ceftazidime

Augmentin ES-600

ceftriaxone sodium

Augmentin XR

cefuroxime axetil

Bactocill IN Dextrose

cefuroxime sodium

Bicillin C-R

January 2016

cephalexin

Bicillin L-a

PREFERRED

Moxatag

SELECT/NATIONAL/ADVANTAGE DRUG LIST

Cefaclor

Nafcillin Sodium

Cephalexin

Nallpen Iso-osmotic IN Dextrose

The HealthSmart Rx Drug List is a guide identifying generic, preferred brand name, and non-preferred brand name medicines within select therapeutic categories. The 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.

NON PREFERRED

Nallpen/Dextrose

Ancef

Penicillin G Potassium IN Iso-osmotic Dextrose

Avycaz

Penicillin G Procaine

Cedax

Penicillin G Sodium

Cefaclor ER

Pfizerpen-G

Cefazolin

Timentin

Cefazolin Sodium

Unasyn

Cefazolin Sodium/Dextrose

Unasyn Bulk Pack

Cefditoren Pivoxil

Zosyn

Cefepime

Cefotetan

QUINOLONES

Cefotetan/Dextrose

GENERIC

Cefoxitin Sodium

ciprofloxacin

Ceftazidime/Dextrose

ciprofloxacin ER

Ceftibuten

ciprofloxacin HCL

Ceftin

ANTI-INFECTIVES

ciprofloxacin I.V.-IN D5W

Ceftriaxone IN Iso-osmotic Dextrose

ANTIFUNGALS

levofloxacin

Ceftriaxone Sodium

GENERIC

levofloxacin IN D5W

Ceftriaxone/Dextrose

fluconazole

moxifloxacin HCL

Cefuroxime Sodium

fluconazole IN dextrose

ofloxacin

Cefuroxime/Dextrose

fluconazole IN NACL

Ciprofloxacin HCL

Claforan

flucytosine

Ofloxacin

Claforan/D5W

griseofulvin microsize

NON PREFERRED

Fortaz

griseofulvin ultramicrosize

Avelox

Keflex

itraconazole

Avelox Abc Pack

Maxipime

ketoconazole

Cipro

Mefoxin

nystatin

Cipro I.V.-IN D5W

Rocephin

terbinafine HCL

Cipro XR

Spectracef

voriconazole

Factive

Suprax

NON PREFERRED

Levaquin

Tazicef

Abelcet

Moxifloxacin HCL

Teflaro

Ambisome

Noroxin

Zerbaxa

Amphotec

Zinacef

Amphotericin B

TETRACYCLINES

Ancobon

GENERIC

PENICILLINS

Cresemba

demeclocycline HCL

GENERIC

Diflucan

doxycycline

amoxicillin

Fluconazole IN NACL

doxycycline hyclate

amoxicillin/clavulanate potassium

Grifulvin V

doxycycline hyclate DR

amoxicillin/clavulanate potassium ER

Gris-peg

doxycycline monohydrate

ampicillin

Lamisil

minocycline HCL

ampicillin sodium

Noxafil

minocycline HCL ER

ampicillin-sulbactam

Onmel

Tetracycline HCL

dicloxacillin sodium

Sporanox

NON PREFERRED

nafcillin sodium

Sporanox Pulsepak

Acticlate

oxacillin sodium

Terbinex

Adoxa

penicillin v potassium

Vfend

Adoxa PAK 1/100

penicillin G potassium

Vfend IV

Adoxa PAK 1/150

piperacillin sodium/ tazobactam sodium

Adoxa PAK 2/100

CEPHALOSPORINS

piperacillin sodium/tazobactam sodium

Alodox Convenience Kit

GENERIC

Doryx

cefaclor

piperacillin/tazobactam

Minocin

cefadroxil

Amoxicillin/Clavulanate Potassium

Minocin Kit

cefazolin sodium

PREFERRED

Monodox

cefdinir

Amoxicillin

Morgidox 1X100MG

cefepime

Ampicillin

Morgidox 2X100MG

cefixime

NON PREFERRED

Nutridox

cefotaxime sodium

Amoxicillin ER

Ocudox

cefoxitin sodium

Ampicillin Sodium

Solodyn

cefpodoxime proxetil

Ampicillin-sulbactam

Targadox

cefprozil

Augmentin

Vibramycin

Effective January 1, 2016 v.3

1

ANTI-INFLAMMATORY

Tivorbex

Edarbi

NSAIDS

Vimovo

Micardis

GENERIC

Vivlodex

Teveten

celecoxib

Voltaren-XR

diclofenac potassium

Zipsor

BETA BLOCKERS

diclofenac sodium DR

Zorvolex

GENERIC

diclofenac sodium ER

acebutolol HCL

diclofenac sodium/misoprostol

AUTO-IMMUNE

atenolol

etodolac

betaxolol HCL

etodolac ER

PREFERRED

bisoprolol fumarate

flurbiprofen

Cimzia

carvedilol

ibuprofen

Cimzia Starter Kit

esmolol HCL

indomethacin

Humira

labetalol HCL

indomethacin ER

Humira Pediatric Crohns Disease Starter Pack

metoprolol succinate ER

ketoprofen

metoprolol tartrate

Humira Pen

ketorolac tromethamine

nadolol

Humira Pen-crohns Diseasestarter

mefenamic acid

pindolol

Humira Pen-psoriasis Starter

meloxicam

propranolol HCL

Remicade

nabumetone

propranolol HCL ER

Simponi

naproxen

sotalol HCL

Simponi Aria

naproxen sodium

sotalol HCL (AF)

NON PREFERRED

naproxen sodium CR

PREFERRED

Actemra

naproxen sodium ER

Bystolic

Enbrel

oxaprozin

Propranolol HCL

Enbrel Sureclick

piroxicam

Timolol Maleate

Kineret

sulindac

NON PREFERRED

Orencia

tolmetin sodium

Betapace

Xeljanz

Meclofenamate Sodium

Betapace AF

Tolmetin Sodium

Brevibloc

CARDIOVASCULAR

PREFERRED

Coreg

ACE-INHIBITORS

Fenoprofen Calcium

Coreg CR

GENERIC

Ketoprofen ER

Corgard

benazepril HCL

Meloxicam

Hemangeol

captopril

Naproxen

Hypertenevide-12.5

enalapril maleate

NON PREFERRED

Inderal LA

enalaprilat

Anaprox

Inderal XL

fosinopril sodium

Anaprox DS

Innopran XL

lisinopril

Arthrotec 50

Kerlone

moexipril HCL

Arthrotec 75

Levatol

perindopril erbumine

Caldolor

Lopressor

quinapril HCL

Cataflam

Sectral

ramipril

Celebrex

Sotalol Hydrochloride

trandolapril

Daypro

Sotylize

NON PREFERRED

Derma Silkrx Anodynexa PAK

Tenormin

Accupril

Derma Silkrx Diclopak

Toprol XL

Aceon

Dermacinrx Inflammatral PAK

Trandate

Altace

Duexis

Zebeta

Epaned

Dyloject

Lotensin

EC-naprosyn

CALCIUM CHANNEL BLOCKERS

Mavik

Feldene

GENERIC

Prinivil

Flanax Pain Relief Kit

amlodipine besylate

Univasc

Ibuprofen Comfort PAC

diltiazem CD

Vasotec

Indocin

diltiazem HCL

Zestril

Indomethacin

diltiazem HCL ER

Indomethacin Sodium

felodipine ER

ANGIOTENSIN RCPTR BLOCKER

IC 400

isradipine

GENERIC

IC 800

nicardipine HCL

candesartan cilexetil

Ketorocaine-l

nifedipine

irbesartan

Ketorocaine-lm

nifedipine ER

losartan potassium

Ketorolac Tromethamine

nimodipine

telmisartan

Meloxicam Comfort PAC

nisoldipine

valsartan

Mobic

verapamil HCL

Eprosartan Mesylate

Nalfon

verapamil HCL ER

PREFERRED

Naprelan

verapamil HCL SR

Benicar

Naprosyn

NON PREFERRED

NON PREFERRED

Naproxen Comfort PAC

Adalat CC

Atacand

Neoprofen

Calan

Avapro

Ponstel

Calan SR

Cozaar

Sprix

Cardene I.v.

Diovan

Effective January 1, 2016

2

Cardene IV

telmisartan/hydrochlorothiazide

gemfibrozil

Cardene SR

trandolapril/verapamil HCL

Fenofibric Acid

Cardizem

trandolapril/verapamil HCL ER

PREFERRED

Cardizem CD

valsartan/hydrochlorothiazide

Fibricor

Cardizem LA

PREFERRED

Lipofen

Cleviprex

Azor

NON PREFERRED

Dilacor XR

Benicar HCT

Antara

Diltiazem HCL

Captopril/Hydrochlorothiazide

Fenofibrate

Nisoldipine

Dutoprol

Fenoglide

Nisoldipine ER

Methyldopa/Hydrochlorothiazide

Lofibra

Norvasc

Propranolol/Hydrochlorothiazide

Lopid

Nymalize

Tekturna HCT

Tricor

Procardia

Tribenzor

Triglide

Procardia XL

NON PREFERRED

Trilipix

Sular

Accuretic

BILE ACID SEQUESTRANTS

Tiazac

Amturnide

GENERIC

Verelan

Atacand HCT

cholestyramine

Verelan PM

Avalide

cholestyramine light

Clorpres

colestipol HCL

NITRATES & NITRITES

Corzide

colestipol HCL for oral suspension

GENERIC

Diovan HCT

PREFERRED

isosorbide dinitrate

Edarbyclor

Welchol

isosorbide mononitrate

Exforge

NON PREFERRED

isosorbide mononitrate ER

Exforge HCT

Colestid

nitroglycerin lingual

Hypertensolol

Colestid Flavored

nitroglycerin transdermal

Hyzaar

Questran

nitroglycerin ER

Lopressor HCT

Questran Light

nitroglycerin IN dextrose 5%

Lotensin HCT

CHOLEST ABS INHBTR/COMBO

nitroglycerin IN 5% dextrose

Lotrel

PREFERRED

Isosorbide Dinitrate

Lytensopril Kit

Vytorin

Nitroglycerin Lingual

Lytensopril-90

NON PREFERRED

PREFERRED

Lytensopril-90 Kit

Zetia

Dilatrate SR

Micardis HCT

NIACIN/COMBINATIONS

Isosorbide Dinitrate ER

Prestalia

GENERIC

Nitro-bid

Tarka

niacin ER

Nitro-dur

Tekamlo

PREFERRED

Nitrostat

Tenoretic 100

Niacor

NON PREFERRED

Tenoretic 50

Simcor

Imdur

Teveten HCT

NON PREFERRED

Isordil Titradose

Twynsta

Advicor

Nitroglycerin

Uniretic

Niaspan

Nitroglycerin IN Dextrose 5%

Vaseretic

OMEGA-3 FATTY ACIDS

Nitrolingual Pumpspray

Zestoretic

GENERIC

Nitromist

Ziac

omega-3-acid ethyl esters

Nitronal

PREFERRED

ANTIHYPERLIPIDEMICS

Vascepa

ANTI-HTN COMBINATIONS

STATINS

NON PREFERRED

GENERIC

GENERIC

Kynamro

amlodipine besylate/benazepril hydrochloride

atorvastatin calcium

Lovaza

fluvastatin

amlodipine besylate/benazepril HCL

fluvastatin sodium ER

DERMATOLOGICALS

amlodipine besylate/valsartan

lovastatin

ACNE

amlodipine/valsartan/hctz

pravastatin sodium

GENERIC

atenolol/chlorthalidone

simvastatin

adapalene

benazepril HCL/hydrochlorothiazide

PREFERRED

benzoyl peroxide

bisoprolol fumarate/hydrochlorothiazide

Crestor

benzoyl peroxide SHORT contact

NON PREFERRED

clindamycin phosphate

candesartan cilexetil/hydrochlorothiazide

Altoprev

clindamycin/benzoyl peroxide

Lescol

erythromycin

enalapril maleate/hydrochlorothiazide

Lescol XL

erythromycin/benzoyl peroxide

fosinopril sodium/hydrochlorothiazide

Lipitor

metronidazole

irbesartan/hydrochlorothiazide

Livalo

sodium sulfacetamide

lisinopril/hydrochlorothiazide

Mevacor

sodium sulfacetamide/sulfur

losartan potassium/hydrochlorothiazide

Pravachol

sodium sulfacetamide/sulfur cleanser

Zocor

sodium sulfacetamide/sulfur cleansing cloths

metoprolol/hydrochlorothiazide

FIBRATES

moexipril/hydrochlorothiazide

sodium sulfacetamide/sulfur green

GENERIC

nadolol/bendroflumethiazide

sodium sulfacetamide/sulfur w/sunscreen

fenofibrate

quinapril/hydrochlorothiazide

fenofibrate micronized

telmisartan/amlodipine

sodium sulfacetamide/sulfur wash

fenofibric acid DR

Effective January 1, 2016

3

sulfacetamide sodium

Rosadan Kit

Cordran

sulfacetamide sodium/sulfur cleanser

Rosanil

Cordran Tape

tretinoin

Rosula

Cortalo

tretinoin microsphere

Sodium Sulfacetamide/Sulfur

Cutivate

tretinoin microsphere P.M.

Sodium Sulfacetamide/Sulfur Cleanser IN Urea

Derma Silkrx Sds PAK

Doxycycline

Derma-smoothe/FS Body

Sodium Sulfacetamide/Sulfur IN Urea

PREFERRED

Derma-smoothe/FS Scalp

Soolantra

Benzamycinpak

Dermasorb HC

Sulfoam

Clindagel

Dermasorb Ta

Sumadan Kit

Finacea

Dermatop

Sumadan Wash

Retinoic Acid

Desonate

Sumadan XLT

Retinoic Acid-all Trans

Desowen

Sumaxin

Tretinoin

Desowen Cream/Cetaphil Lotion

Sumaxin CP Kit

Tretinoin (all-trans Retinoic Acid)

Desowen Lotion/Cetaphil Cream

Sumaxin Ts

NON PREFERRED

Desowen Ointment/Cetaphil Lotion

Sumaxin Wash

Absorica

Diprolene

Tretin-x

Acanya

Diprolene AF

Triseon

Aczone

Elocon

Vanoxide-HC

Adapalene

Epifoam

Veltin

Akne-mycin

First-hydrocortisone

Zacare 4% Kit

Atralin

Halog

Zacare 8% Kit

Avar

Halonate

Ziana

Avar LS

Kenalog

Avar LS Cleanser

Locoid

TOPICAL ANTI-INFLAMMATORY

Avar-e LS

Locoid Lipocream

GENERIC

Azelex

Luxiq

alclometasone dipropionate

Benzac Ac Wash

Nucort

augmented betamethasone dipropionate

Benzac W Wash

Nuzon

Benzaclin

Olux

betamethasone dipropionate

Benzaclin With P.M.

Olux-e

betamethasone valerate

Benzamycin

Pandel

calcipotriene/betamethasone dipropionate

Benzefoam

Pediaderm HC

Benzefoamultra

Pediaderm Ta

clobetasol propionate

Benziq

Scalacort DK

clobetasol propionate emollient

Benziq LS

Silazone Pharmapak

desonide

Clarifoam EF

Synalar

desoximetasone

Cleocin-t

Synalar Cream Kit

fluocinolone acetonide

Clindacin Etz

Synalar Ointment Kit

fluocinonide

Clindacin PAC

Synalar Ts

fluocinonide-e

Clindap-t

Taclonex

fluticasone propionate

Clinoin

Temovate

halobetasol propionate

Dermapak Plus

Temovate E

hydrocortisone

Differin

Texacort

hydrocortisone acetate/aloe

Duac

Topicort

hydrocortisone butyrate

Epiduo

Triamsil Combipak

hydrocortisone butyrate (lipid)

Epiduo Forte

Trianex

hydrocortisone butyrate (lipophilic)

Erygel

Triderma Forte

hydrocortisone valerate

Evoclin

Ultravate

hydrocortisone IN absorbase

Fabior

Ultravate PAC

mometasone furoate

Inova

Ultravate X

prednicarbate

Inova 4/1 Acne Control Therapy

Validerm

triamcinolone acetonide

Inova 8/2 Acne Control Therapy

Vanos

Amcinonide

Klaron

Verdeso

Desoximetasone

Metrocream

Westcort

Diflorasone Diacetate

Metrogel

PREFERRED

Metrolotion

ENDOCRINE

Pramosone

Mirvaso

CONTRACEPTIVE AGENTS

Triamcinolone Acetonide

Neuac Kit

GENERIC

NON PREFERRED

Noritate

desogestrel/ethinyl estradiol

Aclovate

Nuox

drospirenone/ethinyl estradiol

Advanced Allergy Collection Kit

Onexton

levonorgestrel

Ala Scalp

Oracea

levonorgestrel and ethinyl estradiol

Capex

Plexion

levonorgestrel/ethinyl estradiol

Carmol-HC

Plexion Cleanser

norethindrone

Clobex

Plexion Cleansing Cloths

norethindrone & ethinyl estradiol ferrous fumarate

Clocortolone Pivalate

Prascion Ra With Sunscreens

Clocortolone Pivalate P.M.

norethindrone acetate/ethinyl estradiol

Retin-a

Clodan Kit

Retin-a Micro

Cloderm

norethindrone acetate/ethinyl estradiol/ferrous fumarate

Retin-a Micro P.M.

Cloderm P.M.

Riax

Effective January 1, 2016

4

norgestimate/ethinyl estradiol

Cenestin

Humulin 70/30 Kwikpen

Levonorgestrel

Climara

Humulin 70/30 Pen

PREFERRED

Combipatch

Lantus

Natazia

Delestrogen

Lantus Solostar

Necon 1/50-28

Depo-estradiol

Levemir

Necon 10/11-28

Divigel

Levemir Flexpen

Norinyl 1+50

Elestrin

Levemir Flextouch

Nuvaring

Enjuvia

Novolin N

Zovia 1/50e

Estrace

Novolin N Relion

NON PREFERRED

Estradiol

Novolin R

Beyaz

Estrasorb

Novolin R Relion

Brevicon-28

Estring

Novolin 70/30

Cyclessa

Estrogel

Novolin 70/30 Relion

Depo-provera

Evamist

Novolog

Desogen

Femhrt Low Dose

Novolog Flexpen

Ella

Femring

Novolog Mix 70/30

Estrostep FE

Menostar

Novolog Mix 70/30 Prefilled Flexpen

Falessa

Minivelle

Novolog Penfill

Femcon FE

Prefest

Toujeo Solostar

Generess FE

Premarin

NON PREFERRED

Loestrin FE 1.5/30

Vagifem

Afrezza

Loestrin FE 1/20

Vivelle-dot

Apidra

Loestrin 1.5/30-21

Apidra Solostar

Loestrin 1/20-21

TESTOSTERONE AGENTS

Tresiba Flextouch

Loseasonique

GENERIC

LO Loestrin FE

danazol

NON-INSULIN HYPOGLYCEMICS

LO Minastrin FE

methyltestosterone

BIGUANIDES

Minastrin 24 FE

testosterone

GENERIC

Mircette

testosterone cypionate

metformin HCL

Modicon

testosterone enanthate

metformin HCL ER

Nor-QD

testosterone P.M.

NON PREFERRED

Norinyl 1+35

Testosterone

Fortamet

Ortho Evra

Testosterone P.M.

Glucophage

Ortho Micronor

PREFERRED

Glucophage XR

Ortho Tri-cyclen

Androderm

Glumetza

Ortho Tri-cyclen LO

Androgel P.M.

Riomet

Ortho-cept

Androxy

BIGUAN/SULFONYLUREA COMB.

Ortho-cyclen

NON PREFERRED

GENERIC

Ortho-novum 1/35

Androgel

glipizide/metformin HCL

Ortho-novum 7/7/7

Android

glyburide/metformin HCL

Ovcon-35

Aveed

NON PREFERRED

Plan B

Axiron

Glucovance

Plan B One-step

Depo-testosterone

BIGUAN/THIAZOLIDEINEDIONE

Quartette

First-testosterone

GENERIC

Safyral

First-testosterone Mc Compounding Kit

pioglitazone HCL

Seasonique

pioglitazone HCL/metformin HCL

Fortesta

Tri-norinyl 28

NON PREFERRED

Natesto

Yasmin 28

Actoplus Met

Striant

Yaz

Actoplus Met XR

Testim

Actos

Testone Cik

ESTROGENS/COMBINATIONS

Avandamet

Testopel

GENERIC

Avandia

Testred

estradiol

DPP-4 INHIBITORS

Vogelxo

estradiol valerate

PREFERRED

Vogelxo P.M.

estradiol/norethindrone acetate

Januvia

estropipate

Onglyza

INSULIN

norethindrone acetate/ethinyl estradiol

NON PREFERRED

PREFERRED

Nesina

PREFERRED

Humalog

Tradjenta

Alora

Humalog Kwikpen

BIGUANIDE/DPP-4 COMB.

Climara Pro

Humalog Mix 50/50

PREFERRED

Duavee

Humalog Mix 50/50 Kwikpen

Janumet

Estropipate

Humalog Mix 75/25

Janumet XR

Menest

Humalog Mix 75/25 Kwikpen

Kombiglyze XR

Premphase

Humulin N

NON PREFERRED

Prempro

Humulin N Kwikpen

Jentadueto

NON PREFERRED

Humulin N U-100 Pen

Kazano

Activella

Humulin R

SULFONYLUREAS

Angeliq

Humulin R U-500 (concentrated)

GENERIC

Biest/Progesterone

Humulin 70/30

glimepiride

Effective January 1, 2016

5

glipizide

Prevacid

PREFERRED

glipizide ER

Prevacid Solutab

Pegasys

glyburide

Prilosec

Pegasys Proclick

glyburide micronized

Protonix

NON PREFERRED

tolazamide

Infergen

Glyburide

ULCER DRUGS

Peg-intron

PREFERRED

GENERIC

Peg-intron Redipen

Chlorpropamide

cimetidine

Peg-intron Redipen PAK 4

Diabeta

cimetidine HCL

Pegintron

Tolazamide

famotidine

Tolbutamide

misoprostol

PROTEASE INHIBITORS

NON PREFERRED

nizatidine

NON PREFERRED

Amaryl

ranitidine HCL

Olysio

Glucotrol

sucralfate

Victrelis

Glucotrol XL

Famotidine

Glynase

PREFERRED

MULTIPLE SCLEROSIS

SULFONYLUREA/TZD COMB.

Carafate

GENERIC

NON PREFERRED

PREFERRED

pioglitazone HCL-glimepiride

Axid

Ampyra

NON PREFERRED

Cytotec

Avonex

Avandaryl

Deprizine Fusepaq

Avonex Pen

Duetact

Famotidine Premixed

Copaxone

INCRETINS

Pepcid

Plegridy

PREFERRED

Zantac

Plegridy Starter Pack

Bydureon

Tecfidera

Byetta

GROWTH HORMONE

Tecfidera Starter Pack

Victoza

NON PREFERRED

NON PREFERRED

PREFERRED

Aubagio

Tanzeum

Norditropin Cartridge

Betaseron

Trulicity

Norditropin Flexpro

Extavia

AMYLIN ANALOGS

Norditropin Nordiflex Pen

Gilenya

NON PREFERRED

Nutropin AQ Nuspin 10

Lemtrada

Symlinpen 120

Nutropin AQ Nuspin 20

Rebif

Symlinpen 60

Nutropin AQ Nuspin 5

Rebif Rebidose

DIABETIC OTHER

Nutropin AQ Pen

Rebif Rebidose Titration Pack

PREFERRED

Saizen

Rebif Titration Pack

Glucagen Hypokit

Saizen Click.easy

Tysabri

Glucagon Emergency Kit

Serostim

Invokamet

NON PREFERRED

NEUROLOGICALS

Invokana

Genotropin

ALZHEIMER'S DISEASE

Jardiance

Genotropin Miniquick

GENERIC

Proglycem

Humatrope

donepezil HCL

NON PREFERRED

Humatrope Combo Pack

galantamine hydrobromide

Farxiga

Omnitrope

memantine hydrochloride

Synjardy

Tev-tropin

memantine HCL

Xigduo XR

Zomacton

memantine HCL titration PAK

Zorbtive

rivastigmine tartrate

GASTROINTESTINAL

rivastigmine transdermal system

PROTON PUMP INHIBITORS

HEPATITIS C

Galantamine Hydrobromide

GENERIC

ANTIVIRALS

PREFERRED

esomeprazole magnesium

GENERIC

Namenda XR

esomeprazole sodium

ribavirin

Namenda XR Titration Pack

lansoprazole

PREFERRED

NON PREFERRED

omeprazole

Harvoni

Aricept

pantoprazole sodium

Ribatab

Aricept Odt

rabeprazole sodium

Sovaldi

Exelon

Esomeprazole Sodium

NON PREFERRED

Namenda

PREFERRED

Copegus

Namenda Titration PAK

Dexilant

Moderiba

Namzaric

Nexium

Moderiba 1200 Dose Pack

Razadyne

Nexium 24HR

Moderiba 800 Dose Pack

Razadyne ER

NON PREFERRED

Rebetol

Aciphex

Ribasphere

ANTICONVULSANTS

Aciphex Sprinkle

Ribasphere Ribapak

GENERIC

Esomeprazole Strontium

Technivie

carbamazepine

First-lansoprazole

Viekira PAK

carbamazepine ER

First-omeprazole

clonazepam

Nexium I.v.

INTERFERONS

clonazepam odt

Omeprazole + Syrspend SF Alka

divalproex sodium

Effective January 1, 2016

6

divalproex sodium DR

Therapentin-90

ANTI-GLAUCOMA AGENTS

divalproex sodium ER

Topamax

GENERIC

ethosuximide

Topamax Sprinkle

apraclonidine

felbamate

Topiramate ER

betaxolol HCL

fosphenytoin sodium

Trileptal

brimonidine tartrate

gabapentin

Trokendi XR

carteolol HCL

lamotrigine

Vimpat

dorzolamide HCL

lamotrigine odt

Zarontin

dorzolamide HCL/timolol maleate

lamotrigine titration

Zonegran

latanoprost

lamotrigine ER

levobunolol HCL

levetiracetam

MIGRAINE/HEADACHE

timolol maleate

levetiracetam ER

GENERIC

timolol maleate ophthalmic gel forming

oxcarbazepine

almotriptan malate

Bimatoprost

phenytoin

dihydroergotamine mesylate

Metipranolol

phenytoin sodium

naratriptan HCL

PREFERRED

phenytoin sodium extended

rizatriptan benzoate

Alphagan P

primidone

rizatriptan benzoate odt

Azopt

tiagabine hydrochloride

sumatriptan succinate

Betoptic-s

topiramate

sumatriptan succinate refill

Combigan

valproate sodium

zolmitriptan

Levobunolol HCL

valproic acid

zolmitriptan odt

Lumigan

zonisamide

Dihydroergotamine Mesylate

Timoptic Ocudose

PREFERRED

Sumatriptan Succinate

Travatan Z

Diastat Acudial

PREFERRED

Travoprost

Diastat Pediatric

Sumatriptan

NON PREFERRED

Diazepam

Zomig Nasal Spray

Betagan

Lamictal

NON PREFERRED

Betimol

Lamictal Chewable Dispersible

Alsuma

Cosopt

Lamictal Starter/Not Taking Carbamazepine

Amerge

Cosopt PF

Axert

Lamictal Starter/Taking Carbamazepine/Not Taking Valproate

Iopidine

Cafergot

Istalol

Cambia

Lamictal Starter/Taking Valproate

Rescula

D.h.e. 45

Lyrica

Timoptic

Ergomar

NON PREFERRED

Timoptic-xe

Frova

Aptiom

Trusopt

Imitrex

Banzel

Xalatan

Imitrex Statdose Refill

Carbatrol

Zioptan

Imitrex Statdose System

Celontin

Maxalt

Cerebyx

ANTI-INFECTIVES

Maxalt-MLT

Depacon

GENERIC

Migergot

Depakene

ciprofloxacin HCL

Migral

Depakote

erythromycin

Migranal

Depakote ER

gatifloxacin

Relpax

Depakote Sprinkles

gentamicin sulfate

Sumavel Dosepro

Dilantin

levofloxacin

Treximet

Dilantin Infatabs

ofloxacin

Zecuity

Dilantin-125

tobramycin sulfate

Zomig

Fanatrex Fusepaq

PREFERRED

Zomig ZMT

Felbatol

Bacitracin

Fycompa

Moxeza

OPHTHALMICS

Gabitril

Vigamox

ANTI-ALLERGIC AGENTS

Keppra

NON PREFERRED

GENERIC

Keppra XR

Azasite

azelastine HCL

Klonopin

Besivance

cromolyn sodium

Lamictal Odt

Ciloxan

epinastine HCL

Lamictal XR

Garamycin

olopatadine HCL

Levetiracetam

Mitosol

PREFERRED

Mysoline

Ocuflox

Pataday

Neurontin

Tobrex

NON PREFERRED

Onfi

Zymaxid

Alocril

Oxtellar XR

Alomide

Peganone

ANTI-INFLAMMATORY AGENTS

Bepreve

Phenytek

GENERIC

Elestat

Potiga

bromfenac

Emadine

Qudexy XR

cromolyn sodium

Lastacaft

Sabril

diclofenac sodium

Optivar

Stavzor

flurbiprofen sodium

Patanol

Tegretol

ketorolac tromethamine

Pazeo

Tegretol-XR

Therapentin-60

Effective January 1, 2016

7

NON PREFERRED

PREFERRED

Fanapt Titration Pack

Acular

Alendronate Sodium

Fazaclo

Acular LS

NON PREFERRED

Geodon

Acuvail

Actonel

Haldol

Ilevro

Atelvia

Haldol Decanoate 100

Nevanac

Binosto

Haldol Decanoate 50

Ocufen

Boniva

Invega

Prolensa

Etidronate Disodium

Invega Sustenna

Fosamax

Invega Trinza

CORTICOSTEROIDS/RELATED

Fosamax Plus D

Latuda

GENERIC

Pamidronate Disodium

Lithium

dexamethasone sodium phosphate

Reclast

Lithium Carbonate

fluorometholone

Zoledronic Acid

Lithobid

neomycin/polymyxin/bacitracin/hydrocortisone

Zometa

Loxitane

Molindone Hydrochloride

neomycin/polymyxin/dexamethasone

SERM

Rexulti

prednisolone acetate

GENERIC

Risperdal

sulfacetamide sodium/prednisolone sodium phosphate

raloxifene hydrochloride

Risperdal Consta

NON PREFERRED

Risperdal M-TAB

tobramycin/dexamethasone

Evista

Seroquel

PREFERRED

Osphena

Versacloz

Dexamethasone Sodium Phosphate

Zyprexa

FML

PSYCHOTHERAPEUTICS

Zyprexa Relprevv

FML Forte

ANTIPSYCHOTICS/ANTIMANIC

Zyprexa Zydis

Pred Mild

GENERIC

Prednisolone Sodium Phosphate

aripiprazole

PSYCHOTHERAPEUTICS, MISC.

NON PREFERRED

chlorpromazine HCL

GENERIC

Alrex

clozapine

amphetamine/dextroamphetamine

Blephamide

clozapine odt

clonidine HCL ER

Blephamide S.o.p.

fluphenazine decanoate

dexmethylphenidate HCL

Durezol

fluphenazine HCL

dexmethylphenidate HCL ER

Flarex

haloperidol

dextroamphetamine sulfate

FML Liquifilm

haloperidol decanoate

dextroamphetamine sulfate ER

Lotemax

haloperidol lactate

guanfacine ER

Maxidex

lithium carbonate

methamphetamine HCL

Maxitrol

lithium carbonate ER

methylphenidate hydrochloride

Neomycin/Polymyxin/Hydrocortisone

loxapine

methylphenidate HCL

Omnipred

loxapine succinate

methylphenidate HCL CD

Pred Forte

olanzapine

methylphenidate HCL ER

Pred-G

olanzapine odt

methylphenidate HCL SR

Pred-G S.o.p.

paliperidone ER

modafinil

Tobradex

perphenazine

Methylphenidate HCL ER

Tobradex ST

prochlorperazine

PREFERRED

Vexol

prochlorperazine edisylate

Strattera

Zylet

prochlorperazine maleate

Vyvanse

quetiapine fumarate

NON PREFERRED

MIOTICS

risperidone

Adderall

GENERIC

risperidone odt

Adderall XR

pilocarpine HCL

thioridazine HCL

Aptensio XR

PREFERRED

thiothixene

Concerta

Isopto Carbachol

trifluoperazine HCL

Daytrana

Phospholine Iodide

ziprasidone HCL

Desoxyn

NON PREFERRED

Aripiprazole Odt

Dexedrine

Isopto Carpine

Clozapine Odt

Evekeo

PREFERRED

Focalin

MISCELLANEOUS

Abilify Discmelt

Focalin XR

NON PREFERRED

Fluphenazine HCL

Intuniv

Lacrisert

Saphris

Kapvay

Restasis

Seroquel XR

Kapvay Dose Pack

NON PREFERRED

Metadate CD

OSTEOPOROSIS

Abilify

Methylin

BISPHOSPHONATES

Abilify Maintena

Nuvigil

GENERIC

Adasuve

Procentra

alendronate sodium

Aristada

Provigil

ibandronate sodium

Chlorpromazine HCL

Quillivant XR

pamidronate disodium

Clozaril

Ritalin

risedronate sodium

Compazine

Ritalin LA

risedronate sodium DR

Equetro

Ritalin SR

zoledronic acid

Fanapt

Zenzedi

Effective January 1, 2016

8

SNRI ANTIDEPRESSANTS

PREFERRED

olopatadine HCL

GENERIC

Anoro Ellipta

NON PREFERRED

duloxetine HCL

Combivent Respimat

Astelin

venlafaxine HCL

NON PREFERRED

Astepro

venlafaxine HCL ER

Duoneb

Patanase

Venlafaxine HCL ER

PREFERRED

BETA AGONISTS

NASAL CORTICOSTEROIDS

Pristiq

GENERIC

GENERIC

NON PREFERRED

albuterol

budesonide

Cymbalta

albuterol sulfate

flunisolide

Desvenlafaxine ER

albuterol sulfate ER

fluticasone propionate

Duloxetine HCL

albuterol TAB 4MG

triamcinolone acetonide

Effexor XR

levalbuterol

PREFERRED

Fetzima

levalbuterol HCL

Nasonex

Fetzima Titration Pack

terbutaline sulfate

Veramyst

Irenka

PREFERRED

NON PREFERRED

Khedezla

Foradil Aerolizer

Beconase AQ

Metaproterenol Sulfate

Flonase

SSRI ANTIDEPRESSANTS

Proair HFA

Omnaris

GENERIC

Proair Respiclick

Qnasl

citalopram hydrobromide

Serevent Diskus

Qnasl Childrens

escitalopram oxalate

Ventolin HFA

Rhinocort Aqua

fluoxetine DR

NON PREFERRED

Zetonna

fluoxetine HCL

Arcapta Neohaler

fluvoxamine maleate

Brovana

STEROID/BETA AGONIST

fluvoxamine maleate ER

Isuprel

PREFERRED

paroxetine HCL

Maxair Autohaler

Advair Diskus

paroxetine HCL ER

Perforomist

Advair HFA

sertraline HCL

Proventil HFA

Breo Ellipta

PREFERRED

Striverdi Respimat

Symbicort

Fluoxetine HCL

Vospire ER

NON PREFERRED

Paxil

Xopenex

Dulera

NON PREFERRED

Xopenex Concentrate

Celexa

Xopenex HFA

MISCELLANEOUS

Lexapro

NON PREFERRED

Luvox CR

LEUKOTRIENE RCPTR ANTGNST

Dermacinrx Azenase PAK

Paxil CR

GENERIC

Dymista

Pexeva

montelukast sodium

Prozac

zafirlukast

UROLOGICALS

Prozac Weekly

NON PREFERRED

BENIGN PRSTATC HYPRPLSIA

Zoloft

Accolate

GENERIC

Singulair

alfuzosin HCL ER

RESPIRATORY

dutasteride

ANAPHYLAXIS TX AGENTS

PULMONARY CORTICOSTEROIDS

dutasteride/tamsulosin hydrochloride

PREFERRED

GENERIC

finasteride

Epipen 2-PAK

budesonide

tamsulosin HCL

Epipen-JR 2-PAK

PREFERRED

PREFERRED

NON PREFERRED

Flovent Diskus

Rapaflo

Adrenaclick

Flovent HFA

NON PREFERRED

Adrenalin

Pulmicort Flexhaler

Avodart

Auvi-q

Qvar

Cardura XL

Epinephrine

NON PREFERRED

Flomax

Episnap

Aerospan

Jalyn

Alvesco

Proscar

ANTICHOLINERGICS

Arnuity Ellipta

Uroxatral

GENERIC

Asmanex HFA

ipratropium bromide

Asmanex Twisthaler 120 Metered Doses

ERECTILE DYSFUNCTION

PREFERRED

PREFERRED

Asmanex Twisthaler 14 Metered Doses

Incruse Ellipta

Cialis

Spiriva Handihaler

Stendra

Asmanex Twisthaler 30 Metered Doses

Spiriva Respimat

NON PREFERRED

Tudorza Pressair

Levitra

Asmanex Twisthaler 60 Metered Doses

NON PREFERRED

Staxyn

Atrovent HFA

Viagra

Asmanex Twisthaler 7 Metered Doses

Seebri Neohaler

Pulmicort

URINARY ANTISPASMODICS

ANTICHLNRGC/BETA AGONIST

GENERIC

NASAL ANTIHISTAMINES

GENERIC

bethanechol chloride

GENERIC

ipratropium bromide/albuterol sulfate

flavoxate HCL

azelastine HCL

Effective January 1, 2016

9

oxybutynin chloride

oxybutynin chloride ER

tolterodine tartrate

tolterodine tartrate ER

trospium chloride

trospium chloride ER

PREFERRED

Gelnique

Vesicare

NON PREFERRED

Detrol

Detrol LA

Ditropan XL

Enablex

Myrbetriq

Oxytrol

Sanctura

Sanctura XR

Toviaz

Urecholine

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

Effective January 1, 2016 v.3

10