-inflammatory -infectives cefepime - culinary … · capxib kit fosinopril sodium esmolol...
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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
TIER 03 NON PREFERRED
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
TIER 03 NON PREFERRED
mefenamic acid
nystatin
Fortaz
Avelox
meloxicam
terbinafine HCL
Keflex
Avelox Abc Pack
nabumetone
voriconazole
Maxipime
Cipro
naproxen
TIER 02 PREFERRED BRAND
Spectracef
Cipro I.V.-IN D5W
naproxen kit
Noxafil
Suprax
Cipro XR
naproxen sodium
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
penicillin G potassium
tetracycline hydrochloride
Zorvolex
CEPHALOSPORINS
piperacillin sodium/ tazobactam sodium
tetracycline HCL
TIER 03 NON PREFERRED
TIER 01 GENERIC
Minocycline HCL ER
Active Injection Kit Ket-l
cefaclor
piperacillin sodium/tazobactam sodium
Tetracycline HCL
Active Injection Kit Ketmarc-l
cefadroxil
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
Derma Silkrx Anodynexa PAK
perindopril erbumine
Inderal XL
Dilatrate SR
quinapril HCL
Innopran XL
Nitro-bid
Derma Silkrx Diclopak
ramipril
Lopressor
TIER 03 NON PREFERRED
Dermacinrx Inflammatral PAK
trandolapril
Nadolol
Gonitro
TIER 03 NON PREFERRED
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
TIER 03 NON PREFERRED
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
TIER 03 NON PREFERRED
irbesartan/hydrochlorothiazide
acebutolol HCL
AUTO-IMMUNE
Adalat CC
atenolol
lisinopril/hydrochlorothiazide
Calan
betaxolol HCL
TIER 02 PREFERRED BRAND
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
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
Simponi Aria
valsartan/hydrochlorothiazide
isosorbide mononitrate
Bystolic
Xeljanz
isosorbide mononitrate ER
Coreg CR
Captopril/Hydrochlorothiazide
Xeljanz XR
minitran
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
Brevibloc
captopril
nitroglycerin IN dextrose 5%
Byvalson
Coreg
enalapril maleate
nitroglycerin IN 5% dextrose
Tekamlo
Corgard
enalaprilat
Effective January 1, 2017
2
Tekturna HCT
GENERIC
ery
Erygel
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
neuac
Inova 8/2 Acne Control Therapy
Benicar HCT
Welchol
oscion cleanser
Clorpres
TIER 03 NON PREFERRED
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
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
Rosadan Kit
Tenoretic 100
sss 10%-5%
Simcor
Rosula
Tenoretic 50
sulfacetamide sodium
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
Sumadan Kit
TIER 02 PREFERRED BRAND
atorvastatin calcium
Vascepa
Sumadan Wash
Acanya
fluvastatin
TIER 03 NON PREFERRED
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 03 NON PREFERRED
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
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
TIER 03 NON PREFERRED
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
Effective January 1, 2017
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
TIER 02 PREFERRED BRAND
tri femynor
kariva
Pramosone E
ENDOCRINE
tri-estarylla
kelnor 1/35
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
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
TIER 03 NON PREFERRED
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
Effective January 1, 2017
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
TIER 03 NON PREFERRED
Novolog Penfill
Nor-QD
Estrone
Amaryl
TIER 03 NON PREFERRED
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
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
Yaz
testosterone
metformin HCL
Bydureon
testosterone cypionate
metformin HCL ER
Bydureon Pen
ESTROGENS/COMBINATIONS
testosterone enanthate
TIER 02 PREFERRED BRAND
Byetta
TIER 01 GENERIC
testosterone P.M.
Riomet
Victoza
amabelz
Testosterone
TIER 03 NON PREFERRED
TIER 03 NON PREFERRED
covaryx
TIER 02 PREFERRED BRAND
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 03 NON PREFERRED
TIER 01 GENERIC
AMYLIN ANALOGS
Androderm
esterified estrogens/methyltestosterone
glipizide/metformin HCL
TIER 02 PREFERRED BRAND
Androgel
glyburide/metformin HCL
Symlinpen 120
Android
TIER 03 NON PREFERRED
Symlinpen 60
Androxy
esterified estrogens/methyltestosterone DS
Glucovance
DIABETIC OTHER
Danazol
BIGUAN/THIAZOLIDEINEDIONE
TIER 02 PREFERRED BRAND
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
TIER 02 PREFERRED BRAND
Invokamet XR
estradiol valerate
Striant
Actoplus Met XR
Invokana
estradiol/norethindrone acetate
Testim
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
mimvey LO
INSULIN
GASTROINTESTINAL
Januvia
norethindrone acetate/ethinyl estradiol
TIER 02 PREFERRED BRAND
PROTON PUMP INHIBITORS
Onglyza
Basaglar Kwikpen
TIER 01 GENERIC
ortho-est
Tradjenta
Humalog
esomeprazole magnesium
yuvafem
TIER 03 NON PREFERRED
Humalog Kwikpen
esomeprazole sodium
Estropipate
Alogliptin
Humalog Mix 50/50
lansoprazole
TIER 02 PREFERRED BRAND
Nesina
Humalog Mix 50/50 Kwikpen
omeprazole
Alora
BIGUANIDE/DPP-4 COMB.
Humalog Mix 75/25
pantoprazole sodium
Combipatch
TIER 02 PREFERRED BRAND
Humalog Mix 75/25 Kwikpen
rabeprazole sodium
Duavee
Janumet
Humulin N
TIER 03 NON PREFERRED
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
TIER 03 NON PREFERRED
First-lansoprazole
Prempro
Lantus Solostar
Alogliptin/Metformin HCL
First-omeprazole
TIER 03 NON PREFERRED
Levemir
Kazano
Nexium
Activella
Levemir Flextouch
SULFONYLUREAS
Nexium I.v.
Angeliq
Novolin N
TIER 01 GENERIC
glimepiride
Effective January 1, 2017
5
Omeprazole + Syrspend SF Alka
Viekira PAK
GENERIC
Levetiracetam
carbamazepine
Mysoline
Prevacid
INTERFERONS
carbamazepine ER
Neurontin
Prevacid Solutab
TIER 02 PREFERRED BRAND
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
TIER 03 NON PREFERRED
gabapentin
Trileptal
nizatidine
Olysio
lamotrigine
Trokendi XR
ranitidine HCL
Victrelis
lamotrigine odt
Vimpat
sucralfate
lamotrigine titration
Zarontin
Nizatidine
MULTIPLE SCLEROSIS
lamotrigine ER
Zonegran
TIER 02 PREFERRED BRAND
levetiracetam
Carafate
TIER 01 GENERIC
levetiracetam ER
MIGRAINE/HEADACHE
TIER 03 NON PREFERRED
glatopa
oxcarbazepine
TIER 01 GENERIC
Cimetidine
TIER 02 PREFERRED BRAND
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
TIER 02 PREFERRED BRAND
Plegridy
valproic acid
naratriptan HCL
Norditropin Nordiflex Pen
Plegridy Starter Pack
zonisamide
nodolor
Nutropin AQ Nuspin 10
Rebif
Diazepam
rizatriptan benzoate
Nutropin AQ Nuspin 20
Rebif Rebidose
TIER 02 PREFERRED BRAND
rizatriptan benzoate odt
Nutropin AQ Nuspin 5
Rebif Rebidose Titration Pack
Banzel
sumatriptan
Nutropin AQ Pen
Celontin
sumatriptan succinate
TIER 03 NON PREFERRED
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
TIER 03 NON PREFERRED
Oxtellar XR
TIER 02 PREFERRED BRAND
Norditropin Cartridge
Extavia
Peganone
Migergot
Norditropin Flexpro
Ocrevus
Potiga
Relpax
Omnitrope
TIER 03 NON PREFERRED
Sumavel Dosepro
Saizen
NEUROLOGICALS
Aptiom
Treximet
Saizen Click.easy
ALZHEIMER'S DISEASE
Briviact
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
Gabitril
TIER 02 PREFERRED BRAND
Imitrex Statdose System
Epclusa
Keppra
Namenda XR
Maxalt
Harvoni
Keppra XR
Namenda XR Titration Pack
Maxalt-MLT
Moderiba
Klonopin
TIER 03 NON PREFERRED
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
TIER 03 NON PREFERRED
Razadyne ER
Zomig
Copegus
Zomig ZMT
Rebetol
ANTICONVULSANTS
Lamictal Starter/Taking Valproate
Technivie
TIER 01
OPHTHALMICS
Lamictal XR
Effective January 1, 2017
6
ANTI-ALLERGIC AGENTS
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
Zymaxid
TIER 02 PREFERRED BRAND
quetiapine fumarate
Bepreve
Phospholine Iodide
quetiapine fumarate ER
Pataday
ANTI-INFLAMMATORY AGENTS
TIER 03 NON PREFERRED
risperidone
Pazeo
TIER 01 GENERIC
Isopto Carpine
risperidone odt
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
ziprasidone HCL
Lastacaft
TIER 02 PREFERRED BRAND
Restasis
Clozapine Odt
Patanol
Ilevro
Restasis Multidose
Lithium
Nevanac
Xiidra
Lithium Carbonate
ANTI-GLAUCOMA AGENTS
Prolensa
TIER 03 NON PREFERRED
Molindone Hydrochloride
TIER 01 GENERIC
TIER 03 NON PREFERRED
Lacrisert
TIER 02 PREFERRED BRAND
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
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
Equetro
TIER 02 PREFERRED BRAND
Fosamax Plus D
Fanapt
Combigan
neomycin/polymyxin/dexamethasone
TIER 03 NON PREFERRED
Fanapt Titration Pack
Lumigan
Actonel
Fazaclo
poly-dex
Travatan Z
Atelvia
Fluphenazine HCL
prednisolone acetate
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
Rescula
raloxifene hydrochloride
Prochlorperazine Maleate
Alrex
Timoptic
TIER 03 NON PREFERRED
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 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
loxapine
Pred-G S.o.p.
Besivance
dextroamphetamine sulfate
loxapine succinate
Prednisolone/Moxifloxacin
Moxeza
dextroamphetamine sulfate ER
olanzapine
Tobradex
Vigamox
Effective January 1, 2017
7
guanfacine ER
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
Zoloft
TIER 03 NON PREFERRED
modafinil
Dymista
Accolate
zenzedi
TIER 03 NON PREFERRED
RESPIRATORY
Singulair
Methylphenidate HCL
Ticalast
ANAPHYLAXIS TX AGENTS
Methylphenidate HCL ER
TIER 02 PREFERRED BRAND
PULMONARY CORTICOSTEROIDS
Methylphenidate HCL ER (LA)
UROLOGICALS
Adrenaclick
BENIGN PRSTATC HYPRPLSIA
Auvi-q
TIER 01 GENERIC
TIER 02 PREFERRED BRAND
TIER 01 GENERIC
Epinephrine
budesonide
Daytrana
alfuzosin HCL ER
Epipen 2-PAK
TIER 02 PREFERRED BRAND
Quillivant XR
dutasteride
Epipen-JR 2-PAK
Arnuity Ellipta
Strattera
dutasteride/tamsulosin hydrochloride
TIER 03 NON PREFERRED
Asmanex HFA
Vyvanse
Adrenalin
Asmanex Twisthaler 120 Metered Doses
TIER 03 NON PREFERRED
dutasteride/tamsulosin HCL
Adderall
finasteride
Asmanex Twisthaler 14 Metered Doses
ANTICHOLINERGICS
Adderall XR
tamsulosin HCL
TIER 01 GENERIC
Adzenys XR-odt
Asmanex Twisthaler 30 Metered Doses
TIER 02 PREFERRED BRAND
ipratropium bromide
Concerta
Rapaflo
TIER 02 PREFERRED BRAND
Asmanex Twisthaler 60 Metered Doses
Desoxyn
TIER 03 NON PREFERRED
Atrovent HFA
Dexedrine
Avodart
Spiriva Handihaler
Asmanex Twisthaler 7 Metered Doses
Evekeo
Cardura XL
Spiriva Respimat
Focalin
Flomax
Tudorza Pressair
Flovent Diskus
Focalin XR
Jalyn
TIER 03 NON PREFERRED
Flovent HFA
Intuniv
Proscar
Incruse Ellipta
Pulmicort Flexhaler
Kapvay
Uroxatral
Ipratropium Bromide
Qvar
Metadate CD
Ipratropium Bromide Monohydrate
TIER 03 NON PREFERRED
Methylin
ERECTILE DYSFUNCTION
Aerospan
Nuvigil
TIER 02 PREFERRED BRAND
Seebri Neohaler
Alvesco
Procentra
Cialis
Flunisolide
Provigil
Viagra
ANTICHLNRGC/BETA AGONIST
Flunisolide Anhydrous
Ritalin
TIER 03 NON PREFERRED
TIER 01 GENERIC
Pulmicort
Ritalin LA
Levitra
ipratropium bromide/albuterol sulfate
Zenzedi
Stendra
NASAL ANTIHISTAMINES
TIER 02 PREFERRED BRAND
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
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
albuterol sulfate ER
TIER 01 GENERIC
tolterodine tartrate
Desvenlafaxine ER
albuterol TAB 4MG
budesonide
tolterodine tartrate ER
Khedezla
levalbuterol
flunisolide
trospium chloride
TIER 03 NON PREFERRED
levalbuterol HCL
fluticasone propionate
trospium chloride ER
Cymbalta
terbutaline sulfate
mometasone furoate
TIER 02 PREFERRED BRAND
Duloxetine HCL
TIER 02 PREFERRED BRAND
triamcinolone acetonide
Gelnique
Effexor XR
Arcapta Neohaler
TIER 02 PREFERRED BRAND
Gelnique P.M.
Fetzima
Foradil Aerolizer
Qnasl
Myrbetriq
Fetzima Titration Pack
Perforomist
Qnasl Childrens
Oxytrol
Irenka
Proair HFA
TIER 03 NON PREFERRED
Toviaz
Pristiq
Proair Respiclick
Beconase AQ
Vesicare
Serevent Diskus
Nasonex
TIER 03 NON PREFERRED
SSRI ANTIDEPRESSANTS
Ventolin HFA
Omnaris
Bethanechol Chloride
TIER 01 GENERIC
TIER 03 NON PREFERRED
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
TIER 02 PREFERRED BRAND
Urecholine
paroxetine HCL
Proventil HFA
Advair Diskus
paroxetine HCL ER
Striverdi Respimat
Advair HFA
sertraline HCL
Terbutaline Sulfate
Airduo Respiclick 113/14
Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design
Fluoxetine DR
Vospire ER
Airduo Respiclick 232/14
Fluoxetine HCL
Xopenex
Effective January 1, 2017
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.
Effective January 1, 2017
9