-INFLAMMATORY -INFECTIVES Cefepime - Culinary … · Capxib Kit fosinopril sodium Esmolol Hydrochloride Isosorbide Dinitrate ER Celebrex lisinopril Nitroglycerin Lingual Hemangeol

cefotetan

Ampicillin

Adoxa PAK 1/150

cefoxitin sodium

Nafcillin

Adoxa PAK 2/100

cefpodoxime proxetil

TIER 03 NON PREFERRED

Alodox Convenience Kit

cefprozil

Amoxicillin ER

Demeclocycline HCL

January 2017

ceftazidime

Amoxicillin Trihydrate

Doryx

ceftriaxone sodium

Ampicillin Sodium

Doryx Mpc

SELECT DRUG LIST

cefuroxime axetil

Augmentin

Doxycycline Hyclate

The Optum Preferred Drug List is a guide identifying preferred brand-name medicines within select therapeutic categories. The Preferred Drug List may not include all drugs covered by your prescription drug benefit. Generic medicines are available within many of the therapeutic categories listed, in addition to categories not listed, and should be considered as the first line of prescribing. For benefit coverage or restrictions please check your benefit plan document(s). This listing is revised periodically as new drugs and new prescribing information becomes available. It is recommended that you bring this list of medications when you or a covered family member sees a physician or other healthcare provider.

cefuroxime sodium

Augmentin ES-600

Minocin

cephalexin

Augmentin XR

Minocin Kit

tazicef

Bactocill IN Dextrose

Minocycline HCL

Cefaclor ER

Bicillin C-R

Monodox

Cefazolin/D5W

Bicillin L-a

Morgidox 1X100MG

Cefotaxime Sodium

Moxatag

Morgidox 2X100MG

Ceftriaxone IN Iso-osmotic Dextrose

Nafcillin Sodium

Nutridox

Penicillin G Potassium IN Iso-osmotic Dextrose

Ocudox

Ceftriaxone Sodium

Oxytetracycline HCL

Cefuroxime Sodium

Penicillin G Procaine

Solodyn

Cephalexin

Penicillin G Sodium

Targadox

TIER 02 PREFERRED BRAND

Pfizerpen-G

Vibramycin

Zerbaxa

Unasyn


Unasyn Bulk Pack

ANTI-INFLAMMATORY

Avycaz

Zosyn

NSAIDS

Cedax

TIER 01 GENERIC

Cefaclor

QUINOLONES

celecoxib

Cefazolin

TIER 01 GENERIC

diclofenac potassium

Cefazolin Sodium

ciprofloxacin

diclofenac sodium DR

Cefazolin Sodium/Dextrose

ciprofloxacin ER

diclofenac sodium ER

Cefditoren Pivoxil

ciprofloxacin HCL

diclofenac sodium/misoprostol

ANTI-INFECTIVES

Cefepime

ciprofloxacin I.V.-IN D5W

ANTIFUNGALS

Cefepime/Dextrose

levofloxacin

etodolac

TIER 01 GENERIC

Cefotan

levofloxacin IN D5W

etodolac ER

bio-statin

Cefotetan

levofloxacin IN 5% dextrose

flurbiprofen

fluconazole

Cefotetan/Dextrose

moxifloxacin HCL

ibuprofen

fluconazole IN dextrose

Cefoxitin Sodium

ofloxacin

ibuprofen lysine

fluconazole IN NACL

Ceftazidime/Dextrose

Ciprofloxacin

indomethacin

flucytosine

Ceftibuten

Ciprofloxacin HCL

indomethacin ER

griseofulvin microsize

Ceftin

Levofloxacin

inflammacin

griseofulvin ultramicrosize

Ceftriaxone/Dextrose

Moxifloxacin HCL

ketoprofen

itraconazole

Claforan

Ofloxacin

ketorolac tromethamine

ketoconazole

Claforan/D5W


mefenamic acid

nystatin

Fortaz

Avelox

meloxicam

terbinafine HCL

Keflex

Avelox Abc Pack

nabumetone

voriconazole

Maxipime

Cipro

naproxen


Spectracef

Cipro I.V.-IN D5W

naproxen kit

Noxafil

Suprax

Cipro XR

naproxen sodium


Tazicef

Factive

naproxen sodium CR

Abelcet

Teflaro

Levaquin

naproxen sodium ER

Ambisome

Zinacef

naproxen DR

Amphotec

TETRACYCLINES

nudiclo tabpak

Amphotericin B

PENICILLINS

TIER 01 GENERIC

oxaprozin

Ancobon

TIER 01 GENERIC

avidoxy

piroxicam

Bio-statin

amoxicillin

demeclocycline HCL

previdolrx plus analgesicpak

Cresemba

amoxicillin/clavulanate potassium

doxy 100

sulindac

Diflucan

doxycycline

tolmetin sodium

Fluconazole IN NACL

amoxicillin/clavulanate potassium ER

doxycycline hyclate

xenaflamm

Grifulvin V

doxycycline hyclate DR

Fenoprofen Calcium

Gris-peg

ampicillin

doxycycline monohydrate

Ketoprofen ER

Lamisil

ampicillin sodium

minocycline HCL

Ketorolac Tromethamine

Onmel

ampicillin-sulbactam

minocycline HCL ER

Meclofenamate Sodium

Sporanox

dicloxacillin sodium

mondoxyne nl

Meloxicam

Sporanox Pulsepak

nafcillin sodium

morgidox 1X100MG

Naproxen

Vfend

oxacillin sodium

morgidox 1X50MG

Tolmetin Sodium

Vfend IV

penicillin v potassium

morgidox 2X100MG


penicillin G potassium

tetracycline hydrochloride

Zorvolex

CEPHALOSPORINS

piperacillin sodium/ tazobactam sodium

tetracycline HCL


TIER 01 GENERIC

Minocycline HCL ER

Active Injection Kit Ket-l

cefaclor

piperacillin sodium/tazobactam sodium

Tetracycline HCL

Active Injection Kit Ketmarc-l

cefadroxil


piperacillin/tazobactam

cefazolin sodium

Anaprox DS

Acticlate

Amoxicillin

cefdinir

Arthrotec 50

Adoxa

Amoxicillin/Clavulanate Potassium

cefepime

Arthrotec 75

Adoxa PAK 1/100

cefixime

Caldolor

Effective January 1, 2017

1

Capxib Kit

fosinopril sodium

Esmolol Hydrochloride

Isosorbide Dinitrate ER

Celebrex

lisinopril

Hemangeol

Nitroglycerin Lingual

Daypro

moexipril HCL

Inderal LA


Derma Silkrx Anodynexa PAK

perindopril erbumine

Inderal XL

Dilatrate SR

quinapril HCL

Innopran XL

Nitro-bid

Derma Silkrx Diclopak

ramipril

Lopressor


Dermacinrx Inflammatral PAK

trandolapril

Nadolol

Gonitro


Sectral

Isordil Titradose

Dyloject

Accupril

Sotylize

Nitro-dur

EC-naprosyn

Aceon

Tenormin

Nitroglycerin

Feldene

Altace

Toprol XL

Nitroglycerin IN Dextrose 5%

Fenortho

Epaned

Zebeta

Flanax Pain Relief Kit

Nitrolingual Pumpspray

Lotensin

Ibuprofen Comfort PAC

Nitromist

Mavik

CALCIUM CHANNEL BLOCKERS

Indocin

Nitronal

Prinivil

TIER 01 GENERIC

Inflammation Reduction Pack

Nitrostat

Vasotec

afeditab CR

Zestril

amlodipine besylate

IC 400

ANTI-HTN COMBINATIONS

cartia XT

IC 800

TIER 01 GENERIC

ANGIOTENSIN RCPTR BLOCKER

dilt-XR

Ketorocaine-l

amlodipine besylate/benazepril hydrochloride

diltiazem CD

Ketorocaine-lm

TIER 01 GENERIC

diltiazem HCL

Lodine

candesartan cilexetil

diltiazem HCL CD

Meloxicam Comfort PAC

amlodipine besylate/benazepril HCL

irbesartan

diltiazem HCL ER

Mobic

losartan potassium

felodipine ER

amlodipine besylate/valsartan

Nalfon

olmesartan medoxomil

isradipine

Naprelan

telmisartan

matzim LA

amlodipine/olmesartan medoxomil

Naprosyn

valsartan

nicardipine HCL

Naproxen Comfort PAC

amlodipine/valsartan/hctz

Eprosartan Mesylate

nifedical XL

Neoprofen

atenolol/chlorthalidone


nifedipine

Phenylbutazone

benazepril HCL/hydrochlorothiazide

Atacand

nifedipine ER

Ponstel

Avapro

nimodipine

Readysharp Anesthetics + Ketorolac

bisoprolol fumarate/hydrochlorothiazide

Benicar

nisoldipine ER

Cozaar

taztia XT

Readysharp Ketorolac

Diovan

verapamil HCL

Sprix

candesartan cilexetil/hydrochlorothiazide

Edarbi

verapamil HCL ER

Sulindac

Micardis

verapamil HCL SR

Tivorbex

enalapril maleate/hydrochlorothiazide

Diltiazem Hydrochloride/Dextrose

Vivlodex

BETA BLOCKERS

fosinopril sodium/hydrochlorothiazide

Voltaren-XR

Nisoldipine ER

TIER 01 GENERIC


irbesartan/hydrochlorothiazide

acebutolol HCL

AUTO-IMMUNE

Adalat CC

atenolol

lisinopril/hydrochlorothiazide

Calan

betaxolol HCL


losartan potassium/hydrochlorothiazide

Calan SR

bisoprolol fumarate

Cimzia

Cardene IV

carvedilol

Cimzia Starter Kit

Cardizem

esmolol HCL

Humira

metoprolol/hydrochlorothiazide

Cardizem CD

labetalol HCL

Humira Pediatric Crohns Disease Starter Pack

Cardizem LA

metoprolol succinate ER

moexipril/hydrochlorothiazide

Cleviprex

Humira Pen

metoprolol tartrate

Diltiazem HCL

nadolol/bendroflumethiazide

Humira Pen-crohns Diseasestarter

nadolol

Norvasc

olmesartan medoxomil/amlodipine/hydrochlorothiazide

pindolol

Humira Pen-psoriasis Starter

Nymalize

propranolol hydrochloride

Procardia

propranolol HCL


olmesartan medoxomil/hydrochlorothiazide

Procardia XL

propranolol HCL ER

Actemra

Sular

sorine

Enbrel

Tiazac

sotalol HCL

quinapril/hydrochlorothiazide

Enbrel Sureclick

Verelan

sotalol HCL (AF)

Kineret

Verelan PM

Metoprolol Tartrate

telmisartan/amlodipine

Orencia

Propranolol HCL

telmisartan/hydrochlorothiazide

Orencia Clickject

NITRATES & NITRITES

Sotalol Hydrochloride

Remicade

TIER 01 GENERIC

trandolapril/verapamil HCL ER

Timolol Maleate

Simponi

isosorbide dinitrate


Simponi Aria

valsartan/hydrochlorothiazide

isosorbide mononitrate

Bystolic

Xeljanz

isosorbide mononitrate ER

Coreg CR

Captopril/Hydrochlorothiazide

Xeljanz XR

minitran


nitro-time

Acebutolol HCL

Methyldopa/Hydrochlorothiazide

CARDIOVASCULAR

nitroglycerin

Atenolol

ACE-INHIBITORS

nitroglycerin lingual

Betapace

Propranolol/Hydrochlorothiazide

TIER 01 GENERIC

nitroglycerin transdermal

Betapace AF

benazepril HCL

nitroglycerin ER


Brevibloc

captopril

nitroglycerin IN dextrose 5%

Byvalson

Coreg

enalapril maleate

nitroglycerin IN 5% dextrose

Tekamlo

Corgard

enalaprilat


2

Tekturna HCT

GENERIC

ery

Erygel


cholestyramine

erythromycin

Evoclin

Accuretic

cholestyramine light

erythromycin/benzoyl peroxide

Fabior

Atacand HCT

colestipol HCL

Inova

metronidazole

Avalide

prevalite

Inova 4/1 Acne Control Therapy

myorisan

Azor


neuac

Inova 8/2 Acne Control Therapy

Benicar HCT

Welchol

oscion cleanser

Clorpres


Klaron

pr benzoyl peroxide wash

Corzide

Colestid

Metrocream

rosadan

Diovan HCT

Colestid Flavored

Metrogel

rosanil cleanser

Dutoprol

Questran

Metrolotion

sodium sulfacetamide

Edarbyclor

Questran Light

Neuac Kit

sodium sulfacetamide/sulfur

Exforge

CHOLEST ABS INHBTR/COMBO

Noritate

sodium sulfacetamide/sulfur cleanser

Exforge HCT

TIER 01 GENERIC

Onexton

Hyzaar

ezetimibe

sodium sulfacetamide/sulfur cleansing cloths

Plexion

Lopressor HCT

ezetimibe/simvastatin

Plexion Cleanser

Lotensin HCT


sodium sulfacetamide/sulfur green

Plexion Cleansing Cloths

Lotrel

Vytorin

Retin-a

Metoprolol Succinate ER/Hydrochlorothiazide

Zetia

sodium sulfacetamide/sulfur w/sunscreen

Retin-a Micro

NIACIN/COMBINATIONS

Retin-a Micro P.M.

Micardis HCT

TIER 01 GENERIC

sodium sulfacetamide/sulfur wash

Rhofade

Prestalia

niacin ER

Riax

Tarka

ss 10-2


Rosadan Kit

Tenoretic 100

sss 10%-5%

Simcor

Rosula

Tenoretic 50

sulfacetamide sodium


Sodium Sulfacetamide/Sulfur

Tribenzor

sulfacetamide sodium/sulfur

Advicor

Twynsta

sulfacetamide sodium/sulfur cleanser

Equapax/Atorvastatin Calcium/Coq10

Sodium Sulfacetamide/Sulfur Cleanser IN Urea

Vaseretic

sulfacleanse 8/4

Zestoretic

Niacor

Sodium Sulfacetamide/Sulfur IN Urea

tretinoin

Ziac

Niaspan

tretinoin microsphere

OMEGA-3 FATTY ACIDS

Soolantra

tretinoin microsphere P.M.

ANTIHYPERLIPIDEMICS

TIER 01 GENERIC

Sss 10-5

zenatane

STATINS

omega-3-acid ethyl esters

Sulfoam

zencia

TIER 01 GENERIC


Sumadan Kit


atorvastatin calcium

Vascepa

Sumadan Wash

Acanya

fluvastatin


Sumadan XLT

Epiduo

fluvastatin sodium ER

Kynamro

Sumaxin

Epiduo Forte

lovastatin

Lovaza

Sumaxin CP Kit

Finacea

pravastatin sodium

Sumaxin Ts

Mirvaso

rosuvastatin calcium

DERMATOLOGICALS

Sumaxin Wash

Oracea

simvastatin

ACNE

Tretin-x



TIER 01 GENERIC

Vanoxide-HC

Absorica

Altoprev

adapalene

Veltin

Aczone

Crestor

adapalene P.M.

Zacare 4% Kit

Adapalene

Lescol

amnesteem

Zacare 8% Kit

Atralin

Lescol XL

avar cleanser

Zaclir Cleansing

Avar

Lipitor

avar-e emollient

Ziana

Avar LS

Livalo

avar-e green

Avar LS Cleanser

Mevacor

avita

TOPICAL ANTI-INFLAMMATORY

Avar-e LS

Pravachol

benzepro

TIER 01 GENERIC

Azelex

Zocor

benzepro creamy wash

ala-cort

Benzac Ac Wash

FIBRATES

benzepro foaming cloths

alclometasone dipropionate

Benzaclin

TIER 01 GENERIC

benzepro SHORT contact

alphatrex

Benzaclin With P.M.

fenofibrate

benzoyl peroxide

augmented betamethasone dipropionate

Benzamycin

fenofibrate micronized

benzoyl peroxide SHORT contact

Benzefoam

fenofibric acid DR

betamethasone dipropionate

bp foam

Benzefoam Ultra

gemfibrozil

betamethasone valerate

bp foaming wash

Benzefoamultra

Fenofibric Acid

calcipotriene/betamethasone dipropionate

bp wash

Benziq


bp 10-1

Benziq LS

clobetasol propionate

Lipofen

bpo 6% foaming cloths

Benziq Wash

clobetasol propionate e

Triglide

cerisa wash

Benzoyl Peroxide

clobetasol propionate emollient


claravis

Benzoyl Peroxide Hydrous

Antara

clodan

clearplex x

Bp Cleansing Wash

Fenoglide

cormax scalp application

clindacin etz pledgets

Bpo 3% Foaming Cloths

Fibricor

derma silkrx sds PAK

clindacin-p

Bpo 9% Foaming Cloths

Gemfibrozil

dermawerx sds PAK

clindamax

Clarifoam EF

Lofibra

desonide

clindamycin phosphate

Cleocin-t

Lopid

desoximetasone

clindamycin phosphate/tretinoin

Clindacin Etz

Tricor

fluocinolone acetonide

Clindacin PAC

Trilipix

clindamycin/benzoyl peroxide

fluocinolone acetonide body

Clindagel

BILE ACID SEQUESTRANTS

fluocinolone acetonide scalp

Differin

TIER 01

Duac


3

fluocinonide

Locoid Lipocream

drospirenone/ethinyl estradiol/levomefolate calcium

norethindrone & ethinyl estradiol ferrous fumarate

fluocinonide-e

Luxiq

norethindrone acetate/ethinyl estradiol

flurandrenolide

Novacort

elinest

fluticasone propionate

Nucort

norethindrone acetate/ethinyl estradiol/ferrous fumarate

emoquette

halobetasol propionate

Olux

enpresse-28

hydrocortisone

Olux-e

norethindrone/ethinyl estradiol/ferrous fumarate

enskyce

hydrocortisone acetate/pramoxine

Pandel

errin

Pediaderm HC

norgestimate/ethinyl estradiol

estarylla

hydrocortisone butyrate

Pediaderm Ta

ethynodiol diacetate/ethinyl estradiol

hydrocortisone butyrate (lipid)

Pramosone

norlyroc

Psorcon

nortrel 0.5/35 (28)

falmina

hydrocortisone butyrate (lipophilic)

Scalacort DK

nortrel 1/35

fayosim

Sernivo

nortrel 7/7/7

hydrocortisone valerate

femynor

Silazone Pharmapak

ocella

hydrocortisone IN absorbase

gianvi

Silazone-II

orsythia

gildagia

Synalar

philith

hydrocortisone 1% IN absobase

gildess FE 1.5/30

Synalar Cream Kit

pimtrea

gildess FE 1/20

lokara

Synalar Ointment Kit

pirmella 1/35

gildess 1.5/30

mometasone furoate

Synalar Ts

pirmella 7/7/7

gildess 1/20

nutriarx creampak

Taclonex

portia-28

gildess 24 FE

prednicarbate

Temovate

previfem

heather

sanadermrx skin repair solution

Temovate E

quasense

introvale

Texacort

rajani

jencycla

scalacort

Topicort

reclipsen

jolessa

sure result tac PAK

Trianex

rivelsa

jolivette

tri-sila

Tridesilon

setlakin

juleber

triamcinolone acetonide

Ultravate

sharobel

junel FE 1.5/30

triderm

Ultravate X

sprintec 28

junel FE 1/20

Amcinonide

Vanos

sronyx

junel FE 24

Apexicon E

Verdeso

syeda

junel 1.5/30

Desoximetasone

Westcort

tarina FE 1/20

junel 1/20

Diflorasone Diacetate

Whytederm Trilasil PAK

tilia FE

kaitlib FE


tri femynor

kariva

Pramosone E

ENDOCRINE

tri-estarylla

kelnor 1/35


CONTRACEPTIVE AGENTS

tri-legest FE

kimidess

Aclovate

TIER 01 GENERIC

tri-linyah

kurvelo

Ala Scalp

altavera

tri-previfem

larin FE 1.5/30

Capex

alyacen 1/35

tri-sprintec

larin FE 1/20

Clobex

alyacen 7/7/7

tri-LO-estarylla

larin 1.5/30

Clocortolone Pivalate

amethia

tri-LO-marzia

larin 1/20

Clocortolone Pivalate P.M.

amethia LO

tri-LO-sprintec

larin 24 FE

Clodan Kit

amethyst

trinessa

larissia

Cloderm

apri

trinessa LO

layolis FE

Cloderm P.M.

aranelle

trivora-28

leena

Cordran

ashlyna

velivet

lessina

Cordran Tape

aubra

vestura

levonest

Cortane-b

aviane

vienva

levonorgestrel and ethinyl estradiol

Cutivate

azurette

viorele

Derma-smoothe/FS Body

balziva

vyfemla

levonorgestrel/ethinyl estradiol

Derma-smoothe/FS Scalp

bekyree

wera

Dermacinrx Silapak

blisovi FE 1.5/30

wymzya FE

levora 0.15/30-28

Dermasorb HC

blisovi FE 1/20

zarah

lomedia 24 FE

Dermasorb Ta

blisovi 24 FE

zenchent

loryna

Dermatop

briellyn

zenchent FE

low-ogestrel

Dermazone

camila

zovia 1/35e

lutera

Desonate

camrese

zovia 1/50e

lyza

Desonide

camrese LO

Necon 1/50-28

marlissa

Desowen

caziant

Ogestrel

mibelas 24 FE

Diprolene

chateal


microgestin FE

Diprolene AF

cryselle-28

Depo-provera

microgestin FE 1.5/30

Elocon

cyclafem 1/35

LO Loestrin FE

microgestin 1.5/30

Epifoam

cyclafem 7/7/7

Natazia

microgestin 1/20

Fluocinolone Acetonide

cyred

Safyral

microgestin 24 FE

Fluocinonide

dasetta 1/35


mono-linyah

Halac

dasetta 7/7/7

Beyaz

mononessa

Halog

daysee

Brevicon-28

myzilra

Hydrocortisone

deblitane

Cyclessa

necon 0.5/35-28

Hydrocortisone Acetate

delyla

Desogen

necon 1/35

Hydrocortisone Acetate Micronized

desogestrel/ethinyl estradiol

Ella

necon 7/7/7

drospirenone/ethinyl estradiol

Estrostep FE

nikki

Hydrocortisone Micronized

Falessa

nora-be

Kenalog

Femcon FE

norethindrone

Locoid


4

Generess FE

Climara

Novolin N Relion

glipizide

Loestrin FE 1.5/30

Climara Pro

Novolin R

glipizide ER

Loestrin FE 1/20

Delestrogen

Novolin R Relion

glipizide XL

Loestrin 1.5/30-21

Depo-estradiol

Novolin 70/30

glyburide

Loestrin 1/20-21

Divigel

Novolin 70/30 Relion

glyburide micronized

Loseasonique

Elestrin

Novolog

tolazamide

Minastrin 24 FE

Estrace

Novolog Flexpen

Chlorpropamide

Mircette

Estradiol

Novolog Mix 70/30

Tolazamide

Modicon

Estriol

Novolog Mix 70/30 Prefilled Flexpen

Tolbutamide

Necon 10/11-28

Estrogel


Novolog Penfill

Nor-QD

Estrone

Amaryl


Norinyl 1+35

Ethinyl Estradiol

Diabeta

Afrezza

Norinyl 1+50

Femhrt Low Dose

Glipizide

Apidra

Ortho Micronor

Femring

Glucotrol

Apidra Solostar

Ortho Tri-cyclen

Menest

Glucotrol XL

Humulin N Kwikpen

Ortho Tri-cyclen LO

Menostar

Glyburide

Humulin R U-500 Kwikpen

Ortho-cept

Prefest

Glynase

Humulin 70/30 Kwikpen

Ortho-cyclen

Premarin

SULFONYLUREA/TZD COMB.

Relion R

Ortho-novum 1/35

Vagifem

TIER 01 GENERIC

Toujeo Solostar

Ortho-novum 7/7/7

Vivelle-dot

pioglitazone HCL-glimepiride

Tresiba Flextouch

Ovcon-35


Quartette

TESTOSTERONE AGENTS

NON-INSULIN HYPOGLYCEMICS

Avandaryl

Seasonique

TIER 01 GENERIC

BIGUANIDES

Duetact

Tri-norinyl 28

danazol

TIER 01 GENERIC

INCRETINS

Yasmin 28

methyltestosterone

metformin hydrochloride


Yaz

testosterone

metformin HCL

Bydureon

testosterone cypionate

metformin HCL ER

Bydureon Pen

ESTROGENS/COMBINATIONS

testosterone enanthate


Byetta

TIER 01 GENERIC

testosterone P.M.

Riomet

Victoza

amabelz

Testosterone



covaryx


Fortamet

Adlyxin

covaryx HS

Androgel P.M.

Glucophage

Adlyxin Starter Pack

eemt

Axiron

Glucophage XR

Tanzeum

eemt HS

Vogelxo P.M.

BIGUAN/SULFONYLUREA COMB.

Trulicity

esterified estrogens/methltestosterone


TIER 01 GENERIC

AMYLIN ANALOGS

Androderm

esterified estrogens/methyltestosterone

glipizide/metformin HCL


Androgel

glyburide/metformin HCL

Symlinpen 120

Android


Symlinpen 60

Androxy

esterified estrogens/methyltestosterone DS

Glucovance

DIABETIC OTHER

Danazol

BIGUAN/THIAZOLIDEINEDIONE


Depo-testosterone

TIER 01 GENERIC

Farxiga

Fortesta

esterified estrogens/methyltestosterone HS

pioglitazone HCL

Glucagen Hypokit

Methitest

pioglitazone HCL/metformin HCL

Glucagon Emergency Kit

Methyltestosterone

Invokamet

estradiol

Natesto


Invokamet XR

estradiol valerate

Striant

Actoplus Met XR

Invokana

estradiol/norethindrone acetate

Testim


Jardiance

Testopel

Actoplus Met

fyavolv

Proglycem

Testosterone Eo-pro-cyp 220

Actos

jevantique LO

Synjardy

Avandamet

jinteli

Testred

Synjardy XR

Avandia

lopreeza

Vogelxo

Xigduo XR

DPP-4 INHIBITORS

mimvey


mimvey LO

INSULIN

GASTROINTESTINAL

Januvia

norethindrone acetate/ethinyl estradiol


PROTON PUMP INHIBITORS

Onglyza

Basaglar Kwikpen

TIER 01 GENERIC

ortho-est

Tradjenta

Humalog

esomeprazole magnesium

yuvafem


Humalog Kwikpen

esomeprazole sodium

Estropipate

Alogliptin

Humalog Mix 50/50

lansoprazole


Nesina

Humalog Mix 50/50 Kwikpen

omeprazole

Alora

BIGUANIDE/DPP-4 COMB.

Humalog Mix 75/25

pantoprazole sodium

Combipatch


Humalog Mix 75/25 Kwikpen

rabeprazole sodium

Duavee

Janumet

Humulin N


Enjuvia

Janumet XR

Humulin R

Aciphex

Estring

Jentadueto

Humulin R U-500 (concentrated)

Aciphex Sprinkle

Evamist

Jentadueto XR

Dexilant

Minivelle

Humulin 70/30

Kombiglyze XR

Esomeprazole Sodium

Premphase

Lantus


First-lansoprazole

Prempro

Lantus Solostar

Alogliptin/Metformin HCL

First-omeprazole


Levemir

Kazano

Nexium

Activella

Levemir Flextouch

SULFONYLUREAS

Nexium I.v.

Angeliq

Novolin N

TIER 01 GENERIC

glimepiride


5

Omeprazole + Syrspend SF Alka

Viekira PAK

GENERIC

Levetiracetam

carbamazepine

Mysoline

Prevacid

INTERFERONS

carbamazepine ER

Neurontin

Prevacid Solutab


clonazepam

Phenytek

Prilosec

Peg-intron

clonazepam odt

Phenytoin Sodium

Protonix

Peg-intron Redipen

divalproex sodium

Qudexy XR

Peg-intron Redipen PAK 4

divalproex sodium DR

Sabril

ULCER DRUGS

Pegasys

divalproex sodium ER

Tegretol

TIER 01 GENERIC

Pegasys Proclick

epitol

Tegretol-XR

cimetidine

Pegintron

ethosuximide

Topamax

cimetidine HCL

felbamate

Topamax Sprinkle

famotidine

PROTEASE INHIBITORS

fosphenytoin sodium

Topiramate ER

misoprostol


gabapentin

Trileptal

nizatidine

Olysio

lamotrigine

Trokendi XR

ranitidine HCL

Victrelis

lamotrigine odt

Vimpat

sucralfate

lamotrigine titration

Zarontin

Nizatidine

MULTIPLE SCLEROSIS

lamotrigine ER

Zonegran


levetiracetam

Carafate

TIER 01 GENERIC

levetiracetam ER

MIGRAINE/HEADACHE


glatopa

oxcarbazepine

TIER 01 GENERIC

Cimetidine


phenytoin

almotriptan

Cytotec

Ampyra

phenytoin infatabs

almotriptan malate

Famotidine Premixed

Aubagio

phenytoin sodium

dihydroergotamine mesylate

Pepcid

Avonex

phenytoin sodium extended

ergotamine tartrate/caffeine

Sucralfate

Avonex Pen

primidone

frovatriptan succinate

Zantac

Betaseron

roweepra

isometheptene mucate/caffeine/acetaminophen

Copaxone

tiagabine hydrochloride

GROWTH HORMONE

Gilenya

topiramate

isometheptene/dichloralphenazone/acetaminophen

Lemtrada

valproate sodium


Plegridy

valproic acid

naratriptan HCL

Norditropin Nordiflex Pen

Plegridy Starter Pack

zonisamide

nodolor

Nutropin AQ Nuspin 10

Rebif

Diazepam

rizatriptan benzoate


Rebif Rebidose


rizatriptan benzoate odt


Rebif Rebidose Titration Pack

Banzel

sumatriptan

Nutropin AQ Pen

Celontin

sumatriptan succinate


Rebif Titration Pack

Diastat Pediatric

sumatriptan succinate refill

Genotropin

Tecfidera

Fycompa

zolmitriptan

Genotropin Miniquick

Tecfidera Starter Pack

Lyrica

zolmitriptan odt

Humatrope

Tysabri

Onfi

Sumatriptan Succinate

Humatrope Combo Pack


Oxtellar XR


Norditropin Cartridge

Extavia

Peganone

Migergot

Norditropin Flexpro

Ocrevus

Potiga

Relpax

Omnitrope


Sumavel Dosepro

Saizen

NEUROLOGICALS

Aptiom

Treximet

Saizen Click.easy

ALZHEIMER'S DISEASE

Briviact


Saizenprep Reconstitutionkit

TIER 01 GENERIC

Carbatrol

Amerge

Serostim

donepezil HCL

Cerebyx

Axert

Tev-tropin

galantamine hydrobromide

Depacon

Cafergot

Zomacton

galantamine hydrobromide ER

Depakene

Cambia

Zorbtive

Depakote

D.h.e. 45

memantine hydrochloride

Depakote ER

Dihydroergotamine Mesylate

memantine HCL

HEPATITIS C

Depakote Sprinkles

memantine HCL titration PAK

ANTIVIRALS

Diastat Acudial

Ergomar

TIER 01 GENERIC

Dilantin

Ergotamine Tartrate

rivastigmine tartrate

moderiba

Dilantin Infatabs

Frova

rivastigmine transdermal system

ribasphere

Dilantin-125

Imitrex

ribavirin

Felbatol

Galantamine Hydrobromide

Imitrex Statdose Refill


Gabitril


Imitrex Statdose System

Epclusa

Keppra

Namenda XR

Maxalt

Harvoni

Keppra XR

Namenda XR Titration Pack

Maxalt-MLT

Moderiba

Klonopin


Migraine Pack

Moderiba 1200 Dose Pack

Lamictal

Aricept

Migranal

Moderiba 800 Dose Pack

Lamictal Chewable Dispersible

Exelon

Onzetra Xsail

Ribasphere Ribapak

Namenda

Prodrin

Ribatab

Lamictal Odt

Namenda Titration PAK

Sumachip

Sovaldi

Lamictal Starter/Not Taking Carbamazepine

Namzaric

Zecuity

Zepatier

Razadyne

Zembrace Symtouch

Lamictal Starter/Taking Carbamazepine/Not Taking Valproate


Razadyne ER

Zomig

Copegus

Zomig ZMT

Rebetol

ANTICONVULSANTS

Lamictal Starter/Taking Valproate

Technivie

TIER 01

OPHTHALMICS

Lamictal XR


6

ANTI-ALLERGIC AGENTS


Triesence

olanzapine odt

TIER 01 GENERIC

Azasite

Vexol

paliperidone ER

azelastine HCL

Ciloxan

perphenazine

cromolyn sodium

Mitosol

MIOTICS

prochlorperazine

epinastine HCL

Ocuflox

TIER 01 GENERIC

prochlorperazine edisylate

olopatadine HCL

Tobrex

pilocarpine HCL

prochlorperazine maleate


Zymaxid


quetiapine fumarate

Bepreve

Phospholine Iodide

quetiapine fumarate ER

Pataday

ANTI-INFLAMMATORY AGENTS


risperidone

Pazeo

TIER 01 GENERIC

Isopto Carpine

risperidone odt


bromfenac

Miochol-e

risperidone M-TAB

Alocril

cromolyn sodium

Miostat

thioridazine HCL

Alomide

diclofenac sodium

thiothixene

Elestat

flurbiprofen sodium

MISCELLANEOUS

trifluoperazine HCL

Emadine

ketorolac tromethamine


ziprasidone HCL

Lastacaft


Restasis

Clozapine Odt

Patanol

Ilevro

Restasis Multidose

Lithium

Nevanac

Xiidra

Lithium Carbonate

ANTI-GLAUCOMA AGENTS

Prolensa


Molindone Hydrochloride

TIER 01 GENERIC


Lacrisert


apraclonidine

Acular

Abilify Discmelt

betaxolol HCL

Acular LS

OSTEOPOROSIS

Abilify Maintena

brimonidine tartrate

Acuvail

BISPHOSPHONATES

Latuda

carteolol HCL

Bromsite

TIER 01 GENERIC

Quetiapine Fumarate ER

dorzolamide HCL

Ocufen

alendronate sodium

Risperdal Consta

dorzolamide HCL/timolol maleate

ibandronate sodium

Seroquel XR

CORTICOSTEROIDS/RELATED

pamidronate disodium


latanoprost

TIER 01 GENERIC

risedronate sodium

Abilify

levobunolol HCL

dexamethasone sodium phosphate

risedronate sodium DR

Adasuve

timolol maleate

zoledronic acid

Aristada

timolol maleate ophthalmic gel forming

fluorometholone

Alendronate Sodium

Chlorpromazine HCL

neo-polycin HC

Etidronate Disodium

Clozaril

Metipranolol

neomycin/polymyxin/bacitracin/hydrocortisone


Equetro


Fosamax Plus D

Fanapt

Combigan

neomycin/polymyxin/dexamethasone


Fanapt Titration Pack

Lumigan

Actonel

Fazaclo

poly-dex

Travatan Z

Atelvia

Fluphenazine HCL

prednisolone acetate


Binosto

Geodon

sulfacetamide sodium/prednisolone sodium phosphate

Alphagan P

Boniva

Haldol

Azopt

Fosamax

Haldol Decanoate 100

Betagan

Pamidronate Disodium

Haldol Decanoate 50

tobramycin/dexamethasone

Betimol

Reclast

Haloperidol

Dexamethasone Sodium Phosphate

Betoptic-s

Zoledronic Acid

Invega

Cosopt

Neomycin/Polymyxin/Hydrocortisone

Zometa

Invega Sustenna

Cosopt PF

Invega Trinza

Iopidine

Prednisolone Sodium Phosphate

SERM

Lithobid

Istalol

TIER 01 GENERIC

Nuplazid


Rescula

raloxifene hydrochloride

Prochlorperazine Maleate

Alrex

Timoptic


Rexulti

FML

Timoptic Ocudose

Evista

Risperdal

Lotemax

Timoptic-xe

Osphena

Risperdal M-TAB

Ozurdex

Trusopt

Saphris

Pred Mild

Xalatan

PSYCHOTHERAPEUTICS

Seroquel

Retisert

Zioptan

ANTIPSYCHOTICS/ANTIMANIC

Versacloz

Tobradex ST

TIER 01 GENERIC

Vraylar

Zylet

ANTI-INFECTIVES

aripiprazole

Zyprexa


TIER 01 GENERIC

aripiprazole odt

Zyprexa Relprevv

Blephamide

ciprofloxacin HCL

chlorpromazine HCL

Zyprexa Zydis

Blephamide S.o.p.

erythromycin

clozapine

Durezol

gatifloxacin

clozapine odt

PSYCHOTHERAPEUTICS, MISC.

Flarex

gentak

compro

TIER 01 GENERIC

FML Forte

gentamicin sulfate

fluphenazine decanoate

amphetamine/dextroamphetamine

FML Liquifilm

ilotycin

fluphenazine HCL

Iluvien

levofloxacin

armodafinil

haloperidol

Maxidex

ofloxacin

clonidine HCL ER

haloperidol decanoate

Maxitrol

romycin

dexedrine

haloperidol lactate

Omnipred

tobramycin sulfate

dexmethylphenidate HCL

lithium carbonate

Pred Forte

Bacitracin

dexmethylphenidate HCL ER

lithium carbonate ER

Pred-G


loxapine

Pred-G S.o.p.

Besivance

dextroamphetamine sulfate

loxapine succinate

Prednisolone/Moxifloxacin

Moxeza

dextroamphetamine sulfate ER

olanzapine

Tobradex

Vigamox


7

guanfacine ER


Xopenex Concentrate

Airduo Respiclick 55/14

metadate ER

Celexa

Xopenex HFA

Breo Ellipta

methamphetamine HCL

Lexapro

Dulera

methylphenidate hydrochloride

Paxil

LEUKOTRIENE RCPTR ANTGNST

Fluticasone Propionate/Salmeterol

Paxil CR

methylphenidate HCL

Symbicort

Pexeva

TIER 01 GENERIC

methylphenidate HCL CD

Prozac

montelukast sodium

methylphenidate HCL ER

MISCELLANEOUS

Prozac Weekly

zafirlukast

methylphenidate HCL SR


Zoloft


modafinil

Dymista

Accolate

zenzedi


RESPIRATORY

Singulair

Methylphenidate HCL

Ticalast

ANAPHYLAXIS TX AGENTS

Methylphenidate HCL ER


PULMONARY CORTICOSTEROIDS

Methylphenidate HCL ER (LA)

UROLOGICALS

Adrenaclick

BENIGN PRSTATC HYPRPLSIA

Auvi-q

TIER 01 GENERIC


TIER 01 GENERIC

Epinephrine

budesonide

Daytrana

alfuzosin HCL ER

Epipen 2-PAK


Quillivant XR

dutasteride

Epipen-JR 2-PAK

Arnuity Ellipta

Strattera

dutasteride/tamsulosin hydrochloride


Asmanex HFA

Vyvanse

Adrenalin

Asmanex Twisthaler 120 Metered Doses


dutasteride/tamsulosin HCL

Adderall

finasteride


ANTICHOLINERGICS

Adderall XR

tamsulosin HCL

TIER 01 GENERIC

Adzenys XR-odt



ipratropium bromide

Concerta

Rapaflo



Desoxyn


Atrovent HFA

Dexedrine

Avodart

Spiriva Handihaler


Evekeo

Cardura XL

Spiriva Respimat

Focalin

Flomax

Tudorza Pressair

Flovent Diskus

Focalin XR

Jalyn


Flovent HFA

Intuniv

Proscar

Incruse Ellipta

Pulmicort Flexhaler

Kapvay

Uroxatral

Ipratropium Bromide

Qvar

Metadate CD

Ipratropium Bromide Monohydrate


Methylin

ERECTILE DYSFUNCTION

Aerospan

Nuvigil


Seebri Neohaler

Alvesco

Procentra

Cialis

Flunisolide

Provigil

Viagra

ANTICHLNRGC/BETA AGONIST

Flunisolide Anhydrous

Ritalin


TIER 01 GENERIC

Pulmicort

Ritalin LA

Levitra

ipratropium bromide/albuterol sulfate

Zenzedi

Stendra

NASAL ANTIHISTAMINES


TIER 01 GENERIC

SNRI ANTIDEPRESSANTS

Anoro Ellipta

URINARY ANTISPASMODICS

azelastine HCL

TIER 01 GENERIC

Combivent Respimat

TIER 01 GENERIC

olopatadine HCL

desvenlafaxine ER

bethanechol chloride


duloxetine HCL

BETA AGONISTS

darifenacin hydrobromide ER

Astepro

venlafaxine HCL

TIER 01 GENERIC

Patanase

flavoxate HCL

venlafaxine HCL ER

albuterol

oxybutynin chloride

Venlafaxine HCL ER

albuterol sulfate

NASAL CORTICOSTEROIDS

oxybutynin chloride ER


albuterol sulfate ER

TIER 01 GENERIC

tolterodine tartrate

Desvenlafaxine ER

albuterol TAB 4MG

budesonide

tolterodine tartrate ER

Khedezla

levalbuterol

flunisolide

trospium chloride


levalbuterol HCL

fluticasone propionate

trospium chloride ER

Cymbalta

terbutaline sulfate

mometasone furoate


Duloxetine HCL


triamcinolone acetonide

Gelnique

Effexor XR

Arcapta Neohaler


Gelnique P.M.

Fetzima

Foradil Aerolizer

Qnasl

Myrbetriq

Fetzima Titration Pack

Perforomist

Qnasl Childrens

Oxytrol

Irenka

Proair HFA


Toviaz

Pristiq

Proair Respiclick

Beconase AQ

Vesicare

Serevent Diskus

Nasonex


SSRI ANTIDEPRESSANTS

Ventolin HFA

Omnaris

Bethanechol Chloride

TIER 01 GENERIC


Rhinocort Aqua

Detrol

citalopram hydrobromide

Albuterol Sulfate

Veramyst

Detrol LA

escitalopram oxalate

Brovana

Zetonna

Ditropan XL

fluoxetine HCL

Isuprel

Enablex

fluvoxamine maleate

Levalbuterol Tartrate HFA

STEROID/BETA AGONIST

Oxybutinin Chloride

fluvoxamine maleate ER

Metaproterenol Sulfate


Urecholine

paroxetine HCL

Proventil HFA

Advair Diskus

paroxetine HCL ER

Striverdi Respimat

Advair HFA

sertraline HCL

Terbutaline Sulfate


Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design

Fluoxetine DR

Vospire ER


Fluoxetine HCL

Xopenex


8

determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of Optum. The presence of a medication on this formulary list does not guarantee coverage. To determine the most up-to-date formulary status of your medication, please visit your member website or call member services at the number listed on your ID card.


9

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