July 2015 Performance Drug List The CVS/caremark Performance 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 administered by CVS/caremark. 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. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market. You may be responsible for the full cost of non-formulary products that are removed from coverage. For specific information regarding your prescription benefit coverage and copay 1 information, please visit www.caremark.com or contact a CVS/caremark Customer Care representative. 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. In most instances, a brand-name drug for which a generic product becomes available will be designated as a nonpreferred option upon release of the generic product to the market. 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 www.caremark.com to check coverage and copay information for a specific medicine. ANALGESICS NSAIDs diclofenac sodium meloxicam naproxen NSAIDs, diclofenac sodiummisoprostol NSAIDs, TOPICAL diclofenac sodium solution VOLTAREN GEL COX-2 celecoxib GOUT allopurinol colchicine tablet probenecid COLCRYS ULORIC OPIOID ANALGESICS codeine-acetaminophen fentanyl transdermal fentanyl transmucosal lozenge hydrocodone-acetaminophen hydromorphone hydromorphone ext-rel methadone morphine morphine ext-rel morphine suppository oxycodone oxycodone-acetaminophen tramadol tramadol ext-rel ABSTRAL BUTRANS FENTORA NUCYNTA NUCYNTA ER OPANA ER OXYCONTIN SUBSYS VISCOSUPPLEMENTS GEL-ONE HYALGAN SUPARTZ ANTI-INFECTIVES ANTIBACTERIALS CEPHALOSPORINS cefdinir cefprozil cefuroxime axetil cephalexin SUPRAX ERYTHROMYCINS / MACROLIDES azithromycin clarithromycin clarithromycin ext-rel erythromycins DIFICID FLUOROQUINOLONES ciprofloxacin ciprofloxacin ext-rel levofloxacin moxifloxacin PENICILLINS amoxicillin amoxicillin-clavulanate dicloxacillin penicillin VK TETRACYCLINES doxycycline hyclate minocycline tetracycline ANTIFUNGALS fluconazole itraconazole terbinafine tablet ANTIVIRALS HEPATITIS C ribavirin HARVONI SOVALDI HERPES acyclovir valacyclovir INFLUENZA RELENZA TAMIFLU MISCELLANEOUS clindamycin ivermectin metronidazole nitrofurantoin
sulfamet hoxazoletrimethoprim ALBENZA SIVEXTRO XIFAXAN 550 MG ANTINEOPLASTIC KINASE BOSULIF GLEEVEC SPRYCEL CARDIOVASCULAR ACE fosinopril lisinopril quinapril ramipril ACE INHIBITOR / DIURETIC fosinopril-hydrochlorot lisinopril-hydrochlorot quinapril-hydrochlorot ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC candesartan / candesartanhydrochlorot eprosart an irbesartan / irbesartanhydrochlorot losartan / losartanhydrochlorot telmisartan / telmisartanhydrochlorot valsartan / valsartanhydrochlorot BENICAR / BENICAR HC T ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER amlodipine-telmisart an amlodipine-valsartan AZOR ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC amlodipine-valsartanhydrochlorot TRIBENZOR ANTILIPEMICS BILE ACID RESINS cholestyramine WELCHOL CHOLESTEROL ABSORPTION ZE TIA FIBRATES fenofibrat e fenofibric acid HMG-CoA REDUCTASE / atorvast atin fluvastatin lovastatin pravastatin simvastatin CRESTOR VYTORIN NIACINS / niacin ext-rel SIMCOR OMEGA-3 FATTY ACIDS LOVAZA BETA-BLOCKERS atenolol carvedilol metoprolol succinate ext-rel metoprolol tartrate 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-at orvastatin 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 hydrochlorot metolazone spironolactonehydrochlorot torsemide triamterenehydrochlorot NITRATES nitroglycerin sublingual spray NITROLINGUAL NITROSTAT NITRATE / VASODILATOR BIDIL PULMONARY ARTERIAL HYPERTENSION ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS TRACLEER PHOSPHODIESTERASE sildenafil MISCELLANEOUS RANEXA 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 ext ended primidone tiagabine topiramat e valproic acid zonisamide LAMICTAL ODT VIMPAT ANTIDEMENTIA donepezil galantamine galantamine ext-rel rivastigmine EXELON PATCH NAMENDA NAMENDA XR ANTIDEPRESSANTS SELECTIVE SEROTONIN REUPTAKE (SSRIs) citalopram escitalopram fluoxetine paroxetine paroxetine ext-rel sertraline BRINTELLIX FLUOXETINE 60 MG VIIBRYD SEROTONIN NOREPINEPHRINE REUPTAKE (SNRIs) duloxetine venlafaxine venlafaxine ext-rel KHEDEZLA PRISTIQ MISCELLANEOUS bupropion bupropion ext-rel mirtazapine trazodone ANTIPARKINSONIAN amantadine carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone entacapone pramipexole ropinirole ropinirole ext-rel selegiline AZILECT MIRAPEX ER NEUPRO ZELAPAR ANTIPSYCHOTICS ATYPICALS clozapine olanzapine quetiapine risperidone ziprasidone ABILIFY LATUDA SEROQUEL XR ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetaminedextroamphet amine mixed salts amphetaminedextroamphet amine mixed salts ext-rel guanfacine ext-rel methylphenidate methylphenidate ext-rel DAYTRANA QUILLIVANT XR STRATTERA VYVANSE FIBROMYALGIA LYRICA SAVELLA HYPNOTICS NONBENZODIAZEPINES eszopiclone zolpidem zolpidem ext-rel TRICYCLICS SILENOR MIGRAINE SELECTIVE SEROTONIN AGONISTS naratript an rizatriptan sumatriptan zolmitriptan RELPAX SUMAVEL DOSEPRO ZOMIG NASAL SPRAY SELECTIVE SEROTONIN AGONIST / NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) TREXIMET MULTIPLE SCLEROSIS COPAXONE EXTAVIA GILENYA PLEGRIDY TECFIDERA MUSCULOSKELETAL THERAPY cyclobenzaprine NARCOLEPSY NUVIGIL POSTHERPETIC NEURALGIA GRALISE PSYCHOTHERAPEUTIC - MISCELLANEOUS OPIOID ANTAGONISTS EVZIO PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST buprenorphine-naloxone sublingual tablet ZUBSOLV
VASOMOTOR SYMPTOM BRISDELLE ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM AXIRON FORTESTA ANTIDIABETICS AMYLIN ANALOGS SYMLINPEN BIGUANIDES metformin metformin ext-rel BIGUANIDE / SULFONYLUREA glipizide-metformin DIPEPTIDYL PEPTIDASE-4 (DPP-4) JANUVIA TRADJENTA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR JANUMET JANUMET XR JENTADUETO INCRETIN MIMETIC BYDUREON VICTOZA INSULINS 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) INVOKANA SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE INVOKAMET SULFONYLUREAS glimepiride glipizide glipizide ext-rel SUPPLIES BD INSULIN SYRINGES AND NEEDLES DEXCOM G4 ONETOUCH ULTRA STRIPS AND KITS 2 ONETOUCH VERIO STRIPS AND KITS 2 ANTIOBESITY QSYMIA CALCIUM REGULATORS BISPHOSPHONATES alendronate ibandronate ACTONEL ATELVIA CALCITONINS calcitonin-salmon PARATHYROID HORMONES FORTEO CONTRACEPTIVES MONOPHASIC ethinyl estradioldrospirenone ethinyl estradiolnorethindrone acet ate BEYAZ LO LOESTRIN FE MINASTRIN 24 FE SAFYRAL TRIPHASIC ethinyl estradiol-norgestimate ORTHO TRI-CYCLEN LO FOUR PHASE NATAZIA EXTENDED CYCLE ethinyl estradiollevonorgestrel TRANSDERMAL ethinyl estradiolnorelgestromin 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 ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR DUAVEE FERTILITY REGULATORS GNRH / LHRH ANTAGONISTS CETROTIDE OVULATION STIMULANTS, GONADOTROPINS FOLLISTIM AQ OVIDREL GLUCOCORTICOIDS methylprednisolone prednisone GLUCOSE ELEVATING GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT HUMAN GROWTH HORMONES HUMATROPE NORDITROPIN PHOSPHATE BINDER calcium acetate PHOSLYRA RENVELA VELPHORO PROGESTINS ORAL medroxyprogesterone progesterone, micronized MEGACE ES VAGINAL CRINONE ENDOMETRIN SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene OSPHENA THYROID SUPPLEMENTS levothyroxine SYNTHROID GASTROINTESTINAL ANTIEMETICS dronabinol granisetron meclizine metoclopramide ondansetron prochlorperazine promethazine trimethobenzamide DICLEGIS SANCUSO H2 RECEPTOR ANTAGONISTS ranitidine INFLAMMATORY BOWEL DISEASE ORAL balsalazide budesonide capsule sulfasalazine sulfasalazine delayed-rel APRISO LIALDA PENTASA UCERIS RECTAL hydrocortisone enema mesalamine rectal suspension CANASA CORTIFOAM IRRITABLE BOWEL SYNDROME AMITIZA LINZESS LOTRONEX 3 LAXATIVES lactulose peg 3350-electrolytes MOVIPREP SUCLEAR SUPREP PANCREATIC ENZYMES CREON ULTRESA VIOKACE ZENPEP PROTON PUMP lansoprazole omeprazole omeprazole-sodium bicarbonate capsule pant oprazole DEXILANT NEXIUM STEROIDS, RECTAL PROCTOFOAM-HC ULCER THERAPY PYLERA MISCELLANEOUS RELISTOR GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel doxazosin finasteride tamsulosin terazosin AVODART RAPAFLO ERECTILE DYSFUNCTION ALPROSTADIL MUSE PHOSPHODIESTERASE CIALIS VIAGRA URINARY ANTISPASMODICS oxybutynin oxybutynin ext-rel tolterodine tolterodine ext-rel trospium trospium ext-rel GELNIQUE MYRBETRIQ VESICARE HEMATOLOGIC ANTICOAGULANTS warfarin ELIQUIS PRADAXA XARELTO HEMATOPOIETIC GROWTH FACTORS ARANESP PROCRIT PLATELET AGGREGATION clopidogrel
AGGRENOX BRILINTA EFFIENT IMMUNOLOGIC ALLERGENIC EXTRACTS GRASTEK ORALAIR RAGWITEK BIOLOGIC DISEASE- MODIFYING ENBREL HUMIRA DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) RASUVO NUTRITIONAL PRENATAL VITAMINS prenatal vitamins CITRANATAL RESPIRATORY ANAPHYLAXIS TREATMENT AUVI-Q EPIPEN EPIPEN JR ANTICHOLINERGICS SPIRIVA ANTICHOLINERGIC / BETA AGONIST ipratropium-albuterol inhalation solution ANORO ELLIPTA COMBIVENT RESPIMAT BETA AGONISTS, INHALANTS SHORT ACTING albuterol inhalation solution LONG ACTING ARCAPTA FORADIL PERFOROMIST SEREVENT LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast zafirlukast NASAL ANTIHISTAMINES azelastine olopatadine NASAL STEROIDS flunisolide fluticasone triamcinolone NASONEX PHOSPHODIESTERASE-4 DALIRESP STEROID / BETA AGONIST ADVAIR DULERA 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 TA ZORAC ACTINIC KERATOSIS fluorouracil imiquimod PICATO ZYCLARA ANTIFUNGALS ciclopirox clotrimazole econazole ketoconazole nystatin JUBLIA LUZU NAFTIN ANTIPSORIATICS acitretin calcipotriene methoxsalen SORILUX CORTICOSTEROIDS Low Potency desonide hydrocortisone Medium Potency hydrocortisone butyrate momet asone triamcinolone CLODERM LOCOID LOTION High Potency desoximetasone fluocinonide Very High Potency clobetasol IMMUNOMODULATORS tacrolimus ELIDEL ROSACEA metronidazole sulfacetamide-sulfur FINACEA ORACEA MISCELLANEOUS SKIN AND MUCOUS MEMBRANE DENAVIR MOUTH / THROAT / DENTAL PROTECTANTS EPISIL MUGARD OPHTHALMIC ANTIALLERGICS azelastine cromolyn sodium PATADAY PATANOL ANTI-INFECTIVES ciprofloxacin erythromycin gent amicin levofloxacin ofloxacin sulfacetamide tobramycin BESIVANCE MOXEZA VIGAMOX ANTI-INFECTIVE / ANTI-INFLAMMATORY neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- tobramycin-dexamet hasone TOBRADEX OINTMENT TOBRADEX ST ZYLE T ANTI-INFLAMMATORIES Nonsteroidal bromf enac diclofenac ketorolac PROLENSA Steroidal ALREX DUREZOL LOTEMAX BETA-BLOCKERS Nonsel ective timolol maleate solution BETIMOL Selective BETOPTIC S CARBONIC ANHYDRASE 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 OTIC ANTI-INFECTIVE / ANTI-INFLAMMATORY CIPRODEX QUICK REFERENCE DRUG LIST A ABILIFY ABSTRAL ACANYA acitretin ACTONEL acyclovir adapalene ADVAIR AGGRENOX ALBENZA albuterol inhalation solution alendronate alfuzosin ext-rel allopurinol ALPHAGAN P ALREX amantadine AMITIZA amlodipine amlodipine-at orvastatin amlodipine-telmisart an amlodipine-valsartan amlodipine-valsartanhydrochlorot amoxicillin amoxicillin-clavulanate amphetaminedextroamphet amine mixed salts amphetaminedextroamphet amine mixed salts ext-rel AMTURNIDE ANDRODERM ANORO ELLIPTA APRISO ARANESP ARCAPTA ASMANEX ATELVIA atenolol atorvast atin ATRALIN AUVI-Q AVODART AXIRON azelastine AZILECT azithromycin AZOPT AZOR B balsalazide
BD INSULIN SYRINGES AND NEEDLES BENICAR BENICAR HCT BENZACLIN benzoyl peroxide BESIVANCE BETIMOL BETOPTIC S BEYAZ BIDIL BOSULIF BRILINTA brimonidine BRINTELLIX BRISDELLE bromf enac budesonide capsule budesonide inhalation suspension buprenorphine-naloxone sublingual tablet bupropion bupropion ext-rel BUTRANS BYDUREON BYSTOLIC C calcipotriene calcitonin-salmon calcium acetate CANASA candesartan candesartanhydrochlorot carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone carvedilol cefdinir cefprozil cefuroxime axetil celecoxib cephalexin CETROTIDE cholestyramine CIALIS ciclopirox CIPRODEX ciprofloxacin ciprofloxacin ext-rel citalopram CITRANATAL clarithromycin clarithromycin ext-rel clindamycin clindamycin solution clindamycin-benzoyl peroxide clobetasol CLODERM clopidogrel clotrimazole clozapine codeine-acetaminophen colchicine tablet COLCRYS COMBIGAN COMBIVENT RESPIMAT COPAXONE COREG CR CORTIFOAM COSOPT PF CREON CRESTOR CRINONE cromolyn sodium cyclobenzaprine D DALIRESP DAYTRANA DENAVIR desonide desoximetasone DEXCOM G4 DEXILANT diazepam rectal gel DICLEGIS diclofenac diclofenac sodium diclofenac sodium solution diclofenac sodiummisoprostol dicloxacillin DIFFERIN DIFICID digoxin diltiazem ext-rel 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 ENDOMETRIN entacapone EPIDUO EPIPEN EPIPEN JR EPISIL eprosart an erythromycin erythromycin solution erythromycin-benzoyl peroxide erythromycins escitalopram ESTRACE CREAM estradiol estradiol-norethindrone estropipate eszopiclone ethinyl estradioldrospirenone ethinyl estradiollevonorgestrel ethinyl estradiolnorelgestromin ethinyl estradiolnorethindrone acet ate ethinyl estradiol-norgestimate ethosuximide EVAMIST EVZIO EXELON PATCH EXTAVIA F fenofibrat e fenofibric acid fentanyl transdermal fentanyl transmucosal lozenge FENTORA FINACEA finasteride FLOVENT DISKUS FLOVENT HFA fluconazole flunisolide fluocinonide fluorouracil fluoxetine FLUOXETINE 60 MG fluticasone fluvastatin FOLLISTIM AQ FORADIL FORTEO FORTESTA fosinopril fosinopril-hydrochlorot furosemide G gabapentin galantamine galantamine ext-rel GELNIQUE GEL-ONE gent amicin GILENYA GLEEVEC glimepiride glipizide glipizide ext-rel glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GRALISE granisetron GRASTEK guanfacine ext-rel H HARVONI HUMATROPE HUMIRA HUMULIN R U-500 HYALGAN hydrochlorot hydrocodone-acetaminophen hydrocortisone hydrocortisone butyrate hydrocortisone enema hydromorphone hydromorphone ext-rel I ibandronate imiquimod INVOKAMET INVOKANA ipratropium-albuterol inhalation solution irbesartan irbesartanhydrochlorot itraconazole ivermectin J JANUMET JANUMET XR JANUVIA JENTADUETO JUBLIA K ketoconazole ketorolac KHEDEZLA L lactulose LAMICTAL ODT lamotrigine lamotrigine ext-rel lansoprazole LANTUS latanoprost LATUDA LETAIRIS LEVEMIR levetiracetam levetiracetam ext-rel levofloxacin levothyroxine LIALDA LINZESS lisinopril lisinopril-hydrochlorot LO LOESTRIN FE LOCOID LOTION losart an losart an-hydrochlorot LOTEMAX LOTRONEX 3 lovastatin LOVAZA LUZU LYRICA M meclizine medroxyprogesterone MEGACE ES meloxicam mesalamine rectal suspension metformin metformin ext-rel methadone methoxsalen methylphenidate methylphenidate ext-rel methylprednisolone metoclopramide metolazone metoprolol succinate ext-rel metoprolol tartrate metronidazole MINASTRIN 24 FE MINIVELLE minocycline MIRAPEX ER mirtazapine momet asone montelukast morphine morphine ext-rel morphine suppository MOVIPREP MOXEZA moxifloxacin MUGARD MUSE MYRBETRIQ N nadolol NAFTIN NAMENDA NAMENDA XR naproxen naratript an 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 NORDITROPIN NOVOLIN 70/30
NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA NUCYNTA ER NUVARING NUVIGIL nystatin O ofloxacin olanzapine olopatadine omeprazole omeprazole-sodium bicarbonate capsule ondansetron ONETOUCH ULTRA STRIPS AND KITS 2 ONETOUCH VERIO STRIPS AND KITS 2 OPANA ER ORACEA ORALAIR ORTHO TRI-CYCLEN LO OSPHENA OVIDREL oxcarbazepine oxybutynin oxybutynin ext-rel oxycodone oxycodone-acetaminophen OXYCONTIN P pant oprazole paroxetine paroxetine ext-rel PATADAY PATANOL peg 3350-electrolytes penicillin VK PENTASA PERFOROMIST phenobarbital phenytoin phenytoin sodium ext ended PHOSLYRA PICATO pioglitazone pioglitazone-glimepiride pioglitazone-metformin PLEGRIDY PRADAXA pramipexole pravastatin prednisone PREMARIN PREMARIN CREAM PREMPHASE PREMPRO prenatal vitamins primidone PRISTIQ probenecid prochlorperazine PROCRIT PROCTOFOAM-HC progesterone, micronized PROLENSA promethazine propranolol propranolol ext-rel PULMICORT FLEXHALER PYLERA Q QSYMIA quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorot QVAR R RAGWITEK raloxifene ramipril RANEXA ranitidine RAPAFLO RASUVO RELENZA RELISTOR RELPAX RENVELA repaglinide RESTASIS RETIN-A MICRO ribavirin risperidone rivastigmine rizatriptan ropinirole ropinirole ext-rel S SAFYRAL SANCUSO SAVELLA selegiline SEREVENT SEROQUEL XR sertraline sildenafil SILENOR SIMBRINZA SIMCOR simvastatin SIVEXTRO SORILUX SOVALDI SPIRIVA spironolactonehydrochlorot SPRYCEL STRATTERA SUBSYS SUCLEAR sulfacetamide sulfacetamide-sulfur sulfamet hoxazoletrimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptan SUMAVEL DOSEPRO SUPARTZ SUPRAX SUPREP SYMLINPEN SYNTHROID T tacrolimus TAMIFLU tamsulosin TA ZORAC TECFIDERA TEKAMLO TEKTURNA TEKTURNA HCT telmisart an telmisart anhydrochlorot terazosin terbinafine tablet tetracycline tiagabine timolol maleate solution TOBRADEX OINTMENT TOBRADEX ST tobramycin tobramycin-dexamet hasone tolterodine tolterodine ext-rel topiramat e torsemide TRACLEER TRADJENTA tramadol tramadol ext-rel TRAVATAN Z travoprost trazodone tretinoin TREXIMET triamcinolone triamterenehydrochlorot TRIBENZOR trimethobenzamide trospium trospium ext-rel U UCERIS ULORIC ULTRESA V VAGIFEM valacyclovir valproic acid valsartan valsartan-hydrochlorot VELPHORO venlafaxine venlafaxine ext-rel verapamil ext-rel VESICARE VIAGRA VICTOZA VIGAMOX VIIBRYD VIMPAT VIOKACE VOLTAREN GEL VYTORIN VYVANSE W warfarin WELCHOL X XARELTO XIFAXAN 550 MG Z zafirlukast ZELAPAR ZENPEP ZE TIA ZIOPTAN ziprasidone zolmitriptan zolpidem zolpidem ext-rel ZOMIG NASAL SPRAY zonisamide ZUBSOLV ZYCLARA ZYLE T PREFERRED OPTIONS LIST ACCU-CHEK STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 2, ACTOS ADDERALL XR ADRENACLICK ADVICOR AEROSPAN pioglitazone amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts extrel, methylphenidate, methylphenidate extrel, DAYTRANA, QUILLIVANT XR, STRATTERA, VYVANSE AUVI-Q, EPIPEN, EPIPEN JR ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR ALORA ALTOPREV ALVESCO AMRIX ANDROGEL ANGELIQ ANTARA APEXICON E APIDRA estradiol, DIVIGEL, EVAMIST, MINIVELLE ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR cyclobenzaprine estradiol-norethindrone, PREMPHASE, PREMPRO desoximetasone, fluocinonide NOVOLOG
ARMOUR THYROID ARTHROTEC ASACOL HD levothyroxine, SYNTHROID celecoxib; diclofenac sodium, meloxicam or naproxen WITH lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT or NEXIUM balsalazide, budesonide capsule, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS ASCENSIA STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 2, ATACAND, ATACAND HCT ATROVENT HFA AXERT AZELEX BECONASE AQ BENZAC AC, BENZAC W BENZIQ candesartan, candesartan-hydrochlorot, eprosartan, irbesartan, irbesartanhydrochlorot, losartan, losartanhydrochlorot, telmisartan, telmisartanhydrochlorot, valsartan, valsartanhydrochlorot, SPIRIVA naratriptan, rizatriptan, sumatriptan nasal spray, sumatriptan tablet, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycinbenzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN- A MICRO, TAZORAC adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycinbenzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN- A MICRO, TAZORAC BREEZE 2 STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 2, BREO ELLIPTA BYETTA CARDURA XL CLINDAGEL ADVAIR BYDUREON, VICTOZA alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO erythromycin solution CONTOUR NEXT STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 2, CONTOUR STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 2, DELZICOL DETROL LA balsalazide, budesonide capsule, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE DIOVAN, DIOVAN HCT DORAL DUEXIS DYMISTA EDARBI, EDARBYCLOR EDLUAR ENABLEX ENJUVIA ESTRING ESTROGEL EUFLEXXA EXFORGE EXFORGE HCT FARXIGA FEMRING FENOGLIDE FETZIMA FIRST TESTOSTERONE FLECTOR FORTAMET FOSAMAX PLUS D FOSRENOL candesartan, candesartan-hydrochlorot, eprosartan, irbesartan, irbesartanhydrochlorot, losartan, losartanhydrochlorot, telmisartan, telmisartanhydrochlorot, valsartan, valsartanhydrochlorot, celecoxib; diclofenac sodium, meloxicam or naproxen WITH lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT or NEXIUM flunisolide, fluticasone, triamcinolone or NASONEX WITH azelastine or olopatadine candesartan, candesartan-hydrochlorot, eprosartan, irbesartan, irbesartanhydrochlorot, losartan, losartanhydrochlorot, telmisartan, telmisartanhydrochlorot, valsartan, valsartanhydrochlorot, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE estradiol, estropipate, PREMARIN ESTRACE CREAM, PREMARIN CREAM, VAGIFEM estradiol, DIVIGEL, EVAMIST, MINIVELLE GEL-ONE, HYALGAN, SUPARTZ amlodipine-telmisartan, amlodipine-valsartan, AZOR amlodipine-valsartan-hydrochlorot, TRIBENZOR INVOKANA ESTRACE CREAM, PREMARIN CREAM, VAGIFEM duloxetine, venlafaxine, venlafaxine ext-rel, KHEDEZLA, PRISTIQ diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL metformin, metformin ext-rel alendronate, ibandronate, ACTONEL, ATELVIA calcium acetate, PHOSLYRA, RENVELA, VELPHORO FREESTYLE STRIPS AND KITS 4, 5 ONETOUCH ULTRA STRIPS AND KITS 2, FROVA GENOTROPIN GLUMETZA HUMALOG naratriptan, rizatriptan, sumatriptan nasal spray, sumatriptan tablet, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY metformin, metformin ext-rel 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 LEVITRA LIPITOR LIPTRUZET LIVALO LUMIGAN LUNESTA MENEST MENOSTAR MICARDIS, MICARDIS HCT NAPRELAN NATESTO NESINA NITROMIST NORVASC NUTROPIN AQ OLEPTRO OLUX-E OMNARIS OMNITROPE ONGLYZA ORTHOVISC OSENI OXYTROL PANCREAZE PENNSAID PERTZYE NOVOLIN atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, 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 CIALIS, VIAGRA latanoprost, travoprost, TRAVATAN Z, ZIOPTAN estradiol, estropipate, PREMARIN estradiol candesartan, candesartan-hydrochlorot, eprosartan, irbesartan, irbesartanhydrochlorot, losartan, losartanhydrochlorot, telmisartan, telmisartanhydrochlorot, valsartan, valsartanhydrochlorot, celecoxib, diclofenac sodium, meloxicam, naproxen, JANUVIA, TRADJENTA nitroglycerin sublingual spray, NITROLINGUAL, NITROSTAT amlodipine trazodone clobetasol foam JANUVIA, TRADJENTA GEL-ONE, HYALGAN, SUPARTZ JANUMET, JANUMET XR, JENTADUETO oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE CREON, ULTRESA, VIOKACE, ZENPEP diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL CREON, ULTRESA, VIOKACE, ZENPEP PEXEVA PLAVIX PRECISION XTRA STRIPS AND KITS 4 PRED MILD PREFERAOB PREFEST PRENATAL PLUS PREVACID PROTONIX PROTOPIC PROVENTIL HFA QNASL RAYOS REBIF RELION INSULIN RHINOCORT AQUA RIOMET ROZEREM SAIZEN SKELID STRIANT SUBOXONE FILM citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, BRINTELLIX, FLUOXETINE 60 MG, VIIBRYD clopidogrel, BRILINTA, EFFIENT ONETOUCH ULTRA STRIPS AND KITS 2,, DUREZOL, LOTEMAX generic prenatal vitamins, CITRANATAL estradiol-norethindrone, PREMPHASE, PREMPRO generic prenatal vitamins, CITRANATAL lansoprazole, omeprazole, omeprazolesodium bicarbonate capsule, pantoprazole, DEXILANT, NEXIUM lansoprazole, omeprazole, omeprazolesodium bicarbonate capsule, pantoprazole, DEXILANT, NEXIUM tacrolimus, ELIDEL, methylprednisolone, prednisone COPAXONE, EXTAVIA, GILENYA, PLEGRIDY, TECFIDERA NOVOLIN INSULIN metformin, metformin ext-rel alendronate, ACTONEL buprenorphine-naloxone sublingual tablet, ZUBSOLV SURE-TEST STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 2, SYMBICORT SYNVISC, SYNVISC-ONE TANZEUM TESTIM testosterone gel 1% 6 TEVETEN, TEVETEN HCT TEV-TROPIN TOVIAZ TRICOR TRIGLIDE TRILIPIX ADVAIR, DULERA GEL-ONE, HYALGAN, SUPARTZ BYDUREON, VICTOZA candesartan, candesartan-hydrochlorot, eprosartan, irbesartan, irbesartanhydrochlorot, losartan, losartanhydrochlorot, telmisartan, telmisartanhydrochlorot, valsartan, valsartanhydrochlorot, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE
TRUETEST STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 2, TRUETRACK STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 2, TUDORZA VALTREX VANOS VASCEPA VENTOLIN HFA VERAMYST VIEKIRA PAK SPIRIVA acyclovir, valacyclovir clobetasol LOVAZA HARVONI VIMOVO VITAFOL-ONE VOGELXO XIGDUO XR XOPENEX HFA ZETONNA ZYFLO, ZYFLO CR celecoxib; diclofenac sodium, meloxicam or naproxen WITH lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT or NEXIUM generic prenatal vitamins, CITRANATAL INVOKAMET montelukast, zafirlukast You may be responsible for the full cost of certain non-formulary products that are removed from cov erage. Please check w ith y our plan sponsor for more information. 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. New to market products and new variations of products already in the marketplace will not be added to the formulary until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by the CVS/caremark Pharmacy and Therapeutics Committee (or other appropriate reviewing body). In most instances, a brandname drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. 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 w ill include all dosage forms. This list represents brand products in C APS and generic products in low ercase 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 www.caremark.com to check coverage and copay information for a specific medicine. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. Generics are av ailable 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 fix ed amount or other charge, with the balance, if any, paid by a Plan. 2 A OneTouch blood glucose meter will be prov ided 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 toll-free: 1-800-588-4456. 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 w ith Lotronex for sev ere 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 toll-free: 1-888-423-5227 or visit www.lotronex.com to complete the Physician Enrollment Form. CVS/caremark does not manage the Lotronex Prescribing Program or operate the website. CVS/caremark is not responsible for the availability or reliability of the website's content. This listing does not imply or constitute an endorsement, sponsorship or recommendation by CVS/caremark. 4 OneTouch brand test strips are the only preferred options. 5 An exception process is in place for specific clinical circumstances that may require continued coverage for Freesty le diabetic test strips. If y our doctor believ es y ou have a specific clinical need for this product, he or she should fax an exception request toll-free to: 1-888-487-9257. Your plan may choose to prov ide an exception process for additional medications on this list. 6 Listing reflects the authorized generics for Testim and Vogelxo. Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. CVS/caremark may receiv e rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS/caremark. 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. 2015 CVS/caremark. All rights reserved. 15045-1-0715 www.caremark.com