2015 Catamaran National Formulary Reference Guide. List of covered drugs

Transcription

1 2015 Catamaran National Formulary Reference Guide List of covered drugs

2 SHIP Drug Benefit If you have any questions about your SHIP drug benefit please contact: AIG Student Health Pharmacy Help Desk: The SHIP drug benefit has 4 tiers of drug coverage: 1st Tier- 2nd Tier- 3rd Tier- 4th Tier- Formulary Generic drug Formulary Brand drug Non-formulary Brand drug Specialty drugs Generic drugs (1st Tier) have the lowest member copayment. Copayments for tiers 1, 2 and 3, are listed next to RX COPAY on the SHIP membership card. Member cost-sharing for specialty drugs is detailed in the online SHIP Plan Document FDA-approved contraceptive medications are fully covered under the SHIP contraceptive benefit. For a supply of more than 30 days please call AIG Student Health at Note: unless a brand name contraceptive is prescribed as medically necessary, a copayment will apply if a member receives a brand name contraceptive when a generic equivalent is available. USING THIS FORMULARY REFERENCE GUIDE TO HELP CONTAIN COSTS Many health plans use the Catamaran formulary to help manage the overall cost of providing prescription drug benefits. This formulary offers a wide range of medications from which to choose. We realize that this formulary reference guide may not include every drug from every manufacturer. However, choosing a generic or preferred drug when it is appropriate can provide access to the necessary medications to stay healthy, at a cost that is more affordable. SAVING ON OUT-OF-POCKET COSTS SHIP sets the co-payments for each formulary drug status which include generic, preferred brand-name, and non-preferred brand-name medications. Health plans often design prescription drug plans to encourage the use of generic and preferred brand-name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses. Patients may also pay less for generic drugs, or they may be asked to pay the cost difference between brand-name drugs and their generic alternatives. PLEASE NOTE: Brand-name drugs may move to non-preferred status if a generic version becomes available. KNOWING HOW THE FORMULARY INFORMATION IS ORGANIZED The following formulary reference guide is designed so that generic products are listed first in each drug category. The preferred brand name products are listed next.

3 oxacillin sodium penicillin v potassium penicillin G potassium Cimzia piperacillin sodium/ tazobactam sodium Cimzia Starter Kit Humira piperacillin sodium/tazobactam Humira Pediatric Crohns Disease NATIONAL FORMULARY sodium Starter Pack DRUG LIST piperacillin/tazobactam Humira Pen The Catamaran Preferred Drug List is a guide Humira Pen-crohns Diseasestarter identifying preferred brand-name medicines within Augmentin Humira Pen-psoriasis Starter select therapeutic categories. The Preferred Drug List may not include all drugs covered by your QUINOLONES prescription drug benefit. Generic medicines are CARDIOVASCULAR available within many of the therapeutic categories ACE-INHIBITORS ciprofloxacin listed, in addition to categories not listed, and should be considered as the first line of prescribing. ciprofloxacin ER benazepril HCL ciprofloxacin HCL captopril For benefit coverage or restrictions please check ciprofloxacin I.V.-IN D5W enalapril maleate your benefit plan document(s). This listing is revised levofloxacin enalaprilat periodically as new drugs and new prescribing levofloxacin IN D5W fosinopril sodium information becomes available. It is recommended moxifloxacin HCL lisinopril that you bring this list of medications when you or a ofloxacin moexipril HCL covered family member sees a physician or other Ciprofloxacin HCL perindopril erbumine healthcare provider. Ofloxacin quinapril HCL ramipril ANTI-INFECTIVES Avelox trandolapril ANTIFUNGALS TETRACYCLINES fluconazole ANGIOTENSIN RCPTR BLOCKER fluconazole IN dextrose demeclocycline HCL fluconazole IN NACL doxycycline candesartan cilexetil flucytosine doxycycline hyclate eprosartan mesylate griseofulvin microsize doxycycline hyclate DR irbesartan griseofulvin ultramicrosize doxycycline monohydrate losartan potassium itraconazole minocycline HCL telmisartan ketoconazole minocycline HCL ER valsartan nystatin Tetracycline HCL terbinafine HCL Benicar voriconazole ANTI-INFLAMMATORY NSAIDS BETA BLOCKERS Lamisil Noxafil celecoxib acebutolol HCL Sporanox diclofenac potassium atenolol diclofenac sodium DR betaxolol HCL CEPHALOSPORINS diclofenac sodium ER bisoprolol fumarate diclofenac sodium/misoprostol esmolol HCL cefaclor etodolac metoprolol succinate ER cefadroxil etodolac ER metoprolol tartrate cefazolin sodium flurbiprofen nadolol cefdinir ibuprofen pindolol cefepime indomethacin propranolol HCL cefotaxime sodium indomethacin sodium propranolol HCL ER cefoxitin sodium indomethacin ER sotalol HCL cefpodoxime proxetil ketoprofen sotalol HCL (AF) cefprozil ketorolac tromethamine ceftazidime mefenamic acid Bystolic ceftriaxone sodium meloxicam cefuroxime axetil nabumetone cefuroxime sodium naproxen CALCIUM CHANNEL BLOCKERS cephalexin naproxen sodium amlodipine besylate oxaprozin diltiazem CD PENICILLINS piroxicam diltiazem HCL sulindac diltiazem HCL ER amoxicillin tolmetin sodium felodipine ER amoxicillin/clavulanate potassium Meclofenamate Sodium nicardipine HCL amoxicillin/clavulanate potassium ER Tolmetin Sodium nifedipine ampicillin nifedipine ER ampicillin sodium Zorvolex nimodipine ampicillin-sulbactam nisoldipine dicloxacillin sodium AUTO-IMMUNE verapamil HCL nafcillin sodium verapamil HCL ER Effective April 1, 2015 v.1 Catamaran All Rights Reserved. May not be copied or distributed without authorization. 1

4 verapamil HCL SR fenofibric acid DR augmented betamethasone Verapamil HCL gemfibrozil dipropionate betamethasone dipropionate Fenofibrate betamethasone valerate NITRATES & NITRITES Lipofen calcipotriene/betamethasone BILE ACID SEQUESTRANTS dipropionate isosorbide dinitrate clobetasol propionate isosorbide dinitrate ER cholestyramine clobetasol propionate emollient desonide isosorbide mononitrate cholestyramine light isosorbide mononitrate ER colestipol HCL desoximetasone nitroglycerin colestipol HCL for oral suspension diflorasone diacetate fluocinolone acetonide nitroglycerin lingual nitroglycerin transdermal Welchol fluocinonide nitroglycerin IN dextrose 5% CHOLEST ABS INHBTR/COMBO fluocinonide-e fluticasone propionate nitroglycerin IN 5% dextrose Isosorbide Dinitrate Liptruzet halobetasol propionate Vytorin hydrocortisone hydrocortisone acetate/aloe Dilatrate SR Zetia Nitro-bid NIACIN/COMBINATIONS hydrocortisone butyrate Nitrostat hydrocortisone butyrate (lipid) hydrocortisone butyrate (lipophilic) niacin ER hydrocortisone valerate ANTI-HTN COMBINATIONS Simcor hydrocortisone IN absorbase mometasone furoate amlodipine besylate/benazepril OMEGA-3 FATTY ACIDS hydrochloride prednicarbate amlodipine besylate/benazepril HCL omega-3-acid ethyl esters triamcinolone acetonide amlodipine besylate/valsartan Amcinonide amlodipine/valsartan/hctz Vascepa Apexicon E atenolol/chlorthalidone Desoximetasone benazepril HCL/hydrochlorothiazide DERMATOLOGICALS bisoprolol Pramosone ACNE fumarate/hydrochlorothiazide Pramosone E candesartan Taclonex adapalene cilexetil/hydrochlorothiazide benzoyl peroxide Tucks Anti-itch enalapril maleate/hydrochlorothiazide benzoyl peroxide SHORT contact fosinopril sodium/hydrochlorothiazide clindamycin phosphate ENDOCRINE irbesartan/hydrochlorothiazide clindamycin/benzoyl peroxide CONTRACEPTIVE AGENTS lisinopril/hydrochlorothiazide erythromycin losartan desogestrel/ethinyl estradiol potassium/hydrochlorothiazide erythromycin/benzoyl peroxide metronidazole drospirenone/ethinyl estradiol metoprolol/hydrochlorothiazide sodium sulfacetamide levonorgestrel moexipril/hydrochlorothiazide levonorgestrel and ethinyl estradiol nadolol/bendroflumethiazide sodium sulfacetamide/sulfur sodium sulfacetamide/sulfur cleanser levonorgestrel/ethinyl estradiol quinapril/hydrochlorothiazide sodium sulfacetamide/sulfur cleansing norethindrone telmisartan/amlodipine cloths norethindrone acetate/ethinyl telmisartan/hydrochloroth sodium sulfacetamide/sulfur green estradiol telmisartan/hydrochlorothiazide norethindrone acetate/ethinyl valsartan/hydrochlorothiazide sodium sulfacetamide/sulfur w/sunscreen estradiol/ferrous fumarate norgestimate/ethinyl estradiol sodium sulfacetamide/sulfur wash Amturnide sulfacetamide sodium Ogestrel Azor sulfacetamide sodium/sulfur cleanser Benicar HCT Beyaz tretinoin Tarka tretinoin microsphere Depo-provera Tekamlo tretinoin microsphere P.M. LO Loestrin FE Tekturna HCT Minastrin 24 FE Claravis Tribenzor Doxycycline Natazia Safyral ANTIHYPERLIPIDEMICS STATINS Acanya ESTROGENS/COMBINATIONS Atralin atorvastatin calcium estradiol Differin fluvastatin Epiduo estradiol valerate lovastatin Finacea estradiol/norethindrone acetate pravastatin sodium estropipate Mirvaso simvastatin Oracea Jinteli Ziana Crestor Alora FIBRATES Cenestin TOPICAL ANTI-INFLAMMATORY Combipatch fenofibrate Duavee alclometasone dipropionate fenofibrate micronized Effective April 1,

5 Enjuvia pioglitazone HCL/metformin HCL Estrace Carafate Estring Actoplus Met XR Evamist DPP-4 INHIBITORS Minivelle GROWTH HORMONE Premarin Januvia Premphase Onglyza Norditropin Cartridge Prempro Tradjenta Norditropin Flexpro Vagifem BIGUANIDE/DPP-4 COMB. Norditropin Nordiflex Pen Nutropin TESTOSTERONE AGENTS Janumet Nutropin AQ Nuspin 10 Janumet XR Nutropin AQ Nuspin 20 danazol Jentadueto Nutropin AQ Nuspin 5 testosterone cypionate Kombiglyze XR Nutropin AQ Pen testosterone enanthate SULFONYLUREAS Testosterone HEPATITIS C Testosterone P.M. glimepiride glipizide ANTIVIRALS Androgel glipizide ER ribavirin Androgel P.M. glyburide Androxy glyburide micronized Harvoni Axiron tolazamide Moderiba Glyburide Moderiba 1200 Dose Pack INSULIN SULFONYLUREA/TZD COMB. Moderiba 800 Dose Pack Ribasphere Humalog pioglitazone HCL-glimepiride Ribasphere Ribapak Humalog Kwikpen INCRETINS Ribatab Humalog Mix 50/50 Sovaldi Humalog Mix 50/50 Kwikpen Bydureon Humalog Mix 75/25 Byetta INTERFERONS Humalog Mix 75/25 Kwikpen Victoza Humulin N AMYLIN ANALOGS Peg-intron Humulin N Kwikpen Peg-intron Redipen Humulin N U-100 Pen Symlinpen 120 Peg-intron Redipen PAK 4 Humulin R Symlinpen 60 Pegasys Humulin R U-500 (concentrated) DIABETIC OTHER Pegasys Proclick Humulin 70/30 Pegintron Humulin 70/30 Kwikpen Farxiga Humulin 70/30 Pen Glucagen Lantus Glucagen Hypokit PROTEASE INHIBITORS Lantus Solostar Glucagon Emergency Kit Olysio Levemir Invokamet Victrelis Levemir Flexpen Invokana Levemir Flextouch Jardiance MULTIPLE SCLEROSIS Novolin N Proglycem Novolin N Relion Novolin R GASTROINTESTINAL Ampyra Novolin R Relion PROTON PUMP INHIBITORS Aubagio Novolin 70/30 Avonex Novolin 70/30 Relion esomeprazole sodium Avonex Pen Novolog lansoprazole Betaseron Novolog Flexpen omeprazole Copaxone Novolog Mix 70/30 pantoprazole sodium Gilenya Novolog Mix 70/30 Prefilled Flexpen rabeprazole sodium Lemtrada Novolog Penfill Esomeprazole Sodium Plegridy Plegridy Starter Pack NON-INSULIN HYPOGLYCEMICS Nexium Rebif BIGUANIDES Nexium 24HR Rebif Rebidose Rebif Rebidose Titration Pack metformin HCL ULCER DRUGS Rebif Titration Pack metformin HCL ER Tecfidera cimetidine Tecfidera Starter Pack Riomet cimetidine HCL Tysabri BIGUAN/SULFONYLUREA COMB. famotidine misoprostol NEUROLOGICALS glipizide/metformin HCL nizatidine ALZHEIMER'S DISEASE glyburide/metformin HCL ranitidine HCL BIGUAN/THIAZOLIDEINEDIONE sucralfate donepezil HCL Famotidine galantamine pioglitazone HCL Effective April 1,

6 galantamine hydrobromide Sumavel Dosepro neomycin/polymyxin/bacitracin/hydroco rivastigmine tartrate Treximet rtisone Galantamine Hydrobromide Zomig neomycin/polymyxin/dexamethasone Zomig Nasal Spray prednisolone acetate sulfacetamide sodium/prednisolone Exelon OPHTHALMICS sodium phosphate Namenda tobramycin/dexamethasone ANTI-ALLERGIC AGENTS Namenda Titration PAK Alrex Namenda XR azelastine HCL Namenda XR Titration Pack cromolyn sodium FML epinastine HCL Lotemax Ozurdex ANTICONVULSANTS Bepreve Pred Mild carbamazepine Pataday Retisert Tobradex carbamazepine ER Patanol clonazepam Tobradex ST clonazepam odt Zylet ANTI-GLAUCOMA AGENTS divalproex sodium divalproex sodium DR apraclonidine MIOTICS divalproex sodium ER betaxolol HCL pilocarpine HCL ethosuximide brimonidine tartrate felbamate carteolol HCL fosphenytoin sodium dorzolamide HCL Phospholine Iodide Pilopine HS gabapentin dorzolamide HCL/timolol maleate lamotrigine latanoprost lamotrigine odt levobunolol HCL MISCELLANEOUS lamotrigine ER timolol maleate levetiracetam timolol maleate ophthalmic gel Restasis levetiracetam ER forming oxcarbazepine Metipranolol OSTEOPOROSIS phenytoin BISPHOSPHONATES phenytoin sodium Alphagan P Combigan alendronate sodium phenytoin sodium extended primidone Lumigan ibandronate sodium tiagabine hydrochloride Travatan Z pamidronate disodium Travoprost risedronate sodium topiramate valproate sodium zoledronic acid valproic acid ANTI-INFECTIVES Alendronate Sodium zonisamide ciprofloxacin HCL Atelvia erythromycin Fosamax Plus D Banzel gatifloxacin Celontin gentamicin sulfate SERM Diazepam levofloxacin ofloxacin raloxifene hydrochloride Dilantin Fycompa tobramycin sulfate Gabitril Bacitracin PSYCHOTHERAPEUTICS Lyrica ATYPICAL ANTIPSYCHOTICS Onfi Besivance Oxtellar XR Moxeza chlorpromazine HCL Vigamox clozapine Peganone Potiga fluphenazine decanoate Tegretol-XR ANTI-INFLAMMATORY AGENTS fluphenazine HCL haloperidol Vimpat bromfenac haloperidol decanoate cromolyn sodium haloperidol lactate MIGRAINE/HEADACHE diclofenac sodium lithium carbonate dihydroergotamine mesylate flurbiprofen sodium lithium carbonate ER naratriptan HCL ketorolac tromethamine loxapine loxapine succinate rizatriptan benzoate rizatriptan benzoate odt Bromday olanzapine sumatriptan succinate Ilevro olanzapine odt Nevanac perphenazine sumatriptan succinate refill zolmitriptan Prolensa prochlorperazine zolmitriptan odt prochlorperazine edisylate CORTICOSTEROIDS/RELATED prochlorperazine maleate Isometheptene/Caffeine/Acetaminophe n quetiapine fumarate Sumatriptan Succinate dexamethasone sodium phosphate risperidone fluorometholone risperidone odt Relpax thioridazine HCL Effective April 1,

7 thiothixene trifluoperazine HCL Atrovent HFA Nasonex ziprasidone HCL Spiriva Handihaler Qnasl Spiriva Respimat Qnasl Childrens Abilify Tudorza Pressair Abilify Discmelt STEROID/BETA AGONIST Abilify Maintena ANTICHLNRGC/BETA AGONIST Latuda Advair Diskus Risperdal Consta ipratropium bromide/albuterol sulfate Advair HFA Seroquel XR Breo Ellipta Anoro Ellipta Dulera PSYCHOTHERAPEUTICS, MISC. Combivent Symbicort Combivent Respimat amphetamine/dextroamphetamine MISCELLANEOUS clonidine HCL ER BETA AGONISTS dexmethylphenidate HCL Dymista dexmethylphenidate HCL ER albuterol sulfate dextroamphetamine sulfate albuterol sulfate ER UROLOGICALS dextroamphetamine sulfate ER albuterol TAB 4MG guanfacine ER levalbuterol BENIGN PRSTATC HYPRPLSIA methamphetamine HCL levalbuterol HCL alfuzosin HCL ER methylphenidate hydrochloride terbutaline sulfate finasteride methylphenidate HCL tamsulosin HCL methylphenidate HCL CD Arcapta Neohaler methylphenidate HCL ER Foradil Aerolizer Rapaflo methylphenidate HCL SR Perforomist modafinil Proair HFA Methylphenidate HCL ER Serevent Diskus ERECTILE DYSFUNCTION Procentra Ventolin HFA Cialis Viagra Daytrana LEUKOTRIENE RCPTR ANTGNST Nuvigil URINARY ANTISPASMODICS Quillivant XR montelukast sodium Strattera zafirlukast bethanechol chloride Vyvanse flavoxate HCL PULMONARY CORTICOSTEROIDS oxybutynin chloride SNRI ANTIDEPRESSANTS oxybutynin chloride ER budesonide tolterodine tartrate duloxetine HCL tolterodine tartrate ER venlafaxine HCL Asmanex HFA trospium chloride venlafaxine HCL ER Asmanex Twisthaler 120 Metered trospium chloride ER Venlafaxine HCL ER Asmanex Twisthaler 14 Metered Gelnique Pristiq Myrbetriq Asmanex Twisthaler 30 Me Tered Oxytrol SSRI ANTIDEPRESSANTS Asmanex Twisthaler 30 Metered Oxytrol For Women Toviaz citalopram hydrobromide Asmanex Twisthaler 60 Metered Vesicare escitalopram oxalate fluoxetine DR Asmanex Twisthaler 7 Metered fluoxetine HCL Flovent Diskus Formulary Disclaimer: Coverage for some drugs may be fluvoxamine maleate Flovent HFA limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the fluvoxamine maleate ER Pulmicort applicable co-payment. The medications listed on this paroxetine HCL Pulmicort Flexhaler formulary are subject to change pursuant to the formulary paroxetine HCL ER Qvar management activities of Catamaran. The presence of a sertraline HCL medication on this formulary list does not guarantee coverage. To determine the most up-to-date formulary NASAL ANTIHISTAMINES status of your medication, please visit your member website RESPIRATORY or call member services at the number listed on your ID ANAPHYLAXIS TX AGENTS azelastine HCL card. olopatadine HCL Epinephrine Auvi-q NASAL CORTICOSTEROIDS Epipen 2-PAK budesonide Epipen-JR 2-PAK flunisolide fluticasone propionate ANTICHOLINERGICS triamcinolone acetonide Flunisolide ipratropium bromide Effective April 1, 2015 v.1 Catamaran All Rights Reserved. May not be copied or distributed without authorization. 5