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This Preferred Drug List (PDL) is not inclusive of all drugs available on the formulary. Rather, it represents an abbreviated version of approved • Tier 1 generics are denoted in bolded, small case.
drugs on the formulary. In cases where brand • Tier 2 brand drugs are denoted in CAPITAL drugs have FDA approved generics, they will be dispensed with the generic equivalent. This PDL is subject to change upon review by the Pharmacy • (PA) denotes Prior Authorization is required for and Therapeutics Committee. All new drugs to the • (ST) denotes Step Therapy and other formulary market are considered non-formulary until reviewed by the Pharmacy and Therapeutics Committee.
All diabetic testing supplies and insulins (generic or brand) under the category of Diabetic Agents have a $0.00 copay and are paid at 100% through your Group Health Cooperative plan.
This list does not guarantee coverage and is subject to change. To view a complete listing of drugs, please visit the Member Login Area at group-health.com.
valacyclovir
erythromycin / sulfisoxazole
sulfamethoxazole /
ampicillin
trimethoprim
amoxicillin
amoxicillin/clavulanate
all generics in class
clotrimazole troche
clindamycin
fluconazole
methenamine
cefaclor
griseofulvin microsize susp
nitrofurantoin
cefadroxil
itraconazole (PA)
rifampin
cefdinir
ketoconazole
cefpodoxime
nystatin
cefprozil
terbinafine
cefuroxime tabs
gris-peg
cephalexin
clindamycin vaginal cream
estradiol weekly patch
metronidazole vaginal
estropipate tabs
azithromycin
nystatin vaginal
medroxyprogesterone
clarithromycin
terconazole vaginal cr,
clarithromycin xl
erythromycin
doxycycline
minocycline
tetracycline
Note: All brand oral antiviral ciprofloxacin tabs
ofloxacin
generic equivalent is formulary.
acyclovir
amantadine
famciclovir
rimantadine
ramipril
mexiletine
quinapril
nitroglycerin patches
trandolapril
nitroglycerin sublingual
doxazosin
prazosin
finasteride
procainamide
tamsulosin
propafenone
terazosin
losartan (ST)
quinidine gluconate
losartan / hct (ST)
quinidine sulfate
terazosin
chlorpropamide
glimepiride
glipizide, glipizide er
glyburide
alprazolam
metformin, metformin er
chlordiazepoxide
glipizide / metformin
flunisolide (QL)
clorazepate
glyburide / metformin
fluticasone (QL)
clonazepam
tolazamide
diazepam
tolbutamide
lorazepam
amlodipine / benazepril
oxazepam
atenolol /chlorthalidone
buspirone
benazepril / hctz
captopril / hctz
albuterol nebulizer solution
enalapril / hctz
albuterol tabs, syrup
trazodone
fosinopril / hctz
budesonide inhalant sol
citalopram
lisinopril / hctz
ipratropium / albuterol
fluoxetine
metoprolol / hctz
nebulizer soltuion
paroxetine
moexipril/hctz
ipratropium nebulizer
sertraline
nadolol /
solution
venlafaxine
alendronate (QL)
bendroflumethiazide
metaproterenol syrup, tabs
venlavaxine XR (QL)
calcitonin salmon
propranolol / hctz
amitriptyline
quinapril / hctz
nortriptyline
bupropion
bupropion
mirtazapine
maprotiline
all generics in class
acebutolol
atenolol
chlorpromazine
bisoprolol
cholestyramine
clozapine (PA)
carvedilol
colestipol
fluphenazine
labetalol
fenofibrate
haloperidol
metoprolol succinate er
fenofibrate micronized
lithium carbonate
metoprolol tartrate
gemfibrozil
loxapine
lovastatin
perphenazine
pindolol
pravastatin
prochlorperazine
propranolol
simvastatin
cimetidine
risperdone
propranolol LA
famotidine
trifluoperazine
misoprostol
omeprazole 20mg caps
omeprazole magnesium
pantoprazole
amlodipine
ranitidine tabs, syrup
diltiazem generics
sucralfate
nicardipine
nifedipine
nimodipine
nisoldipine generic
estazolam
verapamil
amiodarone
bethanechol
temazepam
clonidine tablets
flavoxate
disopyramide
oxybutynin tabs, syrup
triazolam
zaleplon
doxazosin
zolpidem
benazepril
flecainide
captopril
guanabenz
enalapril
guanfacine
fosinopril
isosorbide dinitrate tab, cr
lisinopril
moexipril
isosorbide mononitrate
methyldopa
amphetamine salts
clonazepam
generic creams, lotions,
amphetamine salts xr (QL)
phenytoin
ointments, solutions
dextroamphetamine
ethosuximide
dexmethylphenidate
divalproex dr
methylphenidate
valproic acid
carbamazepine
acetic acid otic soln
gabapentin
antipyrine/benzocaine otic
lamotrigine
levetiracetam
hc 1%/pramoxine 1%/
oxcarbazepine
chloroxylenol 0.1% otic soln
calcipotriene solution
primidone
neomycin/polymyxin/hc
acetaminophen / codeine
topiramate
zonisamide
ofloxacin otic soln
codeine sulfate
fentanyl patches
hydrocodone /
acetaminophen
hydromorphone
meperidine
amantadine
methadone
benztropine
morphine sulfate
bromocriptine
adapalene cream, gel
morphine sulfate er
carbidopa / levodopa
benzoyl peroxide /
oxycodone / acetaminophen
pramipexole
erythromycin gel
oxycodone / aspirin
ropinirole hcl
benzoyl peroxide generics
oxycodone immediate
selegiline
clindamycin topical
release cap, tab
trihexyphenidyl
erythromycin topical
tramadol
lsotretinoin caps
metronidazole 0.75% topical
cr, gel, lotion
sodium sulfacetamide /
sulfacetamide sodium lotion
diclofenac potassium
tretinoin topical cream, gel
diclofenac sodium
all generics in class
etodolac
fenoprofen
flurbiprofen
ibuprofen
indomethacin
ketoprofen
ketorolac
meclofenamate
meloxicam
nabumetone
all generics in class
ciclopirox 0.77% cream, gel,
naproxen
oxaprozin
clotrimazole
piroxicam
clotrimazole /
sulindac
betamethasone cream,
tolmetin
econazole nitrate
gentamicin cream, ointment
iodoquinol-hc cream
ergotamine / caffeine
all generics in class
ketoconazole cream,
isometheptene /
dichloralphenazone /
mupirocin 2% oint
acetaminophen
nystatin / triamcinolone
naratriptan
cream, ointment
sumatriptan (QL)
nystatin cream, ointment
silver sulfadiazine
brimonidine tartrate
cromolyn sodium opht soln
ketorolac opth soln

Source: https://www.group-health.com/docs/Members/Coop_PreferredDrugList.pdf