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January 2013 NATIONAL FORMULARY DRUG LIST The Catamaran Drug List is a guide identifying preferred band-name medicines (Tier 2) within select therapeutic categories. The Drug List may not include all drugs covered by your prescription drug benefit. Generic medicines (Tier 1) 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. Nonpreferred medicines are Tier 3. 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. ANTI-INFECTIVES ANTIFUNGALS TIER 1 amphotericin b fluconazole flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole nystatin terbinafine hcl voriconazole TIER 2 Noxafil NON PREFERRED Ancobon Bio-statin Diflucan Grifulvin V Gris-peg Lamisil Onmel Sporanox Sporanox Pulsepak Terbinex Vfend CEPHALOSPORINS TIER 1 cefaclor cefaclor er cefadroxil cefazolin sodium cefdinir Cefditoren Pivoxil cefepime cefotaxime sodium cefotetan cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime ceftriaxone sodium cefuroxime axetil cefuroxime sodium cephalexin tazicef NON PREFERRED Cedax Ceftin Claforan Fortaz Keflex Rocephin Spectracef Suprax Zinacef tetracycline hcl NON PREFERRED Adoxa Adoxa Pak 1/100 Adoxa Pak 1/150 Adoxa Pak 2/100 Alodox Convenience Kit Doryx Dynacin Minocin Minocin Kit Monodox Nutridox Ocudox Oraxyl Solodyn Vibramycin PENICILLINS TIER 1 amoxicillin amoxicillin/clavulanate potassium amoxicillin/clavulanate potassium er amoxicillin/potassium clavulanate ampicillin ampicillin sodium ampicillin-sulbactam dicloxacillin sodium nafcillin sodium oxacillin sodium penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium pfizerpen-g TIER 2 Augmentin NON PREFERRED Augmentin Es-600 Augmentin Xr Bicillin C-r Bicillin L-a Moxatag Unasyn Unasyn Bulk Pack QUINOLONES TIER 1 ciprofloxacin er ciprofloxacin hcl levofloxacin ofloxacin TIER 2 Avelox Avelox Abc Pack NON PREFERRED Cipro Cipro Xr Factive Levaquin Noroxin TETRACYCLINES TIER 1 avidoxy demeclocycline hcl doxycycline doxycycline hyclate doxycycline monohydrate minocycline hcl minocycline hcl er morgidox 1x100mg morgidox 2x100mg ANTI-INFLAMMATORY NSAIDS TIER 1 diclofenac potassium diclofenac sodium dr diclofenac sodium er Diclofenac Sodium Xr diclofenac sodium/misoprostol etodolac etodolac er fenoprofen calcium flurbiprofen ibuprofen indomethacin indomethacin er ketoprofen ketoprofen er ketorolac tromethamine meclofenamate sodium mefenamic acid Meloxicam nabumetone naproxen naproxen dr naproxen sodium oxaprozin piroxicam sulindac tolmetin sodium TIER 2 Celebrex Vimovo NON PREFERRED Anaprox Anaprox Ds Arthrotec 50 Arthrotec 75 Cataflam Clinoril Daypro Duexis Ec-naprosyn Feldene Ibuprofen Comfort Pac Ic 400 Ic 800 Indocin Meloxicam Comfort Pac Mobic Nalfon Naprelan Effective January 1, 2013 1 Naprosyn Naproxen Comfort Pac Ponstel Sprix Voltaren-xr Wound Gel Zipsor AUTO-IMMUNE TIER 2 Enbrel Enbrel Sureclick Humira Humira Pen Humira Pen-crohns Diseasestarter Humira Pen-psoriasis Starter NON PREFERRED Cimzia Cimzia Starter Kit Kineret Orencia Simponi Xeljanz CARDIOVASCULAR ACE-INHIBITORS TIER 1 benazepril hcl captopril enalapril maleate fosinopril sodium lisinopril moexipril hcl perindopril erbumine quinapril hcl ramipril trandolapril NON PREFERRED Accupril Aceon Altace Lotensin Mavik Prinivil Univasc Vasotec Zestril ANGIOTENSIN RCPTR BLOCKER TIER 1 eprosartan mesylate irbesartan losartan potassium TIER 2 Atacand Benicar Diovan Micardis NON PREFERRED Avapro Cozaar Edarbi Teveten BETA BLOCKERS TIER 1 acebutolol hcl atenolol betaxolol hcl bisoprolol fumarate metoprolol succinate er metoprolol tartrate nadolol pindolol propranolol hcl propranolol hcl er sorine sotalol hcl sotalol hcl (af) timolol maleate TIER 2 Bystolic NON PREFERRED Betapace Betapace Af Corgard Inderal La Innopran Xl Kerlone Levatol Lopressor Metoprolol Sectral Tenormin Toprol Xl Zebeta CALCIUM CHANNEL BLOCKERS TIER 1 afeditab cr amlodipine besylate cartia xt dilt-cd dilt-xr diltiazem cd diltiazem hcl Diltiazem Hcl Cd diltiazem hcl er diltzac felodipine er isradipine matzim la nicardipine hcl nifediac cc nifedical xl nifedipine nifedipine er nimodipine nisoldipine nisoldipine er taztia xt verapamil hcl verapamil hcl er Verapamil Hcl Sr TIER 2 Cardizem La NON PREFERRED Adalat Cc Calan Calan Sr Cardene Sr Cardizem Cardizem Cd Covera-hs Dilacor Xr Dynacirc Cr Isoptin Sr Nimotop Norvasc Procardia Procardia Xl Sular Tiazac Verelan Verelan Pm NITRATES & NITRITES TIER 1 amyl nitrite isochron isoditrate er isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er minitran nitroglycerin Nitroglycerin Lingual nitroglycerin transdermal TIER 2 Dilatrate Sr Nitro-bid Nitro-dur Nitrolingual Pumpspray Nitrostat NON PREFERRED Imdur Isordil Titradose Monoket Nitromist ANTI-HTN COMBINATIONS TIER 1 amlodipine besylate/benazepril hcl amlodipine besylate/benazepril hydrochloride atenolol/chlorthalidone benazepril hcl/hydrochlorothiazide bisoprolol fumarate/hydrochlorothiazide candesartan cilexetil/hydrochlorothiazide captopril/hydrochlorothiazide enalapril maleate/hydrochlorothiazide fosinopril sodium/hydrochlorothiazide irbesartan/hydrochlorothiazide lisinopril/hydrochlorothiazide losartan potassium/hydrochlorothiazide methyldopa/hydrochlorothiazide metoprolol/hydrochlorothiazide moexipril/hydrochlorothiazide nadolol/bendroflumethiazide propranolol/hydrochlorothiazide quinapril/hydrochlorothiazide valsartan/hydrochlorothiazide TIER 2 Amturnide Azor Benicar Hct Exforge Exforge Hct Micardis Hct Tarka Tekamlo Tekturna Hct Tribenzor Effective January 1, 2013 2 Twynsta Valturna NON PREFERRED Accuretic Atacand Hct Avalide Clorpres Corzide Diovan Hct Dutoprol Edarbyclor Hypertensolol Hyzaar Lopressor Hct Lotensin Hct Lotrel Lytensopril Lytensopril-90 Prinzide Tenoretic 100 Tenoretic 50 Teveten Hct Uniretic Vaseretic Zestoretic Ziac ANTIHYPERLIPIDEMICS STATINS TIER 1 atorvastatin calcium fluvastatin lovastatin pravastatin sodium simvastatin TIER 2 Altoprev Crestor NON PREFERRED Lescol Lescol Xl Lipitor Livalo Mevacor Pravachol Zocor FIBRATES TIER 1 Fenofibrate fenofibrate micronized Fenofibric Acid gemfibrozil TIER 2 Antara Fenoglide Lipofen Triglide Trilipix NON PREFERRED Fibricor Lofibra Lopid Tricor BILE ACID SEQUESTRANTS TIER 1 cholestyramine cholestyramine light colestipol hcl colestipol hcl for oral suspension Micronized Colestipol Hcl prevalite TIER 2 Welchol NON PREFERRED Colestid Colestid Flavored Questran Questran Light CHOLEST ABS INHBTR/COMBO TIER 2 Vytorin Zetia NIACIN/COMBINATIONS TIER 2 Niaspan Simcor NON PREFERRED Advicor OMEGA-3 FATTY ACIDS TIER 2 Lovaza DERMATOLOGICALS ACNE TIER 1 adapalene amnesteem avar cleanser avar-e emollient avar-e green Avita benzepro benzepro short contact benziq wash benzoyl peroxide benzoyl peroxide cleanser benzoyl peroxide cleansing benzoyl peroxide short contact benzoyl peroxide wash benzoyl peroxide wash acne treatment pack bp cleanser bp cleansing wash bp wash bp 10-1 bpo bpo creamy wash complete pack bpo 3% foaming cloths bpo 6% foaming cloths bpo 9% foaming cloths cerisa wash claravis claris clarifying wash clearplex x clenia clenia foaming wash clindacin-p clindamax clindamycin phosphate clindamycin/benzoyl peroxide clindareach ery erythromycin erythromycin/benzoyl peroxide lavoclen-4 acne wash kit lavoclen-4 creamy wash lavoclen-8 acne wash kit lavoclen-8 creamy wash metronidazole myorisan oscion cleanser pacnex wash pr benzoyl peroxide wash prascion prascion fc prascion ra with sunscreens ra renewal medicated acne treatment maximum strength rosadan rosanil cleanser se bpo wash se bpo 3% foaming cloths se bpo 6% foaming cloths se bpo 7-5.5 wash kit se bpo 9% foaming cloths se 10-5 ss Sodium Sulfacetamide sodium sulfacetamide/sulfur sodium sulfacetamide/sulfur cleanser sodium sulfacetamide/sulfur cleanser in urea sodium sulfacetamide/sulfur cleansing cloths sodium sulfacetamide/sulfur green sodium sulfacetamide/sulfur in urea sodium sulfacetamide/sulfur wash sotret sulfacetamide sodium sulfacetamide sodium/sulfur cleanser sulfacleanse 8/4 suphera tl bpo mx cleanser Tretinoin virti-sulf vitazol zaclir cleansing zencia TIER 2 Acanya Aczone Atralin Azelex Epiduo Finacea Metrogel Oracea Veltin NON PREFERRED Absorica Akne-mycin Avar Ls Cleanser Avar-e Ls Benzac Ac Wash Benzac W Wash Benzaclin Benzaclin With Pump Benzamycin Benzamycinpak Benzefoam Benzefoamultra Benziq Benziq Ls Clarifoam Ef Cleocin-t Clindacin Pac Clindagel Delos Desquam-x Wash Differin Duac Effective January 1, 2013 3 Evoclin Finacea Plus Inova Inova 4/1 Acne Control Therapy Inova 8/2 Acne Control Therapy Klaron Metrocream Metrolotion Neobenz Micro Neobenz Micro Plus Pack Neobenz Micro Sd Neobenz Micro Wash Neobenz Micro Wash Plus Pack Noritate Nuox Pacnex Hp Pacnex Lp Pacnex Mx Plexion Cleanser Plexion Cleansing Cloth Plexion Sct Retin-a Retin-a Micro Retin-a Micro Pump Rosadan Kit Rosanil Sss 10-4 Sulfoam Sumadan Kit Sumadan Wash Sumaxin Sumaxin Cp Kit Sumaxin Ts Sumaxin Wash Tretin-x Triaz Triaz Cleanser Triaz Foaming Cloths Vanoxide Hc Vanoxide-hc Zacare 4% Kit Zacare 8% Kit Ziana TOPICAL ANTI-INFLAMMATORY TIER 1 ala cort alclometasone dipropionate alphatrex amcinonide apexicon apexicon e augmented betamethasone dipropionate betamethasone dipropionate betamethasone valerate clobetasol propionate clobetasol propionate e clobetasol propionate emollient cormax cormax scalp application cortalo desonide desoximetasone diflorasone diacetate fluocinolone acetonide fluocinolone acetonide body fluocinolone acetonide scalp fluocinonide fluocinonide emollient base fluocinonide-e fluticasone propionate halac halobetasol propionate halonate pac hydrocortisone hydrocortisone acetate/aloe hydrocortisone butyrate hydrocortisone in absorbase hydrocortisone valerate Lokara mometasone furoate pramcort prednicarbate scalacort synalar triamcinolone acetonide triamcinolone acetonide in absorbase trianex triderm u-cort TIER 2 Capex Cordran Tape Halog Kenalog Locoid Lipocream Taclonex NON PREFERRED Aclovate Ala Scalp Aqua Glycolic Hc Scalp & Body Carmol-hc Clobeta Cream Clobeta Ointment Clobex Cloderm Cloderm Pump Cordran Cordran Sp Cutivate Derma-smoothe/fs Body Oil Derma-smoothe/fs Scalp Oil Dermatop Desonate Desonil Desowen Desowen Cream/cetaphil Lotion Desowen Lotion/cetaphil Cream Desowen Ointment/cetaphil Lotion Diprolene Diprolene Af Elocon Epifoam First-hydrocortisone Halonate Lidamantle Hc Locoid Luxiq Momexin Nucort Nuzon Olux Olux-e Pandel Pediaderm Hc Pediaderm Ta Pramosone Scalacort Dk Synalar Cream Kit Synalar Ointment Kit Synalar Ts Temovate Temovate E Texacort Topicort Ultravate Ultravate Pac Ultravate X Vanos Verdeso Westcort ENDOCRINE CONTRACEPTIVE AGENTS TIER 2 Depo-provera ESTROGENS/COMBINATIONS TIER 1 estradiol estradiol valerate estradiol/norethindrone acetate estropipate Jevantique jinteli mimvey ortho-est TIER 2 Cenestin Combipatch Enjuvia Estring Evamist Premphase Prempro Vagifem Vivelle-dot NON PREFERRED Activella Alora Angeliq Climara Climara Pro Delestrogen Depo-estradiol Divigel Elestrin Estrace Estraderm Estrasorb Estrogel Femhrt Low Dose Femhrt 1/5 Femring Femtrace Menest Menostar Minivelle Prefest Premarin TESTOSTERONE AGENTS TIER 1 danazol testosterone cypionate testosterone enanthate Effective January 1, 2013 4 TIER 2 Androderm Androgel Androgel Pump Androxy Axiron Fortesta Methitest NON PREFERRED android Delatestryl Depo-testosterone First-testosterone First-testosterone Mc Compounding Kit Striant Testim Testopel testred INSULIN TIER 2 Apidra Apidra Solostar Humalog Humalog Kwikpen Humalog Mix 50/50 Humalog Mix 50/50 Kwikpen Humalog Mix 75/25 Humalog Mix 75/25 Kwikpen Humulin R U-500 (concentrated) Lantus Lantus Solostar Levemir Levemir Flexpen Novolog Novolog Flexpen Novolog Mix 70/30 Novolog Mix 70/30 Prefilled Flexpen Novolog Penfill NON-INSULIN HYPOGLYCEMICS BIGUANIDES TIER 1 metformin hcl metformin hcl er TIER 2 Riomet NON PREFERRED Fortamet Glucophage Glucophage Xr Glumetza BIGUAN/SULFONYLUREA COMB. TIER 1 glipizide/metformin hcl glyburide/metformin hcl NON PREFERRED Glucovance Metaglip BIGUAN/THIAZOLIDEINEDIONE TIER 1 Pioglitazone Hcl Pioglitazone Hcl/metformin Hcl TIER 2 Actoplus Met Xr NON PREFERRED Actoplus Met Actos Avandamet Avandia Protonix DPP-4 INHIBITORS TIER 2 Januvia Onglyza Tradjenta BIGUANIDE/DPP-4 COMB. TIER 2 Janumet Janumet Xr Jentadueto Kombiglyze Xr SULFONYLUREAS TIER 1 chlorpropamide glimepiride glipizide glipizide er Glipizide Xl glyburide glyburide micronized tolazamide tolbutamide NON PREFERRED Amaryl Diabeta Glucotrol Glucotrol Xl Glynase SULFONYLUREA/TZD COMB. TIER 2 Duetact NON PREFERRED Avandaryl INCRETINS TIER 2 Bydureon Byetta Victoza AMYLIN ANALOGS TIER 2 Symlin Symlinpen 120 Symlinpen 60 ANTIHYPOGLYCEMIC AGENTS TIER 2 Glucagon Emergency Kit NON PREFERRED Glucagen Glucagen Hypokit Proglycem GASTROINTESTINAL PROTON PUMP INHIBITORS TIER 1 lansoprazole Lansoprazole Odt omeprazole Pantoprazole Sodium TIER 2 Nexium NON PREFERRED Aciphex Dexilant First-lansoprazole First-omeprazole Prevacid Prevacid Solutab Prilosec ULCER DRUGS TIER 1 cimetidine cimetidine hcl famotidine misoprostol nizatidine ranitidine hcl sucralfate TIER 2 Carafate NON PREFERRED Axid Cytotec Pepcid Zantac GROWTH HORMONE TIER 2 Norditropin Cartridge Norditropin Flexpro Norditropin Nordiflex Pen Nutropin Nutropin Aq Nutropin Aq Nuspin 10 Nutropin Aq Nuspin 20 Nutropin Aq Nuspin 5 Nutropin Aq Pen NON PREFERRED Genotropin Genotropin Miniquick Humatrope Humatrope Combo Pack Omnitrope Saizen Saizen Click.easy Serostim Tev-tropin Zorbtive HEPATITIS C ANTIVIRALS TIER 1 ribapak ribasphere ribatab ribavirin NON PREFERRED Copegus Rebetol INTERFERONS TIER 2 Peg-intron Peg-intron Redipen Peg-intron Redipen Pak 4 Pegasys Pegasys Proclick NON PREFERRED Infergen PROTEASE INHIBITORS TIER 2 Incivek Victrelis Effective January 1, 2013 5 MULTIPLE SCLEROSIS TIER 2 Ampyra Avonex Avonex Pen Copaxone Rebif Rebif Titration Pack NON PREFERRED Aubagio Betaseron Extavia Gilenya NEUROLOGICALS ALZHEIMER'S DISEASE TIER 1 donepezil hcl galantamine galantamine hydrobromide rivastigmine tartrate TIER 2 Namenda Namenda Titration Pak NON PREFERRED Aricept Aricept Odt Exelon Razadyne Razadyne Er ANTICONVULSANTS TIER 1 carbamazepine Carbamazepine Er clonazepam clonazepam odt Diazepam divalproex sodium divalproex sodium dr divalproex sodium er epitol ethosuximide Felbamate fosphenytoin sodium gabapentin lamotrigine levetiracetam levetiracetam er oxcarbazepine phenytoin phenytoin sodium phenytoin sodium extended primidone tiagabine hydrochloride topiragen topiramate valproic acid zonisamide TIER 2 Banzel Celontin diastat pediatric Dilantin Infatabs Lamictal Odt Lamictal Xr Lyrica Peganone Potiga Tegretol-xr Vimpat NON PREFERRED Carbatrol Depakene Depakote Depakote Er Depakote Sprinkles diastat acudial Dilantin Felbatol Gabitril Keppra Keppra Xr Klonopin Lamictal Lamictal Chewable Dispersible Lamictal Starter/not Taking Carbamazepine Lamictal Starter/taking Carbamazepine/not Taking Valproate Lamictal Starter/taking Valproate Mysoline Neurontin Onfi Phenytek Sabril Stavzor Tegretol Therapentin-60 Therapentin-90 Topamax Topamax Sprinkle Trileptal Zarontin Zonegran MIGRAINE/HEADACHE TIER 1 dihydroergotamine mesylate naratriptan hcl Sumatriptan sumatriptan succinate Sumatriptan Succinate Refill TIER 2 Cafergot Ergomar Maxalt Maxalt-mlt Relpax Treximet Zomig Zomig Zmt NON PREFERRED Alsuma Amerge Axert Cambia D.h.e. 45 Frova Imitrex Imitrex Statdose Refill Imitrex Statdose System Migergot Migral Migranal Sumavel Dosepro ANTI-ALLERGIC AGENTS TIER 1 azelastine hcl cromolyn sodium epinastine hcl TIER 2 Pataday Patanol NON PREFERRED Alamast Alocril Alomide Bepreve Elestat Emadine Lastacaft Optivar ANTI-GLAUCOMA AGENTS TIER 1 apraclonidine betaxolol hcl brimonidine tartrate carteolol hcl dorzolamide hcl dorzolamide hcl/timolol maleate latanoprost levobunolol hcl Metipranolol timolol maleate Timolol Maleate Ophthalmic Gel Forming TIER 2 Azopt Betoptic-s Combigan Lumigan Travatan Z NON PREFERRED Alphagan P Betagan Betimol Cosopt Cosopt Pf Iopidine Istalol Optipranolol Timoptic Timoptic Ocudose Timoptic-xe Trusopt Xalatan Zioptan ANTI-INFECTIVES TIER 1 bacitracin ciprofloxacin hcl erythromycin garamycin gentak gentamicin sulfate ilotycin levofloxacin ofloxacin romycin tobramycin sulfate tobrasol OPHTHALMICS Effective January 1, 2013 6 TIER 2 Besivance Ciloxan Moxeza Vigamox Zymaxid NON PREFERRED Azasite Iquix Mitosol Ocuflox Quixin Tobrex MIOTICS TIER 1 pilocarpine hcl TIER 2 Isopto Carbachol Phospholine Iodide Pilopine Hs NON PREFERRED Isopto Carpine MISCELLANEOUS TIER 2 Lacrisert Restasis ANTI-INFLAMMATORY AGENTS TIER 1 bromfenac cromolyn sodium diclofenac sodium flurbiprofen sodium ketorolac tromethamine TIER 2 Acuvail Bromday Nevanac NON PREFERRED Acular Acular Ls Ilevro Ocufen Voltaren CORTICOSTEROIDS/RELATED TIER 1 dexamethasone sodium phosphate fluor-op Fluorometholone neomycin/polymyxin/bacitracin/hydroco rtisone neomycin/polymyxin/dexamethasone neomycin/polymyxin/hydrocortisone poly-dex Prednisolone Acetate prednisolone sodium phosphate sulfacetamide sodium/prednisolone sodium phosphate tobramycin/dexamethasone TIER 2 Alrex Blephamide S.o.p. Durezol Fml Lotemax Pred Mild Tobradex St Zylet NON PREFERRED Blephamide Flarex Fml Forte Fml Liquifilm Maxidex Maxitrol Omnipred Poly-pred Pred Forte Pred-g Pred-g S.o.p. Tobradex Vexol OSTEOPOROSIS BISPHOSPHONATES TIER 1 alendronate sodium etidronate disodium ibandronate sodium TIER 2 Actonel Atelvia NON PREFERRED Binosto Boniva Didronel Fosamax Fosamax Plus D Skelid SERM TIER 2 Evista PSYCHOTHERAPEUTICS ATYPICAL ANTIPSYCHOTICS TIER 1 chlorpromazine hcl clozapine Clozapine Odt compro fluphenazine decanoate fluphenazine hcl haloperidol haloperidol decanoate haloperidol lactate Lithium Carbonate lithium carbonate er Lithium Citrate loxapine loxapine succinate olanzapine olanzapine odt perphenazine prochlorperazine prochlorperazine edisylate prochlorperazine maleate quetiapine fumarate risperidone Risperidone M-tab risperidone odt thioridazine hcl thiothixene trifluoperazine hcl ziprasidone hcl TIER 2 Abilify Abilify Discmelt Latuda Seroquel Xr NON PREFERRED Clozaril Equetro Fanapt Fanapt Titration Pack Fazaclo Geodon Haldol Haldol Decanoate 100 Haldol Decanoate 50 Invega Invega Sustenna Lithobid Loxitane Navane Risperdal Risperdal Consta Risperdal M-tab Saphris Seroquel Zyprexa Zyprexa Relprevv Zyprexa Zydis CNS STIMULANTS TIER 1 Amphetamine/dextroamphetamine dexmethylphenidate hcl dextroamphetamine sulfate dextroamphetamine sulfate er metadate er methamphetamine hcl methylin methylin er methylphenidate hcl methylphenidate hcl cd methylphenidate hcl er Methylphenidate Hcl Sr methylphenidate hydrochloride modafinil TIER 2 Daytrana Intuniv Vyvanse NON PREFERRED Adderall Adderall Xr Concerta Desoxyn Dexedrine Focalin Focalin Xr Kapvay Kapvay Dose Pack Metadate Cd Nuvigil Procentra Provigil Quillivant Xr Ritalin Ritalin La Ritalin Sr Effective January 1, 2013 7 SNRI ANTIDEPRESSANTS TIER 1 venlafaxine hcl venlafaxine hcl er TIER 2 Cymbalta Pristiq NON PREFERRED Effexor Xr SSRI ANTIDEPRESSANTS TIER 1 citalopram hydrobromide escitalopram oxalate fluoxetine dr fluoxetine hcl fluvoxamine maleate paroxetine hcl paroxetine hcl er sertraline hcl TIER 2 Paxil NON PREFERRED Celexa Lexapro Luvox Cr Paxil Cr Pexeva Prozac Prozac Weekly Zoloft RESPIRATORY ANAPHYLAXIS TX AGENTS TIER 1 Epinephrine TIER 2 Epipen Epipen 2-pak Epipen-jr Epipen-jr 2-pak NON PREFERRED Twinject ANTICHOLINERGICS TIER 1 ipratropium bromide TIER 2 Atrovent Hfa Spiriva Handihaler Tudorza Pressair ANTICHLNRGC/BETA AGONIST TIER 1 ipratropium bromide/albuterol sulfate TIER 2 Combivent Combivent Respimat NON PREFERRED Duoneb BETA AGONISTS TIER 1 albuterol sulfate albuterol sulfate er levalbuterol Levalbuterol Hcl metaproterenol sulfate terbutaline sulfate TIER 2 Foradil Aerolizer Perforomist Proair Hfa Serevent Diskus Ventolin Hfa NON PREFERRED Accuneb Arcapta Neohaler Brovana Isuprel Maxair Autohaler Proventil Hfa Vospire Er Xopenex Xopenex Concentrate Xopenex Hfa LEUKOTRIENE RCPTR ANTGNST TIER 1 montelukast sodium Zafirlukast NON PREFERRED Accolate Singulair PULMONARY CORTICOSTEROIDS TIER 1 budesonide TIER 2 Alvesco Asmanex 120 Metered Doses Asmanex 14 Metered Doses Asmanex 30 Metered Doses Asmanex 60 Metered Doses Asmanex 7 Metered Doses Pulmicort Flexhaler Qvar NON PREFERRED Flovent Diskus Flovent Hfa Pulmicort NASAL ANTIHISTAMINES TIER 1 azelastine hcl TIER 2 Astepro NON PREFERRED Astelin Patanase NASAL CORTICOSTEROIDS TIER 1 flunisolide fluticasone propionate triamcinolone acetonide TIER 2 Nasonex Qnasl Rhinocort Aqua Veramyst NON PREFERRED Beconase Aq Flonase Nasacort Aq Omnaris Zetonna STEROID/BETA AGONIST TIER 2 Advair Diskus Advair Hfa Dulera Symbicort UROLOGICALS BENIGN PRSTATC HYPRPLSIA TIER 1 alfuzosin hcl er finasteride tamsulosin hcl TIER 2 Rapaflo NON PREFERRED Avodart Cardura Xl Flomax Jalyn Proscar Uroxatral URINARY ANTISPASMODICS TIER 1 bethanechol chloride flavoxate hcl oxybutynin chloride oxybutynin chloride er Tolterodine Tartrate trospium chloride trospium chloride er TIER 2 Detrol La Enablex Gelnique Oxytrol Toviaz Vesicare NON PREFERRED Detrol Ditropan Xl Myrbetriq Sanctura Sanctura Xr 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 Catamaran. The presence of a medication on this formulary list does not guarantee coverage. Effective January 1, 2013 8 Standard Step Therapy Programs January 2013 ST Program Targeted Drugs Requirements First-line Drugs Cardiovascular Generics: irbesartan, irbesartan/HCTZ, losartan, losartan/HCTZ ARBs Atacand HCT† Diovan HCT† Edarbi, Edarbyclor Teveten, Teveten HCT Generics or preferred brands first line Dutoprol Dutoprol Generics first line Central Nervous System Neupro Neupro Generics first line Sedative Hypnotics Edluar# Intermezzo# Rozerem# Zolpimist# Generics or preferred brand first line Selective Serotonin Reuptake Inhibitors* Luvox CR# Pexeva# Viibryd# Generics first line Preferred brands: Atacand Benicar, Benicar HCT, Diovan, Micardis, Micardis HCT atenolol/chlorthalidone, bisoprolol/HCTZ, metoprolol XL metoprolol/HCTZ, nadolol/bendroflumethiazide, propanolol/HCTZ ropinirole, pramipexole Generics: zolpidem, zolpidem CR, zaleplon Preferred brand: Lunesta citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline Gastrointestinal Proton Pump Inhibitors Aciphex# Prevacid Solutab# Prilosec Packets# Zegerid Suspension# Zegerid OTC# Generics or preferred brand first line Generics: lansoprazole, omeprazole, omeprazole/sodium bicarbonate, pantoprazole Preferred brand: Nexium Respiratory Intranasal Steroids Beconase Dymista# Omnaris# Zetonna# AQ# Generics or preferred brands first line (age under 4 exempt) Generics: flunisolide, fluticasone, triamcinolone Preferred brands: Nasonex, Qnasl, Rhinocort Aqua, Veramyst * Applies to new starts only. # Quantity limits may also apply. Please refer to the Standard Quantity Limits document. † Target or preferred drug status will remain until generic exclusivity expires. informedRx® is now Catamaran © 2013 Catamaran Inc. All rights reserved. Catamaran is a registered trademark of Catamaran Inc. Page 1 of 1
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