PRIMARY/PREFERRED DRUG LIST (FORMULARY) A ABILIFY ACANYA ACCU-CHEK STRIPS & KITS 2 ACTONEL ADVAIR AGGRENOX ALPHAGAN P ALREX AMITIZA AMTURNIDE ANDRODERM ANTARA APIDRA APRISO ARCAPTA ASMANEX ASTEPRO ATELVIA ATRALIN AVELOX AVINZA AVODART AVONEX AXIRON AZILECT AZOPT AZOR B BD INSULIN SYRINGES & NEEDLES BENICAR BENICAR HCT BENZACLIN BESIVANCE BETIMOL BETOPTIC S BEYAZ BRILINTA BYDUREON BYSTOLIC C CANASA CARAC CELEBREX CETROTIDE CIPRO SUSPENSION CITRANATAL CLOBEX SPRAY CLODERM COLCRYS COMBIGAN COMBIVENT RESPIMAT COPAXONE COREG CR CORTIFOAM COSOPT PF CREON CRESTOR CRINONE CYMBALTA D DEXILANT DIFFERIN DIOVAN DIVIGEL DULERA DUREZOL E EFFIENT ELIDEL ENBREL EPIDUO EPIPEN EPIPEN JR EPISIL ESTRACE CREAM EVAMIST EVISTA EXALGO EXELON PATCH EXFORGE EXFORGE HCT EXTAVIA F FENTORA FINACEA FLOVENT DISKUS FLOVENT HFA FOLLISTIM AQ FORADIL FORTEO FORTESTA FOSRENOL G GELINIQUE GEL-ONE GILENYA H HUMATROPE HUMIRA HUMULIN R U-500 HYALGAN I INCIVEK INVOKANA J JANUMET JANUMET XR JANUVIA JENTADUETO K KADIAN L LANTUS LATUDA LAZANDA LETARIS LEVEMIR LIALDA LIPOFEN LO LOESTRIN FE LOCOID LIPOCREAM LOCOID LOTION LOESTRIN 24 FE LOTEMAX LOTRONEX 3 LOVAZA LYRICA M MENTAX MICARDIS MICARDIS HCT MINASTRIN 24 FE MINIVELLE MOVIPREP MOXEZA MUGARD N NAMENDA NASONEX NATAZIA NEUPRO NEXIUM NIASPAN NITROLINGUAL NITROSTAT NORDITROPIN NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA NUCYNTA ER NUVARING O ONETOUCH STRIPS & KITS 2 OPANA ER ORACEA ORTHO EVRA ORTHO TRI-CYCLEN LO ORTHOVISC OSPHENA OVIDREL OXISTAT OXSORALEN-ULTRA OXYCONTIN P PATADAY PANTANASE PATANOL PENNSAID PENTASA PERFOROMIST PHOSLYRA PICATO PRADAXA PREMARIN PREMARIN CREAM 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) PREMPHASE PREMPRO PRISTIQ PROAIR HFA PROTOPIC PROVENTIL HFA PULMICORT FLEXHALER TREXIMET TRIBENZOR U ULORIC ULTRESA Q QSYMIA QVAR R RAPAFLO RELENZA RELPAX RENVELA RESTASIS RETIN-A MICRO S SABRIL SANCUSO SAVELLA SEREVENT SEROQUEL XR SIMBRINZA SIMCOR SORIATANE SORILUX SPIRIVA SUMAVEL DOSEPRO SUPRAX SUPREP SYMBICORT SYNTHROID V VAGIFEM VICTOZA VICTRELIS VIGAMOX VIIBRYD VIMOVO VIMPAT VIOKACE VIVELLE-DOT VOLTAREN GEL VYTORIN W WELCHOL X XARELTO Z ZENPREP ZETIA ZIOPTAN ZOMIG NASAL SPRAY ZUBSOLV ZUPLENZ ZYCLARA ZYLET T TAMIFLU TAZAORAC TECFIDERA TEKAMLO TEKTURNA TEKTURNA HCT TOBRADEX TOBRADEX ST TRACLEER TRADJENTA TRAVATAN Z 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.
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)* ACIPHEX lansoprazole, omeprazole, omeprazole CLINDAGEL erythromycin solution sodium bicarbornate capsule, pantoprazole, DEXILANT, NEXIUM ACTOS pioglitazone COMBIVENT COMBIVENT RESPIMAT ADVICOR atorvastin, fluvastin, lovastin, pravastatin, simvastatin, CRESTOR, SIMCOR, VYTORIN CONTOUR NEXT STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, ONETOUCH STRIPS AND KITS 2 ALORA estradiol, DIVIGEL,EVAMIST, MINIVELLE, VIVELLE-DOT CONTOUR STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, ONETOUCH STRIPS AND KITS 2 ALTOPREV ALVESCO pravastin, simvastatin, CRESTOR, SIMCOR VYTORIN ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR DELZICOL DETROL LA balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA oxybutynin ext-rel, tolterodine, trospium, GELNIQUE, ANDROGEL ANDRODERM, AXIRON, FORTESTA DIOVAN HCT candesartan-hydrochlorothiazide, irbesartanhydrochlorothiazide, losartan-hydrochlorothiazide, valsartan-hydrochlorothiazide, BENICAR-HCT, MICARDIS HCT ANGELIQ estradiol-norethindrone, PREMPHASE, DORAL zolpidem, zolpidem ext-rel PREMPRO ARMOUR THYROID levothyroxine, SYNTHROID DUEXIS VIMOVO ARTHROTEC diclofenac sodium-misoprostol, CELEBREX, VIMOVO DYMISTA flunisolide, fluticasone, triamcinolone or NASONEX WITH azelastine, ASTEPRO or PATANASE ASACOL HD ASCENSIA STRIPS & KITS ATACAND, ATACAND HCT Balsalazide, sulfasalazine, sulfasaklazine delayed-rel, APRISO, LIALDA, PENTASA EDARBI,EDARBYCLOR candesartan 4, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan- hydrochlorthiazide, losartan losartan-hydrochlorthiazide, valsartanhydrochlorothiazide, BENICAR, BENICAR HCT, DIOVAN, MICARDIS, MICARDIS HCT ACCU-CHEK STRIPS AND KITS 2, ONETOUCH STRIPS AND KITS 2 EDLUAR zolpidem, zolipidem ext-rel candesartan 4, candesartanhydrochlorothiazide,eprosartan,irbesartan, ENABLEX oxybutynin ext-rel, tolterodine, trospium ext- rel, GELNIQUE, irbesartan-hydrochlorothiazide,losartan, losartan-hydrochlorothiazide, valsartanhydrochlorothiazide, BENICAR, BENICAR HCT, DIOVAN, MICARDIS, MICARDIS-HCT ATROVENT HFA SPIRIVA ENJUVIA estradiol, estropriate, PREMARIN AUVI-Q EPIPEN, EPIPEN JR ESTRASORB estradiol, DIVIGEL, EVAMIST, MINIVELLE, VIVELLE-DOT AXERT naratriptan, rizatriptan, sumatriptan ESTRING ESTRACE CREAM, PREMARIN CREAM, VAGIFEM tablet, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY AZELEX erythromycin solution ESTROGEL estradiol, DIVIGEL, EVAMIST, MINIVELLE, VIVELLE-DOT BECONASE AQ flunisolide, fluticasone, triamicinolone, EUFLEXXA GEL-ONE, HYALGAN, ORTHOVISC NASONEX BENZAC AC, BENZAC W adapalene, clindamycin solution, FEMRING ESTRACE CREAM, PREMARIN CREAM,VAGIFEM clindamycin-benzol peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC BENZAGEL adapalene, clindamycin solution, FEMTRACE estradiol, estropipate, PREMARIN clindamycin-benzol peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC BENZIQ adapalene, clindamycin solution, FENOGLIDE fenofibrate, fenofibric acid, ANTARA, LIPOFEN clindamycin-benzol peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC BREEZE 2 STRIPS AND ACCU-CHEK STRIPS AND KITS 2, ONETOUCH FIRST TESTOSTERONE ANDRODERM, AXIRON, FORTESTA KITS STRIPS AND KITS 2 BREO ELLIPTA ADVAIR, DULERA, SYMBICORT FLECTOR diclofenac, meloxicam, naproxen CARDURA XL alfuzosin ext-rel, doxazosin, tamsulosin, FORTAMET metformin, metformin ext-rel terazosin, RAPAFLO CENESTIN estradiol, estropipate, PREMARIN FOSAMAX PLUS D alendronate, ibandronate, ACTONEL, ATELVIA
Preferred Alternatives List DRUG NAME PREFERRED ALTERNATIVE(S)* DRUG NAME PREFERRED ALTERNATIVE(S)* FREESTYLE STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, ONETOUCH STRIPS AND KITS 2 OXYTROL oxybutynin ext-rel, tolterodine, trospium, trospium extrel, GELNIQUE, FROVA naratriptan, rizatriptan, sumatriptan PANCREAZE CREON, ULTRESA, VIOKACE, ZENPREP tablet, zolmitriptan, ZOMIG NASAL SPRAY GENOTROPIN HUMATROPE, NORDITROPIN PERTZYE CREON, ULTRESA, VIOKACE, ZENPREP GLUMETZA metformin, metformin ext-rel PEXEVA citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, VIIBRYD HUMALOG ADIPRA, NOVOLOG PLAVIX clopidogrel, BRILINTA, EFFIENT HUMALOG MIX 50/50 NOVOLOG MIX 70/30 PRECISION XTRA STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, ONE TOUCH STRIPS AND KITS 2 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 PRED MILD dexamethasone, DUREZOL, LOTEMAX HUMULIN NOVOLIN PREFERAOB generic prenatal vitamins, CITRANATAL INNOPRAN XL atenolol, carvedilol, metoprolol, PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO metoprolol succinate ext-rel, nadolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR INTERMEZZO zolpidem, zolpidem ext-rel PRENATAL PLUS generic prenatal vitamins, CITRANATAL ISTALOL timolol maleate solution, BETIMOL PREVACID lansaprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, NEXIUM JALYN finasteride or AVADART with alfuzosin estrel, doxazosin, tamsulosin, terazosin or PROTONIX lansaprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, NEXIUM RAPAFLO KAZANO JANUMET, JANUMET XR, JENTADUETO QNASL flunisolide, fluticasone, triamcinolone, NASONEX KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO RAYOS dexamethasone, methylprednisolone LASTACAFT azelastine,cromolyn sodium, PATADAY, RELION INSULIN NOVOLIN INSULIN PATANOL LESCOL XL RHINOCORT AQUA flunisolide, fluticasone, triamcinolene, NASONEX pravasrarin, simvastatin, CRESTOR, SIMCOR, VYTORIN LIPITOR RIOMET metformin, metformin ext-rel pravasrarin, simvastatin, CRESTOR, SIMCOR, VYTORIN LIPTRUZET ROZEREM zolpidem, zolpidem ext-rel pravastatin, simvastatin, VYTORIN LIVALO SAIZEN HUMATROPE, NORDITROPIN pravastatin, simvastatin, CRESTOR, VYTORIN LUMIGAN latanoprost, TRAVATAN Z, ZIOPTAN SANCTURA XR 5 oxybutynin ext-rel,tolterodine, trospium, GELNIQUE, LUNESTA zolpidem, zolpidem-ext-rel SKELID alendronate, ACTONEL MAXAIR PROAIR HFA, PROVENTIL HFA STRIANT ANDRODERM, AXIRON, FORTESTA MENEST estradiol, estropipate, PREMARIN SUBOXONE FILM buprenorphine-naloxone sublingual tablet, ZUBSOLV MENOSTAR estradiol, DIVIGEL, EVAMIST, MINIVELLE, VIVELLE-DOT SUPARTZ GEL-ONE, HYALGAN, ORTHOVISC NESINA JANUVIA, TRADJENTA SURE-TEST STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, ONETOUCH STRIPS AND KITS 2 NITROMIST nitroglycerin sublingual spray, SYNVISC, SYNVISC ONE GEL-ONE, HYALGAN, ORTHOVISC NITROLINGUAL, NITROSTAT NUTROPIN, NUTROPIN HUMATROPE, NORDITROPIN TESTIM ANDRODERM, AXIRON, FORTESTA AQ OLEPTRO trazodone TEVETEN, TEVETEN-HCT candesartan, candesartanhydrochlorothiazide,eprosartan,irbesartann,irbesartanhydrochlorothiazide, losartan, losartanhydrochlorothiazide,valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT, DIOVAN, MICARDIS, MICARDIS HCT OLUX-E clobetasol propionate foam,clobex SPRAY TEV-TROPIN HUMATROPE, NORDITROPIN OMNARIS flunisolide, fluticasone, triamcinolone, TOVIAZ oxybutynin ext-rel, tolterodine, trospium, GELNIQUE, NASONEX OMNITROPE HUMATROPE, NORDITROPIN TRICOR fenofibrate, fenofibric acid, ANTARA, LIPOFEN ONGLYZA JANUVIA, TRADJENTA TRIGLIDE fenofibrate, ANTARA,LIPOFEN, TRILIPIX OSENI JANUMET, JANUMET XR, JENTADUETO TRILIPIX fenofibrate, fenofibric acid, ANTARA, LIPOFEN OXYTROL oxybutynin ext-rel, tolterodine, trospium, trospium ext-rel, GELNIQUE,
Preferred Alternatives List TRUE CARE STRIPS AND KITS, TRUETEST SRTIPS AND KITS, TRUETRACK STRIPS AND KITS ACCU-CHEK STRIPS AND KITS 2, ONETOUCH VENTOLIN HFA PROAIR HFA, PROVENTIL HFA STRIPS AND KITS 2 TUDORZA SPIRIVA VERAMYST flunisolide, fluticasone, triamcinolone, NASONEX TWYNSTA AZOR, EXFORGE VITAFOL-ONE generic prenatal vitamins, CITRANATAL VALTREX acyclovir, valacyclovir XOPENEX HFA PROAIR HFA, PROVENTIL HFA VANOS clobetasol ZETONNA flunisolide, flucasone, triamcinolone, NASONEX VASCEPA LOVAZA 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 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. 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 Candesartan should be reserved for members who meet CHARM (Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity) trial criteria.) 5 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, Pxytrol and Sanctura XR. 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. 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.