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Performance Formulary
Introduction
Utilization Management
The Envision Pharmacy and Therapeutics Committee is
responsible for the development and maintenance of the
Performance Formulary. The Committee is comprised of
independent practicing physicians and pharmacists from a
wide variety of medical specialties. The Performance
Formulary is reviewed and updated from time to time as
new drugs or new prescribing information becomes
available. Factors which affect decisions regarding the
Performance Formulary include safe use, clinical efficacy,
and therapeutic need. Only after those factors are
assessed is cost considered. Compliance with the
Performance Formulary is important for improving quality
of care and restraining health care costs.
The Performance Formulary features a set of Utilization
Management protocols for certain drug categories. Within
these drug categories, there are clinically interchangeable
alternatives available with significant deviations in
economic value. In order to maintain the highest quality
care, Envision has selected the most clinically and
economically valuable agents in each class to be included
on the Performance Formulary. Please see the Utilization
Management section of the Performance Formulary to
reference the preferred agents within each drug category.
Certain agents within these categories may be considered
benefit exclusions, or may require the use of primary
treatment options prior to secondary treatment options.
How to Use the Performance Formulary
Prior Authorizations and Quantity Limits may be in place
for certain medications and will vary by plan. The
EnvisionRxOptions Performance Formulary is not all
inclusive and does not guarantee coverage of any
medication.
The Envision Performance Formulary is a reference tool for
identifying preferred medications within certain therapeutic
categories. Preferred brand medications are listed to help
identify products that are clinically appropriate and cost
effective. Generics within therapeutic categories are listed
for reference purposes.
•
Generics are listed in lowercase letters.
•
Brands are listed in UPPERCASE letters.
•
Non-Preferred products are listed with an [NP] symbol.
•
Specialty products are listed with an [SP] symbol.
New-to-Market Drugs
Any medication approved to enter the market will not be
covered under the Performance Formulary until a clinical
review and tier placement decision has been made by the
Envision Pharmacy and Therapeutics Committee. The
committee will review safety, efficacy and cost information
in order to determine coverage on a quarterly basis at
minimum. Please be aware that any new-to-market drug
which has not yet been reviewed by the Envision
Pharmacy and Therapeutics committee will be considered
an exclusion under your benefit plan.
Therapeutic Listing
ADHD/ANTINARCOLEPSY/ANTIOBESITY/ANOREXIANTS
*Amphetamines**
AmphetamineDextroamphetamine
*Stimulants - Misc.**
Dexmethylphenidate HCl
Methylphenidate HCl
NUVIGIL
ANALGESICS - ANTIINFLAMMATORY
Dextroamphetamine Sulfate
VYVANSE
*Anti-TNF-alpha - Monoclonal
Antibodies**
*Anorexiants NonAmphetamine**
HUMIRA [SP]
Phentermine HCl
*Attention-Deficit/Hyperactivity
Disorder (ADHD) Agents**
Naproxen
CELEBREX
Acetaminophen
*Salicylates**
*Pyrimidine Synthesis
Inhibitors**
Aspirin
ANALGESICS - OPIOID
*Opioid Agonists**
Leflunomide
*Soluble Tumor Necrosis
Factor Receptor Agents**
ENBREL [SP]
ANALGESICS - NonNarcotic
*Analgesic Combinations**
*Nonsteroidal Antiinflammatory Agents
(NSAIDs)**
Butalbital-AcetaminophenCaffeine
Ibuprofen
Meloxicam
Butalbital-Aspirin-Caffeine
*Analgesics Other**
INTUNIV
[NP] = Non-Preferred [SP] = Specialty
Morphine Sulfate
Oxycodone HCl
Tramadol HCl
NUCYNTA
NUCYNTA ER
OPANA ER
OXYCONTIN
*Opioid Combinations**
Acetaminophen w/ Codeine
January 2015
Hydrocodone-Acetaminophen
Oxycodone w/ Acetaminophen
*Opioid Partial Agonists**
Buprenorphine HCl
Buprenorphine HCl-Naloxone
HCl Dihydrate
BUTRANS
SUBOXONE
ANDROGENS-ANABOLIC
*Androgens**
Testosterone Cypionate
ANDROGEL
TESTIM
ANORECTAL AGENTS
*Rectal Combinations**
Hydrocortisone Acetate w/
Pramoxine
PROCTOFOAM
*Rectal Steroids**
Hydrocortisone (Rectal)
Hydrocortisone Acetate (Rectal)
ANTIANGINAL AGENTS
*Antianginals-Other**
RANEXA
*Nitrates**
Isosorbide Mononitrate
Nitroglycerin
ANTIANXIETY AGENTS
*Benzodiazepines**
Alprazolam
Diazepam
Lorazepam
ANTIARRHYTHMICS
*Antiarrhythmics Type I-C**
Flecainide Acetate
Propafenone HCl
*Antiarrhythmics Type III**
Amiodarone HCl
MULTAQ
TIKOSYN
ANTIASTHMATIC AND
BRONCHODILATOR AGENTS
*Bronchodilators Anticholinergics**
Ipratropium Bromide
ANORO
INCRUSE
SPIRIVA
*Leukotriene Modulators**
Montelukast Sodium
*Selective Phosphodiesterase
4 (PDE4) Inhibitors**
DALIRESP
*Steroid Inhalants**
Budesonide (Inhalation)
ASMANEX
FLOVENT
PULMICORT FLEXHALER
QVAR
*Sympathomimetics**
Albuterol Sulfate
Ipratropium-Albuterol
Levalbuterol HCl
ADVAIR DISKUS/HFA
BREO ELLIPTA
COMBIVENT RESPIMAT
FORADIL
PROAIR HFA
SEREVENT DISKUS
SYMBICORT
VENTOLIN HFA
ANTICOAGULANTS
*Coumarin Anticoagulants**
BRINTELLIX
VIIBRYD
*Sodium-Glucose CoTransporter 2 (SGLT2)
Inhibitors**
*Serotonin-Norepinephrine
Reuptake Inhibitors (SNRIs)**
FARXIGA
INVOKANA
*Sulfonylureas**
Duloxetine HCl
Venlafaxine HCl
FETZIMA
PRISTIQ
*Tricyclic Agents**
Amitriptyline HCl
Doxepin HCl
Nortriptyline HCl
ANTIDIABETICS
*Antidiabetic Combinations**
Enoxaparin Sodium
FRAGMIN
*Thrombin Inhibitors**
Glyburide-Metformin
Pioglitazone HCl-Metformin HCl
INVOKAMET
JANUMET
JANUMET XR
KAZANO [NP]
KOMBIGLYZE
OSENI [NP]
PRANDIMET
*Biguanides**
Metformin HCl
*Diabetic Other**
PRADAXA
ANTICONVULSANTS
GLUCAGEN
GLUCAGON
*Anticonvulsants Benzodiazepines**
*Dipeptidyl Peptidase-4 (DPP4) Inhibitors**
Clonazepam
*Anticonvulsants - Misc.**
JANUVIA
NESINA [NP]
ONGLYZA
Warfarin Sodium
*Direct Factor Xa Inhibitors**
XARELTO
*Heparins And Heparinoid-Like
Agents**
Gabapentin
Lamotrigine
Topiramate
LAMICTAL ODT
LYRICA
*Valproic Acid**
*Incretin Mimetic Agents (GLP1 Receptor Agonists)**
TANZEUM
VICTOZA
*Insulin Sensitizing Agents**
Divalproex Sodium
ANTIDEPRESSANTS
Pioglitazone HCl
*Insulin**
*Alpha-2 Receptor Antagonists
(Tetracyclics)**
APIDRA
LANTUS
LANTUS F
LEVEMIR
NOVOLIN
NOVOLIN MIX
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG MIX
*Meglitinide Analogues**
Mirtazapine
*Antidepressants - Misc.**
Bupropion HCl
*Selective Serotonin Reuptake
Inhibitors (SSRIs)**
Citalopram Hydrobromide
Escitalopram Oxalate
Sertraline HCl
*Serotonin Modulators**
Repaglinide
Trazodone HCl
[NP] = Non-Preferred [SP] = Specialty
Glimepiride
Glipizide
Glyburide
ANTIDIARRHEALS
*Antiperistaltic Agents**
Diphenoxylate w/ Atropine
Loperamide HCl
ANTIDOTES
*Opioid Antagonists**
Naltrexone HCl
ANTIEMETICS
*5-HT3 Receptor Antagonists**
Ondansetron
Ondansetron HCl
ANZEMET [SP]
*Antiemetics Anticholinergic**
Meclizine HCl
ANTIFUNGALS
*Antifungals**
Terbinafine HCl
*Imidazole-Related
Antifungals**
Fluconazole
Ketoconazole
ANTIHISTAMINES
*Antihistamines Ethanolamines**
Diphenhydramine HCl
*Antihistamines - NonSedating**
Cetirizine HCl
Levocetirizine Dihydrochloride
Loratadine
*Antihistamines Phenothiazines**
Promethazine HCl
*Antihistamines - Piperidines**
Cyproheptadine HCl
ANTIHYPERLIPIDEMICS
*Antihyperlipidemics - Misc.**
Omega-3-acid Ethyl Esters
VASCEPA
*Bile Acid Sequestrants**
Cholestyramine
Colestipol HCl
WELCHOL
*Fibric Acid Derivatives**
Choline Fenofibrate
Fenofibrate
January 2015
Gemfibrozil
LIPOFEN
*HMG CoA Reductase
Inhibitors**
Ropinirole Hydrochloride
*Antiparkinson Monoamine
Oxidase Inhibitors**
AZILECT
Atorvastatin Calcium
Pravastatin Sodium
Simvastatin
CRESTOR
LIVALO
ANTIPSYCHOTICS/ANTIMANIC
AGENTS
*Intestinal Cholesterol
Absorption Inhibitors**
Ziprasidone HCl
*Benzisoxazoles**
ZETIA
ANTIHYPERTENSIVES
*ACE Inhibitors**
Risperidone
*Butyrophenones**
Enalapril Maleate
Lisinopril
Ramipril
*Angiotensin II Receptor
Antagonists**
Irbesartan
Losartan Potassium
Telmisartan
BENICAR
*Antiadrenergic
Antihypertensives**
Clonidine HCl
Doxazosin Mesylate
Terazosin HCl
*Antihypertensive
Combinations**
AMTURNIDE
AZOR
BENICAR HCT
DIOVAN
EXFORGE HCT
TARKA
TEKAMLO
TEKTURNA HCT
TRIBENZOR
*Direct Renin Inhibitors**
Lisinopril & Hydrochlorothiazide
Losartan Potassium &
Hydrochlorothiazide
Valsartan-Hydrochlorothiazide
TEKTURNA
*Vasodilators**
Hydralazine HCl
ANTIPARKINSON AGENTS
*Antiparkinson
Anticholinergics**
Benztropine Mesylate
*Antiparkinson
Dopaminergics**
Carbidopa-Levodopa
Pramipexole Dihydrochloride
*Antimanic Agents**
Lithium Carbonate
*Antipsychotics - Misc.**
Haloperidol
Haloperidol Lactate
*Dibenzapines**
Metoprolol Succinate
Metoprolol Tartrate
*Beta Blockers NonSelective**
Nadolol
Propranolol HCl
Sotalol HCl
CALCIUM CHANNEL
BLOCKERS
*Calcium Channel Blockers**
Amlodipine Besylate
Diltiazem HCl Coated Beads
Nifedipine
CARDIOTONICS
*Cardiac Glycosides**
Digoxin
CARDIOVASCULAR AGENTS MISC.
Olanzapine
Quetiapine Fumarate
SEROQUEL XR
*Phenothiazines**
*Cardiovascular Agents Misc. Combinations**
Prochlorperazine
Prochlorperazine Maleate
*Quinolinone Derivatives**
*Impotence Agents**
ABILIFY
ANTIVIRALS
*CMV Agents**
Ganciclovir
*Hepatitis Agents**
Ribavirin [SP]
OLYSIO [SP]
PEGASYS [SP]
PEG-INTRON [SP]
SOVALDI [SP]
*Herpes Agents**
Acyclovir
Famciclovir
Valacyclovir HCl
ZOVIRAX
*ASSORTED CLASSES*
*Immunosuppressive Agents**
Azathioprine
Mycophenolate Mofetil [SP]
Tacrolimus
BETA BLOCKERS
*Alpha-Beta Blockers**
Carvedilol
Labetalol HCl
COREG CR
*Beta Blockers CardioSelective**
Atenolol
BYSTOLIC
*Beta Blockers CardioSelective**
Amlodipine Besylate-Atorvastatin
Calcium
LEVITRA
VIAGRA
*Pulmonary Hypertension Endothelin Receptor
Antagonists**
OPSUMIT [SP]
LETAIRIS [SP]
TRACLEER [SP]
CONTRACEPTIVES
*Combination Contraceptives Oral**
Norethin Acet & Estrad-Fe
Norgestimate-Ethinyl Estradiol
Norgestimate-Ethinyl Estradiol
(Triphasic)
BEYAZ
NATAZIA
ORTHO TRI CYCLEN LO
SAFYRAL
*Combination Contraceptives Transdermal**
Norelgestromin-Ethinyl Estradiol
*Combination Contraceptives Vaginal**
NUVARING
*Progestin Contraceptives Injectable**
Medroxyprogesterone Acetate
(Contraceptive)
*Progestin Contraceptives Oral**
Norethindrone (Contraceptive)
[NP] = Non-Preferred [SP] = Specialty
CORTICOSTEROIDS
*Glucocorticosteroids**
Dexamethasone
Methylprednisolone
Prednisone
UCERIS [NP]
*Mineralocorticoids**
Fludrocortisone Acetate
COUGH/COLD/ALLERGY
*Antitussives**
Benzonatate
Hydrocodone w/ Homatropine
*Cough/Cold/Allergy
Combinations**
Hydrocodone PolistirexChlorpheniramine Polistirex
Promethazine w/Codeine
Promethazine-DM
*Expectorants**
Guaifenesin
DERMATOLOGICALS
*Acne Products**
Clindamycin Phosphate (Topical)
Clindamycin Phosphate-Benzoyl
Peroxide
Tretinoin
ACANYA
ATRALIN
AZELEX
RETIN-A MICR GEL 0.08%
*Antibiotics - Topical**
Mupirocin
Mupirocin Calcium (Topical)
*Antifungals - Topical**
Clotrimazole w/ Betamethasone
Ketoconazole (Topical)
Nystatin (Topical)
MENTAX
*Anti-inflammatory Agents Topical**
FLECTOR
*Antineoplastic or
Premalignant Lesion Agents Topical**
Fluorouracil (Topical)
FLUOROPLEX
PICATO [NP]
*Antipsoriatics**
*Burn Products**
Silver Sulfadiazine
*Emollient/Keratolytic
Agents**
Urea
*Emollients**
Lactic Acid (Ammonium Lactate)
January 2015
*Immunomodulating Agents Topical**
*Hormone Receptor
Modulators**
Imiquimod
ZYCLARA [NP]
Raloxifene HCl
*Posterior Pituitary
Hormones**
Desmopressin Acetate [SP]
*Prolactin Inhibitors**
*Immunosuppressive Agents Topical**
ELIDEL
PROTOPIC
*Local Anesthetics - Topical**
Lidocaine-Prilocaine
*Misc. Topical**
Aluminum Chloride
DIAGNOSTIC PRODUCTS
*Diagnostic Tests**
BREEZE
CONTOUR
FREESTYLE
PRECISION
DIGESTIVE AIDS
*Digestive Enzymes**
CREON
SUCRAID
ZENPEP
DIURETICS
*Carbonic Anhydrase
Inhibitors**
Acetazolamide
*Diuretic Combinations**
Spironolactone &
Hydrochlorothiazide
Triamterene &
Hydrochlorothiazide
*Loop Diuretics**
Bumetanide
Furosemide
Torsemide
*Potassium Sparing
Diuretics**
Spironolactone
*Thiazides and Thiazide-Like
Diuretics**
Chlorthalidone
Hydrochlorothiazide
Metolazone
ENDOCRINE AND METABOLIC
AGENTS - MISC.
*Bone Density Regulators**
Alendronate Sodium
Ibandronate Sodium
ACTONEL 5MG, 30MG, 35MG
ATELVIA
*Fertility Regulators**
FOLLISTIM AQ [SP]
*Growth Hormones**
GENOTROPIN [SP]
NORDITROPIN [SP]
Cabergoline
ESTROGENS
*Estrogen Combinations**
Esterified Estrogens &
Methyltestosterone
Estradiol & Norethindrone
Acetate
CLIMARA PRO
COMBIPATCH
PREMPHASE
PREMPRO
*Estrogens**
Estradiol
MENEST
MENOSTAR
PREMARIN
VIVELLE-DOT
FLUOROQUINOLONES
*Fluoroquinolones**
Ciprofloxacin HCl
Levofloxacin
Moxifloxacin HCl
GASTROINTESTINAL AGENTS
- MISC.
*Gallstone Solubilizing
Agents**
Ursodiol
*Gastrointestinal Chloride
Channel Activators**
AMITIZA
*Gastrointestinal Stimulants**
Metoclopramide HCl
*Inflammatory Bowel Agents**
Sulfasalazine
APRISO
LIALDA
*Irritable Bowel Syndrome
(IBS) Agents**
LINZESS
LOTRONEX
*Intestinal Acidifiers**
Lactulose (Encephalopathy)
*Phosphate Binder Agents**
FOSRENOL
RENAGEL
RENVELA
GENITOURINARY AGENTS MISCELLANEOUS
*Alkalinizers**
Potassium Citrate (Alkalinizer)
*Prostatic Hypertrophy
Agents**
Alfuzosin HCl
Finasteride
Tamsulosin HCl
AVODART
JALYN
RAPAFLO
*Urinary Analgesics**
Phenazopyridine HCl
GOUT AGENTS
*Gout Agents**
Allopurinol
COLCRYS
ULORIC
HEMATOLOGICAL AGENTS MISC.
*Platelet Aggregation
Inhibitors**
Cilostazol
Clopidogrel Bisulfate
AGGRENOX
BRILINTA
EFFIENT
HEMATOPOIETIC AGENTS
*Folic Acid/Folates**
KRISTALOSE
*Stimulant Laxatives**
Bisacodyl
Sennosides
*Surfactant Laxatives**
Docusate Sodium
MACROLIDES
*Azithromycin**
Azithromycin
*Clarithromycin**
Clarithromycin
*Erythromycins**
Erythromycin Base
MEDICAL DEVICES
*Diabetic Supplies**
BREEZE
CONTOUR
FREESTYLE
PRECISION
*Parenteral Therapy Supplies**
Folic Acid
NOVOFINE
NOVOTWIST
ULTICARE LANCETS
ULTICARE PEN NEEDLES
ULTICARE SYRINGES
MIGRAINE PRODUCTS
*Migraine Combinations**
*Hematopoietic Growth
Factors**
Acetaminophen-IsomethepteneDichloralphenazone
EPOGEN [SP]
NEULASTA [SP]
NEUPOGEN [SP]
PROCRIT
HEMOSTATICS
*Hemostatics - Systemic**
TREXIMET
*Serotonin Agonists**
Tranexamic Acid
HYPNOTICS
*Barbiturate Hypnotics**
Phenobarbital
*Non-Barbiturate Hypnotics**
Eszopiclone
Temazepam
Zolpidem Tartrate
LAXATIVES
PEG 3350-KCl-Sod Bicarb-Sod
Chloride-Sod Sulfate
PEG 3350-Potassium ChlorideSod Bicarbonate-Sod Chloride
Sennosides-Docusate Sodium
*Laxative Combinations**
MOVIPREP
*Laxatives - Miscellaneous**
Lactulose
Polyethylene Glycol 3350
[NP] = Non-Preferred [SP] = Specialty
Rizatriptan Benzoate
Sumatriptan Succinate
Zolmitriptan
RELPAX
MOUTH/THROAT/DENTAL
AGENTS
*Anesthetics Topical Oral**
Lidocaine HCl (Mouth-Throat)
*Anti-infectives - Throat**
Clotrimazole
Nystatin (Mouth-Throat)
*Antiseptics - Mouth/Throat**
Chlorhexidine Gluconate (MouthThroat)
*Dental Products**
Sodium Fluoride (Dental)
*Steroids - Mouth/Throat**
Triamcinolone Acetonide
(Mouth)
MULTIVITAMINS
*Ped MV w/ Fluoride**
Pediatric Multivitamins w/Fl
*Prenatal Vitamins**
January 2015
Prenatal Vit w/ Ferrous
Fumarate-Folic Acid
RESTASIS
*Ophthalmics - Misc.**
PRENATE DHA
PRENATE ELITE
PRENATE ESSENTIAL
Azelastine HCl (Ophth)
Dorzolamide HCl
Ketorolac Tromethamine (Ophth)
ACUVAIL
ALOMIDE
AZOPT
LASTACAFT
NEVANAC
PATADAY
*Prostaglandins Ophthalmic**
Latanoprost
Travoprost
LUMIGAN
TRAVATAN Z
OTIC AGENTS
MUSCULOSKELETAL
THERAPY AGENTS
*Central Muscle Relaxants**
Carisoprodol
Cyclobenzaprine HCl
Tizanidine HCl
NASAL AGENTS - SYSTEMIC
AND TOPICAL
*Nasal Agent Cominations**
DYMISTA [NP]
*Nasal Antiallergy**
Azelastine HCl
*Nasal Anticholinergics**
Ipratropium Bromide (Nasal)
*Nasal Steroids**
Fluticasone Propionate (Nasal)
Triamcinolone Acetonide (Nasal)
NASONEX
QNASL
VERAMYST
OPHTHALMIC AGENTS
*Beta-blockers - Ophthalmic**
Dorzolamide HCl-Timolol
Maleate
Timolol Maleate (Ophth)
BETIMOL
BETOPTIC-S
COMBIGAN
*Cycloplegic Mydriatics**
Atropine Sulfate (Ophthalmic)
*Ophthalmic Adrenergic
Agents**
Brimonidine Tartrate
ALPHAGAN
*Ophthalmic Anti-infectives**
Erythromycin (Ophth)
Polymyxin B-Trimethoprim
Tobramycin (Ophth)
VIGAMOX
*Ophthalmic
Immunomodulators**
*Otic Anti-infectives**
Ofloxacin (Otic)
*Otic Combinations**
Antipyrine-Benzocaine
Neomycin-Polymyxin-HC (Otic)
CIPRO HC
CIPRODEX
PENICILLINS
*Aminopenicillins**
Amoxicillin
Ampicillin
*Natural Penicillins**
Penicillin V Potassium
*Penicillin Combinations**
Amoxicillin & Pot Clavulanate
*Penicillinase-Resistant
Penicillins**
Dicloxacillin Sodium
PROGESTINS
*Progestins**
Medroxyprogesterone Acetate
Norethindrone Acetate
Progesterone Micronized
MEGACE ES SUSP
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS MISC.
*Antidementia Agents**
Donepezil Hydrochloride
EXELON
NAMENDA
NAMENDA XR
*Fibromyalgia Agents**
SAVELLA
*Multiple Sclerosis Agents**
AVONEX [SP]
COPAXONE [SP]
TECFIDERA [SP]
*Smoking Deterrents**
Nicotine
CHANTIX
TETRACYCLINES
*Tetracyclines**
Doxycycline (Monohydrate)
Doxycycline Hyclate
Minocycline HCl
SOLODYN [NP]
THYROID AGENTS
*Antithyroid Agents**
Methimazole
*Thyroid Hormones**
Levothyroxine Sodium
Levoxyl
Liothyronine Sodium
SYNTHROID
ULCER DRUGS
*Antispasmodics**
Dicyclomine HCl
Glycopyrrolate
Hyoscyamine Sulfate
CANTIL
*H-2 Antagonists**
Cimetidine
Famotidine
Ranitidine HCl
*Misc. Anti-Ulcer**
Sucralfate
CARAFATE SUS
*Proton Pump Inhibitors**
NEXIUM
*Ulcer Drugs Prostaglandins**
Misoprostol
*Ulcer Therapy
Combinations**
Omeprazole-Sodium
Bicarbonate
URINARY ANTI-INFECTIVES
*Urinary Anti-infectives**
Nitrofurantoin Macrocrystal
Nitrofurantoin Monohyd Macro
URINARY ANTISPASMODICS
*Urinary Antispasmodic Antimuscarinics
(Anticholinergic)**
Oxybutynin Chloride
Tolterodine Tartrate
ENABLEX
VESICARE
*Urinary Antispasmodics Beta-3 Adrenergic Agonists**
MYRBETRIQ
VAGINAL PRODUCTS
*Vaginal Anti-infectives**
Metronidazole Vaginal
Terconazole Vaginal
AVC
*Vaginal Estrogens**
ESTRING
PREMARIN
PREMARIN VAGINAL CREAM
VAGIFEM
VASOPRESSORS
*Anaphylaxis Therapy
Agents**
AUVI-Q
EPIPEN
EPIPEN-JR
*Vasopressors**
Midodrine HCl
Lansoprazole
Omeprazole
Pantoprazole Sodium
DEXILANT
[NP] = Non-Preferred [SP] = Specialty
January 2015
Alphabetical Listing
AVONEX [SP]
Choline Fenofibrate
ABILIFY
Azathioprine
Cilostazol
ACANYA
Azelastine HCl
Cimetidine
Acetaminophen
Azelastine HCl (Ophth)
CIPRO HC
Acetaminophen w/ Codeine
AZELEX
CIPRODEX
Acetaminophen-IsomethepteneDichloralphenazone
AZILECT
Ciprofloxacin HCl
Azithromycin
Citalopram Hydrobromide
Acetazolamide
AZOPT
Clarithromycin
ACTONEL 5MG, 30MG, 35MG
AZOR
A
Dorzolamide HCl-Timolol
Maleate
Doxazosin Mesylate
Doxepin HCl
Doxycycline (Monohydrate)
Doxycycline Hyclate
Duloxetine HCl
DYMISTA [NP]
E
Acyclovir
BENICAR
ADVAIR DISKUS/HFA
BENICAR HCT
CLIMARA PRO
Clindamycin Phosphate
(Topical)
Clindamycin PhosphateBenzoyl Peroxide
AGGRENOX
Benzonatate
Clonazepam
Albuterol Sulfate
Benztropine Mesylate
Clonidine HCl
Alendronate Sodium
BETIMOL
Clopidogrel Bisulfate
Alfuzosin HCl
BETOPTIC-S
Clotrimazole
Allopurinol
BEYAZ
Clotrimazole w/ Betamethasone
ALOMIDE
Bisacodyl
COLCRYS
ALPHAGAN
BREEZE
Colestipol HCl
Alprazolam
BREO ELLIPTA
COMBIGAN
Aluminum Chloride
BRILINTA
COMBIPATCH
Amiodarone HCl
Brimonidine Tartrate
COMBIVENT RESPIMAT
AMITIZA
Esterified Estrogens &
Methyltestosterone
BRINTELLIX
CONTOUR
Amitriptyline HCl
Estradiol
Budesonide (Inhalation)
COPAXONE [SP]
Amlodipine Besylate
Bumetanide
COREG CR
Estradiol & Norethindrone
Acetate
Amlodipine BesylateAtorvastatin Calcium
Buprenorphine HCl
CREON
ESTRING
Amoxicillin
Buprenorphine HCl-Naloxone
HCl Dihydrate
CRESTOR
Eszopiclone
Amoxicillin & Pot Clavulanate
Cyclobenzaprine HCl
EXELON
Bupropion HCl
AmphetamineDextroamphetamine
Cyproheptadine HCl
EXFORGE HCT
Butalbital-AcetaminophenCaffeine
Ampicillin
Butalbital-Aspirin-Caffeine
ACUVAIL
AMTURNIDE
ANDROGEL
B
BUTRANS
BYSTOLIC
Antipyrine-Benzocaine
ANORO
ANZEMET [SP]
APIDRA
APRISO
ASMANEX
Aspirin
ATELVIA
Atenolol
Atorvastatin Calcium
ATRALIN
C
Cabergoline
CANTIL
CARAFATE SUS
Carbidopa-Levodopa
Carisoprodol
Carvedilol
CELEBREX
Cetirizine HCl
CHANTIX
Atropine Sulfate (Ophthalmic)
Chlorhexidine Gluconate
(Mouth-Throat)
AUVI-Q
Chlorthalidone
AVC
AVODART
Cholestyramine
EFFIENT
ELIDEL
ENABLEX
Enalapril Maleate
ENBREL [SP]
Enoxaparin Sodium
EPIPEN
EPIPEN-JR
EPOGEN [SP]
Erythromycin (Ophth)
Erythromycin Base
Escitalopram Oxalate
D
F
DALIRESP
Famciclovir
Desmopressin Acetate [SP]
Famotidine
Dexamethasone
FARXIGA
DEXILANT
Fenofibrate
Dexmethylphenidate HCl
FETZIMA
Dextroamphetamine Sulfate
Finasteride
Diazepam
Flecainide Acetate
Dicloxacillin Sodium
FLECTOR
Dicyclomine HCl
FLOVENT
Digoxin
Fluconazole
Diltiazem HCl Coated Beads
Fludrocortisone Acetate
DIOVAN
FLUOROPLEX
Diphenhydramine HCl
Fluorouracil (Topical)
Diphenoxylate w/ Atropine
Fluticasone Propionate (Nasal)
Divalproex Sodium
Folic Acid
Docusate Sodium
FOLLISTIM AQ [SP]
Donepezil Hydrochloride
FORADIL
Dorzolamide HCl
FOSRENOL
[NP] = Non-Preferred [SP] = Specialty
January 2015
FRAGMIN
KAZANO [NP]
FREESTYLE
Ketoconazole
Furosemide
Gabapentin
Ketoconazole (Topical)
Ketorolac Tromethamine
(Ophth)
KOMBIGLYZE
Ganciclovir
KRISTALOSE
G
Gemfibrozil
GENOTROPIN [SP]
L
GLUCAGEN
Labetalol HCl
Lactic Acid (Ammonium
Lactate)
Lactulose
GLUCAGON
Lactulose (Encephalopathy)
Glyburide
LAMICTAL ODT
Glyburide-Metformin
Lamotrigine
Glycopyrrolate
Lansoprazole
Guaifenesin
LANTUS
Glimepiride
Glipizide
H
LANTUS F
LASTACAFT
Haloperidol
Haloperidol Lactate
Latanoprost
Leflunomide
HUMIRA [SP]
Hydralazine HCl
Hydrochlorothiazide
Hydrocodone PolistirexChlorpheniramine Polistirex
LETAIRIS [SP]
Levalbuterol HCl
LEVEMIR
LEVITRA
Medroxyprogesterone Acetate
(Contraceptive)
Norethin Acet & Estrad-Fe
MEGACE ES SUSP
Norethindrone Acetate
Meloxicam
Norgestimate-Ethinyl Estradiol
MENEST
Norgestimate-Ethinyl Estradiol
(Triphasic)
MENOSTAR
Norethindrone (Contraceptive)
MENTAX
Nortriptyline HCl
Metformin HCl
NOVOFINE
Methimazole
NOVOLIN
Methylphenidate HCl
NOVOLIN MIX
Methylprednisolone
NOVOLIN N
Metoclopramide HCl
NOVOLIN R
Metolazone
NOVOLOG
Metoprolol Succinate
NOVOLOG MIX
Metoprolol Tartrate
NOVOTWIST
Metronidazole Vaginal
NUCYNTA
Midodrine HCl
NUCYNTA ER
Minocycline HCl
NUVARING
Mirtazapine
NUVIGIL
Misoprostol
Nystatin (Mouth-Throat)
Montelukast Sodium
Nystatin (Topical)
Morphine Sulfate
O
MOVIPREP
Ofloxacin (Otic)
Moxifloxacin HCl
Olanzapine
MULTAQ
OLYSIO [SP]
Mupirocin
Omega-3-acid Ethyl Esters
Mupirocin Calcium (Topical)
Omeprazole
Mycophenolate Mofetil [SP]
Omeprazole-Sodium
Bicarbonate
Hydrocodone w/ Homatropine
Levocetirizine Dihydrochloride
Hydrocodone-Acetaminophen
Levofloxacin
Hydrocortisone (Rectal)
Levothyroxine Sodium
Hydrocortisone Acetate (Rectal)
Levoxyl
Hydrocortisone Acetate w/
Pramoxine
LIALDA
Hyoscyamine Sulfate
Lidocaine-Prilocaine
Nadolol
Ondansetron HCl
LINZESS
Naltrexone HCl
ONGLYZA
Ibandronate Sodium
Liothyronine Sodium
NAMENDA
OPANA ER
Ibuprofen
LIPOFEN
NAMENDA XR
OPSUMIT [SP]
Imiquimod
Lisinopril
Naproxen
ORTHO TRI CYCLEN LO
INCRUSE
Lisinopril & Hydrochlorothiazide
NASONEX
OSENI [NP]
INTUNIV
Lithium Carbonate
NATAZIA
Oxybutynin Chloride
INVOKAMET
LIVALO
Neomycin-Polymyxin-HC (Otic)
Oxycodone HCl
INVOKANA
Loperamide HCl
NESINA [NP]
Oxycodone w/ Acetaminophen
Ipratropium Bromide
Loratadine
NEULASTA [SP]
OXYCONTIN
Ipratropium Bromide (Nasal)
Lorazepam
NEUPOGEN [SP]
Ipratropium-Albuterol
Losartan Potassium
NEVANAC
Pantoprazole Sodium
Irbesartan
Losartan Potassium &
Hydrochlorothiazide
NEXIUM
PATADAY
Nicotine
Pediatric Multivitamins w/Fl
LOTRONEX
Nifedipine
LUMIGAN
Nitrofurantoin Macrocrystal
PEG 3350-KCl-Sod Bicarb-Sod
Chloride-Sod Sulfate
LYRICA
Nitrofurantoin Monohyd Macro
I
Isosorbide Mononitrate
J
JALYN
MYRBETRIQ
JANUMET
M
JANUMET XR
Meclizine HCl
JANUVIA
K
N
Lidocaine HCl (Mouth-Throat)
Medroxyprogesterone Acetate
Nitroglycerin
NORDITROPIN [SP]
Norelgestromin-Ethinyl
Estradiol
[NP] = Non-Preferred [SP] = Specialty
Ondansetron
P
PEG 3350-Potassium ChlorideSod Bicarbonate-Sod Chloride
PEGASYS [SP]
PEG-INTRON [SP]
Penicillin V Potassium
January 2015
Phenazopyridine HCl
Phenobarbital
Phentermine HCl
PICATO [NP]
Q
QNASL
Sulfasalazine
Triamterene &
Hydrochlorothiazide
Quetiapine Fumarate
Sumatriptan Succinate
TRIBENZOR
QVAR
SYMBICORT
Pioglitazone HCl
Pioglitazone HCl-Metformin HCl
Sucralfate
R
U
SYNTHROID
UCERIS [NP]
T
Raloxifene HCl
ULORIC
Ramipril
Tacrolimus
ULTICARE LANCETS
RANEXA
Tamsulosin HCl
ULTICARE PEN NEEDLES
Ranitidine HCl
TANZEUM
ULTICARE SYRINGES
RAPAFLO
TARKA
Urea
RELPAX
TECFIDERA [SP]
Ursodiol
RENAGEL
TEKAMLO
RENVELA
TEKTURNA
VAGIFEM
Repaglinide
TEKTURNA HCT
Valacyclovir HCl
Valsartan-Hydrochlorothiazide
Temazepam
VASCEPA
Terazosin HCl
Venlafaxine HCl
PREMARIN
RESTASIS
RETIN-A MICR GEL 0.08%
Ribavirin [SP]
Risperidone
Telmisartan
Terbinafine HCl
VENTOLIN HFA
PREMARIN VAGINAL CREAM
Rizatriptan Benzoate
Terconazole Vaginal
VERAMYST
PREMPHASE
Ropinirole Hydrochloride
TESTIM
VESICARE
Testosterone Cypionate
VIAGRA
SAFYRAL
TIKOSYN
VICTOZA
SAVELLA
Timolol Maleate (Ophth)
VIGAMOX
Sennosides
Tizanidine HCl
VIIBRYD
Sennosides-Docusate Sodium
Tobramycin (Ophth)
VIVELLE-DOT
SEREVENT DISKUS
Tolterodine Tartrate
VYVANSE
SEROQUEL XR
Topiramate
Sertraline HCl
Torsemide
Warfarin Sodium
Silver Sulfadiazine
TRACLEER [SP]
WELCHOL
Simvastatin
Tramadol HCl
Sodium Fluoride (Dental)
Tranexamic Acid
SOLODYN [NP]
TRAVATAN Z
Sotalol HCl
Travoprost
Polyethylene Glycol 3350
Polymyxin B-Trimethoprim
Potassium Citrate (Alkalinizer)
PRADAXA
Pramipexole Dihydrochloride
PRANDIMET
Pravastatin Sodium
PRECISION
PRECISION
Prednisone
PREMARIN
S
PREMPRO
Prenatal Vit w/ Ferrous
Fumarate-Folic Acid
PRENATE DHA
PRENATE ELITE
PRENATE ESSENTIAL
PRISTIQ
PROAIR HFA
Prochlorperazine
Prochlorperazine Maleate
PROCRIT
PROCTOFOAM
Progesterone Micronized
Promethazine HCl
V
W
X
XARELTO
Z
SOVALDI [SP]
Trazodone HCl
ZENPEP
SPIRIVA
Tretinoin
ZETIA
Spironolactone
TREXIMET
Ziprasidone HCl
Spironolactone &
Hydrochlorothiazide
PROTOPIC
SUBOXONE
PULMICORT FLEXHALER
SUCRAID
Triamcinolone Acetonide
(Mouth)
Triamcinolone Acetonide
(Nasal)
Zolmitriptan
Propranolol HCl
Promethazine w/Codeine
Promethazine-DM
Propafenone HCl
[NP] = Non-Preferred [SP] = Specialty
Zolpidem Tartrate
ZOVIRAX
ZYCLARA [NP]
January 2015
Utilization Management
Drug Exclusions
Preferred products for each drug category are listed in the table below. Agents listed as an Excluded Product are
considered to be a benefit exclusion.
Drug Category
Acne
Androgens
Diabetes/Glucose Testing Supplies
Preferred Product
Amnesteem, Claravis, Myorisan, Zenatane
Absorica
Androgel, generic testosterone (Testim)
Androderm, Axiron, Fortesta
Breeze, Contour, FreeStyle, Precision
Accu-Chek, OneTouch
Novolog, Novolin
Humalog, Humulin
Victoza
Bydureon, Byetta
Oxybutynin, tolterodine, Vesicare
Toviaz
Insulin
Injectable Anti-diabetic
Overactive Bladder
Excluded Product
Step Therapies
The Primary Treatment option for each drug category is listed in the table below. Primary Treatment options should be
exhausted prior to prescribing for Secondary Treatment options.
Drug Category
Primary Treatment
Secondary Treatment
ADD/ADHD
Must try Vyvanse and a generic ADD/ADHD
medication prior to use of a secondary product
Daytrana, Focalin XR, Quillivant, Ritalin LA
Asthma
Must try Proair HFA or Ventolin HFA prior to
use of a secondary product
Proventil HFA, Xopenex HFA
Must try Janumet, Januvia, Kombiglyze or
Onglyza prior to use of a secondary product
Jentadueto, Tradjenta
Erectile Dysfunction*
Must try Viagra or Levitra prior to use of a
secondary product
Cialis (ED), Staxyn, Stendra
Growth Hormone
Must try Genotropin or Norditropin prior to
use of a secondary product
Humatrope, Nutropin AQ, Omnitrope, Saizen,
Tev-Tropin
Must try Apriso or Lialda prior to use of a
secondary product
Asacol HD, Delzicol, Pentasa
Must try Avonex, Copaxone, or Tecifidera
prior to use of a secondary product
Aubagio, Betaseron, Extavia, Gilenya, Rebif
Must try Suboxone Film prior to use of a
secondary product
Buprenorphine/naloxone, Zubsolv
Must try Enbrel and Humira prior to use of a
secondary product
Stelara, Simponi,Cimzia, Xeljanz, Actemra,
Orencia, Kineret
Must try Nuvigil prior to use of a secondary
product
Modafinil
Diabetes
Inflammatory Bowel Disease
Multiple Sclerosis
Opioid Abuse
Rheumatoid Arthritis
Stimulants
*Managed by Prior Authorization to assess indication
January 2015