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All drugs .NOT listed are paid <br />as generic or preferred. <br />Key <br />* - Quantity limits based on FDA <br />dosing guidelines <br />~ - Paid as Preferred with Prior <br />Authorization (PA) approval <br />Oral Antibiotics <br />(~ P NP <br />amoxicillin <br /> <br />amoxicillin/clavulanate -_ <br />ampicillin <br />Augmentin ES $$ <br /> <br />Augmentin XR __-_ <br />$$ - __ <br /> <br />Avelox <br />$$ __ __ <br />Biaxin $$$$ <br />BiaxinXL _ _ $$$$ <br />Ceclor CD $$ <br />Cedax $$ <br />cefaclor <br />cefadroxil <br />cefuroxime r <br />Cefzil $$ <br />cephalexin <br /> <br />Cinoba _ _ <br /> <br />: <br />- - --- <br />$$$$ <br /> <br />Cipro . <br />_. <br />- <br />$$ <br />Cipro XR $$ <br />clindamycin <br />-__ <br />dicloxacillin <br />---- <br />Doryx $$$$ <br />doxycycline <br />Dynabac $$ <br />erythromycin <br />erythromycin base <br />erythromycin estolate <br />(suspension only) <br />erythromycin stearate <br />ethylsuccinate <br />Levaquin $$$$ <br />Lorabid $$$$ <br />Macrobid $$ <br />Maxaquin -_ $$$$- <br />metronidazole <br />- <br />- <br />minocycline <br />nitrofurantoin <br />Noroxin $$$$ <br />ofloxacin <br />Omnicef $:n <br /> <br />Penetrex -- <br />$$$$ <br />penicillin VK <br />Raxar - $$$$ <br />Suprax $$ _ -__ <br />Tequin $$ _ - - <br /> <br />'tetracycline _-__ <br />trimethoprim/smx <br />Vantin $$$$ <br />- <br /> <br />Za am <br />g $$$$ <br />Zithromax $ <br />Zyvox $$$$ <br />Hormone Replacement <br />G P NP <br />Activella $$ <br />Cenestin $$ <br />estradiol <br />estradiol patch <br />-_ ___ - <br />Estratest $$ <br />estropipate <br />Evista $$ <br />Fem HRT $$ <br />medroxyprogesterone > <br />Premarin $$ - _. <br />Premphase $$ <br />Prempro $ <br />Syntest H.S. " $$$$ <br />Anti-Ulcer Gast rc, i ntestinal <br /> U P NP <br />Aciphex * $$$$ <br />Axid $$$$ <br />cimetidine <br />famotidine <br /> <br />Helidac -_ - <br />$$ <br />ranitidine <br />metoclopramide <br />misoprostol <br />Nexium * $$$$ <br />omE~~~rni~~lc OTC-- <br />- <br />Precaci~l $$$$ <br />Prilosec OTC <br />Protonix * $$$$ <br />sucralfate r <br /> <br />Tritec ___ <br />$~ <br />Antidepressants <br />(~ P NP <br />amitriptyline <br />amoxapine <br />bupropion <br /> <br />Celexa - _ _ <br />$$ ___- <br />desipramine <br />doxepin <br />Effexor $$$$ <br />Effexor XR $$ <br />fluoxetine <br />fluvoxamine 3 <br />imipramine <br />Lexapro $$ <br />maprotiline <br />mirtazapine <br />nefazodone <br />nortriptyline > <br />paroxetine <br />-.__ -_ <br />_ <br />Paxil CR $$$$ <br />Remeron Sol Tab $$$$ <br />Sarafem $$$S <br />Tofranil PM $$$$ <br />trazodone <br />Wellbutrin SR S$ _ <br />Wellbutrin XL $$ <br />Cardiovascular - ACE Inhibitors/ <br />Combinations/ACE II Antagonists <br />`~ ~ G P' NP <br />Accupril $$ <br />Aceon $$ <br />____ <br />Altace $$ <br />Atacand $$$$ <br />Atacand HCT $$$$ <br />Avalide $$$$ <br />Avapro $$$$ <br />Benicar $$ <br />Benicar HCT $$ <br />Ca ozide $$ <br />capto ril _ <br />Cozaar $$ _ <br />Diovan $$ <br />-- <br />Diovan HCT $$ <br />emalaprillHCTZ <br />- __ <br />enalapril <br /> <br />Hyzaar _ <br />$$ <br />__ <br /> <br />.. _ _- <br />lisinopril <br />lisinopri]/HCTZ ~, <br />Lotensin $$ <br />Lotensin HCT $$ <br />Mavik $ <br />- _ <br />_.. <br />Micardis $$$$ <br />Micardis HCT $$$$ <br />moexipril <br />Monopril ~~$$ <br />Teveten <br />_._ $$$$ <br />-- <br />Teveten HCT $$$$ <br />Uniretic $$$$ <br />