Preferred Brand, Non-Preferred Brand and Generic Drug List
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1 October 2014 Operating Engineers (Local 12) Health & Welfare Fund Prescription Drug Plan Preferred Brand, Non-Preferred Brand and Generic Drug List This summary prescription drug list is intended as an aid to members and health care providers to minimize member co-payments under the Operating Engineers Health & Welfare Fund prescription drug plan administered by CVS/caremark. This is only a summary of some of the more commonly prescribed medications showing Non-Preferred Brand drugs (highest co-pay), the comparable Preferred Brand drugs (lower co-pay) and the generic equivalents (lowest co-pay). Generic drugs should be considered the first line of prescribing. If there is no generic available, there often are more than one brand-name medications to treat a condition. These Preferred Brand-Name medicines are listed to help identify products that are clinically appropriate and cost-effective. This is not an all-inclusive list. A complete list of Preferred Brand drugs can be obtained by logging into In this list, Brand-Name medications are shown in CAPS and generic products in lowercase italics. PLAN MEMBER Ask your doctor to consider prescribing generic drugs whenever possible. If you request a brand-name drug for which a generic drug is available, you will have to pay the appropriate co-pay plus 50% of the difference in price between the brand-name drug and the generic drug. If there is no generic available for a specific medication, ask your doctor to consider a Preferred Brand drug from this list, when medically appropriate, as opposed to a Non-Preferred Brand drug. Take this list along when you or a covered family member sees a doctor. The co-pays under your prescription drug benefit plan are as follows: Drug Type Retail Pharmacy (Up to 30-day supply) Mail Pharmacy (Up to 90-day supply) Tier 1: Generic $10 $25 Tier 2: Preferred Brand $25 $62.50 Tier 3: Non-Preferred Brand $40 $100 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. Unless specifically indicated, drug list products will include all dosage forms. Log in to to check coverage and copay information for a specific medicine. PREFERRED BRAND AND GENERIC OPTIONS LIST ACTOS ADVICOR AEROSPAN ALORA ALTOPREV ALVESCO pioglitazone ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR ANDROGEL ANGELIQ ANTARA 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 ATACAND, ATACAND HCT ATROVENT HFA AXERT AZELEX BECONASE AQ BENZAC AC, BENZAC W BENZIQ naratriptan, rizatriptan, sumatriptan nasal spray, sumatriptan tablet, zolmitriptan, RELPAX, adapalene, clindamycin solution, clindamycin-benzoyl peroxide,, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC adapalene, clindamycin solution, clindamycin-benzoyl peroxide,, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC BREEZE 2 STRIPS AND KITS ACCU-CHEK STRIPS AND KITS **, BREO ELLIPTA CARDURA XL CENESTIN CLINDAGEL CONTOUR NEXT STRIPS AND KITS ADVAIR, SYMBICORT alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO ACCU-CHEK STRIPS AND KITS **, CONTOUR STRIPS AND KITS ACCU-CHEK STRIPS AND KITS **, DELZICOL DETROL LA DIOVAN HCT DORAL DUEXIS DYMISTA EDARBI, EDARBYCLOR EDLUAR ENABLEX ENJUVIA ESTRASORB ESTRING balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, BENICAR HCT VIMOVO flunisolide, fluticasone, triamcinolone, or NASONEX WITH azelastine, ASTEPRO or PATANASE ESTRACE CREAM, PREMARIN CREAM, VAGIFEM ESTROGEL EUFLEXXA FARXIGA FEMRING FENOGLIDE FETZIMA FIRST TESTOSTERONE FLECTOR FORTAMET FOSAMAX PLUS D FOSRENOL INVOKANA ESTRACE CREAM, PREMARIN CREAM, VAGIFEM duloxetine, venlafaxine, venlafaxine ext-rel, PRISTIQ diclofenac, meloxicam, naproxen alendronate, ibandronate, ACTONEL, ATELVIA calcium acetate, PHOSLYRA, RENVELA, VELPHORO FREESTYLE STRIPS AND KITS ACCU-CHEK STRIPS AND KITS **, FROVA GENOTROPIN GLUMETZA HUMALOG naratriptan, rizatriptan, sumatriptan nasal spray, sumatriptan tablet, zolmitriptan, RELPAX, 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 NUTROPIN AQ OLUX-E 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 azelastine, cromolyn sodium, PATADAY, PATANOL latanoprost, travoprost, TRAVATAN Z, ZIOPTAN JANUVIA, TRADJENTA nitroglycerin sublingual spray, NITROLINGUAL, NITROSTAT clobetasol propionate foam, CLOBEX SPRAY
3 OMNARIS OMNITROPE ONGLYZA ORTHOVISC OSENI OXYTROL PANCREAZE PERTZYE PEXEVA PLAVIX PRECISION XTRA STRIPS AND KITS PRED MILD PREFERAOB PREFEST PRENATAL PLUS PREVACID PROTONIX QNASL RAYOS RELION INSULIN RHINOCORT AQUA RIOMET ROZEREM SAIZEN SKELID STRIANT JANUVIA, TRADJENTA 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 **, dexamethasone, DUREZOL, LOTEMAX estradiol-norethindrone, PREMPHASE, PREMPRO lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, NEXIUM lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, NEXIUM dexamethasone, methylprednisolone, prednisone NOVOLIN INSULIN alendronate, ACTONEL SUBOXONE FILM buprenorphine-naloxone sublingual tablet, ZUBSOLV SURE-TEST STRIPS AND KITS ACCU-CHEK STRIPS AND KITS **, SYNVISC, SYNVISC-ONE TANZEUM TESTIM TEVETEN, TEVETEN HCT TEV-TROPIN TOVIAZ TRICOR TRIGLIDE TRILIPIX BYDUREON, VICTOZA TRUETEST STRIPS AND KITS ACCU-CHEK STRIPS AND KITS **, TRUETRACK STRIPS AND KITS ACCU-CHEK STRIPS AND KITS **, TUDORZA VALTREX VANOS VASCEPA VENTOLIN HFA VERAMYST VITAFOL-ONE VOGELXO XOPENEX HFA ZETONNA ZYFLO, ZYFLO CR acyclovir, valacyclovir clobetasol LOVAZA PROAIR HFA, PROVENTIL HFA PROAIR HFA, PROVENTIL HFA montelukast, zafirlukast PREFERRED BRAND AND GENERIC PRODUCTS IN ALPHABETICAL ORDER A ABILIFY ACANYA ACCU-CHEK STRIPS AND KITS ** acitretin ACTONEL acyclovir adapalene ADVAIR AGGRENOX albuterol alendronate alfuzosin ext-rel allopurinol ALPHAGAN P ALREX amantadine AMITIZA amlodipine amlodipine-atorvastatin amoxicillin amoxicillin-clavulanate amphetaminedextroamphetamine mixed salts amphetaminedextroamphetamine mixed salts ext-rel AMTURNIDE ANDRODERM ANORO ELLIPTA APIDRA APRISO ARCAPTA ASMANEX ASTEPRO ATELVIA atenolol atorvastatin ATRALIN AUVI-Q AVODART AVONEX AXIRON azelastine AZILECT azithromycin AZOPT AZOR B balsalazide BD INSULIN SYRINGES AND NEEDLES BENICAR BENICAR HCT BENZACLIN benzoyl peroxide BESIVANCE BETIMOL BETOPTIC S BEYAZ BOSULIF BRILINTA brimonidine bromfenac budesonide inhalation suspension buprenorphine-naloxone sublingual tablet bupropion bupropion ext-rel BUTRANS 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
4 CELEBREX cephalexin CETROTIDE cholestyramine ciclopirox ciprofloxacin ciprofloxacin ext-rel 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 COPAXONE COREG CR CORTIFOAM COSOPT PF CREON CRESTOR CRINONE cromolyn sodium D DAYTRANA desonide desoximetasone dexamethasone DEXCOM G4 DEXILANT diazepam rectal gel DICLEGIS diclofenac diclofenac sodium solution diclofenac sodiummisoprostol dicloxacillin DIFFERIN DIFICID digoxin diltiazem ext-rel DIOVAN divalproex sodium divalproex sodium ext-rel DIVIGEL donepezil dorzolamide dorzolamide-timolol doxazosin doxycycline hyclate dronabinol DUAVEE DULERA duloxetine DUREZOL E econazole EFFIENT ELIDEL ELIQUIS ENBREL entacapone EPIDUO EPIPEN EPIPEN JR EPISIL eprosartan erythromycin erythromycin-benzoyl peroxide erythromycins escitalopram ESTRACE CREAM estradiol estradiol-norethindrone estropipate ethinyl estradioldrospirenone ethinyl estradiollevonorgestrel ethinyl estradiolnorelgestromin ethinyl estradiolnorethindrone acetate ethinyl estradiol-norgestimate ethosuximide EVAMIST EXELON PATCH EXFORGE EXFORGE HCT EXTAVIA F fenofibrate fenofibric acid fentanyl transdermal fentanyl transmucosal lozenge FENTORA FINACEA finasteride FLOVENT DISKUS FLOVENT HFA fluconazole flunisolide fluocinonide fluorouracil fluoxetine fluticasone fluvastatin FOLLISTIM AQ FORADIL FORTEO FORTESTA fosinopril fosinopril-hydrochlorothiazide furosemide G gabapentin galantamine galantamine ext-rel GELNIQUE GEL-ONE gentamicin GILENYA GLEEVEC glimepiride glipizide glipizide ext-rel glipizide-metformin GRALISE granisetron H HUMATROPE HUMIRA HUMULIN R U-500 HYALGAN hydrochlorothiazide hydrocodone-acetaminophen hydrocortisone hydrocortisone enema hydromorphone hydromorphone ext-rel I ibandronate imiquimod INCIVEK INTUNIV INVOKANA ipratropium-albuterol inhalation solution irbesartan irbesartanhydrochlorothiazide itraconazole J JANUMET JANUMET XR JANUVIA JENTADUETO K ketoconazole ketorolac L lactulose LAMICTAL ODT lamotrigine lamotrigine ext-rel lansoprazole LANTUS latanoprost LATUDA LAZANDA LETAIRIS LEVEMIR levetiracetam levetiracetam ext-rel levofloxacin levothyroxine LIALDA LINZESS lisinopril lisinopril-hydrochlorothiazide LO LOESTRIN FE LOCOID LIPOCREAM LOCOID LOTION losartan losartan-hydrochlorothiazide LOTEMAX LOTRONEX lovastatin LOVAZA LYRICA M meclizine medroxyprogesterone meloxicam MENTAX mesalamine rectal suspension metformin metformin ext-rel methadone methylphenidate methylphenidate ext-rel methylprednisolone metoclopramide metolazone metoprolol metoprolol succinate ext-rel metronidazole MICARDIS MINASTRIN 24 FE MINIVELLE minocycline MIRAPEX ER mirtazapine mometasone montelukast morphine morphine ext-rel morphine suppository MOVIPREP MOXEZA moxifloxacin MUGARD N nadolol NAMENDA NAMENDA XR naproxen naratriptan NASONEX NATAZIA nateglinide neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- dexamethasone NEUPRO NEXIUM niacin ext-rel nifedipine ext-rel nitrofurantoin nitroglycerin sublingual spray NITROLINGUAL NITROSTAT NORDITROPIN NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA NUCYNTA ER NUVARING nystatin O ofloxacin olanzapine omeprazole omeprazole-sodium bicarbonate capsule ondansetron ONETOUCH STRIPS AND KITS ** OPANA ER ORACEA ORTHO TRI-CYCLEN LO OSPHENA OVIDREL 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 QSYMIA
5 quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide QVAR R raloxifene ramipril ranitidine RAPAFLO RELENZA RELPAX RENVELA repaglinide RESTASIS RETIN-A MICRO ribavirin rimantadine risperidone rivastigmine rizatriptan ropinirole ropinirole ext-rel S SANCUSO SAVELLA selegiline SEREVENT SEROQUEL XR sertraline sildenafil SIMBRINZA SIMCOR simvastatin SORILUX SOVALDI spironolactonehydrochlorothiazide SPRYCEL STRATTERA SUCLEAR sulfacetamide sulfacetamide-sulfur sulfamethoxazoletrimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptan SUMAVEL DOSEPRO SUPARTZ SUPRAX SUPREP SYMBICORT SYNTHROID T TAMIFLU tamsulosin TAZORAC TECFIDERA TEKAMLO TEKTURNA TEKTURNA HCT telmisartanhydrochlorothiazide terazosin terbinafine tablet tetracycline tiagabine timolol maleate solution TOBRADEX OINTMENT TOBRADEX ST tobramycin tobramycin-dexamethasone tolterodine tolterodine ext-rel topiramate torsemide TRACLEER 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 VELPHORO venlafaxine venlafaxine ext-rel verapamil ext-rel VESICARE VICTOZA VICTRELIS VIGAMOX VIIBRYD VIMOVO VIMPAT VIOKACE VOLTAREN GEL VYTORIN VYVANSE W warfarin WELCHOL X XARELTO Z zafirlukast ZELAPAR ZENPEP ZETIA ZIOPTAN ziprasidone zolmitriptan zolpidem zolpidem ext-rel zonisamide ZUBSOLV ZYCLARA ZYLET * The Preferred Drug options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. ** 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. 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. OPENJ
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