Preferred Drug List

PREFERRED 1 NON PREFERRED 2 PREFERRED 1 NON PREFERRED 2

DRUGS DRUGS DRUGS DRUGS

CARDIOVASCULAR: ACE INHIBITORS CARDIOVASCULAR: BETA-BLOCKERS
Captopril (Capoten) Quinapril (Accupril)* Atenolol (Tenormin) Carvedilol (Coreg)*
Enalapril (Vasotec) Trandolapril (Mavik)* Metoprolol (Lopressor) Metoprolol (Toprol XL)*
Lisinopril (Prinivil, Zestril) Benazepril (Lotensin)* Nadolol (Corgard)
Fosinopril (Monopril) Moexipril (Univasc)* Pindolol
Perindopril (Aceon) Ramipril (Altace)* Propranolol (Inderal)
Propranolol/HCTZ (Inderide)
CARDIOVASCULAR: ACE INHIBITOR/DIURETIC COMBINATIONS Propranolol SR (Inderal LA)
Captopril/HCTZ (Capozide) Quinapril/HCTZ (Accuretic)* Sotalol (Betapace)
Enalapril/HCTZ (Vaseretic) Benazepril/HCTZ (Lotensin HCT)* Timolol (Blocadren)
Lisinopril/HCTZ (Prinzide, Zestoretic) Moexipril/HCTZ (Uniretic)*
Fosinopril/HCTZ (Monopril HCT) CARDIOVASCULAR: CALCIUM CHANNEL BLOCKERS
Diltiazem (Cardizem) Isradipine (Dynacirc)*
CARDIOVASCULAR: ACE INHIBITORS/CCB COMBINATIONS Diltiazem ER (Dilacor XR) Isradipine CR (Dynacirc CR)*
Benazepril/Amlodipine (Lotrel) Enalapril/Felodipine (Lexxel)* Nifedipine SR (Procardia XL)
Trandolapril/Verapamil (Tarka) Verapamil (Calan)
Verapamil SR (Calan SR)
CARDIOVASCULAR: ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBs) Amlodipine (Norvasc)
Valsartan (Diovan) Candesartan (Atacand)*
Olmesartan (Benicar) Eprosartan (Teveten)*
Irbesartan (Avapro)* ANTIBIOTICS: CEPHALOSPORINS (FIRST GENERATION)
Losartan (Cozaar)* Cephalexin (Keflex)
Telmisartan (Micardis)* Cephadroxil (Duricef )

CARDIOVASCULAR: ANGIOTENSIN II RECEPTOR ANTAGONISTS ANTIBIOTICS: CEPHALOSPORINS (SECOND GENERATION)

(ARBs)/DIURETICS Cefprozil (Cefzil) Loracarbef (Lorabid)*
Valsartan/HCTZ (Diovan HCT) Candesartan/HCTZ (Atacand HCT)* Cefuroxime (Ceftin)
Olmesarta/HCTZ (Benicar HCT) IIrbesartan/HCTZ (Avalide)* Cefaclor (Ceclor)
Eprosartan/HCTZ (Teveten HCT)*
Losartan/HCTZ (Hyzaar)* ANTIBIOTICS: CEPHALOSPORINS (THIRD GENERATION)
Telmisartan/HCTZ (Micardis HCT)* Cefixime (Suprax) Cefditoren (Spectracef )*
Cefdinir (Omnicef ) Cefpodoxime (Vantin)*
ANTIBIOTICS: PENICILLINS Ceftibuten (Cedax)*
Amoxillin (Amoxil)
Ampicillin (Polycillin) * Prior Authorization Required
Penicillin VK (Pen Vee K) GENERICS MUST BE USED WHEN AVAILABLE
Amoxicillin/Potassium Clavulanate (Augmentin)

Member Services: 1-888-276-2020 (Toll-Free) www.selecthealthofsc.com

1 Preferred drugs do not require prior approval from Select Health except for Advair 50/500, Celebrex, Bextra, Prevacid Solutabs, and Protonix
2 Non Preferred Drugs require action from your Doctor and prior approval from Select Health
 PREFERRED 1 NON PREFERRED 2 PREFERRED 1 NON PREFERRED 2
DRUGS DRUGS DRUGS DRUGS
ANTIBIOTICS: ERYTHROMYCINS/MACROLIDES SELECTIVE SERONTONIN REUPTAKE INHIBITORS (SSRIs)
Erythromycin Base (Ery-Tab) (Telithromycin) Ketek* Escitalopram (Lexapro)
Erythromycin Ethylsuccinate (E.E.S) Fluoxetine (Prozac)
Erythromycin/Sulfisoxazole (Pediazole) Citalopram (Celexa)
Azithromycin (Zithromax) Paroxetine (Paxil, Paxil CR)
Clarithromycin (Biaxin, Biaxin XL) Sertraline (Zoloft)

ASTHMA: BETA ADRENERGIC AGENTS NON SEDATING ANTIHISTAMINES

Albuterol (Proventil/Ventolin) Albuterol (Accuneb)* Loratadine (Claritin, Alavert) Fexofenadine (Allegra)*
Salmeterol (Serevent) Levalbuterol (Xopenex)* Cetirizine Syrup (Zyrtec Syrup) for children < 2 Cetirizine (Zyrtec)*
Metaproterenol* years of age only Desloratadine (Clarinex)*

ASTHMA: INTERNASAL STEROIDS PROTON PUMP INHIBITOR (PPIs)

Beclomethasone Flunisolide (Nasarel)* Lansoprazole (Prevacid Solutabs)* Esomeprazole (Nexium)*
(Vancenase, Vancenase AQ) Pantoprazole (Protonix)* Lansoprazole (Prevacid Capsules)*
Budesonide (Rhinocort, Rhinocort AQ) OTC Omeprazole (OTC Prilosec) Rabeprazole (Aciphex)*
Fluticasone (Flonase)
Mometasone (Nasonex) CNS STIMULANTS/ADHD THERAPY
Triamcinolone (Nasacort, Nasacort AQ) Methylphenidate Regular Release (Ritalin) Atomoxetine (Strattera)*
Methylphenidate Sustained Release (Ritalin SR) Methylphenidate (Metadate CD)*
ASTHMA: INHALED CORTICOSTEROID MEDICATIONS Methylphenidate Controlled Release (Concerta)
Beclomethasone (QVAR) Flunisolide (Aerobid)* Methylphenidate LA (Ritalin LA)
Triamcinolone (Azmacort) Dextroamphetamine (Dextrostat)
Fluticasone (Flovent) Mixed Amphetamines (Adderall)
Fluticasone/Salmeterol (Advair)* Mixed Amphetamines Extended Release (Adderall XR)
PA required on 50/500
Budesonide Respules (Pulmicort) Respules MIGRAINE (TRIPTAN) MEDICATIONS (quantity limits apply)
for children under 8 years of age Sumatriptan (Imitrex) Rizatriptan (Maxalt, Maxalt MLT)*
Zolmitriptan (Zomig) Almotriptan (Axert)*
LEUKOTRIENE RECEPTOR ANTAGONISTS Eletriptan (Relpax) Naratriptan (Amerge)*
Montelukast (Singulair)* Zafirlukast (Accolate)* Frovatriptan (Frova)*

NON SEDATING ANTIHISTAMINES/DECONGESTANTS SEDATIVE HYPNOTICS

Loratadine/Pseudoephedrine (Claritin D) Fexofenadine/Pseudoephedrine (Allegra-D)* Estazolam (Prosom) Zolpidem (Ambien)*
Cetirizine/Pseudoephedrine (Zyrtec-D)* Temazepam (Restoril)
Zaleplon (Sonata)
CHOLESTEROL: ANTILIPIDEMICS
Atorvastatin (Lipitor) Simvistatin (Zocor)* COX-2 MEDICATIONS
Fluvastatin (Lescol) Rosuvastatin (Crestor)* Celecoxib (Celebrex)*
Fluvastatin Extended Release (Lescol XL) Ezetimibe/Simvastatin (Vytorin)* Valdecoxib (Bextra)*
Lovastatin (Mevacor)
Lovastatin Extended Release (Altoprev) * Prior Authorization Required
Lovastatin/Niacin (Advicor) GENERICS MUST BE USED WHEN AVAILABLE
Pravastatin (Pravachol)
Other PA Medications: Cialis, Elidel, Levitra, Mobic, Oxycontin, Ponstel, Protopic, Singulair, Viagra,
Xenical
Member Services: 1-888-276-2020 (Toll-Free) www.selecthealthofsc.com
1 Preferred drugs do not require prior approval from Select Health except for Advair 50/500, Celebrex, Bextra, Prevacid Solutabs, and Protonix
2 Non Preferred Drugs require action from your Doctor and prior approval from Select Health