NALC Health Benefit Plan Formulary Drug List

Transcription

1 NALC Health Benefit Plan Formulary Drug List April 2014 The NALC Health Benefit Plan Formulary Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These formulary brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Call CVS Caremark at NALC (6252) to see if your drug is on the NALC Health Benefit Plan Formulary Drug List. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS and generic products in lowercase italics. PLAN MEMBER Your benefit plan provides you with a prescription benefit program administered by CVS Caremark. Ask your doctor to consider prescribing, when medically appropriate, a formulary medicine from this list. Take this list along when you or a covered family member sees a doctor. Please note: For specific information regarding your prescription benefit coverage and copay 1 information, please visit or contact a CVS Caremark Customer Care representative at NALC (6252). CVS 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. Any brand drug for which a generic product becomes available may be designated as a nonformulary product. HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand name on this list. Please note: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. Log in to to check coverage and copay information for a specific medicine. NSAIDs diclofenac meloxicam naproxen ANALGESICS NSAIDs, diclofenac sodiummisoprostol VIMOVO NSAIDs, TOPICAL PENNSAID VOLTAREN GEL COX-2 INHIBITORS CELEBREX GOUT allopurinol probenecid COLCRYS ULORIC OPIOID ANALGESICS codeine-acetaminophen fentanyl transdermal fentanyl transmucosal lozenge hydrocodone-acetaminophen hydromorphone methadone morphine morphine ext-rel morphine suppository oxycodone oxycodone-acetaminophen tramadol tramadol ext-rel AVINZA EXALGO FENTORA KADIAN LAZANDA NUCYNTA NUCYNTA ER OPANA ER OXYCONTIN ANTI-INFECTIVES ANTIBACTERIALS CEPHALOSPORINS cefdinir cefprozil cefuroxime axetil cephalexin SUPRAX ERYTHROMYCINS / MACROLIDES azithromycin clarithromycin clarithromycin ext-rel erythromycins FLUOROQUINOLONES ciprofloxacin ext-rel ciprofloxacin tablet levofloxacin AVELOX CIPRO SUSPENSION PENICILLINS amoxicillin amoxicillin-clavulanate dicloxacillin penicillin VK TETRACYCLINES doxycycline hyclate minocycline tetracycline ANTIFUNGALS fluconazole itraconazole terbinafine tablet ANTIVIRALS HERPES AGENTS acyclovir valacyclovir INFLUENZA AGENTS amantadine rimantadine RELENZA TAMIFLU MISCELLANEOUS clindamycin metronidazole nitrofurantoin sulfamethoxazoletrimethoprim CARDIOVASCULAR ACE INHIBITORS fosinopril lisinopril quinapril ramipril ACE INHIBITOR / DIURETIC fosinopril-hydrochlorothiazide lisinopril-hydrochlorothiazide quinapril-hydrochlorothiazide ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC candesartan / candesartanhydrochlorothiazide eprosartan irbesartan / irbesartanhydrochlorothiazide losartan / losartanhydrochlorothiazide valsartan-hydrochlorothiazide BENICAR / BENICAR HCT DIOVAN MICARDIS / MICARDIS HCT ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER AZOR EXFORGE ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC EXFORGE HCT TRIBENZOR ANTILIPEMICS BILE ACID RESINS cholestyramine WELCHOL CHOLESTEROL ABSORPTION INHIBITORS ZETIA FIBRATES fenofibrate fenofibric acid ANTARA LIPOFEN

2 HMG-CoA REDUCTASE INHIBITORS / atorvastatin fluvastatin lovastatin pravastatin simvastatin CRESTOR VYTORIN NIACINS / niacin ext-rel SIMCOR OMEGA-3 FATTY ACIDS LOVAZA BETA-BLOCKERS atenolol carvedilol metoprolol metoprolol succinate ext-rel nadolol propranolol propranolol ext-rel BYSTOLIC COREG CR CALCIUM CHANNEL BLOCKERS amlodipine diltiazem ext-rel nifedipine ext-rel verapamil ext-rel CALCIUM CHANNEL BLOCKER / ANTILIPEMIC amlodipine-atorvastatin DIGITALIS GLYCOSIDES digoxin DIRECT RENIN INHIBITORS / DIURETIC TEKTURNA / TEKTURNA HCT DIRECT RENIN INHIBITOR / CALCIUM CHANNEL BLOCKER TEKAMLO DIRECT RENIN INHIBITOR / CALCIUM CHANNEL BLOCKER / DIURETIC AMTURNIDE DIURETICS furosemide hydrochlorothiazide metolazone spironolactonehydrochlorothiazide torsemide triamterenehydrochlorothiazide NITRATES nitroglycerin sublingual spray NITROLINGUAL NITROSTAT CENTRAL NERVOUS SYSTEM ANTICONVULSANTS carbamazepine carbamazepine ext-rel diazepam rectal gel divalproex sodium divalproex sodium ext-rel ethosuximide gabapentin lamotrigine lamotrigine ext-rel levetiracetam levetiracetam ext-rel oxcarbazepine phenobarbital phenytoin phenytoin sodium extended primidone tiagabine topiramate valproic acid zonisamide SABRIL VIMPAT ANTIDEMENTIA donepezil galantamine galantamine ext-rel rivastigmine EXELON PATCH NAMENDA ANTIDEPRESSANTS SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) citalopram escitalopram fluoxetine paroxetine paroxetine ext-rel sertraline VIIBRYD SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs) venlafaxine venlafaxine ext-rel CYMBALTA PRISTIQ MISCELLANEOUS AGENTS bupropion bupropion ext-rel mirtazapine trazodone ANTIPARKINSONIAN AGENTS carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone entacapone pramipexole ropinirole ropinirole ext-rel selegiline AZILECT NEUPRO ANTIPSYCHOTICS ATYPICALS clozapine olanzapine quetiapine risperidone ziprasidone ABILIFY LATUDA SEROQUEL XR FIBROMYALGIA LYRICA SAVELLA HYPNOTICS, NONBENZODIAZEPINES zolpidem zolpidem ext-rel MIGRAINE SELECTIVE SEROTONIN AGONISTS naratriptan rizatriptan sumatriptan zolmitriptan RELPAX SUMAVEL DOSEPRO ZOMIG NASAL SPRAY SELECTIVE SEROTONIN AGONIST / NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) TREXIMET PSYCHOTHERAPEUTIC - MISCELLANEOUS PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST buprenorphine-naloxone sublingual tablet ZUBSOLV ENDOCRINE AND METABOLIC ANTIDIABETICS BIGUANIDES metformin metformin ext-rel BIGUANIDE / SULFONYLUREA glipizide-metformin DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TRADJENTA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR JANUMET JANUMET XR JENTADUETO INCRETIN MIMETIC AGENTS BYDUREON VICTOZA INSULINS APIDRA HUMULIN R U-500 LANTUS LEVEMIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 INSULIN SENSITIZERS pioglitazone INSULIN SENSITIZER / BIGUANIDE pioglitazone-metformin INSULIN SENSITIZER / SULFONYLUREA pioglitazone-glimepiride MEGLITINIDES nateglinide repaglinide SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS INVOKANA SULFONYLUREAS glimepiride glipizide glipizide ext-rel SUPPLIES ACCU-CHEK STRIPS AND KITS 2 BD INSULIN SYRINGES AND NEEDLES ONETOUCH STRIPS AND KITS 2 CALCIUM REGULATORS BISPHOSPHONATES alendronate ibandronate ACTONEL ATELVIA CALCITONINS calcitonin-salmon CONTRACEPTIVES MONOPHASIC ethinyl estradioldrospirenone BEYAZ LO LOESTRIN FE MINASTRIN 24 FE TRIPHASIC ethinyl estradiol-norgestimate ORTHO TRI-CYCLEN LO FOUR PHASE NATAZIA EXTENDED CYCLE ethinyl estradiollevonorgestrel TRANSDERMAL ORTHO EVRA VAGINAL NUVARING ESTROGENS ORAL estradiol estropipate PREMARIN TRANSDERMAL estradiol DIVIGEL EVAMIST MINIVELLE VAGINAL ESTRACE CREAM PREMARIN CREAM VAGIFEM ESTROGEN / PROGESTINS, ORAL estradiol-norethindrone PREMPHASE PREMPRO GLUCOCORTICOIDS methylprednisolone prednisone PHOSPHATE BINDER AGENTS calcium acetate FOSRENOL PHOSLYRA RENVELA PROGESTINS ORAL medroxyprogesterone progesterone, micronized SELECTIVE ESTROGEN RECEPTOR MODULATORS EVISTA OSPHENA

3 THYROID SUPPLEMENTS levothyroxine SYNTHROID GASTROINTESTINAL ANTIEMETICS dronabinol granisetron meclizine metoclopramide ondansetron prochlorperazine promethazine trimethobenzamide DICLEGIS SANCUSO ZUPLENZ H2 RECEPTOR ANTAGONISTS ranitidine INFLAMMATORY BOWEL DISEASE ORAL AGENTS balsalazide sulfasalazine sulfasalazine delayed-rel APRISO LIALDA PENTASA RECTAL AGENTS hydrocortisone enema mesalamine rectal suspension CANASA CORTIFOAM IRRITABLE BOWEL SYNDROME AMITIZA LOTRONEX 3 LAXATIVES lactulose peg 3350-electrolytes MOVIPREP SUPREP PANCREATIC ENZYMES CREON ULTRESA VIOKACE ZENPEP PROTON PUMP INHIBITORS lansoprazole omeprazole omeprazole-sodium bicarbonate capsule pantoprazole DEXILANT NEXIUM GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel doxazosin finasteride tamsulosin terazosin AVODART RAPAFLO URINARY ANTISPASMODICS oxybutynin oxybutynin ext-rel tolterodine trospium trospium ext-rel GELNIQUE VESICARE HEMATOLOGIC ANTICOAGULANTS warfarin PRADAXA XARELTO PLATELET AGGREGATION INHIBITORS clopidogrel AGGRENOX BRILINTA EFFIENT NUTRITIONAL PRENATAL VITAMINS prenatal vitamins CITRANATAL RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS EPIPEN EPIPEN JR ANTICHOLINERGICS SPIRIVA ANTICHOLINERGIC / BETA AGONIST ipratropium-albuterol inhalation solution COMBIVENT RESPIMAT BETA AGONISTS, INHALANTS SHORT ACTING albuterol PROAIR HFA PROVENTIL HFA LONG ACTING ARCAPTA FORADIL PERFOROMIST SEREVENT LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast zafirlukast NASAL ANTIHISTAMINES azelastine ASTEPRO PATANASE NASAL STEROIDS flunisolide fluticasone triamcinolone NASONEX STEROID / BETA AGONIST ADVAIR DULERA SYMBICORT STEROID INHALANTS budesonide inhalation suspension ASMANEX FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER QVAR TOPICAL DERMATOLOGY ACNE adapalene benzoyl peroxide clindamycin solution clindamycin-benzoyl peroxide erythromycin solution erythromycin-benzoyl peroxide tretinoin ACANYA ATRALIN BENZACLIN DIFFERIN EPIDUO RETIN-A MICRO TAZORAC ACTINIC KERATOSIS fluorouracil imiquimod CARAC PICATO ZYCLARA ANTIFUNGALS ciclopirox clotrimazole econazole ketoconazole nystatin MENTAX ANTIPSORIATICS calcipotriene OXSORALEN-ULTRA SORIATANE SORILUX CORTICOSTEROIDS Low Potency desonide hydrocortisone Medium Potency mometasone triamcinolone CLODERM LOCOID LIPOCREAM LOCOID LOTION High Potency desoximetasone fluocinonide Very High Potency clobetasol CLOBEX SPRAY IMMUNOMODULATORS ELIDEL PROTOPIC ROSACEA metronidazole sulfacetamide-sulfur FINACEA ORACEA MOUTH / THROAT / DENTAL AGENTS PROTECTANTS EPISIL OPHTHALMIC ANTIALLERGICS azelastine cromolyn sodium PATADAY PATANOL ANTI-INFECTIVES ciprofloxacin erythromycin gentamicin levofloxacin ofloxacin sulfacetamide tobramycin BESIVANCE MOXEZA VIGAMOX ANTI-INFECTIVE / ANTI-INFLAMMATORY neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- tobramycin- TOBRADEX OINTMENT TOBRADEX ST ZYLET ANTI-INFLAMMATORIES Nonsteroidal bromfenac diclofenac ketorolac Steroidal ALREX DUREZOL LOTEMAX BETA-BLOCKERS Nonselective timolol maleate solution BETIMOL Selective BETOPTIC S CARBONIC ANHYDRASE INHIBITORS dorzolamide AZOPT CARBONIC ANHYDRASE INHIBITOR / BETA- BLOCKER dorzolamide-timolol COSOPT PF CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC SIMBRINZA IMMUNOMODULATORS RESTASIS PROSTAGLANDINS latanoprost travoprost TRAVATAN Z ZIOPTAN SYMPATHOMIMETICS brimonidine ALPHAGAN P SYMPATHOMIMETIC / BETA- BLOCKER COMBIGAN

4 QUICK REFERENCE DRUG LIST A ABILIFY ACANYA ACCU-CHEK STRIPS AND KITS 2 ACTONEL acyclovir adapalene ADVAIR AGGRENOX albuterol alendronate alfuzosin ext-rel allopurinol ALPHAGAN P ALREX amantadine AMITIZA amlodipine amlodipine-atorvastatin amoxicillin amoxicillin-clavulanate AMTURNIDE ANTARA APIDRA APRISO ARCAPTA ASMANEX ASTEPRO ATELVIA atenolol atorvastatin ATRALIN AVELOX AVINZA AVODART azelastine AZILECT azithromycin AZOPT AZOR B balsalazide BD INSULIN SYRINGES AND NEEDLES BENICAR BENICAR HCT BENZACLIN benzoyl peroxide BESIVANCE BETIMOL BETOPTIC S BEYAZ BRILINTA brimonidine bromfenac budesonide inhalation suspension buprenorphine-naloxone sublingual tablet bupropion bupropion ext-rel BYDUREON BYSTOLIC C calcipotriene calcitonin-salmon calcium acetate CANASA candesartan candesartanhydrochlorothiazide CARAC carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone carvedilol cefdinir cefprozil cefuroxime axetil CELEBREX cephalexin cholestyramine ciclopirox CIPRO SUSPENSION ciprofloxacin ciprofloxacin ext-rel ciprofloxacin tablet citalopram CITRANATAL clarithromycin clarithromycin ext-rel clindamycin clindamycin solution clindamycin-benzoyl peroxide clobetasol CLOBEX SPRAY CLODERM clopidogrel clotrimazole clozapine codeine-acetaminophen COLCRYS COMBIGAN COMBIVENT RESPIMAT COREG CR CORTIFOAM COSOPT PF CREON CRESTOR cromolyn sodium CYMBALTA D desonide desoximetasone DEXILANT diazepam rectal gel DICLEGIS diclofenac diclofenac sodiummisoprostol dicloxacillin DIFFERIN digoxin diltiazem ext-rel DIOVAN divalproex sodium divalproex sodium ext-rel DIVIGEL donepezil dorzolamide dorzolamide-timolol doxazosin doxycycline hyclate dronabinol DULERA DUREZOL E econazole EFFIENT ELIDEL entacapone EPIDUO EPIPEN EPIPEN JR EPISIL eprosartan erythromycin erythromycin solution erythromycin-benzoyl peroxide erythromycins escitalopram ESTRACE CREAM estradiol estradiol-norethindrone estropipate ethinyl estradioldrospirenone ethinyl estradiollevonorgestrel ethinyl estradiol-norgestimate ethosuximide EVAMIST EVISTA EXALGO EXELON PATCH EXFORGE EXFORGE HCT F fenofibrate fenofibric acid fentanyl transdermal fentanyl transmucosal lozenge FENTORA FINACEA finasteride FLOVENT DISKUS FLOVENT HFA fluconazole flunisolide fluocinonide fluorouracil fluoxetine fluticasone fluvastatin FORADIL fosinopril fosinopril-hydrochlorothiazide FOSRENOL furosemide G gabapentin galantamine galantamine ext-rel GELNIQUE gentamicin glimepiride glipizide glipizide ext-rel glipizide-metformin granisetron H HUMULIN R U-500 hydrochlorothiazide hydrocodone-acetaminophen hydrocortisone hydrocortisone enema hydromorphone I ibandronate imiquimod INVOKANA ipratropium-albuterol inhalation solution irbesartan irbesartanhydrochlorothiazide itraconazole J JANUMET JANUMET XR JANUVIA JENTADUETO K KADIAN ketoconazole ketorolac L lactulose lamotrigine lamotrigine ext-rel lansoprazole LANTUS latanoprost LATUDA LAZANDA LEVEMIR levetiracetam levetiracetam ext-rel levofloxacin levothyroxine LIALDA LIPOFEN lisinopril lisinopril-hydrochlorothiazide LO LOESTRIN FE LOCOID LIPOCREAM LOCOID LOTION losartan losartan-hydrochlorothiazide LOTEMAX LOTRONEX 3 lovastatin LOVAZA LYRICA M meclizine medroxyprogesterone meloxicam MENTAX mesalamine rectal suspension metformin metformin ext-rel methadone methylprednisolone metoclopramide metolazone metoprolol metoprolol succinate ext-rel metronidazole MICARDIS MICARDIS HCT MINASTRIN 24 FE MINIVELLE minocycline mirtazapine mometasone montelukast morphine morphine ext-rel morphine suppository MOVIPREP MOXEZA N nadolol NAMENDA naproxen naratriptan NASONEX NATAZIA nateglinide neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- NEUPRO NEXIUM niacin ext-rel nifedipine ext-rel nitrofurantoin nitroglycerin sublingual spray NITROLINGUAL NITROSTAT NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA NUCYNTA ER NUVARING nystatin

5 O ofloxacin olanzapine omeprazole omeprazole-sodium bicarbonate capsule ondansetron ONETOUCH STRIPS AND KITS 2 OPANA ER ORACEA ORTHO EVRA ORTHO TRI-CYCLEN LO OSPHENA oxcarbazepine OXSORALEN-ULTRA oxybutynin oxybutynin ext-rel oxycodone oxycodone-acetaminophen OXYCONTIN P pantoprazole paroxetine paroxetine ext-rel PATADAY PATANASE PATANOL peg 3350-electrolytes penicillin VK PENNSAID PENTASA PERFOROMIST phenobarbital phenytoin phenytoin sodium extended PHOSLYRA PICATO pioglitazone pioglitazone-glimepiride pioglitazone-metformin PRADAXA pramipexole pravastatin prednisone PREMARIN PREMARIN CREAM PREMPHASE PREMPRO prenatal vitamins primidone PRISTIQ PROAIR HFA probenecid prochlorperazine progesterone, micronized promethazine propranolol propranolol ext-rel PROTOPIC PROVENTIL HFA PULMICORT FLEXHALER Q quetiapine quinapril quinapril-hydrochlorothiazide QVAR R ramipril ranitidine RAPAFLO RELENZA RELPAX RENVELA repaglinide RESTASIS RETIN-A MICRO rimantadine risperidone rivastigmine rizatriptan ropinirole ropinirole ext-rel S SABRIL SANCUSO SAVELLA selegiline SEREVENT SEROQUEL XR sertraline SIMBRINZA SIMCOR simvastatin SORIATANE SORILUX SPIRIVA spironolactonehydrochlorothiazide sulfacetamide sulfacetamide-sulfur sulfamethoxazoletrimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptan SUMAVEL DOSEPRO SUPRAX SUPREP SYMBICORT SYNTHROID T TAMIFLU tamsulosin TAZORAC TEKAMLO TEKTURNA TEKTURNA HCT terazosin terbinafine tablet tetracycline tiagabine timolol maleate solution TOBRADEX OINTMENT TOBRADEX ST tobramycin tobramycin- tolterodine topiramate torsemide TRADJENTA tramadol tramadol ext-rel TRAVATAN Z travoprost trazodone tretinoin TREXIMET triamcinolone triamterenehydrochlorothiazide TRIBENZOR trimethobenzamide trospium trospium ext-rel U ULORIC ULTRESA V VAGIFEM valacyclovir valproic acid valsartan-hydrochlorothiazide venlafaxine venlafaxine ext-rel verapamil ext-rel VESICARE VICTOZA VIGAMOX VIIBRYD VIMOVO VIMPAT VIOKACE VOLTAREN GEL VYTORIN W warfarin WELCHOL X XARELTO Z zafirlukast ZENPEP ZETIA ZIOPTAN ziprasidone zolmitriptan zolpidem zolpidem ext-rel ZOMIG NASAL SPRAY zonisamide ZUBSOLV ZUPLENZ ZYCLARA ZYLET PREFERRED ALTERNATIVES LIST DRUG NAME(S) DRUG NAME(S) ACTOS ADVICOR AEROSPAN ALORA ALTOPREV ALVESCO pioglitazone ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR estradiol, DIVIGEL, EVAMIST, MINIVELLE, ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR ATACAND, ATACAND HCT ATROVENT HFA AUVI-Q AXERT AZELEX BECONASE AQ candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT, DIOVAN, MICARDIS, MICARDIS HCT SPIRIVA EPIPEN, EPIPEN JR naratriptan, rizatriptan, sumatriptan tablet, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY erythromycin solution ANGELIQ ARMOUR THYROID ARTHROTEC ASACOL HD estradiol-norethindrone, PREMPHASE, PREMPRO levothyroxine, SYNTHROID diclofenac sodium-misoprostol, CELEBREX, VIMOVO balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA ASCENSIA STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, BENZAC AC, BENZAC W BENZAGEL adapalene, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC adapalene, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC

6 DRUG NAME(S) BENZIQ adapalene, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC BREEZE 2 STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, BREO ELLIPTA CARDURA XL CENESTIN CLINDAGEL COMBIVENT CONTOUR NEXT STRIPS AND KITS ADVAIR, SYMBICORT alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO estradiol, estropipate, PREMARIN erythromycin solution COMBIVENT RESPIMAT ACCU-CHEK STRIPS AND KITS 2, CONTOUR STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, DELZICOL DETROL LA DIOVAN HCT DORAL DUEXIS DYMISTA EDARBI, EDARBYCLOR EDLUAR ENABLEX ENJUVIA ESTRASORB ESTRING ESTROGEL FEMRING FEMTRACE FENOGLIDE FETZIMA FLECTOR FORTAMET FOSAMAX PLUS D balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, valsartan-hydrochlorothiazide, BENICAR HCT, MICARDIS HCT diclofenac sodium-misoprostol, VIMOVO flunisolide, fluticasone, triamcinolone, or NASONEX WITH azelastine, ASTEPRO or PATANASE candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT, DIOVAN, MICARDIS, MICARDIS HCT estradiol, estropipate, PREMARIN estradiol, DIVIGEL, EVAMIST, MINIVELLE, ESTRACE CREAM, PREMARIN CREAM, VAGIFEM estradiol, DIVIGEL, EVAMIST, MINIVELLE, ESTRACE CREAM, PREMARIN CREAM, VAGIFEM estradiol, estropipate, PREMARIN fenofibrate, fenofibric acid, ANTARA, LIPOFEN venlafaxine, venlafaxine ext-rel, CYMBALTA, PRISTIQ diclofenac, meloxicam, naproxen metformin, metformin ext-rel alendronate, ibandronate, ACTONEL, ATELVIA FREESTYLE STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, FROVA GLUMETZA naratriptan, rizatriptan, sumatriptan tablet, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY metformin, metformin ext-rel DRUG NAME(S) HUMALOG APIDRA, NOVOLOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN INNOPRAN XL INTERMEZZO ISTALOL JALYN KAZANO KOMBIGLYZE XR LASTACAFT LESCOL XL LIPITOR LIPTRUZET LIVALO LUMIGAN LUNESTA MENEST MENOSTAR NESINA NITROMIST OLUX-E OMNARIS ONGLYZA OSENI OXYTROL PANCREAZE PERTZYE PEXEVA PLAVIX PRECISION XTRA STRIPS AND KITS PRED MILD PREFERAOB PREFEST PRENATAL PLUS PREVACID PROTONIX NOVOLIN atenolol, carvedilol, metoprolol, metoprolol succinate ext-rel, nadolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR timolol maleate solution, BETIMOL finasteride or AVODART WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or RAPAFLO JANUMET, JANUMET XR, JENTADUETO JANUMET, JANUMET XR, JENTADUETO azelastine, cromolyn sodium, PATADAY, PATANOL latanoprost, travoprost, TRAVATAN Z, ZIOPTAN estradiol, estropipate, PREMARIN estradiol, DIVIGEL, EVAMIST, MINIVELLE, JANUVIA, TRADJENTA nitroglycerin sublingual spray, NITROLINGUAL, NITROSTAT clobetasol propionate foam, CLOBEX SPRAY JANUVIA, TRADJENTA JANUMET, JANUMET XR, JENTADUETO CREON, ULTRESA, VIOKACE, ZENPEP CREON, ULTRESA, VIOKACE, ZENPEP citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, VIIBRYD clopidogrel, BRILINTA, EFFIENT ACCU-CHEK STRIPS AND KITS 2,, DUREZOL, LOTEMAX generic prenatal vitamins, CITRANATAL estradiol-norethindrone, PREMPHASE, PREMPRO generic prenatal vitamins, CITRANATAL lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, NEXIUM lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, NEXIUM

7 DRUG NAME(S) QNASL RAYOS RELION INSULIN RHINOCORT AQUA RIOMET ROZEREM SANCTURA XR SKELID SUBOXONE FILM, methylprednisolone, prednisone NOVOLIN INSULIN metformin, metformin ext-rel alendronate, ACTONEL buprenorphine-naloxone sublingual tablet, ZUBSOLV SURE-TEST STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, TEVETEN, TEVETEN HCT TOVIAZ TRICOR TRIGLIDE candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT, DIOVAN, MICARDIS, MICARDIS HCT fenofibrate, fenofibric acid, ANTARA, LIPOFEN fenofibrate, fenofibric acid, ANTARA, LIPOFEN DRUG NAME(S) TRILIPIX fenofibrate, fenofibric acid, ANTARA, LIPOFEN TRUE CARE STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, TRUETEST STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, TRUETRACK STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, TUDORZA TWYNSTA VALTREX VANOS VASCEPA VENTOLIN HFA VERAMYST VITAFOL-ONE XOPENEX HFA ZETONNA ZYFLO, ZYFLO CR SPIRIVA AZOR, EXFORGE acyclovir, valacyclovir clobetasol LOVAZA PROAIR HFA, PROVENTIL HFA generic prenatal vitamins, CITRANATAL PROAIR HFA, PROVENTIL HFA montelukast, zafirlukast SPECIALTY DRUGS * Specialty drug copayments = 30-day supply: $150; 60-day supply: $250; 90-day supply: $350. Includes biotech, biological, biopharmaceutical and oral chemotherapy drugs. This drug list represents a summary of prescription coverage and is not inclusive. Hepatitis C Agents ribavirin INCIVEK VICTRELIS Human Growth Hormones HUMATROPE NORDITROPIN Inflammatory Bowel Disease HUMIRA Mouth / Throat / Dental Agents MUGARD Multiple Sclerosis Agents AVONEX COPAXONE EXTAVIA GILENYA TECFIDERA Osteoporosis FORTEO Psoriasis / Rheumatoid Arthritis ENBREL HUMIRA Pulmonary Arterial Hypertension sildenafil LETAIRIS TRACLEER Viscosupplements GEL-ONE HYALGAN ORTHOVISC * All specialty drugs require prior approval. Call Caremark Specialty Pharmacy Services at to obtain prior approval.

8 FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. Any brand drug for which a generic product becomes available may be designated as a nonformulary product. The member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to to check coverage and copay information for a 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. Generics are available in this class and should be considered the first line of prescribing. 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 An Accu-Chek or OneTouch blood glucose meter will be provided at no charge by the manufacturer to those individuals currently using a meter other than Accu-Chek or OneTouch. For more information on how to obtain a blood glucose meter, call toll-free: Members must have CVS Caremark Mail Service Pharmacy benefits to qualify. 3 For safety reasons, to prescribe Lotronex, the physician must be enrolled in the Prescribing Program for Lotronex. Physicians must understand the benefits and risks of treatment with Lotronex for severe diarrhea-predominant IBS, including the information in the Prescribing Information, Medication Guide and Patient-Physician Agreement for Lotronex. To enroll or for more information on the Prescribing Program for Lotronex, call or visit to complete the Physician Enrollment Form. NALC and CVS Caremark do not operate the websites/organizations listed here, nor are they responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by NALC or CVS Caremark. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission All rights reserved. 106-NALC