standard with step therapy drug list...not all formularies will require step therapy. pa – prior...

Not all formularies will require step therapy.

PA – Prior Authorization QL – Quantity Limit SGM – Specialty Guideline Management ST – Step Therapy OTC – Over the Counter§ – Generics are available in the class and should be considered the first line of prescribing

USAble Administrators

The USAble Administrators Standard with Step Therapy Drug List (formerly known as value drug list) is a guide within select therapeutic categories for clients, plan members and healthcare providers. Generics should always be considered the first option. 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 uppercase and lowercase italics and generic products in lowercase italics.

STANDARD WITH STEP THERAPY DRUG LIST

This is not a comprehensive list of covered medications. For the most up-to-date listing of medications, visit our website at: usableadmin.com.

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PLAN MEMBERYour benefit plan provides you with a prescription benefit program administered by USAble Administrators. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list with you when you or a covered family member sees a doctor.

Please note:• Your specific prescription plan 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 coverage and copay1 information, please see our website or contact a customer service representative:

usableadmin.com 1-888 872-2531

• 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 will be designated as a non-preferred option when a generic product becomes available to the market.

HEALTHCARE PROVIDERYour patient is covered under a prescription benefit plan administered by Arkansas Blue Cross and Blue Shield, Health Advantage or BlueAdvantage Administrators of Arkansas. As a way to help manage healthcare 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 into the market.

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

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

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

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ANALGESICS§ NSAIDsdiclofenac sodiummeloxicamnaproxen

§ NSAIDs, COMBINATIONSdiclofenac sodium- misoprostol

§ NSAIDs, TOPICALdiclofenac sodium solutionVOLTAREN GEL PA

§ COX-2 INHIBITORScelecoxib

§ GOUTallopurinolcolchicine tabletprobenecidCOLCRYSULORIC ST

§ OPIOID ANALGESICScodeine-acetaminophenfentanyl transdermalfentanyl transmucosal lozenge PAhydrocodone-acetaminophenhydromorphonehydromorphone ext-relmethadonemorphinemorphine ext-rel QLmorphine suppositoryoxycodoneoxycodone-acetaminophentramadoltramadol ext-relBUTRANSFENTORA PAHYSINGLA ER QLNUCYNTA QLNUCYNTA ER QLOPANA ER QLOXYCONTIN QLSUBSYS PA

ANTI-INFECTIVESANTIBACTERIALS§ CEPHALOSPORINScefdinircefprozilcefuroxime axetilcephalexinSUPRAX

§ ERYTHROMYCINS / MACROLIDESazithromycinclarithromycinclarithromycin ext-relerythromycinsDIFICID

§ FLUOROQUINOLONESciprofloxacinciprofloxacin ext-rellevofloxacinmoxifloxacin

§ PENICILLINSamoxicillinamoxicillin-clavulanate

dicloxacillinpenicillin VK

§ TETRACYCLINESdoxycycline hyclateminocyclinetetracycline

§ ANTIFUNGALSfluconazoleitraconazole PAterbinafine tablet

ANTIRETROVIRAL AGENTS§ ANTIRETROVIRAL COMBINATIONSATRIPLACOMPLERAEPZICOMEVOTAZPREZCOBIXSTRIBILDTRIUMEQTRUVADA

INTEGRASE INHIBITORSISENTRESSTIVICAY

§ NUCLEOSIDE REVERSE TRAN-SCRIPTASE INHIBITORSabacavirlamivudine

PROTEASE INHIBITORSNORVIRPREZISTAREYATAZ

ANTIVIRALS

§ CYTOMEGALOVIRUS AGENTS valganciclovir

§ HEPATITIS C AGENTSribavirin SGMEPCLUSA (genotypes 2, 3) SGMHARVONI (genotypes 1, 4, 5, 6) SGM

§ HERPES AGENTSacyclovirvalacyclovir

INFLUENZA AGENTSRELENZA QLTAMIFLU QL

§ MISCELLANEOUSclindamycinivermectinmetronidazolenitrofurantoinsulfamethoxazole-trimethoprimALBENZASIVEXTROXIFAXAN 550 MG

ANTINEOPLASTIC AGENTSHORMONAL ANTINEOPLAS-TIC AGENTS § ANTIANDROGENSbicalutamide

ZYTIGA SGM

KINASE INHIBITORSimatinib mesylate SGMBOSULIF SGMSPRYCEL SGM

KINASE INHIBITORSVISTOGARD

CARDIOVASCULAR§ ACE INHIBITORSfosinoprillisinoprilquinaprilramipril

§ ACE INHIBITOR / DIURETIC COMBINATIONSfosinopril-hydrochlorothiazidelisinopril-hydrochlorothiazidequinapril-hydrochlorothiazide

§ ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC COMBINATIONScandesartan / candesartan-

hydrochlorothiazideeprosartanirbesartan / irbesartan-

hydrochlorothiazidelosartan / losartan-hydrochlorothiazidetelmisartan / telmisartan-

hydrochlorothiazidevalsartan / valsartan-hydrochlorothiazideBENICAR/ BENICAR HCT

§ ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER COMBINATIONSamlodipine-telmisartanamlodipine-valsartanAZOR

§ ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC COMBINATIONSamlodipine-valsartan-

hydrochlorothiazideTRIBENZOR

ANTILIPEMICS§ BILE ACID RESINScholestyramineWELCHOL

CHOLESTEROL ABSORPTION INHIBITORSZETIA

§ FIBRATESfenofibratefenofibric acid

§ HMG-CoA REDUCTASE INHIBITORS / COMBINATIONSatorvastatinfluvastatinlovastatinpravastatin

rosuvastatin simvastatinVYTORIN ST

§ NIACINSniacin ext-rel

§ OMEGA-3 FATTY ACIDSomega-3 acid ethyl estersVASCEPA

PCSK9 INHIBITORSREPATHA SGM

§ BETA-BLOCKERSatenololcarvedilolmetoprolol succinate ext-relmetoprolol tartratenadololpropranololpropranolol ext-relBYSTOLICCOREG CR

§ CALCIUM CHANNEL BLOCKERSamlodipinediltiazem ext-rel 2

nifedipine ext-relverapamil ext-rel

§ CALCIUM CHANNEL BLOCKER / ANTILIPEMIC COMBINATIONSamlodipine-atorvastatin

§ DIGITALIS GLYCOSIDESdigoxin

DIRECT RENIN INHIBITORS / DIURETIC COMBINATIONSTEKTURNA ST/ TEKTURNA HCT ST

§ DIURETICSfurosemidehydrochlorothiazidemetolazonespironolactone-hydrochlorothiazidetorsemidetriamterene-hydrochlorothiazide

NEPRILYSIN INHIBITOR / AN-GIOTENSIN II RECEPTOR AN-TAGONIST COMBINATIONSENTRESTO PA

§ NITRATESnitroglycerin lingual sprayNITROLINGUALNITROSTAT

NITRATE / VASODILATOR COMBINATIONSBIDIL

PULMONARY ARTERIAL HYPERTENSIONENDOTHELIN RECEPTOR

ANTAGONISTSLETAIRIS SGMTRACLEER SGM

§ PHOSPHODIESTERASE INHIBITORS

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sildenafil SGM

PROSTAGLANDIN VASODILATORSORENITRAM SGM

SOLUBLE GUANYLATE CYCLASE STIMULATORSADEMPAS SGM

MISCELLANEOUSRANEXA

CENTRAL NERVOUS SYSTEM§ ANTICONVULSANTScarbamazepinecarbamazepine ext-reldiazepam rectal geldivalproex sodiumdivalproex sodium ext-relethosuximide gabapentinlamotriginelamotrigine ext-rellevetiracetamlevetiracetam ext-reloxcarbazepinephenobarbitalphenytoinphenytoin sodium extendedprimidonetiagabinetopiramatevalproic acidzonisamideFYCOMPAOXTELLAR XR VIMPAT PA

§ ANTIDEMENTIAdonepezilgalantaminegalantamine ext-relmemantinerivastigminerivastigmine transdermalNAMENDA XR

ANTIDEPRESSANTS§ SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)citalopramescitalopramfluoxetineparoxetineparoxetine ext-relsertralineFLUOXETINE 60 MGTRINTELLIX STVIIBRYD ST

§ SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)duloxetinevenlafaxinevenlafaxine ext-rel capsulePRISTIQ ST

§ MISCELLANEOUS AGENTSbupropionbupropion ext-relmirtazapinetrazodone

§ ANTIPARKINSONIAN AGENTSamantadinecarbidopa-levodopacarbidopa-levodopa ext-relcarbidopa-levodopa-entacaponeentacaponepramipexoleropiniroleropinirole ext-relselegilineAZILECTMIRAPEX ERNEUPRO

ANTIPSYCHOTICS§ ATYPICALSaripiprazoleclozapineolanzapinequetiapinerisperidoneziprasidoneARISTADA †LATUDA STSEROQUEL XR

§ ATTENTION DEFICIT HY-PERACTIVITY DISORDERamphetamine-dextroamphetamine mixed saltsamphetamine-dextroamphetamine mixed salts ext-relguanfacine ext-relmethylphenidatemethylphenidate ext-relAPTENSIO XRQUILLIVANT XRSTRATTERAVYVANSE

FIBROMYALGIALYRICA STSAVELLA

§ HUNTINGTON’S DISEASE AGENTStetrabenazine SGM

HYPNOTICS§ NONBENZODIAZEPINESeszopiclone zolpidem zolpidem ext-rel

TRICYCLICSSILENOR ST

MIGRAINE§ SELECTIVE SEROTONIN AGONISTSnaratriptan QLrizatriptan QLsumatriptan QLzolmitriptan QLRELPAX ST, QLZOMIG NASAL SPRAY QL

MULTIPLE SCLEROSIS AGENTSAUBAGIO SGMCOPAXONE SGMGILENYA SGMREBIF SGMTECFIDERA SGM

§ MUSCULOSKELETAL THERAPY AGENTScyclobenzaprine

NARCOLEPSYNUVIGIL PA

POSTHERPETIC NEURALGIAGRALISE ST

PSYCHOTHERAPEUTIC - MISCELLANEOUS§ OPIOID ANTAGONISTSnaloxone injectionNARCAN NASAL SPRAY

§ PARTIAL OPIOID AGONIST / OPI-OID ANTAGONIST COMBINATIONSbuprenorphine-naloxone sublingual

tablet PASUBOXONE FILM PA

VASOMOTOR SYMPTOM AGENTSBRISDELLE

ENDOCRINE AND METABOLIC§ ANDROGENSANDRODERM PAAXIRON PA

ANTIDIABETICS

AMYLIN ANALOGSSYMLINPEN

§ BIGUANIDESmetforminmetformin ext-rel

§ BIGUANIDE / SULFONYLUREA COMBINATIONSglipizide-metformin

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORSJANUVIATRADJENTA

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR COMBINATIONSJANUMETJANUMET XRJENTADUETOJENTADUETO XR

INCRETIN MIMETIC AGENTSTRULICITY VICTOZA

INSULINSBASAGLAR † HUMULIN R U-500LEVEMIRNOVOLIN 70/30 OTCNOVOLIN N OTCNOVOLIN R OTCNOVOLOGNOVOLOG MIX 70/30TRESIBA

§ INSULIN SENSITIZERSpioglitazone

§ INSULIN SENSITIZER / BIGUA-NIDE COMBINATIONSpioglitazone-metformin

§ INSULIN SENSITIZER / SULFONY-LUREA COMBINATIONSpioglitazone-glimepiride

§ MEGLITINIDESnategliniderepaglinide

SODIUM-GLUCOSE CO-TRANS-PORTER 2 (SGLT2) INHIBITORSFARXIGAJARDIANCE

SODIUM-GLUCOSE CO-TRANS-PORTER 2 (SGLT2) INHIBITOR /BIGUANIDE COMBINATIONSXIGDUO XR

§ SULFONYLUREASglimepirideglipizideglipizide ext-rel

SUPPLIESBD INSULIN SYRINGES

AND NEEDLES OTCDEXCOM CONTINUOUS GLUCOSE

MONITORING SYSTEMONETOUCH ULTRA STRIPS

AND KITS3 OTCONETOUCH VERIO STRIPS

AND KITS3 OTC

CALCIUM REGULATORS§ BISPHOSPHONATESalendronateibandronaterisedronateATELVIA

§ CALCITONINScalcitonin-salmon

PARATHYROID HORMONESFORTEO SGM

§ CARNITINE DEFICIENCY AGENTSlevocarnitine

CONTRACEPTIVES§ MONOPHASICethinyl estradiol-drospirenoneethinyl estradiol-norethindrone acetateBEYAZLO LOESTRIN FEMINASTRIN 24 FESAFYRAL

§ TRIPHASICethinyl estradiol-norgestimateORTHO TRI-CYCLEN LO

FOUR PHASENATAZIA

§ EXTENDED CYCLEethinyl estradiol-levonorgestrel

5

§ TRANSDERMALethinyl estradiol-norelgestromin

VAGINALNUVARING

ESTROGENS§ ORALestradiolestropipatePREMARIN

§ TRANSDERMALestradiolDIVIGELEVAMISTMINIVELLE

VAGINALESTRACE CREAMPREMARIN CREAMVAGIFEM

ESTROGEN / PROGESTINS § ORALestradiol-norethindronePREMPHASEPREMPRO

ESTROGEN / SELECTIVE ES-TROGEN RECEPTOR MODU-LATOR COMBINATIONSDUAVEE

FERTILITY REGULATORSGNRH / LHRH ANTAGONISTSCETROTIDE PA

§ OVULATION STIMULANTS, GO-NADOTROPINSFOLLISTIM AQ PAOVIDREL PA

§ GLUCOCORTICOIDSdexamethasonemethylprednisoloneprednisone

GLUCOSE ELEVATING AGENTSGLUCAGEN HYPOKITGLUCAGON EMERGENCY KIT

HUMAN GROWTH HOR-MONESHUMATROPE SGMNORDITROPIN SGM

§ PHOSPHATE BINDER AGENTScalcium acetatePHOSLYRARENVELAVELPHORO

PROGESTINS§ ORALmedroxyprogesteroneprogesterone, micronizedMEGACE ES

VAGINALCRINONEENDOMETRIN

§ SELECTIVE ESTROGEN RECEPTOR MODULATORSraloxifeneOSPHENA

§ THYROID SUPPLEMENTSlevothyroxineSYNTHROID

GASTROINTESTINAL§ ANTIEMETICSdronabinol PA, QLgranisetron QLmeclizinemetoclopramideondansetron QLprochlorperazinepromethazinetrimethobenzamideDICLEGISSANCUSO PA,QLVARUBI QL

§ H2 RECEPTOR ANTAGO-NISTSranitidine

INFLAMMATORY BOWEL DISEASE§ ORAL AGENTSbalsalazidebudesonide capsulesulfasalazinesulfasalazine delayed-relAPRISOLIALDAPENTASAUCERIS

§ RECTAL AGENTShydrocortisone enemamesalamine rectal suspensionCANASACORTIFOAM

IRRITABLE BOWEL SYN-DROMEAMITIZA LINZESSLOTRONEXVIBERZI

§ LAXATIVESlactulosepeg 3350-electrolytesMOVIPREP SUPREP

OPIOID-INDUCED CONSTI-PATIONMOVANTIK

PANCREATIC ENZYMESCREONVIOKACEZENPEP

§ PROTON PUMP INHIBI-TORSesomeprazolelansoprazoleomeprazoleDEXILANT ST

§ STEROIDS, RECTALPROCTOFOAM-HC

§ ULCER THERAPY COMBI-NATIONSPYLERA

GENITOURINARY§ BENIGN PROSTATIC HY-PERPLASIAalfuzosin ext-reldoxazosindutasteride finasteridetamsulosinterazosinCARDURA XL STRAPAFLO ST

§ URINARY ANTISPASMOD-ICSoxybutyninoxybutynin ext-reltolterodinetolterodine ext-reltrospiumtrospium ext-relMYRBETRIQ STTOVIAZ STVESICARE ST

HEMATOLOGIC§ ANTICOAGULANTSwarfarinELIQUISXARELTO

HEMATOPOIETIC GROWTH FACTORSARANESP SGMPROCRIT SGMZARXIO SGM †

HEMOPHILIA AGENTSKOGENATE FS †KOVALTRY †NOVOEIGHT †NUWIQ †

§ PLATELET AGGREGATION INHIBITORSclopidogreldipyridamole ext-rel-aspirinBRILINTAEFFIENT

IMMUNOLOGIC AGENTSALLERGENIC EXTRACTSGRASTEK PAORALAIR PARAGWITEK PABIOLOGIC DISEASE-MODI-FYING AGENTS 6

ENBREL SGMHUMIRA SGM

§ DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)RASUVO SGM

NUTRITIONAL / SUPPLEMENTS§ ELECTROLYTESpotassium chloride liquid

VITAMINS AND MINERALS§ PRENATAL VITAMINSprenatal vitamins CITRANATAL

RESPIRATORYANAPHYLAXIS TREATMENT AGENTSEPIPENEPIPEN JR

§ ANTICHOLINERGICSSPIRIVA QL

ANTICHOLINERGIC / BETA AGONIST COMBINATIONS§ SHORT ACTINGipratropium-albuterol

inhalation solution QLCOMBIVENT RESPIMAT QL

BETA AGONISTS, INHALANTS§ SHORT ACTINGalbuterol inhalation solution QLPROAIR HFA QLPROAIR RESPICLICK QL

LONG ACTINGHand-held Active Inhalation ARCAPTA QLSEREVENT QL

Nebulized Passive InhalationPERFOROMIST QL

§ CYSTIC FIBROSIStobramycin inhalation solution SGMBETHKIS SGM

§ LEUKOTRIENE RECEPTOR ANTAGONISTSmontelukastzafirlukast

§ NASAL ANTIHISTAMINESazelastine spray QLolopatadine spray QL

§ NASAL STEROIDS / COMBINATIONSflunisolide QLfluticasone QLmometasone nasal spray QLtriamcinolone nasal spray QLDYMISTA QL ST

PHOSPHODIESTERASE-4 INHIBITORSDALIRESP

PULMONARY FIBROSIS AGENTSESBRIET SGMOFEV SGM

STEROID / BETA AGONIST COMBINATIONSADVAIR QLBREO ELLIPTA QLDULERA QL

§ STEROID INHALANTSbudesonide inhalation suspension QLASMANEX QLFLOVENT DISKUS QLFLOVENT HFA QLPULMICORT FLEXHALER QLQVAR QL

TOPICALDERMATOLOGY§ ACNEadapalenebenzoyl peroxideclindamycin solutionclindamycin-benzoyl peroxideerythromycin solutionerythromycin-benzoyl peroxidetretinoinACANYA STATRALIN PABENZACLINDIFFERIN PAEPIDUORETIN-A MICRO PATAZORAC PA

§ ACTINIC KERATOSISfluorouracil cream 5%fluorouracil solutionimiquimodPICATOZYCLARA

§ ANTIFUNGALSciclopirox PAclotrimazole

econazoleketoconazolenystatinJUBLIA PALUZUNAFTIN

§ ANTIPSORIATICSacitretincalcipotrienemethoxsalen

CORTICOSTEROIDS§ Low Potencydesonidehydrocortisone

§ Medium Potencyhydrocortisone butyratemometasonetriamcinoloneCLODERMLOCOID LOTION

§ High Potencydesoximetasonefluocinonide

§ Very High Potencyclobetasol cream, foam, gel, lotion,

ointment, shampoo

§ IMMUNOMODULATORStacrolimusELIDEL PA

§ ROSACEAmetronidazoleFINACEAORACEASOOLANTRA

OPHTHALMIC§ ANTIALLERGICSazelastinecromolyn sodiumolopatadinePATADAYPATANOL

§ ANTI-INFECTIVESciprofloxacinerythromycingentamicinlevofloxacinofloxacinsulfacetamidetobramycinBESIVANCEMOXEZAVIGAMOX

§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONSneomycin-polymyxin B-bacitracin-

hydrocortisoneneomycin-polymyxin B-dexamethasonetobramycin-dexamethasoneTOBRADEX OINTMENTTOBRADEX STZYLET

ANTI-INFLAMMATORIES§ NonsteroidalbromfenacdiclofenacketorolacPROLENSA

§ SteroidaldexamethasoneALREXDUREZOLLOTEMAX

BETA-BLOCKERS§ Nonselectivetimolol maleate solutionBETIMOL

SelectiveBETOPTIC S

§ CARBONIC ANHYDRASE INHIBITORSdorzolamideAZOPT

§ CARBONIC ANHYDRASE INHIBITOR / BETA-BLOCKER COMBINATIONSdorzolamide-timololCOSOPT PF

CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMI-METIC COMBINATIONSSIMBRINZA

DRY EYE DISEASERESTASISXIIDRA

§ PROSTAGLANDINSlatanoprosttravoprostTRAVATAN Z STZIOPTAN ST

§ SYMPATHOMIMETICSbrimonidineALPHAGAN P

SYMPATHOMIMETIC / BETA-BLOCKER COMBINATIONSCOMBIGAN

OTIC§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONSCIPRODEX

6

7

Aabacavir ACANYA ST acitretin acyclovir adapalene ADEMPAS SGMADVAIR QLALBENZA albuterol inhalation solution QLalendronate alfuzosin ext-rel allopurinol ALPHAGAN P ALREX amantadine AMITIZA amlodipine amlodipine-atorvastatin amlodipine-telmisartan amlodipine-valsartan amlodipine-valsartan-hydro-

chlorothiazide amoxicillin amoxicillin-clavulanate amphetamine-dextroam-

phetamine mixed salts amphetamine-dextroam-

phetamine mixed salts ext-rel ANDRODERM PAANORO ELLIPTA QLAPRISO APTENSIO XR ARANESP SGMARCAPTA QLaripiprazole ARISTADA †ASMANEX QLATELVIA atenolol atorvastatin ATRALIN PAATRIPLA AUBAGIO SGMAXIRON PAazelastine azelastine spray QLAZILECT azithromycin AZOPT AZOR

Bbalsalazide BASAGLAR #BD ULTRAFINE INSULIN

SYRINGES AND NEEDLES OTC

BENICARBENICAR HCTBENZACLIN benzoyl peroxide BESIVANCE BETASERON SGMBETHKIS SGMBETIMOL BETOPTIC S BEVESPI AEROSPHERE QLBEYAZ bicalutamide BIDIL BOSULIF SGMBREO ELLIPTA QLBRILINTA brimonidine BRISDELLE bromfenac budesonide capsule budesonide inhalation sus-

pension QLbuprenorphine-naloxone

sublingual tablet PAbupropion bupropion ext-rel BUTRANS BYSTOLIC

Ccalcipotriene calcitonin-salmon calcium acetate CANASA candesartan candesartan-hydrochlorothi-

azide carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopa-entaca-

pone CARDURA XL STcarvedilol cefdinir cefprozil cefuroxime axetil celecoxib cephalexin CETROTIDE PAcholestyramine ciclopirox PACIPRODEX ciprofloxacin ciprofloxacin ext-rel

citalopram CITRANATAL clarithromycin clarithromycin ext-rel clindamycin clindamycin solution clindamycin-benzoyl perox-

ide clobetasol cream, foam, gel,

lotion, ointment, shampoo CLODERM clopidogrel clotrimazole clozapine codeine-acetaminophen colchicine tablet COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT QLCOMPLERA COPAXONE 40 MG SGMCOREG CR CORTIFOAM COSOPT PF CREON CRINONE cromolyn sodium cyclobenzaprine

DDALIRESP desonide desoximetasone dexamethasone DEXCOM CONTINUOUS

GLUCOSE MONITORING SYSTEM

DEXILANT STdiazepam rectal gel DICLEGIS diclofenac diclofenac sodium diclofenac sodium solution diclofenac sodium-miso-

prostol dicloxacillin DIFFERIN PADIFICID digoxin diltiazem ext-rel 2 dipyridamole ext-rel-aspirin divalproex sodium divalproex sodium ext-rel DIVIGEL donepezil dorzolamide dorzolamide-timolol

doxazosin doxycycline hyclate dronabinol PA, QLDUAVEE DULERA QLduloxetine DUREZOL dutasteride DYMISTA QL ST

Eeconazole EFFIENT ELIDEL PA ELIQUIS ENBREL SGMENDOMETRIN entacapone ENTRESTO PAEPCLUSA SGMEPIDUO EPIPEN EPIPEN JR eprosartan EPZICOM erythromycin erythromycin solution erythromycin-benzoyl per-

oxide erythromycins ESBRIET SGMescitalopram esomeprazole ESTRACE CREAM estradiol estradiol-norethindrone estropipate eszopiclone ethinyl estradiol-drospire-

none ethinyl estradiol-levonorge-

strel ethinyl estradiol-norelge-

stromin ethinyl estradiol-norethin-

drone acetate ethinyl estradiol-norgesti-

mate ethosuximide EVAMIST EVOTAZ

FFARXIGA fenofibrate fenofibric acid fentanyl transdermal fentanyl transmucosal loz-

enge PA

QUICK REFERENCE DRUG LIST

8

FENTORA PAFINACEA finasteride FLOVENT DISKUS QLFLOVENT HFA QLfluconazole flunisolide QLfluocinonide fluorouracil cream 5% fluorouracil solution fluoxetine FLUOXETINE 60 MG fluticasone QLfluvastatin FOLLISTIM AQ PAFORTEO SGMfosinopril fosinopril-hydrochlorothia-

zide furosemide FYCOMPA

Ggabapentin galantamine galantamine ext-rel gentamicin GILENYA SGMglatiramer SGMglimepiride glipizide glipizide ext-rel glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY

KIT GRALISE STgranisetron QLGRASTEK PAguanfacine ext-rel

HHARVONI SGMHUMATROPE SGMHUMIRA SGMHUMULIN R U-500 hydrochlorothiazide hydrocodone-acetamino-

phen hydrocortisone hydrocortisone butyrate hydrocortisone enema hydromorphone hydromorphone ext-rel HYSINGLA ER QL

Iibandronate imatinib mesylate SGM

imiquimod ipratropium-albuterol inha-

lation solution QLirbesartan irbesartan-hydrochlorothia-

zide ISENTRESS itraconazole PAivermectin

JJANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR JUBLIA PA

Kketoconazole ketorolac KOGENATE FS †KOVALTRY †

Llactulose lamivudine lamotrigine lamotrigine ext-rel lansoprazole latanoprost LATUDA STLETAIRIS SGMLEVEMIR levetiracetam levetiracetam ext-rel levocarnitine levofloxacin levothyroxine LIALDA LINZESS lisinopril lisinopril-hydrochlorothia-

zide LO LOESTRIN FE LOCOID LOTION losartan losartan-hydrochlorothiazide LOTEMAX LOTRONEX lovastatin LUZU LYRICA ST

Mmeclizine medroxyprogesterone MEGACE ES

meloxicam memantine mesalamine rectal suspen-

sion metformin metformin ext-rel methadone 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 QLmontelukast morphine morphine ext-rel QLmorphine suppository MOVANTIK MOVIPREP MOXEZA moxifloxacin MYRBETRIQ ST

Nnadolol NAFTIN naloxone injection NAMENDA XR naproxen naratriptan QLNARCAN NASAL SPRAY NATAZIA nateglinide neomycin-polymyxin B-baci-

tracin-hydrocortisone neomycin-polymyxin

B-dexamethasone NEUPRO niacin ext-rel nifedipine ext-rel nitrofurantoin nitroglycerin lingual spray NITROLINGUAL NITROSTAT NORDITROPIN SGMNORVIR NOVOEIGHT †NOVOLIN 70/30 OTC

NOVOLIN N OTCNOVOLIN R OTCNOVOLOG NOVOLOG MIX 70/30 NUCYNTA QLNUCYNTA ER QLNUVARING NUVIGIL PANUWIQ †nystatin

OOFEV SGMofloxacin olanzapine olopatadine olopatadine spray QLomega-3 acid ethyl esters omeprazole ondansetron QLONETOUCH ULTRA STRIPS

AND KITS 3 OTCONETOUCH VERIO STRIPS AND KITS 3 OTCOPANA ER QLORACEA ORALAIR PAORENITRAM SGMORTHO TRI-CYCLEN LO OSPHENA OVIDREL PAoxcarbazepine OXTELLAR XR oxybutynin oxybutynin ext-rel oxycodone oxycodone-acetaminophen OXYCONTIN QL

Ppantoprazole paroxetine paroxetine ext-rel PATADAY PAZEO peg 3350-electrolytes penicillin VK PENTASA PERFOROMIST QLphenobarbital phenytoin phenytoin sodium extended PHOSLYRA PICATO pioglitazone pioglitazone-glimepiride pioglitazone-metformin potassium chloride liquid pramipexole


9

pravastatin prednisone PREMARIN PREMARIN CREAM PREMPHASE PREMPRO prenatal vitamins PREZCOBIX PREZISTA primidone PRISTIQ STPROAIR HFA QLPROAIR RESPICLICK QLprobenecid prochlorperazine PROCRIT SGMPROCTOFOAM-HC progesterone, micronized PROLENSA promethazine propranolol propranolol ext-rel PULMICORT FLEXHALER QLPYLERA

Qquetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothia-

zide QVAR QL

RRAGWITEK PAraloxifene ramipril RANEXA ranitidine RAPAFLO ST RASUVO SGMREBIF SGMRELENZA QLRELPAX ST, QLRENVELA repaglinide REPATHA SGMRESTASIS RETIN-A MICRO PAREYATAZ ribavirin SGMrisedronate risperidone rivastigmine rivastigmine transdermal rizatriptan QLropinirole ropinirole ext-rel

rosuvastatin

SSAFYRAL SANCUSO PA, QLSAVELLA selegiline SEREVENT QLSEROQUEL XR sertraline sildenafil SGMSILENOR STSIMBRINZA simvastatin SIVEXTRO SOOLANTRA SPIRIVA QLspironolactone-hydrochloro-

thiazide SPRYCEL SGMSTRATTERA STRIBILD SUBOXONE FILM PASUBSYS PAsulfacetamide sulfamethoxazole-trimetho-

prim sulfasalazine sulfasalazine delayed-rel sumatriptan QLSUPRAX SUPREP SYMLINPEN SYNTHROID

Ttacrolimus TAMIFLU QLtamsulosin TAZORAC PATECFIDERA SGMTEKTURNA STTEKTURNA HCT STtelmisartan telmisartan-hydrochlorothi-

azide terazosin terbinafine tablet tetrabenazine SGMtetracycline tiagabine timolol maleate solution TIVICAY TOBRADEX OINTMENT TOBRADEX ST tobramycin tobramycin inhalation solu-

tion SGMtobramycin-dexamethasone

tolterodine tolterodine ext-rel topiramate torsemide TOVIAZ STTRACLEER SGMTRADJENTA tramadol tramadol ext-rel TRAVATAN Z ST travoprost trazodone TRESIBA tretinoin triamcinolone triamcinolone nasal spray QLtriamterene-hydrochlorothi-

azide TRIBENZOR trimethobenzamide TRINTELLIX STTRIUMEQ trospium trospium ext-rel TRULICITY TRUVADA

UUCERIS ULORIC ST

VVAGIFEM valacyclovir valganciclovir valproic acid valsartan valsartan-hydrochlorothia-

zide VARUBI QLVASCEPA VELPHORO venlafaxine venlafaxine ext-rel capsule verapamil ext-rel VESICARE STVIBERZI VICTOZA VIGAMOX VIIBRYD STVIMPAT PAVIOKACE VOLTAREN GEL PAVYTORIN STVYVANSE

W

warfarin WELCHOL

XXARELTO XIFAXAN 550 MG XIGDUO XR XIIDRA

Zzafirlukast ZARXIO SGM †ZENPEP ZETIA ZIOPTAN ST ziprasidone zolmitriptan QLzolpidem zolpidem ext-rel ZOMIG NASAL SPRAY QLzonisamide ZYCLARA ZYLET ZYTIGA SGM


10

NON-PREFERRED OR EXCLUDED DRUGS PREFERRED OPTION(S)*ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone,

LATUDA ST, SEROQUEL XR

ABSTRAL fentanyl transmucosal lozenge PA, FENTORA PA, SUBSYS PA

ACCU-CHEK STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3 OTC

ACTOS pioglitazone

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

ADRENACLICK EPIPEN, EPIPEN JR

ADVICOR atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN ST

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

ALCORTIN A hydrocortisone

ALLISON MEDICAL INSULIN SYRINGES 5 BD ULTRAFINE INSULIN SYRINGES OTC

ALOQUIN hydrocortisone

ALORA estradiol, DIVIGEL, EVAMIST, MINIVELLE

ALTOPREV atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN ST

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

AMRIX cyclobenzaprine

ANDROGEL ANDRODERM PA, AXIRON 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 celecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT ST

ASACOL HD balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PEN-TASA, UCERIS

ASCENSIA STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3 OTC,

ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbe-sartan-hydrochlorothiazide, losartan, candesartan, candesartan-hydrochlo-rothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT

ATROVENT HFA SPIRIVA QL

AVONEX glatiramer SGM, AUBAGIO SGM, BETASERON SGM, COPAXONE 40 MG SGM, GILENYA SGM, REBIF SGM, TECFIDERA SGM

AXERT naratriptan QL, rizatriptan QL, sumatriptan nasal spray QL, sumatriptan tablet QL, zolmitriptan QL, RELPAX ST, QL, ZOMIG NASAL SPRAY QL

PREFERRED OPTIONS LIST

11

NON-PREFERRED OR EXCLUDED DRUGS PREFERRED OPTION(S)*

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

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

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

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

BREEZE 2 STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3 OTC,

butalbital-acetaminophen-caffeine capsule naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, RELPAX ST, QL, ZOMIG NASAL SPRAY QL

BYDUREON TRULICITY, VICTOZA

BYETTA TRULICITY, VICTOZA

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

CLIMARA PRO COMBIPATCH

CLINDAGEL erythromycin solution

clobetasol spray clobetasol foam

CLOBEX SPRAY clobetasol foam

CONTOUR NEXT STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3 OTC,

CONTOUR STRIPS AND KITS 4 ONETOUCH VERIO STRIPS AND KITS 3 OTC

CRESTOR atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN ST

CYMBALTA duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ ST

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

DELZICOL balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PEN-TASA, UCERIS

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

DEXPAK dexamethasone, methylprednisolone, prednisone

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

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

DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide

EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT


12


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

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

ENJUVIA estradiol, estropipate, PREMARIN

ESTRING ESTRACE CREAM, PREMARIN CREAM, VAGIFEM

EVZIO naloxone injection, NARCAN NASAL SPRAY

EXFORGE amlodipine-telmisartan, amlodipine-valsartan, AZOR

EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, TRIBENZOR

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

FEMRING ESTRACE CREAM, PREMARIN CREAM, VAGIFEM

FETZIMA duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ ST

FIORICET CAPSULE naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, RELPAX ST, QL, ZOMIG NASAL SPRAY QL

FIRST TESTOSTERONE ANDRODERM PA, AXIRON PA

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

FORTAMET metformin, metformin ext-rel

FORTESTA ANDRODERM PA, AXIRON PA

FOSAMAX PLUS D alendronate, ibandronate, risedronate, ATELVIA

FOSRENOL calcium acetate, PHOSLYRA, RENVELA, VELPHORO

FREESTYLE STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3 OTC

FROVA naratriptan QL, rizatriptan QL, sumatriptan nasal spray QL, sumatriptan tablet QL, zolmitriptan QL, RELPAX ST, QL, ZOMIG NASAL SPRAY QL

GELNIQUE oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ ST, TOVIAZ ST, VESICARE ST

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 †

HUMALOG NOVOLOG

HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN NOVOLIN OTC

INCRUSE ELLIPTA SPIRIVA QL

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

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

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

INVOKAMET XIGDUO XR

INVOKANA FARXIGA, JARDIANCE

ISTALOL timolol maleate solution, BETIMOL


13


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

KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

KLOR-CON/25 potassium chloride liquid

KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

LANTUS BASAGLAR #, LEVEMIR, TRESIBA

LASTACAFT azelastine, cromolyn sodium, olopatadine, PATADAY, PAZEO

LESCOL XL atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN ST

LIPITOR atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN ST

LIPTRUZET atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN ST

LIVALO atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN ST

LUMIGAN latanoprost, travoprost, TRAVATAN Z ST, ZIOPTAN ST

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

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

MENEST estradiol, estropipate, PREMARIN

MENOSTAR estradiol

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

MILLIPRED dexamethasone, methylprednisolone, prednisone

NAPRELAN celecoxib, diclofenac sodium, meloxicam, naproxen

NATESTO ANDRODERM PA, AXIRON PA

NESINA JANUVIA, TRADJENTA

NEUPOGEN ZARXIO SGM †

NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST

NILANDRON bicalutamide, ZYTIGA SGM

NITROMIST nitroglycerin lingual spray, NITROLINGUAL, NITROSTAT

NORITATE metronidazole, FINACEA, SOOLANTRA

NORVASC amlodipine

NOVACORT hydrocortisone

NOVO NORDISK NEEDLES 5 BD ULTRAFINE NEEDLES OTC

NUTROPIN AQ HUMATROPE SGM, NORDITROPIN SGM

OLEPTRO trazodone

OLUX-E clobetasol foam

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

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

OMNITROPE HUMATROPE SGM, NORDITROPIN SGM

ONGLYZA JANUVIA, TRADJENTA


14


OPSUMIT LETAIRIS SGM, TRACLEER SGM

OSENI JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

OWEN MUMFORD NEEDLES 5 BD ULTRAFINE NEEDLES OTC

OXYTROL 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 5 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, BRILINTA, EFFIENT

PLEGRIDY glatiramer SGM, AUBAGIO SGM, BETASERON SGM, COPAXONE 40 MG SGM, GILENYA SGM, REBIF SGM, TECFIDERA SGM

PRADAXA warfarin, ELIQUIS, XARELTO

PRALUENT REPATHA SGM

PRECISION XTRA STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3 OTC,

PRED MILD dexamethasone, DUREZOL, LOTEMAX

PREFERAOB generic prenatal vitamins, CITRANATAL

PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO

PRENATAL PLUS generic prenatal vitamins, CITRANATAL

PREVACID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST

PROTONIX esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST

PROTOPIC tacrolimus, ELIDEL PA

PROVENTIL HFA PROAIR HFA QL, PROAIR RESPICLICK QL

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

RAYOS dexamethasone, methylprednisolone, prednisone

RELION INSULIN NOVOLIN INSULIN OTC

RELISTOR MOVANTIK

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

RIOMET metformin, metformin ext-rel

ROZEREM eszopiclone, zolpidem, zolpidem ext-rel, SILENOR ST

SAIZEN HUMATROPE SGM, NORDITROPIN SGM

STRIANT ANDRODERM PA, AXIRON PA

SURE-TEST STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3 OTC

SYMBICORT ADVAIR QL, BREO ELLIPTA QL, DULERA QL

TANZEUM TRULICITY, VICTOZA

TASIGNA imatinib mesylate SGM, BOSULIF SGM, SPRYCEL SGM

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

TESTIM ANDRODERM PA, AXIRON PA


15


testosterone gel 1% 7 ANDRODERM PA, AXIRON PA

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

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 5 BD ULTRAFINE INSULIN SYRINGES OTC

TRUETEST STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3 OTC,

TRUETRACK STRIPS AND KITS 4 ONETOUCH VERIO STRIPS AND KITS 3 OTC

TUDORZA SPIRIVA QL

ULTIMED INSULIN SYRINGES 5 BD ULTRAFINE INSULIN SYRINGES OTC

ULTIMED NEEDLES 5 BD ULTRAFINE NEEDLES OTC

VALCYTE valganciclovir

VALTREX acyclovir, valacyclovir

venlafaxine ext-rel tablet (except 225 mg) duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ ST

VENLAFAXINE EXT-REL TABLET (except 225 mg) duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ ST

VENTOLIN HFA PROAIR HFA QL, PROAIR RESPICLICK QL

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

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

VITAFOL-ONE generic prenatal vitamins, CITRANATAL

VOGELXO ANDRODERM PA, AXIRON PA

XENAZINE tetrabenazine SGM

XOPENEX HFA PROAIR HFA QL, PROAIR RESPICLICK QL

XTANDI bicalutamide, ZYTIGA SGM

ZEGERID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT ST

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

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

ZUBSOLV buprenorphine-naloxone sublingual tablet PA, SUBOXONE FILM PA

ZYFLO, ZYFLO CR montelukast, zafirlukast


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MPI 5980 12/16

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 until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by an independent National Pharmacy and Therapeutics Committee (or other appropriate reviewing body). 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. Log in to usableadmin.com to check coverage and copay 1 information for a specific medicine.

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# Expected Availability 12/15/16OTC Over the CounterPA Prior AuthorizationQL Quantity LimitSGM Specialty Guideline ManagementST Step Therapy1 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 Listing does not include generic CARDIZEM LA.3 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.

4 ONETOUCH brand test strips are the only preferred options.5 BD ULTRAFINE syringes and needles are the only preferred options.6 Coverage may be altered or copay 1 amounts may vary based on the condition being treated (e.g. psoriasis).7 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.

©2016. All rights reserved. 106-1058412-1-010117

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

standard with step therapy drug list...not all formularies will require step therapy. pa – prior...

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