1. No category

THE NYHTC & HANYC EMPLOYEE BENEFIT FUNDS DRUG FORMULARY
amoxicillin drops, susp)
amphetamine salts
ABILIFY [PA] (tab)
amphetamine salts combo-xr
acarbose
(cap)
acebutolol
acetaminophen/butalbital/caff ampicillin
anastrozole
eine
ANORO (inhalation powder)
acetaminophen/codeine
acetaminophen/hydrocodone APHTHASOL
apraclonidine ophth.
acetaminophen/oxycodone
ASACOL
acetazolamide
ASMANEX
acetic acid/alum otic
atenolol
acetic acid/hc otic
atenolol/chlorthalidone
acyclovir 800mg
atorvastatin (tab)
acyclovir (susp.)
acyclovir 200mg caps, 400mg atropine ophth.
ATROVENT HFA
ADVAIR (Diskus, HFA)
AVC
AEROCHAMBER
azathioprine (tab)
ALAMAST
azithromycin (powder, susp,
albuterol (nebul. Sol, syrup,
tab)
tablet)
albuterol (inhaler, inhalation AZOPT
solution, tab)
B ________________
alclometasone
bacitracin (ophth.)
alendronate
bacitracin/neomycin
allopurinol
/polymyxin/hc ophth.
baclofen
ALOCRIL
balsalazide disodium
ALOMIDE
balziva 0.04/0.035mg
ALPHAGAN-P
alprazolam
benazepril
benzonatate
ALREX
benzoyl peroxide (gel, liq)
amantadine
benzoyl peroxide w/
amcinonide
erythromycin (gel)
amiloride
benztropine
amiloride/hctz
betamethasone (crm, oint)
amiodarone
betamethasone/clotrimazole
amitriptyline
(crm, oint)
amlodipine
bethanechol
amoxicillin/clavunate
BETIMOL
(chewable, suspen., tab,
A ________________
January, 2015 v.1
BETOPTIC-S
bisoprolol
bisoprolol/hctz
BLEPHAMIDE
brimonidine
bromocriptine
budesonide (nebul sol)
bumetanide 0.5mg, 1mg
bupropion
bupropion-sr
bupropion-xl
buspirone 5mg, 10mg
CELEBREX [PA]
cephalexin
CHANTIX
CHEMET
CHEMOTHERAPY
(PARENTERAL) AGENTS [PA]
chlorhexidine gluconate
chloroquine
chlorpromazine
chlorpropamide
chlorthalidone
cholestyramine
cholestyramine lite
C ________________
ciclopirox (crm, gel, lotion)
cabergoline
calcipotriene (crm, ointm, soln) cimetidine 300mg, 400mg,
800mg
calcitonin spray
ciprofloxacin
calcium acetate
citalopram 20, 40mg
camila 0.35mg
clarithromycin (susp, tab)
CAMPRAL [PA]
CLEOCIN 100mg (vaginal
CANASA (suppository)
suppos.)
CAPEX 0.01% (shampoo)
clindamycin (cap, cream, gel,
captopril
lotion, solution)
captopril/hctz
clobetasol (crm, gel, ointm.,
carbamazepine
topical soln.)
carbamazepine-sr
clomiphene
carbidopa/levodopa
clomipramine
carbidopa/levodopa-sr
clonazepam
carisoprodol
clonidine (tab)
carisoprodol/aspirin
clonidine (patch)
carteolol ophthalmic
clopidogrel 75mg (tab)
carvedilol (tablet)
clorazepate
cefaclor
clotrimazole
cefadroxil
clotrimazole/betamethasone
cefdinir oral susp 125mg/5ml, colestipol
250mg/5ml (susp)
COMBIPATCH 0.05, 0.14
cefpodoxime
COMBIVENT
ceftriaxone
CREON
cefuroxime
CRINONE (gel)
The NYHTC & HANYC Drug Formulary is a list of preferred drugs, which are covered under your prescription drug plan. The Formulary
is subject to change without prior notice. The latest version of the Formulary is available online at hotelfunds.org. You are
encouraged to ask your doctor to treat your medical condition(s) with a drug listed on our Formulary.
DRUG FORMULARY KEY:
● CAPITAL LETTERS = Brand-name drugs. (the brand-name drug is no longer covered when its generic equal becomes available.)
● lowercase letters = FDA-approved generic drugs. (Generic drugs contain the same exact active ingredient as their brand-name equal,
although the shape, smell or color may differ. They are FDA-approved with the same strict standards as brand-name drugs.)
● [PA] = medication requiring prior authorization by the Medical Director. Coverage is not guaranteed.
● bold letters = 90-day supply program.
THE NYHTC & HANYC EMPLOYEE BENEFIT FUNDS DRUG FORMULARY
cromolyn (nebul soln)
cyclobenzaprine
cyclopentolate ophth.
cyclosporine (cap)
cyproheptadine
D ________________
danazol
desipramine
desmopressin
desonide
desoximetasone
DETROL LA [PA]
dexamethasone
diazepam (tab, gel)
dibenzyline
diclofenac (tab)
diclofenac/misoprostol (tab)
dicloxacillin
dicyclomine 10, 20mg
diflorasone
diflunisal
digoxin (tab)
diltiazem 30, 60, 90, 120mg
(tab)
diltiazem-cd
dipyridamole
disopyramide
divalproex sodium
divalproex-er
donepezil (tab)
dorzolamide
dorzolamide/timolol
doxazosin
doxepin (liquid)
doxepin (cap)
doxycycline
DULERA
E ________________
econazole
emoquette 0.15/0.03mg
enalapril
enalapril/hctz
enpresse-28
epinephrine auto-injector
epinephrine auto-injector jr.
erythromycin (caps, gel, ophth
ointm, susp, tab)
erythromycin/sulfisoxazole
escitalopram (tab)
estradiol (crm, patch)
estradiol (tab)
estrogen/methyltestosterone
estropipate 0.75, 1.5mg (tab)
ethambutol
ethosuximide
etodolac
EURAX (crm, lotion)
EXELDERM (crm, soln)
F ________________
famciclovir
famotidine 40mg
FEMCON-FE 0.4/0.035MG
fenofibrate 48mg, 54mg,
67mg, 134mg, 160mg (tab)
fentanyl
finasteride
FLAGYL ER
flavoxate
flecainide
FLOVENT (Diskus, HFA)
fluconazole (oral suspension,
tab)
fludrocortisone
flunisolide (nasal spray)
fluocinolone
fluocinonide 0.05% (crm,
ointm, soln)
fluoride oral supplements
(chewables, drops)
fluoride oral supplements
fluorometholone (ophth.
ointm & susp.)
fluorouracil (crm, top. soln)
fluoxetine
fluphenazine
flurazepam
flurbiprofen
fluticasone (nasal spray,
cream, ointment)
fluvoxamine
folic acid 1mg
FOLLISTIM AQ [PA]
furosemide
G ________________
gabapentin
ganciclovir
gemfibrozil
gentamicin (crm, ophth, oint,
soln)
glimepiride
glipizide
glipizide-xl
glucagon kit
glyburide
glyburide micronized
griseofulvin v (susp, tab)
guaifenesin/codeine
guanfacine
January, 2015 v.1
HIGHLY ACTIVE ANTIRETROVIRAL THERAPY
(HAART) AGENTS [PA]
homatropine
homatropine/hydrocodone
(syr)
hydralazine
hydrochlorothiazide
hydrocortisone 2.5% (lotion)
hydrocortisone (crm,
suppositories)
hydrocortisone/iodoquinol
hydrocortisone/pramoxine
hydromorphone
hydroquinone (crm)
hydroxychloroquine
hydroxyzine
hyoscyamine
hyoscyamine-er
I ________________
ibuprofen 400mg, 600mg,
800mg (tab)
imipramine
imiquimod (Limit: 12
packets/30 days)
indapamide
indomethacin 25mg, 50mg
ipratropium (neb. sol)
isoniazid
ISOPTO CARBACHOL
ISOPTO HOMATROPINE
H ________________ ISOPTO HYOSCINE
isosorbide dinitrate
[h.pylori 14-day triple therapy
amox/clarithomycin/lansopraz isosorbide mononitrate 30mg,
60mg, 120mg
ole]
halobetasol
HALOG (crm, oint)
haloperidol
heparin
J ________________
JANUMET
JANUMET-XR
JANUVIA
The NYHTC & HANYC Drug Formulary is a list of preferred drugs, which are covered under your prescription drug plan. The Formulary
is subject to change without prior notice. The latest version of the Formulary is available online at hotelfunds.org. You are
encouraged to ask your doctor to treat your medical condition(s) with a drug listed on our Formulary.
DRUG FORMULARY KEY:
● CAPITAL LETTERS = Brand-name drugs. (the brand-name drug is no longer covered when its generic equal becomes available.)
● lowercase letters = FDA-approved generic drugs. (Generic drugs contain the same exact active ingredient as their brand-name equal,
although the shape, smell or color may differ. They are FDA-approved with the same strict standards as brand-name drugs.)
● [PA] = medication requiring prior authorization by the Medical Director. Coverage is not guaranteed.
● bold letters = 90-day supply program.
THE NYHTC & HANYC EMPLOYEE BENEFIT FUNDS DRUG FORMULARY
jinteli 1/0.005mg
jolivette 0.35mg
junel 1/0.02mg or 1.5/.03mg
junel-fe 1.5/0.03mg
JUVISYNC
K ________________
kariva
kelnor 1/0.035mg
ketoconazole (crm, shampoo,
tab)
ketoprofen
ketorolac
L ________________
labetolol
lactic acid (lotion)
lactulose (syrup)
lamotrigine
LANTUS
latanoprost ophth.
LATUDA [PA] (tab)
leena
letrozole
leuprolide injection
levetiracetam
levobunolol ophth.
levofloxacin
levothyroxine (tablet)
LEVOXYL
lidocaine (crm, gel, ointm,
viscous liq)
lidocaine/prilocaine (top.)
LIDODERM [PA] (patch)
lindane
liothyronine
lisinopril
lisinopril/hctz
lithium carbonate
lorazepam
losartan
losartan/hctz
LOTEMAX
lovastatin
low-ogestrel 0.3/0.03mg
loxapine
M ________________
MAXAIR
mebendazole
meclofenamate
medroxyprogesterone
mefloquine
megestrol 20mg (tab)
meloxicam
meprobamate
MEPRON
mesalamine
metaproterenol (syr)
metformin
methazolamide
methimazole
methocarbamol
methotrexate (tab)
methyldopa
methylphenidate
methylphenidate-sr 20mg
methylprednisolone
metipranolol opht.
metoclopramide (syr, tab)
metolazone
metoprolol
metoprolol/hctz
metoprolol-xl
metronidazole (crm, vag. gel,
tab)
mexiletine
microgestin 1/0.02mg or
1.5/0.03mg
microgestin-fe 1/0.02mg or
1.5/0.03mg
minocycline
minoxidil
mirtazapine (tab)
misoprostol
mometasone (crm, lotion,
ointment)
montelukast (chew, tab)
morphine
MULTAQ [PA]
mupirocin (crm, ointm)
MYCOBUTIN
mycophenolate mofetil
N ________________
nabumetone
nadolol
naltrexone
naproxen
naproxen-ec
naratriptan
neomycin
neomycin/polymyxin/ hc
ophth. (crm, ointm, susp )
neomycin/polymyxin/gramici
din ophth.
nicotine (gum, lozenges,
patches)
nifedipine
nitrofurantoin
nitroglycerin (ointm, patch, SL,
spray)
norethindrone
nortrel 7/7/7 (0.5/0.035mg)
nortriptyline
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
January, 2015 v.1
NUVARING
nystatin (crm, ointm, powd,
susp)
O ________________
ocella 3-0.03mg
ofloxacin (ophth, otic)
orphenadrine
orphenadrine compound
ORTHO EVRA
ORTHO-PREFEST
OXSORALEN-ULTRA
oxybutynin
oxybutynin-xl
oxycodone
oxycodone/acetaminophen
oxycodone-er
P ________________
PANCREAZE
pantoprazole
paroxetine
peg 3350/electrolytes
PEGASYS [PA]
PEG-INTRON [PA]
penicilln vk
PENTASA
pentoxifylline-er
permethrin
perphenazine
perphenazine/amitriptyline
phenazopyridine
phenobarbital
phenytoin
PHISOHEX 0.3%
pilocarpine (ophth.)
PILOPINE HS
pindolol
piroxicam
podofilox
The NYHTC & HANYC Drug Formulary is a list of preferred drugs, which are covered under your prescription drug plan. The Formulary
is subject to change without prior notice. The latest version of the Formulary is available online at hotelfunds.org. You are
encouraged to ask your doctor to treat your medical condition(s) with a drug listed on our Formulary.
DRUG FORMULARY KEY:
● CAPITAL LETTERS = Brand-name drugs. (the brand-name drug is no longer covered when its generic equal becomes available.)
● lowercase letters = FDA-approved generic drugs. (Generic drugs contain the same exact active ingredient as their brand-name equal,
although the shape, smell or color may differ. They are FDA-approved with the same strict standards as brand-name drugs.)
● [PA] = medication requiring prior authorization by the Medical Director. Coverage is not guaranteed.
● bold letters = 90-day supply program.
THE NYHTC & HANYC EMPLOYEE BENEFIT FUNDS DRUG FORMULARY
polymyxin-b & trimethoprim
portia-28 0.15/0.03mg
potassium chloride
potassium chloride-er
PRADAXA [PA]
pramipexole
PRANDIN
pravastatin
prazosin
prednicarbate
prednisolone (oral liquid,
ophth. Drop)
prednisone (tab)
PREMARIN (tab, vag crm)
PREMPHASE
PREMPRO
prenatal plus vitamins
primidone
probenecid
procainamide
prochlorperazine
progesterone 50mg/ml
(injection)
promethazine (syr, tab)
promethazine/codeine
promethazine-dm
propranolol
propranolol-er
propranolol-la
propylthiouracil
PROTOPIC
PROVENTIL HFA
PULMICORT FLEXHALER
PULMOZYME
pyrazinamide
pyridostigmine
Q ________________
quetiapine fumarate
quinidine sulfate
quinidine sulfate-er
QVAR
R ________________
ramipril
ranitidine 150, 300mg
REGRANEX
RENAGEL
ribavirin (caps, tabs)
rifampin
risperidone (tab)
rizatriptan
ropinirole
sulindac
sumatriptan
SURMONTIL
SYNTHROID
T ________________
tacrolimus (cap)
TAMIFLU
tamoxifen
tamsulosin
temazepam
teraconazole vaginal
terazosin
terbinafine (tab)
testosterone depot
S ________________
tetracycline
salsalate 500mg
THEO-24 CR
SANTYL
theophylline-er
selegiline
thioridazine
selenium sulfide (lotion)
thiothixene
SEROQUEL-XR [PA]
ticlopidine
sertraline
timolol (sol)
silver sulfadiazine
timolol-xe (ophth.)
simvastatin
sodium citrate/citric acid (liq) TOBI NEB SOLN [PA]
tobramycin ophth.
SOLU-CORTEF
tobramycin/dexamethasone
sotalol 80mg
ophth.
SPIRIVA
TOBREX (ophth. ointment)
spironolactone 25mg
tolterodine
spironolactone/hctz
topiramate
sprintec 0.25/0.035mg
torsemide
sucralfate
tramadol
sulfacetamide sodium 10%
TRANSDERM-SCOP
ophth.
trazodone
sulfacetamide/prednisolone
triamcinolone (crm)
sulfacetamide/sulfur (lot)
triamcinolone (ointm)
sulfamethoxazoletrimethoprim
triamcinolone/orabase
sulfasalazine
triamterene/hctz
sulfasalazine-ec
triazolam
January, 2015 v.1
trifluoperazine
trifluridine ophth.
trihexyphenidyl
trimethobenzamide
trimethoprim/polymyxin
tri-sprintec
U ________________
urea 40% (crm, gel)
ursodiol
V ________________
VAGIFEM
valacyclovir
VALCYTE
valproic acid
vancomycin injectable
VANOXIDE-HC
venlafaxine (cap)
venlafaxine-er (cap)
verapamil
verapamil-er
VEXOL
VICTRELIS [PA]
VIGAMOX [PA]
VIREAD
VYTORIN
W ________________
warfarin
Z ________________
zafirlukast
ZENPEP
ZETIA
zolpidem
zonisamide
Diabetes Care Supplies
BAYER BREEZE-2 (Glucose test
strips - provided at cost)
BAYER BREEZE-2 (Glucometer)
BAYER CONTOUR (Glucometer)
The NYHTC & HANYC Drug Formulary is a list of preferred drugs, which are covered under your prescription drug plan. The Formulary
is subject to change without prior notice. The latest version of the Formulary is available online at hotelfunds.org. You are
encouraged to ask your doctor to treat your medical condition(s) with a drug listed on our Formulary.
DRUG FORMULARY KEY:
● CAPITAL LETTERS = Brand-name drugs. (the brand-name drug is no longer covered when its generic equal becomes available.)
● lowercase letters = FDA-approved generic drugs. (Generic drugs contain the same exact active ingredient as their brand-name equal,
although the shape, smell or color may differ. They are FDA-approved with the same strict standards as brand-name drugs.)
● [PA] = medication requiring prior authorization by the Medical Director. Coverage is not guaranteed.
● bold letters = 90-day supply program.
THE NYHTC & HANYC EMPLOYEE BENEFIT FUNDS DRUG FORMULARY
January, 2015 v.1
BAYER CONTOUR (Glucose test
strips - provided at cost)
BAYER CONTOUR NEXT
(Glucose test strips - provided
at cost)
BAYER CONTOUR NEXT EZ
(Glucometer)
BAYER MICROLANCETS
(Lancets)
The NYHTC & HANYC Drug Formulary is a list of preferred drugs, which are covered under your prescription drug plan. The Formulary
is subject to change without prior notice. The latest version of the Formulary is available online at hotelfunds.org. You are
encouraged to ask your doctor to treat your medical condition(s) with a drug listed on our Formulary.
DRUG FORMULARY KEY:
● CAPITAL LETTERS = Brand-name drugs. (the brand-name drug is no longer covered when its generic equal becomes available.)
● lowercase letters = FDA-approved generic drugs. (Generic drugs contain the same exact active ingredient as their brand-name equal,
although the shape, smell or color may differ. They are FDA-approved with the same strict standards as brand-name drugs.)
● [PA] = medication requiring prior authorization by the Medical Director. Coverage is not guaranteed.
● bold letters = 90-day supply program.