April 2013 VIVA Health Custom Drug List The VIVA Health Custom 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 preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. 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. 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. Please note: Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Please visit www.vivahealth.com for specific information regarding your prescription benefit coverage and copay 1 information. 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 non-preferred product. HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan. 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 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 www.vivahealth.com to check coverage and copay information for a specific medicine. ANALGESICS NSAIDs diclofenac meloxicam naproxen NSAIDs, VIMOVO NSAIDs, TOPICAL PENNSAID VOLTAREN GEL COX-2 CELEBREX OPIOID ANALGESICS codeine-acetaminophen hydrocodone-acetaminophen tramadol tramadol ext-rel OPIOID ANALGESICS, CII fentanyl transdermal hydromorphone methadone morphine morphine ext-rel morphine suppository oxycodone oxycodone-acetaminophen AVINZA EXALGO KADIAN NUCYNTA NUCYNTA ER OPANA ER OXYCONTIN VISCOSUPPLEMENTS SYNVISC 2 SYNVISC-ONE 2 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 2 ANTIRETROVIRAL ANTIRETROVIRAL lamivudine-zidovudine ATRIPLA EPZICOM TRIZIVIR TRUVADA CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY FUSION FUZEON 2 INTEGRASE ISENTRESS NON-NUCLEOSIDE REVERSE TRANSCRIPTASE nevirapine EDURANT INTELENCE RESCRIPTOR SUSTIVA VIRAMUNE XR NUCLEOSIDE REVERSE TRANSCRIPTASE abacavir didanosine delayed-rel lamivudine stavudine zidovudine EMTRIVA VIDEX SOLUTION ZIAGEN SOLUTION NUCLEOTIDE REVERSE TRANSCRIPTASE VIREAD PROTEASE APTIVUS CRIXIVAN INVIRASE KALETRA LEXIVA NORVIR PREZISTA REYATAZ VIRACEPT ANTIVIRALS CYTOMEGALOVIRUS VALCYTE HEPATITIS B BARACLUDE EPIVIR-HBV HEPSERA TYZEKA HEPATITIS C ribavirin 2 INCIVEK 2 REBETOL SOLUTION 2 VICTRELIS 2 HERPES acyclovir valacyclovir INFLUENZA amantadine rimantadine RELENZA TAMIFLU MISCELLANEOUS clindamycin metronidazole
nitrofurantoin sulfamethoxazoletrimethoprim CARDIOVASCULAR ACE fosinopril lisinopril quinapril ramipril ACE INHIBITOR / CALCIUM CHANNEL BLOCKER amlodipine-benazepril ACE INHIBITOR / DIURETIC fosinopril-hydrochlorothiazide lisinopril-hydrochlorothiazide quinapril-hydrochlorothiazide ADRENOLYTICS, CENTRAL clonidine transdermal ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC 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 ANTIARRHYTHMICS amiodarone disopyramide flecainide propafenone propafenone ext-rel sotalol TIKOSYN ANTILIPEMICS BILE ACID RESINS cholestyramine WELCHOL CHOLESTEROL ABSORPTION ZETIA FIBRATES fenofibrate ANTARA LIPOFEN TRILIPIX HMG-CoA REDUCTASE / atorvastatin fluvastatin lovastatin pravastatin simvastatin CRESTOR LESCOL XL VYTORIN NIACINS / NIASPAN SIMCOR 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 / 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 CENTRAL NERVOUS SYSTEM ANTICONVULSANTS carbamazepine carbamazepine ext-rel diazepam rectal gel divalproex sodium delayed-rel divalproex sodium ext-rel ethosuximide gabapentin lamotrigine lamotrigine ext-rel levetiracetam levetiracetam ext-rel oxcarbazepine phenobarbital phenytoin phenytoin sodium extended primidone tiagabine 2 mg, 4 mg topiramate valproic acid zonisamide BANZEL GABITRIL LAMICTAL ODT LYRICA SABRIL VIMPAT ANTIDEMENTIA donepezil galantamine galantamine ext-rel rivastigmine EXELON PATCH NAMENDA ANTIDEPRESSANTS MONOAMINE OXIDASE (MAOIs) phenelzine tranylcypromine MARPLAN SELECTIVE SEROTONIN REUPTAKE (SSRIs) citalopram escitalopram fluoxetine paroxetine paroxetine ext-rel sertraline VIIBRYD SEROTONIN NOREPINEPHRINE REUPTAKE (SNRIs) 5 venlafaxine venlafaxine ext-rel CYMBALTA PRISTIQ MISCELLANEOUS bupropion bupropion ext-rel mirtazapine trazodone ANTIPARKINSONIAN amantadine benztropine bromocriptine carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone entacapone pramipexole ropinirole ropinirole ext-rel selegiline tabs trihexyphenidyl AZILECT NEUPRO ANTIPSYCHOTICS, ATYPICALS clozapine olanzapine quetiapine risperidone ziprasidone ABILIFY FANAPT INVEGA SAPHRIS SEROQUEL XR ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetaminedextroamphetamine mixed salts ext-rel 2 dexmethylphenidate 2 dextroamphetamine 2 dextroamphetamine ext-rel 2 methylphenidate 2 methylphenidate ext-rel 2 DAYTRANA 2 FOCALIN XR 2 INTUNIV 2 STRATTERA 2 VYVANSE 2 HYPNOTICS, NONBENZODIAZEPINES zolpidem 3 zolpidem ext-rel 3 MIGRAINE SELECTIVE SEROTONIN AGONISTS naratriptan 3 rizatriptan 3 sumatriptan 3 SUMAVEL DOSEPRO 3 ZOMIG 3 SELECTIVE SEROTONIN AGONIST / NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) TREXIMET 3 MULTIPLE SCLEROSIS AVONEX 2 BETASERON 2 COPAXONE 2 REBIF 2 MUSCULOSKELETAL THERAPY baclofen carisoprodol chlorzoxazone cyclobenzaprine dantrolene metaxalone methocarbamol orphenadrine-aspirin-caffeine tizanidine tabs NARCOLEPSY / CATAPLEXY modafinil 2 NUVIGIL 2 ENDOCRINE AND METABOLIC ANTIDIABETICS ALPHA-GLUCOSIDASE acarbose BIGUANIDES metformin metformin ext-rel BIGUANIDE / SULFONYLUREA glipizide-metformin DIPEPTIDYL PEPTIDASE-4 (DPP-4) JANUVIA TRADJENTA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE JANUMET JANUMET XR JENTADUETO INCRETIN MIMETIC 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 DUETACT MEGLITINIDES nateglinide PRANDIN SULFONYLUREAS glimepiride glipizide glipizide ext-rel SUPPLIES ACCU-CHEK STRIPS AND BD INSULIN SYRINGES AND NEEDLES 4 ONETOUCH STRIPS AND CALCIUM REGULATORS BISPHOSPHONATES alendronate ibandronate ACTONEL ATELVIA CALCITONINS calcitonin-salmon PARATHYROID HORMONES FORTEO CONTRACEPTIVES MONOPHASIC ethinyl estradioldrospirenone BEYAZ LO LOESTRIN FE LOESTRIN 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 VIVELLE-DOT VAGINAL PREMARIN CREAM VAGIFEM ESTROGEN / PROGESTINS, ORAL estradiol-norethindrone PREMPHASE PREMPRO HUMAN GROWTH HORMONES HUMATROPE 2 NORDITROPIN 2 PHOSPHATE BINDER calcium acetate FOSRENOL PHOSLYRA RENVELA PROGESTINS, ORAL medroxyprogesterone progesterone, micronized SELECTIVE ESTROGEN RECEPTOR MODULATORS EVISTA THYROID SUPPLEMENTS levothyroxine SYNTHROID GASTROINTESTINAL ANTIEMETICS dronabinol granisetron meclizine metoclopramide ondansetron oral 2 prochlorperazine promethazine trimethobenzamide caps TRANSDERM SCOP CHOLELITHOLYTICS ursodiol H2 RECEPTOR ANTAGONISTS ranitidine INFLAMMATORY BOWEL DISEASE ORAL budesonide delayed-rel caps ASACOL ASACOL HD LIALDA PENTASA RECTAL CANASA CORTIFOAM LAXATIVES KRISTALOSE PANCREATIC ENZYMES CREON ZENPEP PROTON PUMP lansoprazole pantoprazole SALIVA STIMULANTS cevimeline STEROIDS, RECTAL PROCTOFOAM-HC GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel doxazosin finasteride tamsulosin terazosin AVODART RAPAFLO URINARY ANTISPASMODICS oxybutynin oxybutynin ext-rel tolterodine trospium GELNIQUE HEMATOLOGIC ANTICOAGULANTS warfarin PRADAXA XARELTO PLATELET AGGREGATION clopidogrel AGGRENOX BRILINTA EFFIENT IMMUNOLOGIC BIOLOGIC DISEASE- MODIFYING ENBREL 2 HUMIRA 2 IMMUNOMODULATORS INTERFERONS SYLATRON 2, 3 IMMUNOSUPPRESSANTS ANTIMETABOLITES mycophenolate mofetil AZASAN MYFORTIC CALCINEURIN cyclosporine cyclosporine, modified tacrolimus SANDIMMUNE RAPAMYCIN DERIVATIVES RAPAMUNE NUTRITIONAL PRENATAL VITAMINS prenatal vitamins CITRANATAL RESPIRATORY ANAPHYLAXIS TREATMENT 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 NEOHALER FORADIL SEREVENT LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast zafirlukast NASAL ANTIHISTAMINES azelastine ASTEPRO NASAL STEROIDS flunisolide fluticasone triamcinolone NASONEX STEROID / BETA AGONIST ADVAIR DULERA SYMBICORT STEROID INHALANTS budesonide inhalation suspension ASMANEX PULMICORT FLEXHALER QVAR XANTHINES THEO-24 TOPICAL DERMATOLOGY ACNE adapalene 2 benzoyl clindamycin solution clindamycin-benzoyl erythromycin-benzoyl tretinoin 2 ACANYA 2 DIFFERIN 2 EPIDUO 2 RETIN-A MICRO 2 VELTIN 2 ACTINIC KERATOSIS fluorouracil imiquimod CARAC PICATO SOLARAZE ZYCLARA ANTIBIOTICS mupirocin BACTROBAN NASAL ANTIFUNGALS ciclopirox MENTAX ANTIPSORIATICS calcipotriene OXSORALEN-ULTRA SORIATANE SORILUX TAZORAC CORTICOSTEROIDS Low Potency desonide hydrocortisone Medium Potency mometasone triamcinolone LOCOID LIPOCREAM High Potency desoximetasone fluocinonide APEXICON E Very High Potency clobetasol CLOBEX SPRAY
IMMUNOMODULATORS ELIDEL PROTOPIC LOCAL ANALGESICS LIDODERM ROSACEA metronidazole sulfacetamide-sulfur FINACEA METROGEL ORACEA OPHTHALMIC ANTIALLERGICS azelastine cromolyn sodium ALREX LASTACAFT PATADAY ANTI-INFECTIVES ciprofloxacin erythromycin gentamicin levofloxacin ofloxacin sulfacetamide tobramycin MOXEZA VIGAMOX ANTI-INFECTIVE / ANTI-INFLAMMATORY bacitracin-hydrocortisone tobramycin- TOBRADEX ST ZYLET ANTI-INFLAMMATORIES Nonsteroidal diclofenac ketorolac BROMDAY Steroidal DUREZOL LOTEMAX BETA-BLOCKERS Nonselective timolol maleate solution BETIMOL Selective BETOPTIC S CARBONIC ANHYDRASE dorzolamide AZOPT CARBONIC ANHYDRASE INHIBITOR / BETA- BLOCKER dorzolamide-timolol COSOPT PF IMMUNOMODULATORS RESTASIS PROSTAGLANDINS latanoprost TRAVATAN Z ZIOPTAN SYMPATHOMIMETICS brimonidine ALPHAGAN P SYMPATHOMIMETIC / BETA- BLOCKER COMBIGAN OTIC ANTI-INFECTIVES ofloxacin otic ANTI-INFECTIVE / ANTI-INFLAMMATORY CIPRO HC CIPRODEX QUICK REFERENCE DRUG LIST A abacavir ABILIFY ACANYA 2 acarbose ACCU-CHEK STRIPS AND ACTONEL acyclovir adapalene 2 ADVAIR AGGRENOX albuterol alendronate alfuzosin ext-rel ALPHAGAN P ALREX amantadine amiodarone amlodipine amlodipine-atorvastatin amlodipine-benazepril amoxicillin amoxicillin-clavulanate amphetaminedextroamphetamine mixed salts ext-rel 2 AMTURNIDE ANTARA APEXICON E APIDRA APTIVUS ARCAPTA NEOHALER ASACOL ASACOL HD ASMANEX ASTEPRO ATELVIA atenolol atorvastatin ATRIPLA AVELOX AVINZA AVODART AVONEX 2 AZASAN azelastine AZILECT azithromycin AZOPT AZOR B baclofen BACTROBAN NASAL BANZEL BARACLUDE BD INSULIN SYRINGES AND NEEDLES 4 BENICAR BENICAR HCT benzoyl benztropine BETASERON 2 BETIMOL BETOPTIC S BEYAZ BRILINTA brimonidine BROMDAY bromocriptine budesonide delayed-rel caps budesonide inhalation suspension bupropion bupropion ext-rel BYDUREON BYSTOLIC C calcipotriene calcitonin-salmon calcium acetate CANASA CARAC carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone carisoprodol carvedilol cefdinir cefprozil cefuroxime axetil CELEBREX cephalexin cevimeline chlorzoxazone cholestyramine ciclopirox CIPRO HC CIPRO SUSPENSION CIPRODEX ciprofloxacin ciprofloxacin ext-rel ciprofloxacin tablet citalopram CITRANATAL clarithromycin clarithromycin ext-rel clindamycin clindamycin solution clindamycin-benzoyl clobetasol CLOBEX SPRAY clonidine transdermal clopidogrel clozapine codeine-acetaminophen COMBIGAN COMBIVENT RESPIMAT COPAXONE 2 COREG CR CORTIFOAM COSOPT PF CREON CRESTOR CRIXIVAN cromolyn sodium cyclobenzaprine cyclosporine cyclosporine, modified CYMBALTA D dantrolene DAYTRANA 2 desonide desoximetasone dexmethylphenidate 2 dextroamphetamine 2 dextroamphetamine ext-rel 2 diazepam rectal gel diclofenac dicloxacillin didanosine delayed-rel DIFFERIN 2 digoxin diltiazem ext-rel DIOVAN disopyramide divalproex sodium delayed-rel divalproex sodium ext-rel DIVIGEL donepezil dorzolamide dorzolamide-timolol doxazosin doxycycline hyclate dronabinol DUETACT DULERA DUREZOL E EDURANT EFFIENT ELIDEL EMTRIVA ENBREL 2 entacapone EPIDUO 2 EPIPEN EPIPEN JR EPIVIR-HBV eprosartan EPZICOM erythromycin erythromycin-benzoyl erythromycins escitalopram estradiol estradiol-norethindrone estropipate ethinyl estradioldrospirenone ethinyl estradiollevonorgestrel ethinyl estradiol-norgestimate ethosuximide EVAMIST EVISTA EXALGO EXELON PATCH EXFORGE EXFORGE HCT F FANAPT fenofibrate fentanyl transdermal FINACEA finasteride flecainide fluconazole flunisolide fluocinonide fluorouracil fluoxetine fluticasone fluvastatin FOCALIN XR 2 FORADIL FORTEO fosinopril fosinopril-hydrochlorothiazide FOSRENOL furosemide FUZEON 2
G gabapentin GABITRIL galantamine galantamine ext-rel GELNIQUE gentamicin glimepiride glipizide glipizide ext-rel glipizide-metformin granisetron H HEPSERA HUMATROPE 2 HUMIRA 2 HUMULIN R U-500 hydrochlorothiazide hydrocodone-acetaminophen hydrocortisone hydromorphone I ibandronate imiquimod INCIVEK 2 INTELENCE INTUNIV 2 INVEGA INVIRASE ipratropium-albuterol inhalation solution irbesartan irbesartanhydrochlorothiazide ISENTRESS itraconazole J JANUMET JANUMET XR JANUVIA JENTADUETO K KADIAN KALETRA ketorolac KRISTALOSE L LAMICTAL ODT lamivudine lamivudine-zidovudine lamotrigine lamotrigine ext-rel lansoprazole LANTUS LASTACAFT latanoprost LESCOL XL LEVEMIR levetiracetam levetiracetam ext-rel levofloxacin levothyroxine LEXIVA LIALDA LIDODERM LIPOFEN lisinopril lisinopril-hydrochlorothiazide LO LOESTRIN FE LOCOID LIPOCREAM LOESTRIN 24 FE losartan losartan-hydrochlorothiazide LOTEMAX lovastatin LYRICA M MARPLAN meclizine medroxyprogesterone meloxicam MENTAX metaxalone metformin metformin ext-rel methadone methocarbamol methylphenidate 2 methylphenidate ext-rel 2 metoclopramide metolazone metoprolol metoprolol succinate ext-rel METROGEL metronidazole MICARDIS MICARDIS HCT minocycline mirtazapine modafinil 2 mometasone montelukast morphine morphine ext-rel morphine suppository MOXEZA mupirocin mycophenolate mofetil MYFORTIC N nadolol NAMENDA naproxen naratriptan 3 NASONEX NATAZIA nateglinide bacitracin-hydrocortisone NEUPRO nevirapine NIASPAN nifedipine ext-rel nitrofurantoin NORDITROPIN 2 NORVIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA NUCYNTA ER NUVARING NUVIGIL 2 O ofloxacin ofloxacin otic olanzapine ondansetron oral 2 ONETOUCH STRIPS AND OPANA ER ORACEA orphenadrine-aspirin-caffeine ORTHO EVRA ORTHO TRI-CYCLEN LO oxcarbazepine OXSORALEN-ULTRA oxybutynin oxybutynin ext-rel oxycodone oxycodone-acetaminophen OXYCONTIN P pantoprazole paroxetine paroxetine ext-rel PATADAY penicillin VK PENNSAID PENTASA phenelzine phenobarbital phenytoin phenytoin sodium extended PHOSLYRA PICATO pioglitazone pioglitazone-metformin PRADAXA pramipexole PRANDIN pravastatin PREMARIN PREMARIN CREAM PREMPHASE PREMPRO prenatal vitamins PREZISTA primidone PRISTIQ PROAIR HFA prochlorperazine PROCTOFOAM-HC progesterone, micronized promethazine propafenone propafenone ext-rel propranolol propranolol ext-rel PROTOPIC PROVENTIL HFA PULMICORT FLEXHALER Q quetiapine quinapril quinapril-hydrochlorothiazide QVAR R ramipril ranitidine RAPAFLO RAPAMUNE REBETOL SOLUTION 2 REBIF 2 RELENZA RENVELA RESCRIPTOR RESTASIS RETIN-A MICRO 2 REYATAZ ribavirin 2 rimantadine risperidone rivastigmine rizatriptan 3 ropinirole ropinirole ext-rel S SABRIL SANDIMMUNE SAPHRIS selegiline tabs SELZENTRY SEREVENT SEROQUEL XR sertraline SIMCOR simvastatin SOLARAZE SORIATANE SORILUX sotalol SPIRIVA spironolactonehydrochlorothiazide stavudine STRATTERA 2 sulfacetamide sulfacetamide-sulfur sulfamethoxazoletrimethoprim sumatriptan 3 SUMAVEL DOSEPRO 3 SUPRAX SUSTIVA SYLATRON 2, 3 SYMBICORT SYNTHROID SYNVISC 2 SYNVISC-ONE 2 T tacrolimus TAMIFLU tamsulosin TAZORAC TEKAMLO TEKTURNA TEKTURNA HCT terazosin terbinafine tablet 2 tetracycline THEO-24 tiagabine 2 mg, 4 mg TIKOSYN timolol maleate solution tizanidine tabs TOBRADEX ST tobramycin tobramycin- tolterodine topiramate torsemide TRADJENTA tramadol tramadol ext-rel TRANSDERM SCOP tranylcypromine TRAVATAN Z trazodone tretinoin 2 TREXIMET 3 triamcinolone triamterenehydrochlorothiazide TRIBENZOR trihexyphenidyl TRILIPIX trimethobenzamide caps TRIZIVIR trospium TRUVADA TYZEKA U ursodiol V VAGIFEM valacyclovir VALCYTE valproic acid valsartan-hydrochlorothiazide VELTIN 2 venlafaxine venlafaxine ext-rel verapamil ext-rel VICTOZA VICTRELIS 2 VIDEX SOLUTION VIGAMOX VIIBRYD VIMOVO VIMPAT VIRACEPT VIRAMUNE XR VIREAD VIVELLE-DOT VOLTAREN GEL VYTORIN VYVANSE 2 W warfarin WELCHOL X XARELTO
Z zafirlukast ZENPEP ZETIA ZIAGEN SOLUTION zidovudine ZIOPTAN ziprasidone zolpidem 3 zolpidem ext-rel 3 ZOMIG 3 zonisamide ZYCLARA ZYLET PREFERRED ALTERNATIVES LIST DRUG NAME(S) DRUG NAME(S) ACIPHEX lansoprazole, pantoprazole ESTRACE CREAM PREMARIN CREAM, VAGIFEM ADVICOR SIMCOR ESTRASORB ALORA ESTRING PREMARIN CREAM, VAGIFEM ALTOPREV ALVESCO ANGELIQ ARMOUR THYROID atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, LESCOL XL, VYTORIN ASMANEX, PULMICORT FLEXHALER, QVAR estradiol-norethindrone, PREMPHASE, PREMPRO levothyroxine, SYNTHROID ASCENSIA STRIPS AND ACCU-CHEK STRIPS AND, ONETOUCH STRIPS AND ATACAND, ATACAND HCT ATROVENT HFA eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, valsartanhydrochlorothiazide, BENICAR, BENICAR HCT, DIOVAN, MICARDIS, MICARDIS HCT SPIRIVA AXERT 3 naratriptan 3, rizatriptan 3, sumatriptan 3, ZOMIG 3 AZELEX BECONASE AQ BENZAC AC, BENZAC W BENZAGEL BENZIQ CARDURA XL CENESTIN CLINDAGEL COMBIVENT DESQUAM E, DESQUAM X DETROL LA clindamycin-benzoyl,, erythromycin-benzoyl, tretinoin 2, ACANYA 2, clindamycin-benzoyl,, erythromycin-benzoyl, tretinoin 2, ACANYA 2, clindamycin-benzoyl,, erythromycin-benzoyl, tretinoin 2, ACANYA 2, alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO COMBIVENT RESPIMAT clindamycin-benzoyl,, erythromycin-benzoyl, tretinoin 2, ACANYA 2, DORAL 3 zolpidem 3, zolpidem ext-rel 3 DUEXIS VIMOVO EDARBI, EDARBYCLOR eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, valsartanhydrochlorothiazide, BENICAR, BENICAR HCT, DIOVAN, MICARDIS, MICARDIS HCT ESTROGEL FEMRING PREMARIN CREAM, VAGIFEM FEMTRACE FENOGLIDE fenofibrate, ANTARA, LIPOFEN, TRILIPIX FLECTOR diclofenac, meloxicam, naproxen FLOVENT, FLOVENT HFA ASMANEX, PULMICORT FLEXHALER, QVAR FORTAMET metformin, metformin ext-rel FOSAMAX PLUS D alendronate, ibandronate, ACTONEL, ATELVIA FREESTYLE STRIPS AND ACCU-CHEK STRIPS AND, ONETOUCH STRIPS AND FROVA 3 naratriptan 3, rizatriptan 3, sumatriptan 3, ZOMIG 3 GENOTROPIN 2 HUMATROPE 2, NORDITROPIN 2 GLUMETZA metformin, metformin ext-rel HUMALOG APIDRA, NOVOLOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN NOVOLIN INNOPRAN XL atenolol, carvedilol, metoprolol, metoprolol succinate ext-rel, nadolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR INTERMEZZO 3 zolpidem 3, zolpidem ext-rel 3 ISTALOL KOMBIGLYZE XR LIVALO timolol maleate solution, BETIMOL JANUMET, JANUMET XR, JENTADUETO atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, LESCOL XL, VYTORIN LUMIGAN latanoprost, TRAVATAN Z, ZIOPTAN LUNESTA 3 zolpidem 3, zolpidem ext-rel 3 MAXAIR PROAIR HFA, PROVENTIL HFA MENEST MENOSTAR MINIVELLE NUTROPIN 2, NUTROPIN AQ 2 HUMATROPE 2, NORDITROPIN 2 OLEPTRO trazodone OLUX-E clobetasol propionate foam, CLOBEX SPRAY OMNARIS OMNITROPE 2 HUMATROPE 2, NORDITROPIN 2 ONGLYZA JANUVIA, TRADJENTA EDLUAR 3 zolpidem 3, zolpidem ext-rel 3 ENABLEX ENJUVIA OXYTROL PATANASE azelastine, ASTEPRO
DRUG NAME(S) PEXEVA PRECISION XTRA STRIPS AND PRED MILD PREFERAOB PREFEST PRENATAL PLUS QNASL RELION INSULIN citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, VIIBRYD ACCU-CHEK STRIPS AND, ONETOUCH STRIPS AND, DUREZOL, LOTEMAX generic prenatal vitamins, CITRANATAL estradiol-norethindrone, PREMPHASE, PREMPRO generic prenatal vitamins, CITRANATAL NOVOLIN INSULIN RELPAX 3 naratriptan 3, rizatriptan 3, sumatriptan 3, ZOMIG 3 RHINOCORT AQUA RIOMET metformin, metformin ext-rel ROZEREM 3 zolpidem 3, zolpidem ext-rel 3 SAIZEN 2 HUMATROPE 2, NORDITROPIN 2 SANCTURA XR SKELID alendronate, ACTONEL DRUG NAME(S) SURE-TEST STRIPS AND ACCU-CHEK STRIPS AND, ONETOUCH STRIPS AND TEVETEN, TEVETEN HCT eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, valsartanhydrochlorothiazide, BENICAR, BENICAR HCT, DIOVAN, MICARDIS, MICARDIS HCT TEV-TROPIN 2 HUMATROPE 2, NORDITROPIN 2 TOVIAZ TRIGLIDE fenofibrate, ANTARA, LIPOFEN, TRILIPIX TRUE CARE STRIPS AND, TRUETEST STRIPS AND, TRUETRACK STRIPS AND VANOS VENTOLIN HFA VERAMYST VITAFOL-ONE XOPENEX HFA ZETONNA ZYFLO, ZYFLO CR ACCU-CHEK STRIPS AND, ONETOUCH STRIPS AND clobetasol PROAIR HFA, PROVENTIL HFA generic prenatal vitamins, CITRANATAL PROAIR HFA, PROVENTIL HFA montelukast, zafirlukast FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. Any brand drug for which a generic product becomes available may be designated as a non-preferred product. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. 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. This is not an all-inclusive list. 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 www.vivahealth.com 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 These medications may require prior authorization from VIVA Health. Before going to the pharmacy, please have your doctor call VIVA Health Medical Management toll-free at 1-800-294-7780, ext. 475. 3 These medications may have quantity limitations. 4 Only covered under pharmacy benefit when excluded from your medical benefit. 5 Indicates the proposed mechanism of action, based on the American Psychiatric Association Summary of Treatment Recommendations. 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 information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. 2013. All rights reserved. 106-11947-1-0413 www.vivahealth.com