PRIMARY/PREFERRED DRUG LIST (FORMULARY) A ABILIFY ABSTRAL ACANYA ACTONEL ADVAIR AGGRENOX ALBENZA ALPHAGAN P ALREX AMITIZA AMTURNIDE ANDRODERM ANORO ELLIPTA APRISO ARANESP ARCAPTA ASMANEX ATELVIA ATRALIN ATRIPLA AUVI-Q AVODART AXIRON AZILECT AZOPT AZOR B BD INSULIN SYRINGES & NEEDLES BENICAR BENICAR HCT BENZACLIN BESIVANCE BETIMOL BETOPTIC S BEYAZ BIDIL BOSULIF BRILINTA BRINTELLIX BRISDELLE BUTRANS BYDUREON BYSTOLIC C CANASA CETROTIDE CIALIS CIPRODEX CITRANATAL CLODERM COLCRYS COMBIGAN COMBIVENT RESPIMAT COMPLERA COPAXONE COREG CR CORTIFOAM COSOPT PF CREON CRESTOR CRINONE D DALIRESP DAYTRANA DENAVIR DEXCOM G4 DEXILANT DICLEGIS DIFFERIN DIFICID DIVIGEL DUAVEE DULERA DUREZOL E EFFIENT ELIDEL ELIQUIS ENBREL ENDOMETRIN EPIDUO EPIPEN EPIPEN JR EPISIL EPZICOM ESTRACE CREAM EVAMIST EVOTAZ EVZIO EXELON PATCH EXTAVIA F FENTORA FINACEA FLOVENT DISKUS FLOVENT HFA FLUOXETINE 60 MG FOLLISTIM AQ FORADIL FORTEO FORTESTA G GELINIQUE GEL-ONE GILENYA GLEEVEC GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GRALISE GRASTEK H HARVONI HUMATROPE HUMIRA HUMULIN R U-500 HYALGAN I ISENTRESS INVOKAMET INVOKANA J JANUMET JANUMET XR JANUVIA JENTADUETO JUBLIA K KHEDEZIA L LANTUS 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 MOVIPREP MOXEZA MUGARD MUSE MYBETRIQ N NAFTIN NAMENDA NAMENDA XR NASONEX NATAZIA NEUPRO NITROLINGUAL NITROSTAT NORDITROPIN NORVIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA NUCYNTA ER NUVARING NUVIGIL O ONETOUCH ULTRA STRIPS & 2 ONETOUCH VERIO STRIPS & 2 OPANA ER ORACEA ORALAIR ORTHO TRI-CYCLEN LO OSPHENA OVIDREL OXYCONTIN 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.
PRIMARY/PREFERRED DRUG LIST (FORMULARY) P PATADAY PATANOL PENTASA PERFOROMIST PHOSLYRA PICATO PLEGRIDY PRADAXA PREMARIN PREMARIN CREAM PREMPHASE PREMPRO PREZCOBIX PREZISTA PRISTIQ PROAIR HFA PROCRIT PROCTOFOAM -HC PROLENSA PROVENTIL HFA PULMICORT FLEXHALER PYLERA Q QSYMIA QUILLIVANT XR QVAR R RAGWITEK RANEXA RAPAFLO RASUVO RELENZA RELISTOR RELPAX RENVELA RESTASIS RETIN-A MICRO REYATAZ S SAFRYAL SANCUSO SAVELLA SAXENDA SEREVENT SEROQUEL XR SILENOR SIMBRINZA SIMCOR SIVEXTRO SOOLANTRA SORILUX SOVALDI SPIRIVA SPRYCEL STRATTERA STRIBILD SUBSYS SUCLEAR SUMAVEL DOSEPRO SUPARTZ SUPRAX SUPREP SYMLINPEN SYNTHROID T TAMIFLU TECFIDERA TEKAMLO TEKTURNA TEKTURNA HCT TIVICAY TOBRADEX OINTMENT TOBRADEX ST TOUJEO TRACLEER TRADJENTA TRAVATAN Z TREXIMET TRIBENZOR TRIUMUEQ TRUVADA U UCERIS ULORIC ULTRESA V VAGIFEM VELPHORO VESICARE VIAGRA VICTOZA VIGAMOX VIIBRYD VIMPAT VIOKACE VOLTAREN GEL VYVANSE W WELCHOL X XARELTO XIFIXAN 550 MG Z ZELAPAR ZENPREP ZETIA ZIOPTAN ZOMIG NASAL SPRAY ZUBSOLV ZYCLARA ZYLET 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.
j 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: 1-800-455-4460. 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 SignatureScripts Customer Service. The drug list is subject to change. For the most up-to-date list visit www.signaturescripts.com 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 www.signaturescripts.com 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. Tier 3 = All brand name / non-formulary medications that DO NOT 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 1-800-455-4460. 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.
Preferred Alternatives List DRUG NAME PREFERRED ALTERNATIVE(S)* DRUG NAME PREFERRED ALTERNATIVE(S)* ACCU-CHEK STRIPS ATROVENT HFA SPIRIVA 5 ACTOS pioglitazone AXERT naratriptan, rizatriptan, sumatriptan nasal spray, sumatriptan tablet, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY ADDERALL XR amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts extrel, methylphenidate ext-rel, DAYTRANA, QUILLIVANT XR, STRATTERA, VYVANSE AZELEX adapalene,benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, ADRENACLICK AUVI-Q, EPIPEN, EPIPEN JR BECONASE AQ flunisolide, fluticasone, triamcinolone, NASONEX ADVICOR AEROSPAN atorvastin, fluvastin, lovastin, pravastatin, simvastatin, CRESTOR, SIMCOR, ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR BENZAC AC, BENZAC W BENZIQ adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzol peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzol peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, ALORA estradiol, DIVIGEL,EVAMIST, MINIVELLE BREEZE 2 STRIPS ALTOPREV atorvastatin, fluvastatin, lovastatin, pravastin, BREO ELLIPTA ADVAIR simvastatin, CRESTOR, SIMCOR ALVESCO ASMANEX, FLOVENT DISKUS, FLOVENT HFA, BYETTA BYDUREON, VICTOZA PULMICORT FLEXHALER, QVAR AMRIX cyclobenzaprine CARDURA XL alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO ANDROGEL ANDRODERM, AXIRON, FORTESTA CLINDAGEL erythromycin solution ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO CONTOUR NEXT STRIPS ANTARA fenofibrate,fenofibric acid CONTOUR STRIPS AND APEXICON E desoximestasone, flucinonide DELZICOL balsalazide, budesonide capsule, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS APIDRA NOVOLOG DETROL LA oxybutynin ext-rel, tolterodine, tolterodine extrel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE ARMOUR THYROID levothyroxine, SYNTHROID DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, BENICAR, BENICAR-HCT ARTHROTEC ASACOL HD ASCENSIA STRIPS & ATACAND, ATACAND HCT celecoxib, diclofenac sodium, meloxicam or naproxen WITH lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT OR balsalazide, budesonide capsule, sulfasalazine, sulfasaklazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS DORAL eszopiclone, zolpidem, zolpidem ext-rel, SILENOR DUEXIS celecoxib, diclofenac sodium, meloxicam, naproxen WITH lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, or DYMISTA flunisolide, fluticasone, triamcinolone or NASONEX WITH azelastine, or olopatadine candesartan 4, candesartan-hydrochlorothiazide, eprosartan,irbesartan, irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, EDARBI,EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartanhydrochlorthiazide, losartan, losartanhydrochlorthiazide,telmisartan, telmisartanhydrochlorothiazide,
Preferred Alternatives List DRUG NAME PREFERRED ALTERNATIVE(S)* DRUG NAME PREFERRED ALTERNATIVE(S)* EDLUAR eszopiclone, zolpidem, zolipidem ext-rel, SILENOR LIPITOR atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, SIMCOR, ENABLEX oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext- rel, GELNIQUE, MYRBETRIQ, VESICARE LIPTRUZET atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, SIMCOR, ENJUVIA estradiol, estropriate, PREMARIN LIVALO atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, SIMCOR, ESTRING ESTRACE CREAM, PREMARIN CREAM, VAGIFEM LUMIGAN latanoprost, travoprost, TRAVATAN Z, ZIOPTAN ESTROGEL estradiol, DIVIGEL, EVAMIST, MINIVELLE LUNESTA eszopiclone, zolpidem, zolpidem-ext-rel, SILENOR EUFLEXXA GEL-ONE, HYALGAN, SUPARTZ MENEST estradiol, estropipate, PREMARIN EXFORGE amlodipine-telmisartan, amlodipine-valsartan, AZOR MENOSTAR estradiol EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, TRIBENZOR MICARDIS, MICARDIS HCT candesartan,candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, FARXIGA INVOKANA NAPRELAN celecoxib, diclofenac sodium, meloxicam, naproxen FEMRING ESTRACE CREAM, PREMARIN CREAM,VAGIFEM NATESTO ANDRODERM, AXIRON, FORTESTA FENOGLIDE fenofibrate, fenofibric acid NESINA JANUVIA, TRADJENTA FETZIMA duloxetine, venlafaxine, venlafaxine ext-rel, KHEDEZLA, PRISTIQ NITROMIST nitroglycerin sublingual spray, NITROLINGUAL, NITROSTAT FIRST TESTOSTERONE ANDRODERM, AXIRON, FORTESTA NORVASC amlodipine FLECTOR diclofenac sodium, diclofenac sodium solution, NUTROPIN AQ HUMATROPE, NORDITROPIN meloxicam, naproxen, VOLTERAN GEL FORTAMET metformin, metformin ext-rel OLEPTRO trazadone FOSAMAX PLUS D alendronate, ibandronate, ACTONEL, ATELVIA OLUX-E clobetasol foam FOSRENOL calcium acetate, PHOSLYRA, RENVELA, VELPHORO OMNARIS flunisolide, fluticasone, triamcinolone, NASONEX FREESTYLE STRIPS OMNITROPE HUMATROPE, NORDITROPIN FROVA naratriptan, rizatriptan, sumatriptan nasal spray, ONGLYZA JANUVIA, TRADJENTA sumatriptan tablet, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY GENOTROPIN HUMATROPE, NORDITROPIN ORTHOVISC GEL-ONE, HYALGAN, SUPARTZ GLUMETZA metformin, metformin ext-rel OSENI JANUMET, JANUMET XR, JENTADUETO HUMALOG NOVOLOG OXYTROL oxybutynin ext-rel, tolterodine, tolterodine extrel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE HUMALOG MIX 50/50 NOVOLOG MIX 70/30 PANCREAZE CREON, ULTRESA, VIOKACE, ZENPREP HUMALOG MIX 75/25 NOVOLOG MIX 70/30 PENNSAID diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL HUMULIN NOVOLIN PERTZYE CREON, ULTRESA, VIOKACE, ZENPREP INNOPRAN XL atenolol, carvedilol, metoprolol, metoprolol succinate ext-rel, metroprolol tartrate, nadolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR PEXEVA citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, BRINTELLIX, FLUOXETINE 60 MG, VIIBRYD INTERMEZZO eszopiclone, zolpidem, zolpidem ext-rel, SILENOR PLAVIX clopidogrel, BRILINTA, EFFIENT ISTALOL timolol maleate solution, BETIMOL PRECISION XTRA STRIPS JALYN finasteride or AVODART with alfuzosin ext-rel, PRED MILD dexamethasone, DUREZOL, LOTEMAX doxazosin, tamsulosin, terazosin or RAPAFLO KAZANO JANUMET, JANUMET XR, JENTADUETO PREFERAOB generic prenatal vitamins, CITRANATAL KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO LASTACAFT azelastine, cromolyn sodium, PATADAY, PATANOL PRENATAL PLUS generic prenatal vitamins, CITRANATAL LESCOL XL atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, SIMCOR, PREVACID lansaprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, LEVITRA CIALIS, VIAGRA PROTONIX lansaprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT,
Preferred Alternatives List PROTOPIC tacrolimus, ELIDEL TEV-TROPIN HUMATROPE, NORDITROPIN PROVENTIL HFA PROAIR HFA TOVIAZ oxybutynin ext-rel, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE,MYRBETRIQ, VESICARE QNASL flunisolide, fluticasone, triamcinolone, NASONEX TRICOR fenofibrate, fenofibric acid RAYOS dexamethasone, methylprednisolone, prednisone TRIGLIDE fenofibrate, fenofibric acid REBIF COPAXONE, EXTAVIA, GILENYA, PLEGRIDY, TECFIDERA TRILIPIX fenofibrate, fenofibric acid RELION INSULIN NOVOLIN INSULIN TRUETEST STRIPS AND RHINOCORT AQUA flunisolide, fluticasone, triamcinolene, NASONEX TRUETACK STRIPS AND RIOMET metformin, metformin ext-rel TUDORZA SPIRIVA ROZEREM eszopiclone, zolpidem, zolpidem ext-rel, SILENOR VALTREX acyclovir, valacyclovir SAIZEN HUMATROPE, NORDITROPIN VANOS clobetasol SKELID alendronate, ACTONEL VASCEPA omega-3 acid ethyl esters STRIANT ANDRODERM, AXIRON, FORTESTA VENTOLIN HFA PROAIR HFA SUBOXONE FILM buprenorphine-naloxone sublingual tablet, ZUBSOLV VERAMYST flunisolide, fluticasone, triamcinolone, NASONEX SURE-TEST STRIPS VIEKIRA PAK HARVONI SYMBICORT ADVAIR, DULERA VIMOVO CELEBREX; diclofenac sodium, meloxicam, or naproxen WITH lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, or SYNVISC, SYNVISC GEL-ONE, HYALGAN, SUPARTZ VITAFOL-ONE generic prenatal vitamins, CITRANATAL ONE TANZEUM BYDUREON, VICTOZA VOGELXO ANDRODERM, AXIRON, FORTESTA TESTIM ANDRODERM, AXIRON, FORTESTA XIGDUO XR INVOKAMET testerone gel 1% ANDRODERM, AXIRON, FORTESTA XOPENEX HFA PROAIR HFA TEVETEN, TEVETEN- HCT candesartan, candesartanhydrochlorothiazide,eprosartan,irbesartan,irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide,valsartan, valsartanhydrochlorothiazide, ZETONNA flunisolide, flucasone, triamcinolone, NASONEX 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 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 1-888-838-6337. 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 PrescribingProgram for Lotronex, call 1-888423-5227 or visit www.lotronex.com. 4 A medical exception process is in place for specific clinical circumstances that may require continued coverage for one of these specific drugs: Freestyle diabetic test strips. If your doctor believes you have a specific clinical need for one of these drugs, he or she should fax a medical exception request to 1-866-443-1172. 5 OneTouchbrand test strips are the only preferred options. 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 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. Your specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. For specific information, visit www.signaturescripts.com or contact a SignatureScripts Customer Service Representative. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber.