not be covered because
they are not appropriate for retail use, used for cosmetic purposes, not available as a prescription, or require
healthcare administration. However, these products may be available over-the-counter or through your medical
benefit. Please talk to your doctor or pharmacist about other medications available for your condition.
Institutional packs These medications are no longer covered through your drug benefit because it is packaged for use or
redistribution by an institution (e.g. hospital). Institutional packs are not intended for use or sale outside of an
institution. Please talk to your doctor or pharmacist about a version of your medication that is packaged for use
outside of an institution.
Non‑FDA approved medications These medications are no longer covered under your drug benefit because they are not approved as a drug by
the Food and Drug Administration (FDA). Medications marketed without required FDA approval may not meet
standards for safety, effectiveness and quality. Please talk to your doctor or pharmacist about FDA-approved
medications available for your condition.
Repackaged medications Repackaged products are not covered. Please talk to your pharmacist about a version of your medication that is
not repackaged.
6 continued3 Non‑covered with over‑the‑counter alternatives
Generics and preferred Non‑preferred
Drug class Non‑covered brand alternatives brand alternatives
Acne agents: adapalene cream, adapalene gel, Talk to your pharmacist or doctor about
retinoids and retinoid‑like agents ADAPALENE LOTION, ADAPALENE over-the-counter options. The following
SOLUTION, DIFFERIN LOTION prescription alternatives are available:
tretinoin cream, tretinoin gel.
Antihistamines cetirizine solution, CLARINEX SYRUP, Talk to your pharmacist or doctor about
desloratadine tablet, levocetirizine over-the-counter options.
solution, levocetirizine tablet
Dry eyes CEQUA, RESTASIS, XIIDRA Talk to your pharmacist or doctor about LACRISERT
over-the-counter options.
Fish oil omega-3-acid ethyl esters capsule, Talk to your pharmacist or doctor about
triklo capsule over-the-counter options. The following
prescription alternative is available:
VASCEPA.
Nasal steroids BECONASE AQ, budesonide nasal, Talk to your pharmacist or doctor about
FLUNISOLIDE NASAL, mometasone over-the-counter options.
nasal, OMNARIS, QNASL, triamcinolone
nasal, XHANCE, ZETONNA
Ophthalmic antiallergic agents ALOCRIL, ALOMIDE, BEPREVE, Talk to your pharmacist or doctor about
EMADINE, epinastine solution, over-the-counter options. The following
LASTACAFT, olopatadine solution prescription alternative are available:
(0.2%), PAZEO azelastine hcl solution, olopatadine hcl
solution (0.1%).
Topical: acyclovir ointment, DENAVIR, XERESE, Talk to your pharmacist or doctor about
antivirals ZOVIRAX over-the-counter options.
Ulcer drugs: CIMETIDINE SOLUTION, cimetidine Talk to your pharmacist or doctor about
H2 antagonists tablet, famotidine suspension, over-the-counter options. The following
famotidine tablet (20 mg), nizatidine prescription alternatives are available:
capsule, NIZATIDINE SOLUTION, famotidine tablet (40 mg), ranitidine
ranitidine capsule, ranitidine tablet syrup, ranitidine tablet (300 mg).
(150 mg)
Ulcer drugs: ACIPHEX, DEXILANT, esomeprazole, Talk to your pharmacist or doctor about
proton pump inhibitors lansoprazole, PRILOSEC POWDER over-the-counter options. The following
PACKET, PROTONIX POWDER PACKET, prescription alternatives are available:
rabeprazole NEXIUM POWDER PACKET, omeprazole
capsule, pantoprazole tablet.
7 continued4 Non‑covered due to high costs
Generics and preferred Non‑preferred
Drug class Non‑covered brand alternatives brand alternatives
Acne agents: ABSORICA, adapalene/benzoyl amnesteem capsule, claravis capsule,
retinoids and retinoid-like agents peroxide gel, ALTRENO, EPIDUO FORTE, myorisan capsule, tretinoin cream,
RETIN-A MICRO GEL, TRETIN-X CREAM, tretinoin gel
tretinoin microsphere gel
Acne and rosacea agents: ACANYA, ACZONE, AKTIPAK, AZELEX, azelaic acid gel, clindamycin gel, MIRVASO
topical antibacterials and clindamycin foam, clindamycin/ clindamycin lotion, clindamycin
combinations tretinoin gel, dapsone gel, solution, clindamycin/benzoyl
erythromycin/benzoyl peroxide gel, peroxide gel, metronidazole cream,
NORITATE CREAM, ONEXTON, VELTIN metronidazole gel, metronidazole
lotion, SOOLANTRA
Agents for painful intercourse INTRAROSA, OSPHENA estradiol vaginal cream, ESTRING RING,
PREMARIN CREAM, VAGIFEM TABLET FEMRING RING,
Alzheimer's agents memantine ER capsule, NAMENDA XR, donepezil, memantine tablet,
NAMZARIC memantine solution
Antibiotics: ARESTIN, DORYX MPC, MINOLIRA, doxycycline hyclate, doxycycline
tetracyclines ORACEA, SEYSARA, TARGADOX, monohydrate, minocycline
VIBRAMYCIN SYRUP, XIMINO
Anticonvulsants BRIVIACT, GRALISE, HORIZANT, clobazam tablet, gabapentin,
OXTELLAR XR, SYMPAZAN lamotrigine, levetiracetam, LYRICA,
oxcarbazepine, topiramate tablet
Antidepressants APLENZIN, FORFIVO XL, KHEDEZLA bupropion SR, bupropion XL,
desvenlafaxine ER, duloxetine,
venlafaxine, venlafaxine ER
Anti-nausea and vomiting agents BONJESTA TABLET CR, DICLEGIS Talk to your pharmacist or doctor
TABLET ENTERIC COATED, doxylamine/ about over-the-counter options.
pyridoxine tablet
SYNDROS dronabinol capsule
Antirheumatics XATMEP methotrexate injection, methotrexate
tablet, OTREXUP
BPH/enlarged prostate CARDURA XL, silodosin capsule alfuzosin ER, tamsulosin
Corticosteroids DXEVO, EMFLAZA, MILLIPRED, dexamethasone, hydrocortisone,
prednisolone ODT, RAYOS, ZODEX methylprednisolone therapy pack,
prednisolone solution, prednisone
Diabetes: metformin ER modified release metformin, metformin ER
biguanides (generic GLUMETZA), metformin ER (generic GLUCOPHAGE XR)
osmotic (generic FORTAMET),
RIOMET SOLUTION
Diabetes: AVANDIA pioglitazone tablet
thiazolidinediones (TZD)
Excessive sweating QBREXZA PAD Talk to your pharmacist or doctor about
over-the-counter options.
Glaucoma: BETIMOL, BETOPTIC-S, COMBIGAN, betaxolol solution, carteolol solution,
ophthalmic beta-blockers and COSOPT PF, ISTALOL, TIMOPTIC dorzolamide solution, dorzolamide/
combinations OCUDOSE timolol solution, levobunolol solution,
timolol solution, timolol gel
Glaucoma: LUMIGAN, RESCULA, TRAVATAN Z, latanoprost solution
ophthalmic prostaglandins XELPROS, ZIOPTAN
Glaucoma: AZOPT dorzolamide solution
ophthalmic carbonic anhydrase
inhibitors
8 continued4 Non‑covered due to high costs (continued)
Generics and preferred Non‑preferred
Drug class Non‑covered brand alternatives brand alternatives
Gout ULORIC allopurinol, probenecid/colchicine
High blood pressure: BYSTOLIC, DUTOPROL, HEMANGEOL atenolol, bisoprolol, carvedilol,
beta blockers SOLUTION, INDERAL XL, INNOPRAN XL, metoprolol, PROPRANOLOL SOLUTION,
KAPSPARGO, SOTYLIZE SOLUTION propranolol tablet
High blood pressure: aliskiren tablet, TEKTURNA, enalapril, lisinopril, irbesartan,
direct renin inhibitors and TEKTURNA HCT losartan, valsartan
combinations
High cholesterol: ALTOPREV, FLOLIPID, fluvastatin atorvastatin, lovastatin, pravastatin,
statins capsule, fluvastatin ER tablet, LIVALO, rosuvastatin, simvastatin
ZYPITAMAG
Irritable bowel syndrome (IBS) alosetron tablet VIBERZI, XIFAXAN 550 mg
Migraine products: almotriptan tablet, frovatriptan tablet, eletriptan, rizatriptan, SUMATRIPTAN
triptans SUMAVEL DOSEPRO, TREXIMET SYRINGE, sumatriptan, zolmitriptan
Muscle relaxants AMRIX, BACLOFEN 5 mg TABLET, baclofen tablet, cyclobenzaprine
LORZONE, metaxalone tablet, tablet, methocarbamol tablet,
tizanidine capsule tizanidine tablet
Nasal steroid combination products DYMISTA azelastine nasal (0.1%), fluticasone
nasal
Ophthalmic: AZASITE, BESIVANCE, CILOXAN BACITRACIN OINTMENT, ciprofloxacin
anti-infectives OINTMENT, MITOSOL, MOXEZA, ZIRGAN solution, erythromycin ointment,
moxifloxacin solution, NATACYN,
ofloxacin solution, tobramycin solution
Ophthalmic: ACUVAIL, BROMSITE, ILEVRO, NEVANAC, bromfenac solution, diclofenac
nonsteroidal anti-inflammatory agents PROLENSA solution, flurbiprofen solution,
(NSAIDS) ketorolac solution
Ophthalmic: BLEPHAMIDE, BLEPHAMIDE S.O.P. neomycin/polymyxin/bacitracin/
steroid combinations OINTMENT, BLEPHAMIDE SUSPENSION, hydrocortisone ointment, neomycin/
TOBRADEX ST, ZYLET polymyxin/dexamethasone ointment,
neomycin/polymyxin/dexamethasone
suspension, sulfacetamide/
prednisolone solution, tobramycin/
dexamethasone suspension
Opioid: EVZIO naloxone solution, NARCAN NASAL
antidote
Opioid: BUNAVAIL, ZUBSOLV buprenorphine sublingual tablet,
dependence agents buprenorphine/naloxone sublingual
film, buprenorphine/naloxone
sublingual tablet
Otic anti-infectives, steroids and OTOVEL neomycin/polymyxin/hydrocortisone CIPRODEX
combinations solution, neomycin/polymyxin/
hydrocortisone suspension, ofloxacin
solution
Pain: ABSTRAL, BELBUCA, BUPRENORPHINE fentanyl patch, hydromorphone, XTAMPZA ER
narcotic analgesics PATCH, EMBEDA, FENTORA, HYSINGLA ER, morphine ER, oxycodone, OXYCONTIN
KADIAN, LAZANDA NASAL, OXAYDO,
SUBSYS LIQUID, ZOHYDRO ER
Pain: CONZIP, NUCYNTA , NUCYNTA ER, tramadol, tramadol ER tablet
tramadol/tapentadol TRAMADOL ER CAPSULE
Pain: DUEXIS, naproxen ER, QMIIZ ODT, SPRIX diclofenac tablet, ibuprofen tablet,
NSAIDS NASAL, TIVORBEX, VIMOVO, VIVLODEX, indomethacin capsule, meloxicam
ZIPSOR, ZORVOLEX tablet, naproxen tablet
9 continued4 Non‑covered due to high costs (continued)
Generics and preferred Non‑preferred
Drug class Non‑covered brand alternatives brand alternatives
Parkinson’s agents GOCOVRI, OSMOLEX ER, amantadine capsule, amantadine
pramipexole ER, ropinirole ER, syrup, amantadine tablet, pramipexole
XADAGO, ZELAPAR tablet, rasagiline tablet, ropinirole
tablet, selegiline capsule, selegiline
tablet
Potassium sparing diuretics CAROSPIR SUSPENSION spironolactone tablet
Sleep aids, hypnotics BELSOMRA, SILENOR eszopiclone, zaleplon, zolpidem,
zolpidem ER
Topical: AMELUZ, CARAC, FLUOROPLEX, diclofenac gel (3%), fluorouracil cream
actinic keratosis (AK) agents FLUOROURACIL CREAM (0.5%), (5%), fluorouracil solution (2%, 5%)
PANRETIN GEL, PICATO, TARGRETIN,
TOLAK
Topical: ECOZA, ERTACZO, EXELDERM, JUBLIA, ciclopirox nail lacquer, ciclopirox
antifungals KERYDIN, ketoconazole foam, LUZU, cream, econazole nitrate cream,
NAFTIN, oxiconazole cream, OXISTAT, ketoconazole cream, ketoconazole
XOLEGEL shampoo
Topical: DOXEPIN CREAM, PRUDOXIN CREAM, betamethasone valerate cream,
anti-itch ZONALON CREAM betamethasone valerate ointment,
tacrolimus ointment, triamcinolone
cream, triamcinolone ointment
Topical: EUCRISA, pimecrolimus cream, imiquimod cream, tacrolimus ointment,
immunomodulators for AK ZYCLARA triamcinolone cream, triamcinolone
and/or atopic dermatitis ointment
Topical: calcipotriene/betamethasone ENSTILAR
steroid combination products dipropionate ointment
Ulcer drugs: CARAFATE SUSPENSION sucralfate tablet
sucralfate
Ulcer therapy combinations packs lansoprazole/amoxicillin/ amoxicillin, clarithyromycin,
clarithromycin, OMECLAMOX-PAK, metronidazole, omeprazole,
PYLERA pantoprazole, tetracycline
Wilson’s disease penicillamine capsule DEPEN
10About Prime Therapeutics
We are trusted by your health plan to help you get the medicine you need
to feel better and live well. Our pharmacy experts are working hard to make
your medicine more affordable and your experience easier.
SourceRx 1.0 September 2019
This list may not be all inclusive. This list is subject to change.
New‑to‑market products and variations of those products will not be added to this formulary until they have been evaluated and approved by Prime Therapeutics.
Please discuss with your health care provider before you switch any medications to ensure clinically appropriate use. This list is not intended to dictate to physicians how to practice medicine or intended
to replace the judgment of your physician. Prime Therapeutics is not liable for any treatment administered or prescribed as a result of this formulary information.
Additional restrictions may apply.
Neither this document, nor the successful adjudication of a pharmacy claim, is guarantee of payment. Please refer to your member guide for detailed information regarding your pharmacy benefits, including
your benefit design, out‑of‑pocket costs, prior review and restricted access medication requests, and applicable exclusions. For more information, please contact your Prime Therapeutics representative.
03004354-E
All brand names are the property of their respective owner.
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