Drug Coverage Tiers

APEX 6 Tier Formulary

The following is an abbreviated version of the drug list (formulary) that is at the fundamental basis of your prescription drug benefit. The list is not all-inclusive and does not guarantee coverage. This list is subject to change.

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TIER 1 ($1.00)

ACEBUTOLOL HCL
ACYCLOVIR
ALA-CORT
ALBUTEROL SULFATE
ALENDRONATE SODIUM
ALLOPURINOL
AMANTADINE HCL
AMILORIDE HCL W/HCTZ
AMIODARONE HCL
AMLODIPINE BESYLATE
AMMONIUM LACTATE
AMOXICILLIN
AMOXICILLIN-CLAVULANATE POTASS
AQUA CARE SODIUM CHLORIDE
ATENOLOL
ATORVASTATIN CALCIUM
BACLOFEN
BENAZEPRIL HCL
BENAZEPRIL HCL-HCTZ
BENZONATATE
BENZTROPINE MESYLATE
BISOPROLOL FUMARATE/HCTZ
BP FOAMING WASH
CARBAMAZEPINE
CARBIDOPA/LEVODOPA
CARBIDOPA-LEVODOPA ER
CARVEDILOL
CEPHALEXIN
CETIRIZINE HCL
CHLORHEXIDINE GLUCONATE
CHOLESTYRAMINE
CHOLESTYRAMINE LIGHT
CILOSTAZOL
CIPROFLOXACIN HCL
CLINDAMYCIN HCL
CLONIDINE HCL
CONSTULOSE
CORVITE
CYCLOBENZAPRINE HCL
DECADRON
DELTASONE
DEXAMETHASONE
DICLOFENAC SODIUM
DICYCLOMINE HCL
DILANTIN
DILTIAZEM HCL
DIPHENHYDRAMINE HCL
TOPIRAMATE
TOPROL XL
TORSEMIDE
TRAMADOL HCL

DIPYRIDAMOLE
DONEPEZIL HCL
DOXYCYCLINE HYCLATE
DOXYCYCLINE MONOHYDRATE
ENALAPRIL MALEATE/HCTZ
ENDOCET
ENULOSE
ESTRADIOL
ETHOSUXIMIDE
EUTHYROX
FAMOTIDINE
FINASTERIDE
FLECAINIDE ACETATE
FLUCONAZOLE
FLUORIDE
FLUORITAB
FLURBIPROFEN
FOLIC ACID
FOSINOPRIL SODIUM
FUROSEMIDE
GABAPENTIN
GAVILYTE
GEMFIBROZIL
GENERLAC
GLIMEPIRIDE
GLIPIZIDE
GLIPIZIDE ER
GLIPIZIDE XL
GLYBURIDE
GLYBURIDE MICRONIZED
GLYBURIDE-METFORMIN HCL
GLYCOLAX
GUANFACINE HCL
HYDRALAZINE HCL
HYDROCHLOROTHIAZIDE
HYDROCORTISONE
HYDROMET
HYDROXYZINE HCL
HYDROXYZINE PAMOATE
IBU
IBUPROFEN
INDOMETHACIN
IPRATROPIUM BROMIDE
IPRATROPIUM-ALBUTEROL
ISONIAZID
ISOSORBIDE MONONITRATE
JANTOVEN
KALEXATE
TRAMADOL HCL-ACETAMINOPHEN
TRIAMCINOLONE ACETONIDE
TRIAMTERENE W/HCTZ
TRIHEXYPHENIDYL HCL
TRILYTE WITH FLAVOR PACKETS
TRIPHROCAPS

KETOCONAZOLE
KIONEX
LACTULOSE
LEVETIRACETAM
LEVOCETIRIZINE DIHYDROCHLORIDE
LEVO-T
LEVOTHYROXINE SODIUM
LEVOXYL
LIDOCAINE
LIDOCAINE HCL
LISINOPRIL
LISINOPRIL-HCTZ
LOSARTAN POTASSIUM
LOSARTAN-HYDROCHLOROTHIAZIDE
LOVASTATIN
LUDENT FLUORIDE
LYSIPLEX PLUS
MECLIZINE HCL
MEDROXYPROGESTERONE ACETATE
MEGESTROL ACETATE
MELOXICAM
METFORMIN HCL
METFORMIN HCL ER
METHIMAZOLE
METHOCARBAMOL
METHYLDOPA
METHYLPHENIDATE HCL
METOCLOPRAMIDE HCL
METOPROLOL SUCCINATE
METOPROLOL TARTRATE
METRONIDAZOLE
MINOCYCLINE HCL
MINOXIDIL
MOBIC
MONDOXYNE NL
MONTELUKAST SODIUM
MULTIVIT W/FLUORIDE & IRON
MULTIVITAMIN W/FLUORIDE & IRON
MULTIVITAMIN WITH FLUORIDE
MVC-FLUORIDE
MYNEPHROCAPS
MYNEPHRON
NAPROXEN
NEVIRAPINE
NIACIN-AZE AC-TURMER-FA-B6-ZN
OMEPRAZOLE
ONDANSETRON HCL
OXCARBAZEPINE
TRIPLE-VITAMIN W-FLUORIDE
TRI-VITAMIN WITH FLUORIDE
UNITHROID
VERAPAMIL HCL
VIRT-CAPS
VITACEL

PACERONE
PANTOPRAZOLE SODIUM
PEG 3350-ELECTROLYTE
PENICILLIN V POTASSIUM
PERIOGARD
PHENTERMINE HCL
PHENYTOIN
PHENYTOIN SODIUM
POLYETHYLENE GLYCOL
PRAMIPEXOLE DI-HCL
PREDNISONE
PREVALITE
PRIMIDONE
PROMETHAZINE HCL
PROMETHAZINE VC W/CODEINE
PROMETHAZINE W/CODEINE
PROMETHAZINE W/DM
PROMETHAZINE-PHENYLEPH-CODEINE
PROPAFENONE HCL
PROPRANOLOL HCL
QUINAPRIL
RAMIPRIL
RANITIDINE HCL
RENAL CAPS
RENO CAPS
REPAGLINIDE
ROSUVASTATIN CALCIUM
SALSALATE
SELENIUM SULFIDE
SILVER SULFADIAZINE
SIMVASTATIN
SMZ-TMP DS
SODIUM CHLORIDE
SODIUM FLUORIDE
SODIUM POLYSTYRENE SULFONATE
SORINE
SOTALOL
SOTALOL AF
SPIRONOLACTONE
SUBVENITE
SUCRALFATE
SULFAMETHOXAZOLE/TRIMETHOPRIM
SULFASALAZINE DR
SULFATRIM
SULINDAC
TERAZOSIN HCL
TERBINAFINE
TIZANIDINE HCL
VITAMINS A.C.D & FLUORIDE
WARFARIN SODIUM
ZALEPLON
ZOLPIDEM TARTRATE

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TIER 2 (Generics)

ACARBOSE
ACETAMINOPHEN W/CODEINE
ACETAZOLAMIDE
ACYCLOVIR
AFEDITAB CR
ALENDRONATE SODIUM
ALFUZOSIN HCL ER
ALLOPURINOL
ALTAVERA
AMLODIPINE BESYLATE-BENAZEPRIL
AMOXICILLIN
AMOXICILLIN-CLAVULANATE POTASS
ANASTROZOLE
APRI
ATORVASTATIN CALCIUM
AUBRA
AUBRA EQ
AVIANE
AV-PHOS 250 NEUTRAL
AV-VITE FB FORTE
BACLOFEN
BENZONATATE
BISOPROLOL FUMARATE
BROMFED-DM
BROMIPHENIRAMIN-PSEUDOEPHED-DM
BROMPHENIRAMINE
W/PSEUDOEPHED
BUMETANIDE
CALCITRIOL
CARBAMAZEPINE
CARBIDOPA/LEVODOPA
CARBIDOPA-LEVODOPA ER
CARISOPRODOL
CARTIA XT
CEFDINIR
CEFPROZIL
CHATEAL
CHATEAL EQ
CIMETIDINE
CIPROFLOXACIN HCL
CLINDACIN ETZ
CLINDACIN P
PENTOXIFYLLINE
PERINDOPRIL ERBUMINE
PHOSPHA 250 NEUTRAL
PHOSPHOROUS
PHOSPHO-TRIN 250 NEUTRAL
PINDOLOL
PIOGLITAZONE HCL
PORTIA
POTASSIUM CHLORIDE
PRAVASTATIN SODIUM
PRAZOSIN HCL
PREDNISOLONE SODIUM PHOSPHATE
PREVIFEM

CLINDAMYCIN HCL
CLINDAMYCIN PALMITATE HCL
CLINDAMYCIN PEDIATRIC
CLINDAMYCIN PHOSPHATE
CLONIDINE HCL
CLOTRIMAZOLE
CYPROHEPTADINE HCL
CYRED
CYRED EQ
DELYLA
DESOGESTREL-ETHINYL ESTRADIOL
DICLOFENAC SODIUM
DICLOXACILLIN SODIUM
DILTIAZEM 24HR ER (CD)
DILTIAZEM 24HR ER (XR)
DILTIAZEM ER
DILTIAZEM HCL
DILT-XR
DIPHENOXYLATE W/ATROPINE
DOXAZOSIN MESYLATE
DOXYCYCLINE MONOHYDRATE
EMOQUETTE
ENALAPRIL MALEATE
ENDOCET
ENSKYCE
EPITOL
ERYTHROMYCIN
ESTARYLLA
ETHYNODIOL-ETHINYL ESTRADIOL
ETODOLAC
EUTHYROX
FALMINA
FELODIPINE ER
FEMYNOR
FENOFIBRATE
FLECAINIDE ACETATE
FLUCONAZOLE
FLUDROCORTISONE ACETATE
FLUTICASONE PROPIONATE
FOLBIC
GABAPENTIN
GLIPIZIDE ER
GLIPIZIDE XL
PROBENECID
PROPAFENONE HCL
PROPRANOLOL HCL
PYRIDOSTIGMINE BROMIDE
QUINAPRIL-HYDROCHLOROTHIAZIDE
RANITIDINE HCL
RECLIPSEN
ROCALTROL
ROPINIROLE HCL
ROWEEPRA
ROWEEPRA XR
SIMVASTATIN
SORINE
SOTALOL

GLIPIZIDE-METFORMIN
GRISEOFULVIN
HYDROCODONE BIT-IBUPROFEN
HYDROCODONE-CHLORPHENIRAMINE
HYDROCORTISONE
HYDROMORPHONE HCL
HYDROXYUREA
HYDROXYZINE HCL
HYOSCYAMINE SULFATE
IBUPROFEN
INDAPAMIDE
INDOMETHACIN
IPRATROPIUM BROMIDE
IRBESARTAN
ISIBLOOM
ISONIAZID
ISOSORBIDE DINITRATE
ISOSORBIDE MONONITRATE
JULEBER
KELNOR 1-50
KLOR-CON
KLOR-CON M
KURVELO
LABETALOL HCL
LANSOPRAZOLE
LARISSIA
LESSINA
LEVETIRACETAM
LEVOCETIRIZINE DIHYDROCHLORIDE
LEVOFLOXACIN HEMIHYDRATE
LEVONORGESTREL-ETH ESTRADIOL
LEVORA
LEVO-T
LEVOTHYROXINE SODIUM
LEVOXYL
LILLOW
LIOTHYRONINE SODIUM
LISINOPRIL
LOMOTIL
LOPERAMIDE HCL
LOSARTAN POTASSIUM
LOSARTAN-HYDROCHLOROTHIAZIDE
LOVASTATIN
SOTALOL AF
SPIRONOLACTONE
SPRINTEC
SRONYX
SULFASALAZINE
SULFAZINE
SULINDAC
SYMAX-SL
TAZTIA XT
THEOCHRON
THEOPHYLLINE ANHYDROUS
TIZANIDINE HCL
TOPIRAMATE
TORSEMIDE

LUTERA
MARLISSA
MEGESTROL ACETATE
MEPERIDINE HCL
METHIMAZOLE
METHYLDOPA
METHYLPHENIDATE HCL
METOPROLOL SUCCINATE
METRONIDAZOLE
MILI
MINITRAN
MINOCYCLINE HCL
MISOPROSTOL
MOEXIPRIL HCL
MOMETASONE FUROATE
MONDOXYNE NL
MONO-LINYAH
MONONESSA
MONTELUKAST SODIUM
MYCOPHENOLATE MOFETIL
NABUMETONE
NAPROXEN
NIFEDICAL XL
NIFEDIPINE
NIFEDIPINE ER
NITROGLYCERIN
NITRO-TIME
NIVA-FOL
NIZATIDINE
NORGESTIMATE-ETHINYL ESTRADIOL
NYSTATIN
OKEBO
OMEPRAZOLE
ORSYTHIA
OSCIMIN
OSCIMIN SL
OXCARBAZEPINE
OXYBUTYNIN CHLORIDE
OXYCODONE HCL
OXYCODONE W/ACETAMINOPHEN
OXYCODONE W/ASPIRIN
TRANDOLAPRIL
TRIAMCINOLONE ACETONIDE
TRIDERM
TRIMETHOPRIM
UNITHROID
VALACYCLOVIR
VERAPAMIL ER
VIENVA
VIRT-PHOS 250 NEUTRAL
VIRT-VITE FORTE
VITAMIN D2
VYLIBRA
ZIDOVUDINE
ZOVIA

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TIER 3 (Preferred Brands)

A.I.R.S. NEBULIZER
ACACIA
ACCU-CHEK SPIRIT
ACD
ACD-A
ACETAMINOPHEN
ACETIC ACID
ACETIC ACID/ALUMINUM
ACETONE
ACETYL SALICYLIC ACID
ACETYLCYSTEINE
ACIDOPHILUS LACTOBACILLUS
ACTIVATED CHARCOAL
ACUICYN
ADDAMEL N
ADYNOVATE
AFSTYLA
ALBUTEROL SULFATE
ALENDRONATE SODIUM
ALPHA PINENE
ALPROLIX
AMINOBENZOIC ACID
AMINOBUTYRIC ACID
AMINOCAPROIC ACID
AMINOPHYLLINE
AMINOSALICYLIC ACID
AMINOSYN
AMOXICILLIN
AMOXICILLIN-CLAVULANATE POTASS
AMPICILLIN TRIHYDRATE
ANASPAZ
ANECTINE
APRISO
ARALAST NP
ARGININE
THREONINE
THYMOL
THYROID
TIMOLOL MALEATE
TITANIUM DIOXIDE
TOBRAMYCIN SULFATE
TOLAZAMIDE
TOLBUTAMIDE
TOLMETIN SODIUM
TOMMY GEL
TRACE ELEMENTS-4

ARMOUR THYROID
BARIUM SULFATE
BENZOCAINE
BENZOIC ACID
BENZOIN
BENZOQUINONE
BENZOYL PEROXIDE
BENZPHETAMINE HCL
BENZYL ALCOHOL
BENZYL BENZOATE
BETA-CAROTENE
BETAINE
BETAINE HYDROCHLORIDE
BETAMETHASONE DIPROPIONATE
BUTALBITAL-ASP-CAFFEINE
CALCIUM-FOLIC ACID PLUS D
CALDOLOR
CAPTOPRIL/HYDROCHLOROTHIAZIDE
CARAFATE
CARAMEL
CARBAMAZEPINE
CARBAMIDE PEROXIDE
CARBIDOPA-LEVODOPA-ENTACAPONE
CARBOCAINE
CARBOGEL
CARBOHOL
CARISOPRODOL
CEFACLOR
CEFAZOLIN SODIUM
CEFEPIME HCL
CEFOTAXIME SODIUM
CEFTRIAXONE
CIMETIDINE
CIPROFLOXACIN
CIPROFLOXACIN HCL
CITRATE PHOSPHATE DEXTROSE
TRAGACANTH
TRANSDERMAL PAIN BASE
TRANS-PEN TRANSDERMAL
TRAVASOL
TRETINOIN
TRIACETIN
TRIAMTERENE W/HCTZ
TRIANEX
TRICHLOROACETIC ACID
TRICITRASOL
TRICITRATES
TRIETHANOLAMINE LAURYL SULFATE

CLARITHROMYCIN
CLENPIQ
CLEOCIN PHOSPHATE
CLINIMIX
CLINIMIX E
CLIOQUINOL
CLOMIPHENE CITRATE
CORTISONE ACETATE
COUMARIN
CYCLOSPORINE
CYSTEINE
DEXAMETHASONE
DIGOXIN
DILANTIN
DILTIAZEM 24HR ER (XR)
DILT-XR
EPINEPHRINE
ERY-TAB
ERYTHROMYCIN
FAMOTIDINE
FLUNISOLIDE
FUROSEMIDE
GLUCOSAMINE
GRISEOFULVIN
GUAIFENESIN
HYDROCORTISONE
K-TAB
LABETALOL HCL
LACTASE
LACTOSE
LANOLIN
LANOLIN ALCOHOL
LIDOCAINE
MEBENDAZOLE
MECLIZINE HCL
METFORMIN HCL
TRIMETHOPRIM
TRIMO-SAN
TRINATAL GT
TRINATAL RX 1
TRINATE
TRITON X-100
TRIVEEN-DUO DHA
TRI-VITAMIN WITH IRON-FLUORIDE
TROCHE BASE
TROLAMINE
TROMETHAMINE
TROPHAMINE

METHADOSE
METHANOL
METHENAMINE
METHOCARBAMOL
METHOTREXATE
METOPROLOL SUCCINATE
NAPROXEN
NITROGLYCERIN
OMEPRAZOLE
PANCREATIN
PREDNISOLONE
PREMARIN
PREMASOL
PROVENT
PRUCLAIR
RETROVIR
SULFADIAZINE
SULFAMERAZINE
SULFAMETHOXAZOLE
SULFAMYLON
SULFANILAMIDE
SULFAPYRIDINE
SULFASALAZINE
SULFATHIAZOLE
SULFUR
SULFURIC ACID
SYRPALTA
TAURINE
TERCONAZOLE
TESTOSTERONE
TETRACAINE
TETRACAINE HCL
TETRACYCLINE HCL
THEANINE
THEOPHYLLINE ANHYDROUS
THIAMINE HCL
TROPICAL PUNCH FLAVOR
TRYPSIN
TRYPTOPHAN (L)
TYROSINE
UREA
VALINE
VANCOMYCIN HCL
VASCEPA
VIMPAT
ZOSYN
ZOVIA

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TIER 4 (Non-Preferred Brands)

ACCUPRIL
ACEON
ACTICOAT
ADALAT CC
ADDERALL
ADIPEX-P
ADZENYS ER
AFREZZA
AGGRASTAT
AGGRENOX
ALBUMINEX
ALBUTEROL SULFATE HFA
ALCAINE
ALDACTAZIDE
ALDACTONE
ALEVICYN
ALEVICYN ANTIPRURITIC SG
ALEVICYN PLUS
ALFENTA
ALLEVYN AG ADHESIVE
ALTACE
ALTADERM CREAM BASE
ALTRENO
ALUVEA
AMARYL
AMBIEN
AMIDATE
AMINOBENZOATE POTASSIUM
ANACAINE
ANALPRAM-HC
ANAPROX DS
ANDROGEL
ANGELIQ
ANGIOCATH
ANTICOAGULANT SODIUM CITRATE
VITUZ
VOGELXO
VOLTAREN
VOLUMEN
VOSPIRE ER
WITEPSOL
WP THYROID
XAQUIL XR

APPTRIM
ARTHROTEC
ASCOR
ASTAGRAF XL
ASTRINGYN
ATACAND
ATREVIS HYDROGEL
ATROPINE SULFATE
ATROPINE SULF-NS
AUGMENTIN
AVANDAMET
AVANDIA
AVAPRO
BACLOFEN
BACTRIM
BENZAMYCIN
CAFERGOT
CAPHOSOL
CARAFATE
CARBATROL
CARBOCAINE
CARDENE
CARDIOTEK RX
CARDIOVID PLUS
CARDURA
CARNITOR
CEFTIN
CELACYN POST PROCEDURE
CELEBREX
CERACADE
CERAMAX
CETACAINE
CHLORPROPAMIDE
CICLODAN
CIPRO
CLAFORAN
XARTEMIS XR
XENICAL
XERAC AC
XOPENEX
XOPENEX HFA
XYLOCAINE
YASMIN
YAZ
YOSPRALA

CLAFORAN-DEXTROSE
CLARINEX
CLOBEX
CLOROTEKAL
COLESTID
COLYTE
CONTRAVE ER
COREG
COUMADIN
COZAAR
CROTAMITON
CURCUMIN
DEMADEX
DEMEROL
DETROL
DILANTIN
DIOVAN
FELDENE
FENOFIBRATE
FLORIVA
GABITRIL
GLUCOPHAGE
GLUCOPHAGE XR
GLUCOTROL
GLUCOTROL XL
GLUCOVANCE
IMURAN
KEFLEX
LANOXIN
LASIX
LECITHIN SOYA
LEUCINE
LEVICYN
LIDOCAINE HCL
LIDOCAINE HCL-NS
MACROBID
ZANABIN
ZANAFLEX
ZANTAC RX
ZARONTIN
ZESTORETIC
ZESTRIL
ZINACEF
ZITHROMAX
ZOCOR

NAPROSYN
NORVASC
OVACE PLUS
PARAFON FORTE DSC
PROCARDIA XL
PROGRAF
REGLAN
REJUVACARE PLUS
RELAGARD
REQUIP XL
RETIN-A
RITALIN
SINEMET CR
SPORANOX
TAMIFLU
ULTANE
ULTRACET
ULTRAVATE X
ULTRAVIST
ULTRESA
UMECTA
UROCIT-K
VANCOMYCIN HCL
VASCAZEN
VASOTEC
VAYACOG
VAYARIN
VAYAROL
VENELEX
VERSAPRO LOTION BASE
VERSATILE
VIBRAMYCIN
VIRTPREX
VISIPAQUE
VISTARIL
VITATRUE
ZOLOFT
ZONATUSS
ZONEGRAN
ZOVIRAX
ZUTRIPRO
ZYBAN
ZYLOPRIM
ZYVOX

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TIER 5 (Preferred Specialty)

ADVATE
ALPHANATE
ALPHANINE SD
ALPROLIX
ARALAST NP
BEBULIN
BENEFIX
CRIXIVAN
CYSTAGON
EMTRIVA

EPIVIR HBV
FEIBA NF
HELIXATE FS
HEMOFIL-M
HUMATE-P
INTELENCE
ISENTRESS
IXINITY
KOGENATE FS
KOVALTRY
LEXIVA

MONOCLATE-P
MONONINE
NEVIRAPINE
NOVOEIGHT
NOVOSEVEN RT
OBIZUR
PAMIDRONATE DISODIUM
PREZISTA
PROFILNINE SD
PROLASTIN C
RESCRIPTOR

RETROVIR
RIASTAP
SELZENTRY
THROMBATE III
UVADEX
VIDEX
WILATE
ZEMAIRA
ZOLEDRONIC ACID

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TIER 6 (Non-Preferred Specialty)

DUOPA
EPIVIR
FIBRYGA
GLASSIA

KALETRA
KOATE
KOATE-DVI
PROFILNINE
REBETOL

RETROVIR
RIXUBIS
SUSTIVA
VIRAMUNE
ZERIT

ZIAGEN
ZOLEDRONIC ACID

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The information contained herein is company confidential and proprietary. It should not be used for any purpose not expressly approved in writing by Apex.