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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
4
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
QUICK REFERENCE DRUG LIST
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
QUICK REFERENCE DRUG LIST
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
PREFERRED OPTIONS LIST
12
NON-PREFERRED OR EXCLUDED DRUGS PREFERRED OPTION(S)*
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
PREFERRED OPTIONS LIST
13
NON-PREFERRED OR EXCLUDED DRUGS PREFERRED OPTION(S)*
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
PREFERRED OPTIONS LIST
14
NON-PREFERRED OR EXCLUDED DRUGS PREFERRED OPTION(S)*
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
PREFERRED OPTIONS LIST
15
NON-PREFERRED OR EXCLUDED DRUGS PREFERRED OPTION(S)*
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
PREFERRED OPTIONS LIST
Our Company complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
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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.
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Your specifc prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document.