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11q1 mp formulary.ai

MaxorPlus National
Tiered Drug Formulary
A Tiered Drug Formulary is a list of medications to be used as a guideline for physicians when prescribing medications and is designed to help keep your prescription drug benefit affordable. It also informs you of the availability of generic or less-expensive drugs, which often can reduce your out-of-pocket costs.
First (1st)-tier drugs are generic medications and are available at the lowest copay. First-tier drugs are in lower case letters (ex. isoniazid). Most generic medications are considered formulary even if they are not listed. Second (2nd)-tier drugs are brand name medications which are capitalized on the tiered drug formulary and do not indicate a generic is available (ex. EPIPEN). Third (3rd)-tier brand name drugs are followed by –GENERIC (ex. NIZORAL- GENERIC) or are brand name drugs not listed on the formulary.
Note: Depending on your prescription drug benefit, if you request a brand name drug which has a generic equivalent, you may be responsible for paying your copay plus the price difference between the generic and equivalent brand name drug. As brand name drugs become available generically, only the generic will be considered formulary.
Not all drugs listed may be covered by your prescription drug benefit. In addition, certain restrictions, quantity limits or prior authorization requirements may apply. Some medications on this list may be subject to a special copay depending on your prescription drug benefit.
We encourage you to present this tiered drug formulary to your physician each time a prescription is written. Please
contact a MaxorPlus Customer Service Representative if you have any questions at 806-324-5430 or 800-687-0707. For
the most up to date MaxorPlus Tiered Drug Formulary, go to www.maxorplus.com and click on formulary listings under
common questions or go to http://maxsource.maxor.com/maxorplus/formulary.aspx. To view your plan’s formulary,
just enter your MaxorPlus Group Number in the Group ID field.
MaxorPlus National Tiered Drug Formulary
MACROBID- GENERIC (nitrofurantoin monohyd mac) Antifungals
FULVICIN PG- GENERIC (griseofulvin microsize) GRIS-PEG- GENERIC (griseofulvin ultramicrosize) Cardiac Glycosides
ARIMIDEX- GENERIC (anastrozole)CASODEX- GENERIC (bicalutamide) Cholesterol Lowering Agents
Antimalarials
PLAQUENIL- GENERIC (hydroxychloroquine sulfate) Antiretrovirals
MEVACOR- GENERIC (lovastatin)PRAVACHOL – GENERIC (pravastatin) PLAQUENIL- GENERIC (hydroxychloroquine sulfate) Diuretics
Loop Diuretics
Potassium Sparing Diuretics
Thiazide & Related Diuretics
HYDRODIURIL- GENERIC (hydrochlorothiazide) Combination Potassium Sparing/Thiazide Diuretics
ALDACTAZIDE- GENERIC (spironolactone/hctz) Alpha/Beta Blockers
Antituberculosis Agents
Misc. Antihypertensive Combinations
ACE Inhibitors
Antivirals
COMBIPRES- GENERIC (clonidine/chlorthalidone) INDERIDE- GENERIC (propranolol/hctz)LOTREL- GENERIC (amlodipine/benazepril) Angiotensin II Antagonists
TENORETIC- GENERIC (atenolol/chlorthalidone) Antiadrenergic-Centrally Acting Agents
Potassium Removing Resins
CATAPRES-TTS- GENERIC (clonidine transdermal) Cephalosporins
Antiadrenergic-Peripherally Acting Agents
Vasodilators
Nitrates
ISORDIL- GENERIC (isosorbide dinitrate)MONOKET- GENERIC (isosorbide mononitrate) Fluoroquinolones
Antiarrhythmics
NITRO-DUR- GENERIC (nitroglycerin transdermal) Macrolides
Peripheral Vasodilators
NORPACE- GENERIC (disopyramide phosphate) Penicillins
NORPACE CR- GENERIC (disopyramide phosphate CR) Vasopressors Used in Shock
AUGMENTIN/ES- GENERIC (amoxicillin/pot. clavulanate) QUINAGLUTE- GENERIC (quinidine gluconate ER) AUGMENTIN XR- GENERIC (amoxicillin/pot. clavulanate) Acetylcholinesterase Inhibitors
Sulfonamides
Beta-Blockers
Tetracyclines
Analgesics & Antipyretics
SECTRAL- GENERIC (acebutolol HCl)TENORMIN- GENERIC (atenolol) Agents for Migraines
Anti-infective Combinations
TOPROL XL- GENERIC (metoprolol succinate) CAFERGOT-GENERIC (ergotamine tartrate/caffeine) PEDIAZOLE- GENERIC (erythromycin eth/sulfisoxazole) Calcium Channel Blockers
Miscellaneous Anti-infectives
Narcotic Analgesics
DARVOCET-N – GENERIC (propoxyphene naps/APAP) Antipsychotic Agents
Other Dermatological Agents
TRIAVIL- GENERIC (perphenazine/amitriptyline HCl) Antivertigo & Antiemetics
Adrenal Corticosteroids
SUBOXONETALWIN NX- GENERIC (pentazocine HCl/naloxone HCl) TYLENOL w/CODEINE- GENERIC (APAP w/codeine)VICODIN- GENERIC (hydrocodone/APAP) Anxiolytics, Sedatives, & Hypnotics
FLORINEF ACETATE- GENERIC (fludrocortisone acet.) Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Agents & Supplies for Diabetes
TRANXENE- GENERIC (clorazepate dipotassium) CNS Stimulants/ Drugs for ADD-ADHD
Salicylates
GLUCOPHAGE XR- GENERIC (metformin HCl ER) RITALIN/SR- GENERIC (methylphenidate HCl) TRILISATE- GENERIC (choline-magnesium salicylates) GLUCOVANCE- GENERIC (glyburide/metformin) Miscellaneous CNS Agents
Miscellaneous Analgesics & Antipyretics
FIORICET- GENERIC (butalbital/APAP/caffeine) FIORINAL- GENERIC (butalbital/ASA/caffeine) Anticonvulsants
Skeletal Muscle Relaxants
PARAFON FORTE DSC- GENERIC (chlorzoxazone) METAGLIP – GENERIC (glipizide/metformin) Anti-infectives, Topical
CLEOCIN VAGINAL CREAM- GENERIC (clindamycin) CLEOCIN T- GENERIC (clindamycin phosphate) Agents for Gout
LOPROX 0.77% SUSP, CREAM- GENERIC (ciclopirox) Antidepressants
Androgens
NIZORAL 2% SHAMPOO- GENERIC (ketoconazole) Biphosphonates
SILVADENE- GENERIC (silver sulfasalazine) Contraceptive Hormones
PROZAC CAPSULES- GENERIC (fluoxetine HCl) Anti-infective/Anti-inflammatory Combinations
ALESSE- GENERIC (levonorgestrel/ethinyl estradiol) MYCOLOG II- GENERIC (nystatin/triamcinolone acetonide) DEMULEN- GENERIC (ethynodiol d/ethinyl estradiol) DEPO-PROVERA- GENERIC (medroxyprogesterone) Anti-inflammatory Agents
LOESTRIN- GENERIC (norethindrone/ethinyl estradiol) WELLBUTRIN SR- GENERIC (bupropion HCl SR) LO/OVRAL- GENERIC (norgestrel/ethinyl estradiol) WELLBUTRIN XL - GENERIC (bupropion HCl XL) DIPROSONE- GENERIC (betamethasone dipropionate) KENALOG- GENERIC (triamcinolone acetonide) MODICON- GENERIC (norethindrone/ethinyl estradiol) Antimania Agents
KENALOG IN ORABASE- GENERIC (triamcinolone) NORDETTE- GENERIC (levonorgestrel/ethinyl estradiol) ESKALITH CR- GENERIC (lithium carbonate ER) ORTHOCEPT- GENERIC (desogestrel/ethinyl estradiol) SYNALAR- GENERIC (fluocinolone acetonide) ORTHO-CYCLEN- GENERIC (norgestimate/ethinyl estradiol) Antiparkinson Agents
ULTRAVATE- GENERIC (halobetasol propionate) ORTHO-NOVUM- GENERIC (norethindrone/ethinyl estradiol) VALISONE- GENERIC (betamethasone valerate) ORTHO-NOVUM 1/50- GENERIC (norethindrone/mestranol) WESTCORT- GENERIC (hydrocortisone valerate) ORTHO-TRI-CYCLEN- GENERIC (norgest/ethinyl estradiol) OVRAL- GENERIC (norgestrel/ethinyl estradiol) Anti-psoriatic Agents
PARLODEL- GENERIC (bromocriptine mesylate) TRI-NORINYL- GENERIC (norethindrone/ethinyl estradiol) TRIPHASIL- GENERIC (levonorgestrel/ethinyl estradiol) YASMIN- GENERIC (drospierenone/ethinyl estradiol) YAZ- GENERIC (drospierenone/ethinyl estradiol) MaxorPlus National Tiered Drug Formulary
Nasal Antihistamines
ASTELIN NASAL SPRAY - GENERIC (azelastine HCl) Estrogens
Antihistamine/Decongestant Combinations
RONDEC- GENERIC (carbinoxamine/pseudoephedrine) Antitussive, Expectorant, & Combination Cough Agents
ENTEX PSE- GENERIC (guiafenesin/PSE)
Estrogen/Androgen Combinations
HYCODAN- GENERIC (hydrocodone bit/homatropine) ESTRATEST- GENERIC (methyltest./estrogens, est)ESTRATEST HS- GENERIC (methyltest./estrogens, est) Estrogen/Progestin Combinations
PHENERGAN w/CODEINE- GENERIC (promethazine/codeine) ROBITUSSIN AC- GENERIC (guaifenesin/codeine) ROBITUSSIN DAC- GENERIC (guaifenesin/codeine/PSE) Glucose Elevating Agents
CELLCEPT- GENERIC (mycophenolate mofetil) RONDEC DM- GENERIC (carbinoxamine/PSE/DM) Other Endocrine & Metabolic Agents
Bronchodilators
ATROVENT NEB SOLN- GENERIC (ipratropium Br) PARLODEL- GENERIC (bromocriptine mesylate) PROVENTIL- GENERIC (albuterol neb soln, tabs, syr) SLO BID- GENERIC (theophylline ER) Ovulation Stimulants
Agents for Glaucoma
PROFASI- GENERIC (chorionic gonadotropin) ALPHAGAN P- GENERIC (brimonidine tartrate) THEO-DUR- GENERIC (theophylline ER)VENTOLIN- GENERIC (albuterol) Progestins
PROVERA- GENERIC (medroxyprogesterone acetate) Combination Products, Orally Inhaled
Thyroid & Antithyroid Agents
DIAMOX SEQUELS- GENERIC (acetazolamide SR) Corticosteroids, Orally Inhaled
SYNTHROID- GENERIC (levothyroxine sodium) Leukotriene Receptor Antagonists
Antiallergenic Agents
Agents for PUD/GERD/H. pylori
Mast Cell Stabilizers
INTAL NEB SOLN- GENERIC (cromolyn sodium soln) Anti-infective Agents
Mucolytic Agents
NEOSPORIN- GENERIC (Neomycin/Polymixin B/Gramicidin) Nasal Preparations
ASTELIN NASAL SPRAY - GENERIC (azelastine HCl) POLYSPORIN- GENERIC (polymixin B/bacitracin) POLYTRIM- GENERIC (polymixin B/trimethoprim) Antidiarrheals
LOMOTIL- GENERIC (diphenoxylate HCl/atropine sulf.) Antispasmodics
Anti-infective/Anti-inflammatory Combinations
DONNATAL- GENERIC (belladonna/ergotamine/Pb) MAXITROL- GENERIC (dexamethasone/neomycin/polymixin B) TOBRADEX- GENERIC (tobramycin/dexamethasone) LEVSIN SL- GENERIC (hyoscyamine sulfate SL) VASOCIDIN- GENERIC (prednisolone sod phos/sulfacetamide) LIBRAX- GENERIC (chlordiazepoxide/clidinium Br) Anti-inflammatory Agents
Miscellaneous GI Agents
ANUSOL HC SUPP- GENERIC (hydrocortisone supp) POLY VI FLOR- GENERIC (polyvitamins w/fluoride) PRED FORTE- GENERIC (prednisolone acetate) POLY VI FLOR w/IRON- GENERIC (polyvitamins w/Fl & Fe) Mydriatic/Cycloplegic Agents
ISOPTO ATROPINE- GENERIC (atropine sulfate) CORTENEMA- GENERIC (hydrocortisone enema) TRI VI FLOR- GENERIC (triple vitamins w/Fluoride) GOLYTELY- GENERIC (polyethylene glycol/electrolytes) TRI VI FLOR w/IRON- GENERIC (triple vitamins w/Fl & Fe) PROCTOFOAM HCROWASA ENEMA- GENERIC (mesalamine) AURALGAN- GENERIC (antipyrine/benzocaine) CORTISPORIN OTIC- GENERIC (neomycin/polymixin B/HC) WELLCOVORIN- GENERIC (leucovorin calcium) VOSOL HC- GENERIC (acetic acid/hydrocortisone) DETROL/DETROL LADITROPAN- GENERIC (oxybutynin Cl) Antihistamines

Source: http://www.riohondoisd.net/departments/insurance/Maxor-%20Texas%20Pharmacies/Maxor%20-%202011%20Formulary.pdf