PRIMARY/PREFERRED DRUG LIST (FORMULARY)

Transcription

1 A ABILIFY MAINTENA ACANYA ADEMPAS ADVAIR ALPHAGAN P ALREX AMITZA ANDRODERM ANORO ELLIPTA APRISO APTENSIO XR ARANESP ARISTADA ASMANEX ATELVIA ATRALIN ATRIPLA AUBAGIO AXIRON AZILECT AZOPT AZOR B BASAGLAR BD INSULIN SYRINGES & NEEDLES BELSOMRA BELVIQ BELVIQ XR BENICAR BENICAR HCT BENZACLIN BESIVANCE BETASERON BETHKIS BETIMOL BETOPTIC S BEVESPI AEROSPHERE BEYAZ BIDIL BOSULIF BREO ELLIPTA BRILINTA BRISDELLE BUTRANS BYSTOLIC C CABOMETYX CANASA CARDURA XL CETROTIDE CIALIS CIPRODEX CITRANATAL CLIMARA PRO CLODERM COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMPLERA CONTRAVE COPAXONE 40 MG COREG CR CORLANOR CORTIFOAM COSOPT PF CREON CRINONE D DALIRESP DESCOVY DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM DEXILANT DICLEGIS DIFFERIN DIFICID DIVIGEL DUAVEE DULERA DUPIXENT DUREZOL E EFFIENT ELIDEL ELIQUIS EMVERM ENBREL ENDOMETRIN ENTRESTO EPCLUSA EPIDUO EPIPEN EPIPEN JR EPISIL ESBRIET ESTRACE CREAM EVAMIST EVOTAZ F FARXIGA FENTORA FINACEA FLOVENT DISKUS FLOVENT HFA FLUOXETINE 60 MG FOLLISTIM AQ FORTEO FYCOMPA G GEL-ONE GENVOYA GILENYA GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GRALISE GRASTEK H HARVONI HORIZANT HUMATROPE HUMIRA HUMULIN R U-500 HYALGAN HYSINGLA ER I ISENTRESS J JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR JUBLIA JUXTAPID K KOGENATE FS KOVALTRY L LATUDA LETAIRIS LEVEMIR LIALDA LINZESS LO LOESTRIN FE LOCOID LOTION LOTEMAX LOTRONEX 3 LUZU LYRICA M MEGACE ES MINASTRIN 24 FE MINIVELLE MIRAPEX ER MOVANTIK MOXEZA MUGARD MULTAQ MUSE MYRBETRIQ FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This SignatureScripts primary drug list is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. Specific prescription benefit plan design may not cover categories, regardless of their appearance in this document. The plan participant s prescription benefit plan may have a different copay 1 for specific products on this list. Unless otherwise indicated, drug list products will include all dosage forms. 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. Contact SignatureScripts Customer Service to check coverage and co-payments* for a specific medicine.

2 O NAFTIN NAMENDA XR NAMZARIC NARCAN NASAL SPRAY NATAZIA NEUPRO NITROLINGUAL NORDITROPIN NORVIR NOVOEIGHT NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA NUCYNTA ER NUEDEXTA NUVARING NUWIQ O ODEFSEY OFEV ONETOUCH ULTRA STRIPS & KITS 3 ONETOUCH VERIO STRIPS & KITS 3 ONZETRA SAIL OPANA ER ORACEA ORALAIR ORENITRAM OSPHENA OVIDREL OXTELLAR XR OXYCONTIN P PATADAY PAZEO PENTASA PERFOROMIST PHOSLYRA PICATO PREMARIN PREMARIN CREAM PREMPHASE PREMPRO PREZCOBIX PREZISTA PROAIR HFA PROAIR RESPICLICK PROCRIT PROCTOFOAM -HC PROLENSA PULMICORT FLEXHALER PYLERA Q QUDEXY XR QUILLIVANT XR QVAR R RAGWITEK RANEXA RAPAFLO RASUVO REBIF RELENZA RELPAX RENVELA REPATHA RESTASIS RETIN-A MICRO REYATAZ RUCONEST S SAFRYAL SANCUSO SAVELLA SAXENDA SEREVENT SEROQUEL XR SILENOR SIMBRINZA SIVEXTRO SOMATULINE DEPOT SOMAVERT SOOLANTRA SPIRIVA SPRYCEL STRATTERA STRIBILD STRIVERDI RESPIMAT SUBOXONE FILM SUBSYS SUPARTZ FX SUPRAX SUPREP SYMLINPEN SYNTHROID T TAMIFLU TAZORAC TECFIDERA TEKTURNA TEKTURNA HCT TIVICAY TOBRADEX OINTMENT TOBRADEX ST TOVIAZ TRACLEER TRADJENTA TRAVATAN Z TRESIBA TREXIMET TRIBENZOR TRINTELLIX TRIUMUEQ TROKENDI XR TRULICITY TRUVADA U UCERIS ULORIC V VAGIFEM VARUBI VASCEPA VELPHORO VELTASSA VEMLIDY VESICARE VIBERZI VICTOZA VIGAMOX VIIBRYD VIMPAT VIOKACE VISTOGARD VOLTAREN GEL VYTORIN VYVANSE W WELCHOL X XARELTO XIFIXAN 550 MG XIGDUO XR XIIDRA Z ZARXIO ZEMBRANCE SYMTOUCH ZENPREP ZIOPTAN ZYCLARA ZYLET ZYTIGA FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This SignatureScripts primary drug list is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. Specific prescription benefit plan design may not cover categories, regardless of their appearance in this document. The plan participant s prescription benefit plan may have a different copay 1 for specific products on this list. Unless otherwise indicated, drug list products will include all dosage forms. 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. Contact SignatureScripts Customer Service to check coverage and co-payments* for a specific medicine.

3 INFORMATION FOR THE PLAN PARTICIPANT Your Benefit Plan provides you with a prescription benefit program that is administered by SignatureScripts. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor. For specific information regarding your prescription benefit coverage and co-pay* information, contact a SignatureScripts customer service representative, toll-free: A OneTouch blood glucose meter will 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 SignatureScripts Customer Service. The drug list is subject to change. For the most up-to-date list visit SignatureScripts/Caremark 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. Generics should be considered the first line of prescribing. The drug list is not all inclusive nor does it guarantee coverage, but represents a summary of prescription coverage. The plan participant's specific prescription benefit plan may have different co-pays for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. Any brand drug for which a generic product becomes available may be designated as a non-preferred product. The drug list is subject to change. For the most up-to-date list visit For plans with traditional 3-tier co-pays: Tier 1 = All generic medications. Tier 2 = All brand name / formulary medications that appear on this list. INFORMATION FOR THE HEALTHCARE PROVIDER Your patient is covered under a prescription benefit plan administered by SignatureScripts. 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 listed in this brochure. Healthcare providers may direct questions about the list to a SignatureScripts customer service representative at Thank you for your professional cooperation in providing cost-effective quality healthcare. * Co-payment or co-pay means the amount a plan participant 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. This SignatureScripts primary / preferred drug list contains prescription brand name medicines that are registered or trademarks of pharmaceutical manufacturers that are not affiliated with SignatureScripts. Listed products are for informational purposes only and are not intended to replace clinical judgment of the prescriber. Your privacy is important to us. Our associates are trained regarding the appropriate way to handle your private health information.

4 ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, SEROQUEL XR APEXICON E desoximetasone, fluocinonide ABSTRAL fentanyl transmucosal lozenge, FENTORA, SUBSYS APIDRA NOVOLOG ARMOUR THYROID levothyroxine, SYNTHROID ACCU-CHEK STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 4 ONETOUCH VERIO STRIPS AND KITS 4 ACTOS pioglitazone ARTHROTEC celecoxib, or diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, ome prazole, pantoprazole or DEXILANT ADDERAL XR amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts extrel, guanfacine ext-rel, methylphenidate, methylphenidate ext rel, APTENSIO XR, QUILLIVANT XR, STRATTERA, VYVANSE ASACOL HD balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA ADRENACLICK epinephrine autoinjector, EPIPEN, EPIPEN JR ASCENSIA STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 4 AEROSPAN ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR ATACAND, ATACAND HCT ONETOUCH VERIO STRIPS AND KITS 4 candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan-hydrochlorothiazide, losartan, losartan hydrochlorothiazide, telmisartan, telmisartan hydrochlorothiazide, valsartan, valsartanhydrochlorothiazide, BENICAR, BENICAR-HCT ALCORTIN A hydrocortisone ATROVENT HFA irpratropium inhalation solution, SPIRVA ALLISON MEDICAL INSULIN SYRINGES 5 BD ULTRAFINE INSULIN SYRINGES AVONEX glatiramer, AUBAGIO, BETASERON, COPAXONE 40 MG, GILENYA, REBIF, TECFIDERA ALOQUIN hydrocortisone AXERT naratriptan, rizatriptan, sumatriptan, zolmitriptan, ALORA estradiol, DIVIGEL, EVAMIST, MINIVELLE AZELEX adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC ALTOPREV atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvistatin, VYTORIN BECONASE AQ flunisolide, fluticasone, mometasone, triamcinolone, ALVESCO ASMANEX, FLOVENT DISKUS, FLOVENT HFA, BENSAL HP desonide, hydrocortisone PULMICORT FLEXHALER, QVAR AMRIX cyclobenazprine BENZAC AC, BENZAC W adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC ANDROGEL testosterone gel 2%, ANDRODERM, AXIRON BENZIQ adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO BETAPACE, BETAPACE AF sotalol ANTARA fenofibrate, fenofibric acid BREEZE 2 STRIPS AND KITS 4 ONE TOUCH ULTRA STRIPS AND KITS 3 ONE TOUCH VERIO STRIPS AND KITS 3

5 butalbital-acetaminophen-caffeine capsule naratriptan, rizatriptan, sumatriptan, zolmitriptan, DORAL sublingual, BELSOMRA, SILENOR BYDUREON TRULICITY, VICTOZA DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide BYETTA TRULICITY, VICTOZA DYRENIUM amiloride CAFERGOT naratriptan, rizatriptan, sumatriptan, zolmitriptan, EDARBI, EDARBYCLOR candesartan, camdesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartanhydrochlorothiazide, losartan, losartan hydrochlorothiazide, telmisartan, telmisartan hydrochlorothiazide, valsartan, valsartan hydrochlorothiazide, BENICAR, BENICAR HCT CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA EDLUAR sublingual, BELSOMRA, SILENOR CARDIZEM diltiazem ext-rel (except CARDIZEM LA) E.E.S. GRANULES erythromycins CARDIZEM CD diltiazem ext-rel (except CARDIZEM LA) ENABLEX darifenacin ext-rel, oxybutynin ext-rel, tolterodine extrel, trospium, trospium ext-rel, MYBETRIQ, TOVIAZ, VESICARE CARDIZEM LA (and its generics) diltiazem ext-rel (except CARDIZEM LA) ERYPED erythromycins CARNITOR levocarnitine ESTRING ESTRACE CREAM, PREMARIM CREAM, VAGIFEM CARNITOR SF levocarnitine EUFLEXXA GEL-ONE, HYALGAN, SUPARTZ FX CLINDAGEL erythromycin solution EVZIO naloxone injection, NARCAN NASAL SPRAY clobetasol spray clobetasol foam EXFORGE amlodipine-telmisartan, amlodipine-valsartan, AZOR CLOBEX SPRAY clobetasol foam EXFORGE HCT amlodipine-valsartan-hydorchlorothiazide, TRIBENZOR COLAZAL balsalazide EXTAVIA glatiramer, AUBAGIO, BETASERON, COPAXONE 40 MG, GILENYA, REBIF, TECFIDERA CONTOUR NEXT STRIPS AND KITS 4 ONE TOUCH ULTRA STRIPS AND KITS 3 CONTOUR STRIPS AND KITS 4 ONE TOUCH ULTRA STRIPS AND KITS 3 CRESTOR ONE TOUCH VERIO STRIPS AND KITS 3 risperidone, ziprasidone, LATUDA, SEROQUEL XR FANAPT aripiprazole, clozapine, olanzapine, quetiapine, FEMRING ESTRACE CREAM, PREMARIM CREAM, VAGIFEM atorvastatin, fluvastatin, lovastatin, pravastatin, FETZIMA duloxetine, venlafaxine, venlafaxine ext-rel capsule, rosuvastatin, simvastatin, VYTORIN CYMBALTA duloxetine, venlafaxine, venlafaxine ext rel capsule, FIORICET CAPSULE naratriptan, rizatriptan, sumatriptan, zolmitriptan, DAKLINZA EPCLUSA (genotypes 2,3) FIRST TESTOSTERONE testosterone gel 2%, ANDRODERM, AXIRON HARVONI (genotypes 1,4,5,6) DELZICOL balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA DETROL LA darifenacin ext-rel, oxybutynin ext-rel, tolterodine extrel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, FML dexamethasone, prednisone acetate 1 %, DUREZOL, LOTEMAX VESICARE DEXPAX dexamethasone, methylprednisone, prednisone FORTAMET metformin, metformin ext-rel DIOVAN, DIOVAN HCT candesartan, camdesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartanhydrochlorothiazide, losartan, losartan hydrochlorothiazide, telmisartan, telmisartan hydrochlorothiazide, valsartan, valsartan hydrochlorothiazide, BENICAR, BENICAR HCT FORTESTA testosterone gel 2%, ANDRODERM, AXIRON

6 FOSRENOL calcium acetate, PHOSLYRA, RENVELA, VELPHORO Matzim LA diltazim ext-rel FREESTYLE STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3 FROVA naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONETOUCH VERIO STRIPS AND KITS 3 MENEST estradiol, estropripate, PREMARIN MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risendronate, ATELVIA, FORTEO GELNIQUE darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYBETRIQ, TOVIAZ, VESICARE MICARDIS, MICARDIS-HCT candesartan, candesartanhydrochlorothiazide,eprosartan, irbesartan, irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, valsartan, valsartanhydrochlorothiazide, BENICAR, BENICAR-HCT GENOTROPIN HUMATROPE, NORDITROPIN MILLIPRED dexamethasone, methylprednisolone, prednisone GLEEVAC imatinib mesylate, BOSULIF, SPRYCEL MINOCIN minocycline GLUMETZA metformin, metformin ext-rel MONOVISC GEL-ONE,HYALGAN, SUPARTZ FX HELIXATE FS KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ NAPRELAN celecoxib, diclofenac sodium, meloxicam, naproxen HUMALOG NOVOLOG NATESTO testosterone gel 2%, ANDRODERM, AXIRON HUMALOG MIX 50/50 NOVOLOG MIX 70/30 NESINA JANUVIA, TRADJENTA HUMALOG MIX 75/25 NOVOLOG MIX 70/30 NEUPOGEN ZARXIO HUMALIN NOVOLIN NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT INCRUSE ELLIPTA SPIRIVA NILANDRON bicalutamide, ZYTIGA INNOPRAN XL atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual, NITROLINGUAL INTERMEZZO sublingual, BELSOMRA, SILENOR NORITRATE metronidazole, FINACEA, SOOLANTRA INTUNIV amphetamine-dextroamphetamine mixed salts, NORVASC amlodipine amphetamine-dextroamphetamine mixed salts extrel, guanfacine ext-rel, methylphenidate, methylphenidate ext-rel INVOKAMET XIGDUO XR NOVACORT hydrocortisone INVOKANA FARXIGA, JARDIANCE NOVO NORDISK NEEDLES 4 BD ULTRAFINE NEEDLES ISTALOL timolol maleate solution, BETIMOL NUTROPIN AQ HUMATROPE, NORDITROPIN JALYN dutasteride-tamsulosin OLEPTRO trazodone KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO OLUX-E clobetasol foam XR KLOR-CON/25 potassium chloride liquid OLYSIO HARVONI (genotypes 1,4,5,6) KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR OMNARIS flunisolide, fluticasone, mometasone, triamcinolone, LANOXIN TABLET (125 MCG and 250 MCG only digoxin OMNITROPE HUMATROPE, NORDITROPIN LANTUS BASAGLAR, LEVEMIR, TRESIBA ONGLYZA JANUVIA, TRADJENTA LASTACAFT azelastine, cromolyn sodium, olopatadine, PATADAY, OPSUMIT LETAIRIS, TRACLEER PAZEO LESCOL XL atorvastatin, fluvastatin, pravastatin, rosuvastatin, ORTHOVISC GEL-ONE,HYALGAN, SUPARTZ FX simvastatin, VYTORIN LEVITRA CIALIS OSENI JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR LIPITOR atorvastatin, fluvastatin, pravastatin, rosuvastatin, OWEN MUMFORD NEEDLES 4 BD ULTRAFINE NEEDLES simvastatin, VYTORIN LIVALO atorvastatin, fluvastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN OXYTROL darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE LUMIGAN latanoprost, TRAVATAN Z, ZIOPTAN PANCREAZE CREON, VIOKACE, ZENPREP LUNESTA PENNSAID diclofenac sodium, diclofenac sodium solution, sublingual, BELSOMRA, SILENOR meloxicam, naproxen, VOLTERAN GEL

7 PERRIGO NEEDLES 4 BD ULTRAFINE NEEDLES testosterone gel 1% testosterone gel 2%, ANDRODERM, AXIRON PERTYZE CREON, VIOKACE, ZENPREP TOBI tobramycin inhalation solution, BETHKIS PEXEVA citalopram, escitalopram, fluoxetine, paroxetine, TOBI PODHALER tobramycin inhalation solution, BETHKIS paroxetine ext-rel, sertraline, FLUXETINE 60 MG, TRINTELLIX, VIIBRYD PLAVIX clopidogrel, BRILINTA, EFFIENT TOUJEO BASAGLAR, LEVEMIR, TRESIBA PLEGRIDY glatiramer, AUBAGIO, BETASERON, COPAXONE 40 MG, GILENYA, REBIF, TECFIDERA TRICOR fenofibrate, fenofibric acid PRADAXA warfarin, ELIQUIS, XARELTO TRIGLIDE fenofibrate, fenofibric acid PRAULENT REPATHA TRILPIX fenofibrate, fenofibric acid PRECISION XTRA STRIPS AND KITS 4 ONE TOUCH ULTRA STRIPS AND KITS 3 4 TRIVIDIA INSULIN SYRINGES BD ULTRAFINE INSULIN SYRINGES ONE TOUCH VERIO STRIPS AND KITS 3 PRED FORTE dexamethasone, prednisone acetate 1%, DUREZOL, TRUETEST STRIPS AND KITS 4 ONE TOUCH ULTRA STRIPS AND KITS3 LOTEMAX ONE TOUCH VERIO STRIPS AND KITS3 PREFERAOB generic prenatal vitamins, CITRANATAL TRUETACK STRIPS AND KITS 4 ONE TOUCH ULTRA STRIPS AND KITS3 ONE TOUCH VERIO STRIPS AND KITS3 PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO TUDORZA SPIRIVA PRENATAL PLUS ULTIMED INSULIN SYRINGES 4 BD ULTRAFINE INSULIN SYRINGES PREVACID esomeprazole, lansoprazole, omeprazole, ULTIMED NEEDLES 4 BD ULTRADINE NEEDLES pantoprazole, DEXILANT PROTONIX esomeprazole, lansoprazole, omeprazole, UROXATRAL alfuzosin ext-rel, tamsulosin pantoprazole, DEXILANT PROTOPIC tacrolimus, ELIDEL VALCYTE valganciclovir PROVENTIL HFA PROAIR HFA, PROAIR RESPICLICK VALTREX acyclovir, valacyclovir QNASL flunisolide, fluticasone, mometasone, triamcinolone, VANOXIDE-HC benzoyl peroxide QSYMIA BELVIQ, BELVIQ XR, CONTRAVE, SAXENDA venlafaxine ext-rel tablet (except 225 MG) duloxetine, venlafaxine, venlafaxine ext-rel capsule, RAYOS dexamethasone, methylprednisone, prednisone VENAFAXINE EXT-REL TABLET (except 225 MG) duloxetine, venlafaxine, venlafaxine ext-rel capsule, RELION INSULIN NOVOLIN INSULIN VENTOLIN HFA PROAIR HFA, PROAIR RESPICLICK RELISTOR MOVANTIK VIAGRA CIALIS RHINOCORT AQUA flunisolide, fluticasone, mometasone, triamcinolone, VIEKIRA PAK HARVONI (genotypes 1,4,5,6) RIMSO-50 Consult Doctor VIEKIRA XR HARVONI (genotypes 1,4,5,6) RIOMET metformin, metformin ext-rel VITAFOL-ONE generic prenatal vitamins, CITRANATAL ROZEREM sublingual, BELSOMRA, SILENOR VOGELXO testosterone gel 2%, ANDRODERM, AXIRON SAIZEN HUMATROPE, NORDITROPIN XENAZINE tetrabenazine STRIANT testosterone gel 2%, ANDRODERM, AXIRON XOPENEX HFA PROAIR HFA, PROAIR RESPICLICK XTANDI bicalutamide, ZYTIGA SURE TEST STRIPS AND KITS 4 ONE TOUCH ULTRA STRIPS AND KITS 3 ONE TOUCH VERIO STRIPS AND KITS 3 SYMBICORT ADVAIR, BREO ELLIPTA, DULERA ZEGERID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT SYNVISC, SYNVISC-ONE GEL-ONE, HYALGAN, SUPARTZ FX ZEPATIER HARVONI (genotypes 1,4,5,6) TANZEUM TRULICITY ZETONNA flunisolide, fluticasone, mometasone, triamcinolone, TASIGNA imatinib mesylate, BOSULIF, SPRYCEL ZONEGRAN zonisamide TECHNIVIE HARVONI (genotypes 1,4,5,6) ZUBSOLV buprenorphine-naloxone sublingual tablet, SUBOXONE FILM TESTIM testosterone gel 2%, ANDRODERM, AXIRON ZYFLO, ZYFLO CR montelukast, zafirlukast 1 Higher co-payments may apply depending on the plan participant s specific prescription benefit plan. Call SignatureScripts to find the co-payment under a specific plan. 2 Listing does not include generic Cardizem LA. 3 A OneTouch blood glucose meter will 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 SignatureScripts Customer Service at OneTouch brand test strips are the only preferred options. 5 BD ULTRAFINE syringes are the only preferred options. 6 Listing reflects the authorized generics for TESTIM and VOGELXO. NOTE: Your specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. Contact SignatureScripts Customer Service to check coverage and co-pays for specific medicine. *The preferred alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. Your specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. For specific information, visit or contact a SignatureScripts Customer Service Representative. Listed products are for informational purposes only and are not intended to replace the clinical judgement of the prescriber.