arkansas blue cross and blue shield standard with step ... bc… · your specific prescription...

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance

in this document.

January 2018

Arkansas Blue Cross and Blue Shield Standard with Step Drug List

The Arkansas Blue Cross and Blue Shield Standard with Step Therapy Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic

available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

PLAN MEMBER

Your benefit plan provides you with a prescription benefit program administered by Arkansas Blue Cross and Blue Shield, Health Advantage or Blue Advantage Administrators of Arkansas. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor.

Please note:

• Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market.

• You may be responsible for the full cost of non-formulary products that are removed from coverage.

• For specific information regarding your prescription benefit coverage and copay

1 information, please see website or contact

a customer service representative: www.arkansasbluecross.com

1-800-863-5561

healthadvantage-hmo.com 1-800-863-5567 blueadvantagearkansas.com 1-888-293-3748

• Your plan may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription.

• In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market.

HEALTH CARE PROVIDER

Your patient is covered under a prescription benefit plan administered by Arkansas Blue Cross and Blue Shield, Health Advantage or Blue Advantage Administrators of Arkansas. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand name on this list.

Please note:

• Generics should be considered the first line of prescribing.

• This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member's specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to the market.

• The member's prescription benefit plan may have a different copay for specific products on the list.

• Unless specifically indicated, drug list products will include all dosage forms.

• Logon to the plan’s website to check coverage and copay information for a specific medicine.

ANALGESICS

§ NSAIDs

diclofenac sodium

meloxicam

naproxen

§ NSAIDs, COMBINATIONS

diclofenac sodium-misoprostol

§ NSAIDs, TOPICAL

diclofenac sodium solution

VOLTAREN GEL PA

§ COX-2 INHIBITORS

celecoxib

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document.

§ GOUT

allopurinol colchicine tablet probenecid

COLCRYS

ULORIC ST

§ OPIOID ANALGESICS

codeine-acetaminophen QL

fentanyl transdermal QL

fentanyl transmucosal lozenge PA

hydrocodone- acetaminophen QL

hydromorphone QL

hydromorphone ext-rel QL

methadone QL

morphine QL

morphine ext-rel QL

morphine suppository QL

oxycodone QL

oxycodone- acetaminophen QL

tramadol QL

tramadol ext-rel QL

BELBUCA QL

BUTRANS QL

FENTORA PA

HYSINGLA ER QL

NUCYNTA QL

NUCYNTA ER QL

OXYCONTIN QL

SUBSYS PA

ANTI-INFECTIVES

ANTIBACTERIALS

§ CEPHALOSPORINS

cefdinir cefprozil cefuroxime axetil cephalexin

SUPRAX

§ ERYTHROMYCINS / MACROLIDES

azithromycin

clarithromycin

clarithromycin ext-rel erythromycins

DIFICID PA

§ FLUOROQUINOLONES

ciprofloxacin

ciprofloxacin ext-rel levofloxacin

moxifloxacin

§ PENICILLINS

amoxicillin

amoxicillin-clavulanate

dicloxacillin

penicillin VK

§ TETRACYCLINES

doxycycline hyclate

minocycline

tetracycline

§ ANTIFUNGALS

fluconazole

itraconazole PA

terbinafine tablet

ANTIRETROVIRAL AGENTS

§ ANTIRETROVIRAL COMBINATIONS

abacavir-lamivudine

ATRIPLA

COMPLERA

DESCOVY

EVOTAZ

GENVOYA

ODEFSEY

PREZCOBIX

STRIBILD

TRIUMEQ

TRUVADA

INTEGRASE INHIBITORS

ISENTRESS

TIVICAY

§ NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

abacavir tablet lamivudine

§ PROTEASE INHIBITORS

NORVIR

PREZISTA

REYATAZ

ANTIVIRALS

§ CYTOMEGALOVIRUS AGENTS

valganciclovir

§ HEPATITIS B AGENTS

VEMLIDY

§ HEPATITIS C AGENTS

ribavirin SGM

EPCLUSA

(genotypes 1, 2, 3, 4, 5, 6) SGM

HARVONI

(genotypes 1, 4, 5, 6) SGM

VOSEVI 2 SGM

§ HERPES AGENTS

acyclovir valacyclovir

§ INFLUENZA AGENTS

RELENZA QL

TAMIFLU QL

§ MISCELLANEOUS

clindamycin

ivermectin

metronidazole

nitrofurantoin

sulfamethoxazole-trimethoprim

EMVERM

SIVEXTRO

XIFAXAN 550 MG

ANTINEOPLASTIC

AGENTS

HORMONAL ANTINEOPLASTIC AGENTS

§ ANTIANDROGENS

bicalutamide

XTANDI SGM

ZYTIGA SGM

§ LUTEINIZING HORMONE-RELEASING HORMONE (LHRH) AGONISTS

ELIGARD SGM

LUPRON DEPOT †

§ KINASE INHIBITORS

imatinib mesylate SGM

BOSULIF SGM

CABOMETYX SGM

IBRANCE SGM

IRESSA SGM

KISQALI SGM

KISQALI FEMARA CO-PACK SGM

RYDAPT SGM

SPRYCEL SGM

CARDIOVASCULAR

§ ACE INHIBITORS

fosinopril lisinopril quinapril ramipril

§ ACE INHIBITOR / DIURETIC COMBINATIONS

fosinopril-hydrochlorothiazide

lisinopril-hydrochlorothiazide

quinapril-hydrochlorothiazide

§ ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC COMBINATIONS

candesartan / candesartan-hydrochlorothiazide

eprosartan

irbesartan / irbesartan-hydrochlorothiazide

losartan / losartan-hydrochlorothiazide

olmesartan / olmesartan-hydrochlorothiazide

telmisartan / telmisartan-hydrochlorothiazide

valsartan / valsartan-hydrochlorothiazide

§ ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine-olmesartan

amlodipine-telmisartan

amlodipine-valsartan

§ ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC COMBINATIONS

amlodipine-valsartan-hydrochlorothiazide

olmesartan-amlodipine-hydrochlorothiazide

§ ANTIARRHYTHMICS

sotalol MULTAQ

ANTILIPEMICS

§ BILE ACID RESINS

cholestyramine

WELCHOL

§ CHOLESTEROL ABSORPTION INHIBITORS

ezetimibe

§ FIBRATES

fenofibrate

fenofibric acid

§ HMG-CoA REDUCTASE INHIBITORS / COMBINATIONS

atorvastatin

ezetimibe-simvastatin

fluvastatin

lovastatin

pravastatin

rosuvastatin

simvastatin

MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS

JUXTAPID SGM

§ NIACINS

niacin ext-rel

§ OMEGA-3 FATTY ACIDS

omega-3 acid ethyl esters PA

VASCEPA PA

PCSK9 INHIBITORS

PRALUENT SGM

REPATHA SGM

§ BETA-BLOCKERS

atenolol carvedilol metoprolol succinate ext-rel metoprolol tartrate

nadolol pindolol propranolol propranolol ext-rel BYSTOLIC

COREG CR

§ CALCIUM CHANNEL BLOCKERS

amlodipine

diltiazem ext-rel 3

nifedipine ext-rel verapamil ext-rel

§ CALCIUM CHANNEL BLOCKER / ANTILIPEMIC COMBINATIONS

amlodipine-atorvastatin

§ DIGITALIS GLYCOSIDES

digoxin

DIRECT RENIN INHIBITORS / DIURETIC COMBINATIONS

TEKTURNA ST / TEKTURNA HCT ST

§ DIURETICS

amiloride

furosemide

hydrochlorothiazide

metolazone

spironolactone-hydrochlorothiazide

torsemide

triamterene-hydrochlorothiazide

HEART FAILURE

BIDIL

CORLANOR PA

ENTRESTO PA

§ NITRATES

nitroglycerin lingual spray

nitroglycerin sublingual

PULMONARY ARTERIAL HYPERTENSION

ENDOTHELIN RECEPTOR ANTAGONISTS

LETAIRIS SGM

OPSUMIT SGM

TRACLEER SGM

§ PHOSPHODIESTERASE INHIBITORS

sildenafil SGM

PROSTACYCLIN RECEPTOR AGONISTS

UPTRAVI SGM

§ PROSTAGLANDIN VASODILATORS

ORENITRAM SGM

SOLUBLE GUANYLATE CYCLASE STIMULATORS

ADEMPAS SGM

§ MISCELLANEOUS

RANEXA


CENTRAL NERVOUS

SYSTEM

§ ANTICONVULSANTS

carbamazepine

carbamazepine ext-rel diazepam rectal gel divalproex sodium

divalproex sodium ext-rel ethosuximide

gabapentin

lamotrigine

lamotrigine ext-rel levetiracetam

levetiracetam ext-rel oxcarbazepine

phenobarbital phenytoin

phenytoin sodium extended

primidone

tiagabine

topiramate

valproic acid

zonisamide

FYCOMPA

OXTELLAR XR

VIMPAT

§ ANTIDEMENTIA

donepezil galantamine

galantamine ext-rel memantine

rivastigmine

rivastigmine transdermal NAMENDA XR

NAMZARIC

ANTIDEPRESSANTS

§ SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

citalopram

escitalopram

fluoxetine

paroxetine

paroxetine ext-rel sertraline

FLUOXETINE 60 MG

TRINTELLIX ST

VIIBRYD ST

§ SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)

desvenlafaxine ext-rel duloxetine

venlafaxine

venlafaxine ext-rel capsule

§ MISCELLANEOUS AGENTS

bupropion

bupropion ext-rel mirtazapine

trazodone

§ ANTIPARKINSONIAN AGENTS

amantadine

carbidopa-levodopa

carbidopa-levodopa ext-rel carbidopa-levodopa-

entacapone

entacapone

pramipexole

ropinirole

ropinirole ext-rel selegiline

AZILECT

MIRAPEX ER

NEUPRO

ANTIPSYCHOTICS

§ ATYPICALS

aripiprazole

clozapine

olanzapine

quetiapine

risperidone

ziprasidone

ABILIFY MAINTENA

ARISTADA †

LATUDA ST

VRAYLAR ST

§ ATTENTION DEFICIT HYPERACTIVITY DISORDER

amphetamine-dextroamphetamine mixed salts

amphetamine-dextroamphetamine mixed salts ext-rel

atomoxetine

guanfacine ext-rel methylphenidate

methylphenidate ext-rel APTENSIO XR

QUILLIVANT XR

VYVANSE

FIBROMYALGIA

LYRICA ST, QL

SAVELLA

§ HUNTINGTON'S DISEASE AGENTS

tetrabenazine SGM

HYPNOTICS

§ NONBENZODIAZEPINES

eszopiclone

zolpidem

zolpidem ext-rel zolpidem sublingual BELSOMRA ST

TRICYCLICS

SILENOR ST

MIGRAINE

§ ERGOTAMINE DERIVATIVES

ergotamine-caffeine

§ SELECTIVE SEROTONIN AGONISTS

eletriptan QL

naratriptan QL

rizatriptan QL

sumatriptan QL

zolmitriptan QL

ONZETRA XSAIL ST

ZEMBRACE SYMTOUCH ST

ZOMIG NASAL SPRAY QL

§ MULTIPLE SCLEROSIS AGENTS

glatiramer SGM

AUBAGIO SGM

BETASERON SGM

COPAXONE 40 MG SGM

GILENYA SGM

REBIF SGM

TECFIDERA SGM

TYSABRI †

§ MUSCULOSKELETAL THERAPY AGENTS

cyclobenzaprine

§ NARCOLEPSY

armodafinil PA

POSTHERPETIC NEURALGIA (PHN)

GRALISE ST

PSYCHOTHERAPEUTIC - MISCELLANEOUS

§ OPIOID ANTAGONISTS

naloxone injection

NARCAN NASAL SPRAY

§ PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST COMBINATIONS

buprenorphine-naloxone sublingual tablet QL

SUBOXONE FILM QL

ZUBSOLV QL

PSEUDOBULBAR AFFECT AGENTS

NUEDEXTA

VASOMOTOR SYMPTOM AGENTS

BRISDELLE

ENDOCRINE AND

METABOLIC

ACROMEGALY

SOMATULINE DEPOT SGM

SOMAVERT SGM

§ ANDROGENS

testosterone gel 2% PA

testosterone solution PA

ANDRODERM PA

ANDROGEL 1.62% PA

ANTIDIABETICS

AMYLIN ANALOGS

SYMLINPEN

§ BIGUANIDES

metformin

metformin ext-rel

§ BIGUANIDE / SULFONYLUREA COMBINATIONS

glipizide-metformin

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

JANUVIA

TRADJENTA

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE COMBINATIONS

JANUMET

JANUMET XR

JENTADUETO

JENTADUETO XR

INCRETIN MIMETIC AGENTS

TRULICITY

VICTOZA

INCRETIN MIMETIC AGENT / INSULIN COMBINATIONS

SOLIQUA

INSULINS

BASAGLAR

HUMULIN R U-500

LEVEMIR

NOVOLIN 70/30 OTC

NOVOLIN N OTC

NOVOLIN R OTC

NOVOLOG

NOVOLOG MIX 70/30

TRESIBA

§ INSULIN SENSITIZERS

pioglitazone

§ INSULIN SENSITIZER / BIGUANIDE COMBINATIONS

pioglitazone-metformin

§ INSULIN SENSITIZER / SULFONYLUREA COMBINATIONS

pioglitazone-glimepiride

§ MEGLITINIDES

nateglinide

repaglinide

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS

FARXIGA

INVOKANA

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE COMBINATIONS

INVOKAMET

INVOKAMET XR

XIGDUO XR

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR COMBINATIONS

QTERN

§ SULFONYLUREAS

glimepiride

glipizide

glipizide ext-rel

SUPPLIES

BD ULTRAFINE INSULIN SYRINGES AND NEEDLES OTC

DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM

ONETOUCH ULTRA STRIPS AND KITS 4 OTC

ONETOUCH VERIO STRIPS AND KITS 4 OTC

CALCIUM REGULATORS

§ BISPHOSPHONATES

alendronate

ibandronate

risedronate

§ CALCITONINS

calcitonin-salmon

PARATHYROID HORMONES

FORTEO SGM

TYMLOS SGM

MISCELLANEOUS

PROLIA SGM

§ CARNITINE DEFICIENCY AGENTS

levocarnitine

CONTRACEPTIVES

§ MONOPHASIC

ethinyl estradiol-drospirenone

ethinyl estradiol-norethindrone acetate

BEYAZ

LO LOESTRIN FE


MINASTRIN 24 FE

SAFYRAL

§ TRIPHASIC

ethinyl estradiol-norgestimate

FOUR PHASE

NATAZIA

§ EXTENDED CYCLE

ethinyl estradiol-levonorgestrel

§ TRANSDERMAL

ethinyl estradiol-norelgestromin

VAGINAL

NUVARING

ESTROGENS

§ ORAL

estradiol estropipate

PREMARIN

§ TRANSDERMAL

estradiol DIVIGEL

EVAMIST

MINIVELLE

§ VAGINAL

estradiol ESTRACE CREAM

PREMARIN CREAM

ESTROGEN / PROGESTINS

§ ORAL

estradiol-norethindrone

PREMPHASE

PREMPRO

TRANSDERMAL

CLIMARA PRO

COMBIPATCH

ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS

DUAVEE

FERTILITY REGULATORS

GNRH / LHRH ANTAGONISTS

CETROTIDE

§ OVULATION STIMULANTS, GONADOTROPINS

GONAL-F PA

OVIDREL

GAUCHER DISEASE

CERDELGA SGM

CEREZYME †

§ GLUCOCORTICOIDS

dexamethasone

methylprednisolone

prednisolone solution

prednisone

GLUCOSE ELEVATING AGENTS

GLUCAGEN HYPOKIT

GLUCAGON EMERGENCY KIT

HUMAN GROWTH HORMONES

HUMATROPE SGM

NORDITROPIN SGM

§ PHOSPHATE BINDER AGENTS

calcium acetate

PHOSLYRA

RENVELA

VELPHORO

POTASSIUM-REMOVING AGENTS

VELTASSA

PROGESTINS

§ ORAL

medroxyprogesterone

megestrol acetate

progesterone, micronized

VAGINAL

CRINONE

ENDOMETRIN

§ SELECTIVE ESTROGEN RECEPTOR MODULATORS

raloxifene

OSPHENA

§ THYROID SUPPLEMENTS

levothyroxine

SYNTHROID

GASTROINTESTINAL

§ ANTIEMETICS

dronabinol PA, QL

granisetron QL

meclizine

metoclopramide

ondansetron QL

prochlorperazine

promethazine

trimethobenzamide

DICLEGIS

SANCUSO PA, QL

VARUBI QL

§ H2 RECEPTOR ANTAGONISTS

ranitidine

INFLAMMATORY BOWEL DISEASE

§ ORAL AGENTS

balsalazide

budesonide capsule

sulfasalazine

sulfasalazine delayed-rel APRISO

LIALDA

PENTASA

UCERIS

§ RECTAL AGENTS

hydrocortisone enema

mesalamine rectal suspension

CANASA

CORTIFOAM

§ IRRITABLE BOWEL SYNDROME

AMITIZA

LINZESS

LOTRONEX

VIBERZI

§ LAXATIVES

lactulose

peg 3350-electrolytes

SUPREP

OPIOID-INDUCED CONSTIPATION

MOVANTIK

PANCREATIC ENZYMES

CREON

VIOKACE

ZENPEP

§ PROTON PUMP INHIBITORS

esomeprazole

lansoprazole

omeprazole

pantoprazole

DEXILANT ST

§ STEROIDS, RECTAL

PROCTOFOAM-HC

§ ULCER THERAPY COMBINATIONS

PYLERA

GENITOURINARY

§ BENIGN PROSTATIC HYPERPLASIA

alfuzosin ext-rel doxazosin

dutasteride ST

dutasteride-tamsulosin

finasteride

tamsulosin

terazosin

RAPAFLO ST

§ URINARY ANTISPASMODICS

darifenacin ext-rel oxybutynin

oxybutynin ext-rel tolterodine

tolterodine ext-rel trospium

trospium ext-rel MYRBETRIQ ST

TOVIAZ ST

VESICARE ST

HEMATOLOGIC

§ ANTICOAGULANTS

warfarin

ELIQUIS

XARELTO

HEMATOPOIETIC GROWTH FACTORS

ARANESP SGM

PROCRIT SGM

ZARXIO †

HEMOPHILIA AGENTS

KOGENATE FS †

KOVALTRY †

NOVOEIGHT †

NUWIQ †

§ PLATELET AGGREGATION INHIBITORS

clopidogrel dipyridamole ext-rel-aspirin

prasugrel BRILINTA

IMMUNOLOGIC

AGENTS

ALLERGENIC EXTRACTS

GRASTEK PA

ORALAIR PA

RAGWITEK PA

AUTOIMMUNE AGENTS 5

COSENTYX SGM

ENBREL SGM

HUMIRA SGM

KEVZARA SGM

OTEZLA SGM

STELARA SUBCUTANEOUS SGM

§ DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)

RASUVO SGM

NUTRITIONAL /

SUPPLEMENTS

§ ELECTROLYTES

potassium chloride liquid

VITAMINS AND MINERALS

§ PRENATAL VITAMINS

prenatal vitamins

CITRANATAL

RESPIRATORY

§ ANAPHYLAXIS TREATMENT AGENTS

epinephrine auto-injector EPIPEN

EPIPEN JR

§ ANTICHOLINERGICS

ipratropium inhalation solution QL

INCRUSE ELLIPTA QL

SPIRIVA QL

ANTICHOLINERGIC / BETA AGONIST COMBINATIONS

§ SHORT ACTING

ipratropium-albuterol inhalation solution QL

COMBIVENT RESPIMAT QL

LONG ACTING

ANORO ELLIPTA QL

BEVESPI AEROSPHERE QL

STIOLTO RESPIMAT QL

BETA AGONISTS, INHALANTS

§ SHORT ACTING

albuterol inhalation solution QL

levalbuterol tartrate CFC-free aerosol QL

PROAIR HFA QL

PROAIR RESPICLICK QL

LONG ACTING

Hand-held Active Inhalation

SEREVENT QL

STRIVERDI RESPIMAT QL

Nebulized Passive Inhalation

PERFOROMIST QL

§ CYSTIC FIBROSIS

tobramycin inhalation solution SGM

BETHKIS SGM

§ LEUKOTRIENE MODULATORS

montelukast zafirlukast zileuton ext-rel

§ NASAL ANTIHISTAMINES

azelastine spray QL

olopatadine spray QL


§ NASAL STEROIDS / COMBINATIONS

flunisolide QL

fluticasone QL

mometasone nasal spray ST, QL

triamcinolone nasal spray QL

DYMISTA QL

PHOSPHODIESTERASE-4 INHIBITORS

DALIRESP

PULMONARY FIBROSIS AGENTS

ESBRIET SGM

OFEV SGM

STEROID / BETA AGONIST COMBINATIONS

ADVAIR QL

BREO ELLIPTA QL

SYMBICORT QL

§ STEROID INHALANTS

budesonide inhalation suspension QL

ASMANEX QL

FLOVENT DISKUS QL

FLOVENT HFA QL

PULMICORT FLEXHALER QL

QVAR QL

TOPICAL

DERMATOLOGY

§ ACNE

adapalene PA

benzoyl peroxide

clindamycin solution

clindamycin-benzoyl

peroxide

erythromycin solution

erythromycin-benzoyl peroxide

tretinoin PA

ACANYA ST

ATRALIN PA

BENZACLIN

DIFFERIN PA

EPIDUO

RETIN-A MICRO PA

TAZORAC PA

§ ACTINIC KERATOSIS

fluorouracil cream 5%

fluorouracil solution

imiquimod

PICATO

ZYCLARA

§ ANTIFUNGALS

ciclopirox PA

clotrimazole

econazole

ketoconazole

nystatin

JUBLIA PA

LUZU

NAFTIN

§ ANTIPSORIATICS

acitretin PA

calcipotriene

methoxsalen

ATOPIC DERMATITIS

Injectable

DUPIXENT SGM

§ Topical

tacrolimus

ELIDEL

CORTICOSTEROIDS

§ Low Potency

desonide

hydrocortisone

§ Medium Potency

clocortolone

hydrocortisone butyrate

mometasone

triamcinolone

§ High Potency

desoximetasone

fluocinonide

§ Very High Potency

clobetasol cream, foam, gel, lotion, ointment, shampoo

§ ROSACEA

metronidazole

FINACEA PA

ORACEA

SOOLANTRA PA

OPHTHALMIC

§ ANTIALLERGICS

azelastine

cromolyn sodium

olopatadine

LASTACAFT

PAZEO

§ ANTI-INFECTIVES

ciprofloxacin

erythromycin

gentamicin

levofloxacin

moxifloxacin

ofloxacin

sulfacetamide

tobramycin

BESIVANCE

CILOXAN OINTMENT

MOXEZA

§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS

neomycin-polymyxin B-bacitracin-hydrocortisone

neomycin-polymyxin B-dexamethasone

tobramycin-dexamethasone

TOBRADEX OINTMENT

TOBRADEX ST

ZYLET

ANTI-INFLAMMATORIES

§ Nonsteroidal

bromfenac

diclofenac

ketorolac QL

ACUVAIL

ILEVRO

NEVANAC

§ Steroidal

dexamethasone

prednisolone acetate 1%

DUREZOL

FLAREX

FML FORTE

FML S.O.P. MAXIDEX

PRED MILD

BETA-BLOCKERS

§ Nonselective

timolol maleate solution

BETIMOL

Selective

BETOPTIC S

§ CARBONIC ANHYDRASE INHIBITORS

dorzolamide

AZOPT

§ CARBONIC ANHYDRASE INHIBITOR / BETA-BLOCKER COMBINATIONS

dorzolamide-timolol

CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC COMBINATIONS

SIMBRINZA

DRY EYE DISEASE

RESTASIS

XIIDRA

§ PROSTAGLANDINS

latanoprost LUMIGAN ST

TRAVATAN Z ST

§ SYMPATHOMIMETICS

brimonidine

ALPHAGAN P

SYMPATHOMIMETIC / BETA-BLOCKER COMBINATIONS

COMBIGAN

OTIC

§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS

CIPRODEX

QUICK REFERENCE DRUG LIST

A

abacavir tablet

abacavir-lamivudine

ABILIFY MAINTENA

ACANYA ST

acitretin PA

ACUVAIL

acyclovir

adapalene PA

ADEMPAS SGM

ADVAIR QL

albuterol inhalation solution QL

alendronate

alfuzosin ext-rel

allopurinol

ALPHAGAN P

amantadine

amiloride

AMITIZA

amlodipine

amlodipine-atorvastatin

amlodipine-olmesartan

amlodipine-telmisartan

amlodipine-valsartan

amlodipine-valsartan-hydrochlorothiazide

amoxicillin

amoxicillin-clavulanate

amphetamine-dextroamphetamine mixed salts

amphetamine-dextroamphetamine mixed salts ext-rel

ANDRODERM PA

ANDROGEL 1.62% PA

ANORO ELLIPTA QL

APRISO

APTENSIO XR

ARANESP SGM

aripiprazole

ARISTADA †

armodafinil PA

ASMANEX QL

atenolol

atomoxetine

atorvastatin

ATRALIN PA

ATRIPLA

AUBAGIO SGM

azelastine

azelastine spray QL

AZILECT

azithromycin

AZOPT

B

balsalazide

BASAGLAR

BD ULTRAFINE INSULIN SYRINGES AND NEEDLES OTC

BELBUCA QL

BELSOMRA ST

BENZACLIN

benzoyl peroxide

BESIVANCE

BETASERON SGM

BETHKIS SGM

BETIMOL

BETOPTIC S

BEVESPI AEROSPHERE QL

BEYAZ

bicalutamide

BIDIL

BOSULIF SGM

BREO ELLIPTA QL

BRILINTA

brimonidine

BRISDELLE

bromfenac

budesonide capsule

budesonide inhalation suspension QL

buprenorphine-naloxone sublingual tablet QL

bupropion

bupropion ext-rel

BUTRANS QL

BYSTOLIC

C

CABOMETYX SGM

calcipotriene

calcitonin-salmon

calcium acetate

CANASA

candesartan


candesartan-hydrochlorothiazide

carbamazepine

carbamazepine ext-rel

carbidopa-levodopa

carbidopa-levodopa ext-rel

carbidopa-levodopa-entacapone

carvedilol

cefdinir

cefprozil

cefuroxime axetil

celecoxib

cephalexin

CERDELGA SGM

CEREZYME †

CETROTIDE

cholestyramine

ciclopirox PA

CILOXAN OINTMENT

CIPRODEX

ciprofloxacin

ciprofloxacin ext-rel

citalopram

CITRANATAL

clarithromycin

clarithromycin ext-rel

CLIMARA PRO

clindamycin

clindamycin solution

clindamycin-benzoyl peroxide

clobetasol cream, foam, gel, lotion, ointment, shampoo

clocortolone

clopidogrel

clotrimazole

clozapine

codeine-acetaminophen QL

colchicine tablet

COLCRYS

COMBIGAN

COMBIPATCH

COMBIVENT RESPIMAT QL

COMPLERA

COPAXONE 40 MG SGM

COREG CR

CORLANOR PA

CORTIFOAM

COSENTYX SGM

CREON

CRINONE

cromolyn sodium

cyclobenzaprine

D

DALIRESP

darifenacin ext-rel

DESCOVY

desonide

desoximetasone

desvenlafaxine ext-rel

dexamethasone

DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM

DEXILANT ST

diazepam rectal gel

DICLEGIS

diclofenac

diclofenac sodium

diclofenac sodium solution

diclofenac sodium-misoprostol

dicloxacillin

DIFFERIN PA

DIFICID PA

digoxin

diltiazem ext-rel 3

dipyridamole ext-rel-aspirin

divalproex sodium

divalproex sodium ext-rel

DIVIGEL

donepezil

dorzolamide

dorzolamide-timolol

doxazosin

doxycycline hyclate

dronabinol PA, QL

DUAVEE

duloxetine

DUPIXENT SGM

DUREZOL

dutasteride ST

dutasteride-tamsulosin

DYMISTA QL

E

econazole

eletriptan QL

ELIDEL PA

ELIGARD SGM

ELIQUIS

EMVERM

ENBREL SGM

ENDOMETRIN

entacapone

ENTRESTO PA

EPCLUSA SGM

EPIDUO

epinephrine auto-injector

EPIPEN

EPIPEN JR

eprosartan

ergotamine-caffeine

erythromycin

erythromycin solution

erythromycin-benzoyl peroxide

erythromycins

ESBRIET SGM

escitalopram

esomeprazole

ESTRACE CREAM

estradiol

estradiol-norethindrone

estropipate

eszopiclone

ethinyl estradiol-drospirenone

ethinyl estradiol-levonorgestrel

ethinyl estradiol-norelgestromin

ethinyl estradiol-norethindrone acetate

ethinyl estradiol-norgestimate

ethosuximide

EVAMIST

EVOTAZ

ezetimibe

ezetimibe-simvastatin

F

FARXIGA

fenofibrate

fenofibric acid

fentanyl transdermal QL

fentanyl transmucosal lozenge PA

FENTORA PA

FINACEA PA

finasteride

FLAREX

FLOVENT DISKUS QL

FLOVENT HFA QL

fluconazole

flunisolide QL

fluocinonide

fluorouracil cream 5%

fluorouracil solution

fluoxetine

FLUOXETINE 60 MG

fluticasone QL

fluvastatin

FML FORTE

FML S.O.P.

FORTEO SGM

fosinopril

fosinopril-hydrochlorothiazide

furosemide

FYCOMPA

G

gabapentin

galantamine

galantamine ext-rel

gentamicin

GENVOYA

GILENYA SGM

glatiramer SGM

glimepiride

glipizide

glipizide ext-rel

glipizide-metformin

GLUCAGEN HYPOKIT

GLUCAGON EMERGENCY KIT

GONAL-F PA

GRALISE ST

granisetron QL

GRASTEK PA

guanfacine ext-rel

H

HARVONI SGM

HUMATROPE SGM

HUMIRA SGM

HUMULIN R U-500

hydrochlorothiazide

hydrocodone-acetaminophen QL

hydrocortisone

hydrocortisone butyrate

hydrocortisone enema

hydromorphone QL

hydromorphone ext-rel QL

HYSINGLA ER QL

I

ibandronate

IBRANCE SGM

ILEVRO

imatinib mesylate SGM

imiquimod

INCRUSE ELLIPTA QL

INVOKAMET

INVOKAMET XR

INVOKANA

ipratropium inhalation solution QL

ipratropium-albuterol inhalation solution QL

irbesartan

irbesartan-hydrochlorothiazide

IRESSA SGM

ISENTRESS

itraconazole PA

ivermectin

J

JANUMET

JANUMET XR

JANUVIA

JENTADUETO

JENTADUETO XR

JUBLIA PA

JUXTAPID SGM

K

ketoconazole

ketorolac QL

KEVZARA SGM

KISQALI SGM

KISQALI FEMARA CO-PACK SGM

KOGENATE FS † KOVALTRY †

L

lactulose

lamivudine

lamotrigine

lamotrigine ext-rel

lansoprazole

LASTACAFT

latanoprost

LATUDA ST

LETAIRIS SGM

levalbuterol tartrate CFC-free aerosol QL

LEVEMIR

levetiracetam

levetiracetam ext-rel

levocarnitine

levofloxacin

levothyroxine

LIALDA

LINZESS

lisinopril

lisinopril-hydrochlorothiazide

LO LOESTRIN FE

losartan

losartan-hydrochlorothiazide

LOTRONEX

lovastatin

LUMIGAN ST

LUPRON DEPOT † LUZU

LYRICA ST, QL

M

MAXIDEX

meclizine

medroxyprogesterone

megestrol acetate

meloxicam

memantine

mesalamine rectal suspension

metformin

metformin ext-rel

methadone QL

methoxsalen

methylphenidate

methylphenidate ext-rel

methylprednisolone

metoclopramide

metolazone

metoprolol succinate ext-rel

metoprolol tartrate

metronidazole

MINASTRIN 24 FE

MINIVELLE

minocycline

MIRAPEX ER

mirtazapine

mometasone

mometasone nasal spray ST, QL

montelukast

morphine QL

morphine ext-rel QL

morphine suppository QL

MOVANTIK

MOXEZA

moxifloxacin

MULTAQ

MYRBETRIQ ST

N

nadolol

NAFTIN

naloxone injection

NAMENDA XR

NAMZARIC

naproxen

naratriptan QL

NARCAN NASAL SPRAY

NATAZIA

nateglinide

neomycin-polymyxin B-bacitracin-hydrocortisone

neomycin-polymyxin B-dexamethasone

NEUPRO

NEVANAC

niacin ext-rel

nifedipine ext-rel

nitrofurantoin

nitroglycerin lingual spray

nitroglycerin sublingual

NORDITROPIN SGM

NORVIR

NOVOEIGHT † NOVOLIN 70/30 OTC

NOVOLIN N OTC


NOVOLIN R OTC

NOVOLOG

NOVOLOG MIX 70/30

NUCYNTA QL

NUCYNTA ER QL

NUEDEXTA

NUVARING

NUWIQ †

nystatin

O

ODEFSEY

OFEV SGM

ofloxacin

olanzapine

olmesartan

olmesartan-amlodipine-hydrochlorothiazide

olmesartan-hydrochlorothiazide

olopatadine

olopatadine spray QL

omega-3 acid ethyl esters PA

omeprazole

ondansetron QL

ONETOUCH ULTRA STRIPS AND KITS 4 OTC

ONETOUCH VERIO STRIPS AND KITS 4 OTC

ONZETRA XSAIL ST

OPSUMIT SGM

ORACEA

ORALAIR PA

ORENITRAM SGM

OSPHENA

OTEZLA SGM

OVIDREL

oxcarbazepine

OXTELLAR XR

oxybutynin

oxybutynin ext-rel

oxycodone QL

oxycodone- acetaminophen QL

OXYCONTIN QL

P

pantoprazole

paroxetine

paroxetine ext-rel

PAZEO

peg 3350-electrolytes

penicillin VK

PENTASA

PERFOROMIST QL

phenobarbital

phenytoin

phenytoin sodium extended

PHOSLYRA

PICATO

pindolol

pioglitazone

pioglitazone-glimepiride

pioglitazone-metformin

potassium chloride liquid

PRALUENT SGM

pramipexole

prasugrel

pravastatin

PRED MILD

prednisolone acetate 1%

prednisolone solution

prednisone

PREMARIN

PREMARIN CREAM

PREMPHASE

PREMPRO

prenatal vitamins

PREZCOBIX

PREZISTA

primidone

PROAIR HFA QL

PROAIR RESPICLICK QL

probenecid

prochlorperazine

PROCRIT SGM

PROCTOFOAM-HC

progesterone, micronized

PROLIA SGM

promethazine

propranolol

propranolol ext-rel

PULMICORT FLEXHALER QL

PYLERA

Q

QTERN

quetiapine

QUILLIVANT XR

quinapril

quinapril-hydrochlorothiazide

QVAR QL

R

RAGWITEK PA

raloxifene

ramipril

RANEXA

ranitidine

RAPAFLO ST

RASUVO SGM

REBIF SGM

RELENZA QL

RENVELA

repaglinide

REPATHA SGM

RESTASIS

RETIN-A MICRO PA

REYATAZ

ribavirin SGM

risedronate

risperidone

rivastigmine

rivastigmine transdermal

rizatriptan QL

ropinirole

ropinirole ext-rel

rosuvastatin

RYDAPT SGM

S

SAFYRAL

SANCUSO PA, QL

SAVELLA

selegiline

SEREVENT QL

sertraline

sildenafil SGM

SILENOR ST

SIMBRINZA

simvastatin

SIVEXTRO

SOLIQUA

SOMATULINE DEPOT SGM

SOMAVERT SGM

SOOLANTRA PA

sotalol

SPIRIVA QL

spironolactone-hydrochlorothiazide

SPRYCEL SGM

STELARA SUBCUTANEOUS SGM

STIOLTO RESPIMAT QL

STRIBILD

STRIVERDI RESPIMAT QL

SUBOXONE FILM QL

SUBSYS PA

sulfacetamide

sulfamethoxazole-trimethoprim

sulfasalazine

sulfasalazine delayed-rel

sumatriptan QL

SUPRAX

SUPREP

SYMBICORT QL

SYMLINPEN

SYNTHROID

T

tacrolimus PA

TAMIFLU QL

tamsulosin

TAZORAC PA

TECFIDERA SGM

TEKTURNA ST

TEKTURNA HCT ST

telmisartan

telmisartan-hydrochlorothiazide

terazosin

terbinafine tablet

testosterone gel 2% PA

testosterone solution PA

tetrabenazine SGM

tetracycline

tiagabine

timolol maleate solution

TIVICAY

TOBRADEX OINTMENT

TOBRADEX ST

tobramycin

tobramycin inhalation solution SGM

tobramycin-dexamethasone

tolterodine

tolterodine ext-rel

topiramate

torsemide

TOVIAZ ST

TRACLEER SGM

TRADJENTA

tramadol QL

tramadol ext-rel QL

TRAVATAN Z ST

trazodone

TRESIBA

tretinoin PA

triamcinolone

triamcinolone nasal spray QL

triamterene-hydrochlorothiazide

trimethobenzamide

TRINTELLIX ST

TRIUMEQ

trospium

trospium ext-rel

TRULICITY

TRUVADA

TYMLOS SGM

TYSABRI †

U

UCERIS

ULORIC ST

UPTRAVI SGM

V

valacyclovir

valganciclovir

valproic acid

valsartan

valsartan-hydrochlorothiazide

VARUBI QL

VASCEPA PA

VELPHORO

VELTASSA

VEMLIDY

venlafaxine

venlafaxine ext-rel capsule

verapamil ext-rel

VESICARE ST

VIBERZI

VICTOZA

VIIBRYD ST

VIMPAT

VIOKACE

VOLTAREN GEL PA

VOSEVI 2 SGM

VRAYLAR ST

VYVANSE

W

warfarin

WELCHOL

X

XARELTO

XIFAXAN 550 MG

XIGDUO XR

XIIDRA

XTANDI SGM

Z

zafirlukast

ZARXIO † ZEMBRACE

SYMTOUCH ST

ZENPEP

zileuton ext-rel

ziprasidone

zolmitriptan QL

zolpidem

zolpidem ext-rel

zolpidem sublingual

ZOMIG NASAL SPRAY QL

zonisamide

ZUBSOLV QL

ZYCLARA

ZYLET

ZYTIGA SGM

PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)*

ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA ST, VRAYLAR ST

ACCU-CHEK STRIPS AND KITS 6 ONETOUCH ULTRA STRIPS AND KITS 4 OTC, ONETOUCH VERIO STRIPS AND KITS 4 OTC

ACTEMRA EMBREL SGM, HUMIRA SGM, KEVZARA SGM

ACTOS pioglitazone

DRUG NAME(S) PREFERRED OPTION(S)*

ADDERALL XR amphetamine-dextroamphetamine mixed salts ext-rel, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, VYVANSE

AEROSPAN ASMANEX QL, FLOVENT DISKUS QL, FLOVENT HFA QL, PULMICORT FLEXHALER QL, QVAR QL

ALCORTIN A desonide, hydrocortisone


.


ALLISON MEDICAL INSULIN SYRINGES 7

BD ULTRAFINE INSULIN SYRINGES OTC

ALOQUIN desonide, hydrocortisone

ALORA estradiol, DIVIGEL, EVAMIST, MINIVELLE

ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

ALVESCO ASMANEX QL, FLOVENT DISKUS QL, FLOVENT HFA QL, PULMICORT FLEXHALER QL, QVAR QL

AMRIX cyclobenzaprine

ANDROGEL 1% testosterone gel 2% PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA

ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO

ANTARA fenofibrate, fenofibric acid

APEXICON E desoximetasone, fluocinonide

APIDRA NOVOLOG

ARMOUR THYROID levothyroxine, SYNTHROID

ARTHROTEC celecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT ST

ASACOL HD balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA

ASCENSIA STRIPS AND KITS 6 ONETOUCH ULTRA STRIPS AND KITS 4 OTC, ONETOUCH VERIO STRIPS AND KITS 4 OTC

ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

ATROVENT HFA ipratropium inhalation solution QL, INCRUSE ELLIPTA QL, SPIRIVA QL

AXERT eletriptan QL, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL

AZELEX adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA ST, ATRALIN PA, BENZACLIN, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, TAZORAC PA

BECONASE AQ flunisolide QL, fluticasone QL, mometasone nasal spray ST, QL, triamcinolone nasal spray QL, DYMISTA QL

BENICAR, BENICAR HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

BENSAL HP desonide, hydrocortisone

BENZAC AC, BENZAC W adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA ST, ATRALIN PA, BENZACLIN, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA,


TAZORAC PA

BENZIQ adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA ST, ATRALIN PA, BENZACLIN, DIFFERIN PA, EPIDUO, RETIN-A MICRO PA, TAZORAC PA

BETAPACE, BETAPACE AF sotalol

BREEZE 2 STRIPS AND KITS 6 ONETOUCH ULTRA STRIPS AND KITS 4 OTC, ONETOUCH VERIO STRIPS AND KITS 4 OTC

butalbital-acetaminophen-caffeine capsule

eletriptan QL, ergotamine-caffeine, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL

BYDUREON TRULICITY, VICTOZA

BYETTA TRULICITY, VICTOZA

CAFERGOT eletriptan QL, ergotamine-caffeine, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL

CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA

CARDIZEM diltiazem ext-rel (except generic CARDIZEM LA)

CARDIZEM CD diltiazem ext-rel (except generic CARDIZEM LA)

CARDIZEM LA (and its generics) diltiazem ext-rel (except generic CARDIZEM LA)

CARNITOR levocarnitine

CARNITOR SF levocarnitine

CIMZIA COSENTYX SGM, EMBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS SGM

CLINDAGEL erythromycin solution

clobetasol spray clobetasol foam

CLOBEX SPRAY clobetasol foam

COLAZAL balsalazide

CONTOUR NEXT STRIPS AND KITS 6

ONETOUCH ULTRA STRIPS AND KITS 4 OTC, ONETOUCH VERIO STRIPS AND KITS 4 OTC

CONTOUR STRIPS AND KITS 6 ONETOUCH ULTRA STRIPS AND KITS 4 OTC, ONETOUCH VERIO STRIPS AND KITS 4 OTC

CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

DAKLINZA EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM

DELZICOL balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA

DETROL LA darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST, VESICARE ST

DEXPAK dexamethasone, methylprednisolone, prednisolone solution, prednisone

DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide,


.


losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

DORAL eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST

DORYX doxycycline hyclate

DORYX MPC doxycycline hyclate

DULERA ADVAIR QL, BREO ELLIPTA QL, SYMBICORT QL

DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide

DYRENIUM amiloride

EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

EDLUAR eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST

E.E.S. GRANULES erythromycins

EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

ELELYSO CERDELGA SGM, CEREZYME †

ENABLEX darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST, VESICARE ST

ENTYVIO HUMIRA SGM, STELARA SUBCUTANEOUS SGM

ERYPED erythromycins

ESTRING estradiol, ESTRACE CREAM, PREMARIN CREAM

EVZIO naloxone injection, NARCAN NASAL SPRAY

EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan

EXFORGE HCT amlodipine-olmesartan-hydrochlorothiazide, amlodipine-valsartan-hydrochlorothiazide

EXTAVIA glatiramer SGM, AUBAGIO SGM, BETASERON SGM, COPAXONE 40 MG SGM, GILENYA SGM, REBIF SGM, TECFIDERA SGM, TYSABRI †

FANAPT aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA ST, VRAYLAR ST

FEMRING estradiol, ESTRACE CREAM, PREMARIN CREAM

FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

FIORICET CAPSULE eletriptan QL, ergotamine-caffeine, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL

FIRST TESTOSTERONE testosterone gel 2% PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA

fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA

FOLLISTIM AQ GONAL-F PA

FORTAMET metformin, metformin ext-rel

FORTESTA testosterone gel 2% PA, testosterone solution PA,


ANDRODERM PA, ANDROGEL 1.62% PA

FOSAMAX PLUS D alendronate, ibandronate, risedronate

FOSRENOL calcium acetate, PHOSLYRA, RENVELA, VELPHORO

FREESTYLE STRIPS AND KITS 6 ONETOUCH ULTRA STRIPS AND KITS 4 OTC, ONETOUCH VERIO STRIPS AND KITS 4 OTC

FROVA eletriptan QL, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL

GENOTROPIN HUMATROPE SGM, NORDITROPIN SGM

GLEEVEC imatinib mesylate SGM, BOSULIF SGM, SPRYCEL SGM

GLUMETZA metformin, metformin ext-rel

HELIXATE FS KOGENATE FS †, KOVALTRY †, NOVOEIGHT †, NUWIQ †

HORIZANT gabapentin, GRALISE ST

HUMALOG NOVOLOG

HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN 70/30 NOVOLIN 70/30 OTC

HUMULIN N NOVOLIN N OTC

HUMULIN R NOVOLIN R OTC

INDOCIN celecoxib, diclofenac sodium, meloxicam, naproxen

INNOPRAN XL atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR

INTERMEZZO eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST

INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel, atomoxetine, guanfacine ext-rel, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, VYVANSE

ISTALOL timolol maleate solution, BETIMOL

JALYN dutasteride-tamsulosin; dutasteride ST or finasteride WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO ST

JARDIANCE FARXIGA, INVOKANA

KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

KINERET EMBREL SGM, HUMIRA SGM, KEVZARA SGM

KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

LANOXIN TABLET (125 MCG and 250 MCG only)

digoxin

LANTUS BASAGLAR, LEVEMIR, TRESIBA

LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin


.


LUNESTA eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA ST, SILENOR ST

MACRODANTIN nitrofurantoin

Matzim LA diltiazem ext-rel (except generic CARDIZEM LA)

MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM, VOSEVI 2 SGM

MENEST estradiol, estropipate, PREMARIN

MENOSTAR estradiol

MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO SGM, PROLIA SGM, TYMLOS SGM

MIACALCIN NASAL SPRAY calcitonin-salmon

MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide

MILLIPRED dexamethasone, methylprednisolone, prednisolone solution, prednisone

MINOCIN minocycline

MONODOX doxycycline hyclate

NAPRELAN celecoxib, diclofenac sodium, meloxicam, naproxen

NATESTO testosterone gel 2% PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA

NESINA JANUVIA, TRADJENTA

NEUPOGEN ZARXIO †

NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST

NILANDRON bicalutamide, XTANDI SGM, ZYTIGA SGM

NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual

NORITATE metronidazole, FINACEA PA, SOOLANTRA PA

NORVASC amlodipine

NOVACORT desonide, hydrocortisone

NOVO NORDISK NEEDLES 7 BD ULTRAFINE NEEDLES OTC

NUTROPIN AQ HUMATROPE SGM, NORDITROPIN SGM

NUVIGIL armodafinil

OLEPTRO trazodone

OLUX-E clobetasol foam

OLYSIO EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM

OMNARIS flunisolide QL, fluticasone QL, mometasone nasal spray ST, QL, triamcinolone nasal spray QL, DYMISTA QL

OMNITROPE HUMATROPE SGM, NORDITROPIN SGM

ONGLYZA JANUVIA, TRADJENTA

ORENCIA CLICKJECT COSENTYX SGM, EMBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS SGM

ORENCIA INTRAVENOUS COSENTYX SGM, EMBREL SGM, HUMIRA SGM,


KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS SGM

ORENCIA SUBCUTANEOUS COSENTYX SGM, EMBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS SGM

OSENI JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

OWEN MUMFORD NEEDLES 7 BD ULTRAFINE NEEDLES OTC

OXYTROL darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST, VESICARE ST

PANCREAZE CREON, VIOKACE, ZENPEP

PENNSAID diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL PA

PERRIGO NEEDLES 7 BD ULTRAFINE NEEDLES OTC

PERTZYE CREON, VIOKACE, ZENPEP

PEXEVA citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, FLUOXETINE 60 MG, TRINTELLIX ST, VIIBRYD ST

PLAVIX clopidogrel, prasugrel, BRILINTA

PRADAXA warfarin, ELIQUIS, XARELTO

PRECISION XTRA STRIPS AND KITS 6


PRED FORTE dexamethasone, prednisolone acetate 1%, DUREZOL, FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD

PREFERAOB generic prenatal vitamins, CITRANATAL

PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO

PRENATAL PLUS generic prenatal vitamins, CITRANATAL

PREVACID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST

PRIMLEV hydrocodone-acetaminophen QL, hydromorphone QL, morphine QL, oxycodone-acetaminophen QL, NUCYNTA QL

PROTONIX esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST

PROTOPIC tacrolimus PA, ELIDEL PA

PROVENTIL HFA levalbuterol tartrate CFC-free aerosol QL, PROAIR HFA QL, PROAIR RESPICLICK QL

QNASL flunisolide QL, fluticasone QL, mometasone nasal spray ST, QL, triamcinolone nasal spray QL, DYMISTA QL

RAYOS dexamethasone, methylprednisolone, prednisolone solution, prednisone

RELION INSULIN NOVOLIN INSULIN OTC

RELISTOR MOVANTIK

RHINOCORT AQUA flunisolide QL, fluticasone QL, mometasone nasal spray ST, QL, triamcinolone nasal spray QL, DYMISTA QL

RIMSO-50 Consult doctor

RIOMET metformin, metformin ext-rel

ROZEREM eszopiclone, zolpidem, zolpidem ext-rel,


.


zolpidem sublingual, BELSOMRA ST, SILENOR ST

SAIZEN HUMATROPE SGM, NORDITROPIN SGM

SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, VRAYLAR ST

SIMPONI COSENTYX SGM, ENBREL SGM, HUMIRA SGM, KEVZARA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS SGM

SPRIX diclofenac sodium, meloxicam, naproxen

STRIANT testosterone gel 2% PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA

SUMAVEL DOSEPRO eletriptan QL, naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL ST, ZEMBRACE SYMTOUCH ST, ZOMIG NASAL SPRAY QL

SURE-TEST STRIPS AND KITS 6 ONETOUCH ULTRA STRIPS AND KITS 4 OTC, ONETOUCH VERIO STRIPS AND KITS 4 OTC

SYNJARDY INVOKAMET, INVOKAMET XR, XIGDUO XR

SYNJARDY XR INVOKAMET, INVOKAMET XR, XIGDUO XR

TALTZ COSENTYX SGM, EMBREL SGM, HUMIRA SGM, OTEZLA SGM, STELARA SUBCUTANEOUS SGM

TANZEUM TRULICITY, VICTOZA

TASIGNA imatinib mesylate SGM, BOSULIF SGM, SPRYCEL SGM

TECHNIVIE EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM

TESTIM testosterone gel 2% PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA

testosterone gel 1% 8 testosterone gel 2% PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA

TOBI tobramycin inhalation solution SGM, BETHKIS SGM

TOBI PODHALER tobramycin inhalation solution SGM, BETHKIS SGM

TOUJEO BASAGLAR, LEVEMIR, TRESIBA

TRICOR fenofibrate, fenofibric acid

TRIGLIDE fenofibrate, fenofibric acid

TRILIPIX fenofibrate, fenofibric acid

TRIVIDIA INSULIN SYRINGES 7 BD ULTRAFINE INSULIN SYRINGES OTC

TRUETEST STRIPS AND KITS 6 ONETOUCH ULTRA STRIPS AND KITS 4 OTC, ONETOUCH VERIO STRIPS AND KITS 4 OTC

TRUETRACK STRIPS AND KITS 6


TUDORZA INCRUSE ELLIPTA QL, SPIRIVA QL

ULTIMED INSULIN SYRINGES 7 BD ULTRAFINE INSULIN SYRINGES OTC

ULTIMED NEEDLES 7 BD ULTRAFINE NEEDLES OTC


UROXATRAL alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO ST

VALCYTE valganciclovir

VALTREX acyclovir, valacyclovir

VANOXIDE-HC adapalene PA, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA ST, ATRALIN PA, BENZACLIN, DIFFERIN PA, EPIDUO, RETIN-A-MICRO PA, TAZORAC PA

venlafaxine ext-rel tablet (except 225 mg)

desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

VENLAFAXINE EXT-REL TABLET (except 225 MG)

desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

VENTOLIN HFA levalbuterol tartrate CFC-free aerosol QL, PROAIR HFA QL, PROAIR RESPICLICK QL

VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM

VIEKIRA XR EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM

VITAFOL-ONE generic prenatal vitamins, CITRANATAL

VOGELXO testosterone gel 2% PA, testosterone solution PA, ANDRODERM PA, ANDROGEL 1.62% PA

XELJANZ EMBREL SGM, HUMIRA SGM, KEVZARA SGM

XELJANZ XR EMBREL SGM, HUMIRA SGM, KEVZARA SGM

XENAZINE tetrabenazine SGM

XOPENEX HFA levalbuterol tartrate CFC-free aerosol QL, PROAIR HFA QL, PROAIR RESPICLICK QL

ZEGERID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST

ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) SGM, HARVONI (genotypes 1, 4, 5, 6) SGM

ZETIA ezetimibe

ZETONNA flunisolide QL, fluticasone QL, mometasone nasal spray ST, QL, triamcinolone nasal spray QL, DYMISTA QL

ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, VIMPAT

ZYFLO, ZYFLO CR montelukast, zafirlukast, zileuton ext-rel


You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information.

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay 1 for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed.

An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication.

* The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency.

§ Generics are available in this class and should be considered the first line of prescribing. † Coverage determined under the Medical Benefit

OTC Over the Counter

PA Prior Authorization

QL Quantity Limit

SGM Specialty Guideline Management

ST Step Therapy 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the

prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3 3 Listing does not include generic CARDIZEM LA. 4 A ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ONETOUCH. For more information on

how to obtain a blood glucose meter, call: 1-800-588-4456. 5 Coverage may be altered or copay1 amounts may vary based on the condition being treated (e.g. psoriasis). 6 ONETOUCH brand test strips are the only preferred options. 7 BD ULTRAFINE syringes and needles are the only preferred options. 8 Listing reflects the authorized generics for TESTIM and VOGELXO.

Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2017. All rights reserved. 106-1058413-1-010118

NOTICE 1557 09232016

NON-DISCRIMINATION AND LANGUAGE ASSISTANCE NOTICE

NOTICE: Our Company complies with applicable federal and state civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, disability, or sex.

We provide free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, written information in various formats (large print, audio, accessible electronic formats, other formats), and language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact our Civil Rights Coordinator.

If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Civil Rights Coordinator 601 Gaines Street, Little Rock, AR 72201 Phone: 1-844-662-2276; TDD: 1-844-662-2275

You can file a grievance in person, by mail, or by email. If you need help filing a grievance our Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201 Phone: 1-800-368-1019; TDD: 1-800-537-7697

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATTENTION: Language assistance services, free of charge, are available to you. Call 1- 844-662-2276.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-844-662-2276 .

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-844-662-2276.

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https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

NOTICE 1557 09232016

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ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-844-662-2276.

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注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-844-662-2276

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ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-844-662-2276.

1-488-227-7722 االتصال يرجى. لك بالنسبة مجانا المقدمة اللغوية والخدمات الفارسية، باللغة تتحدث كنت إذا :مالحظة .

સચુના: જો તમે ગજુરાતી બોલતા હો, તો નન:શલુ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો1-844-662-2276.

ध्यान दें: यदद आप ह िंदी बोलते हैं तो आपके ललए मुफ्त में भाषा सहायता सेवाए ंउपलब्ध हैं। 1-844-662-2276

पर कॉल करें।

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