Catamaran Essential Health Benefits PDL April 2015

Cefotetan
Cefotetan/Dextrose
Cefoxitin Sodium
Ceftazidime
Ceftazidime/Dextrose
Ceftriaxone IN Iso-osmotic Dextrose
Ceftriaxone/Dextrose
Cefuroxime Sodium
Cefuroxime/Dextrose
Cephalexin
April 2015
ESSENTIAL HEALTH BENEFITS
FORMULARY PREFERRED DRUG LIST
The Catamaran Preferred Drug List is a guide
identifying preferred brand-name medicines within
select therapeutic categories. The Preferred Drug
List may not include all drugs covered by your
prescription drug benefit. Generic medicines are
available within many of the therapeutic categories
listed, in addition to categories not listed, and should
be considered as the first line of prescribing.
GENERIC
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium ER
ampicillin
ampicillin sodium
ampicillin-sulbactam
dicloxacillin sodium
nafcillin sodium
oxacillin sodium
penicillin v potassium
penicillin G potassium
piperacillin sodium/ tazobactam
sodium
piperacillin sodium/tazobactam
sodium
piperacillin/tazobactam
Amoxicillin
Ampicillin
Ampicillin Sodium
Ampicillin-sulbactam
Nafcillin Sodium
Penicillin G Potassium IN Iso-osmotic
Dextrose
Penicillin G Procaine
Penicillin G Sodium
Pfizerpen-G
PREFERRED
Augmentin
ANTI-INFECTIVES
ANTIFUNGALS
QUINOLONES
GENERIC
ciprofloxacin
ciprofloxacin ER
ciprofloxacin HCL
ciprofloxacin I.V.-IN D5W
levofloxacin
levofloxacin IN D5W
moxifloxacin HCL
ofloxacin
Ciprofloxacin HCL
Ofloxacin
PREFERRED
Avelox
CEPHALOSPORINS
GENERIC
cefaclor
cefadroxil
cefazolin sodium
cefdinir
cefepime
cefotaxime sodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
cephalexin
tazicef
tazidime
Cefaclor
Cefaclor ER
Cefazolin Sodium
Cefazolin Sodium/Dextrose
Cefditoren Pivoxil
Cefepime
ANTI-INFLAMMATORY
NSAIDS
GENERIC
QL,PA
celecoxib
diclofenac potassium
diclofenac sodium DR
diclofenac sodium ER
diclofenac sodium/misoprostol
etodolac
etodolac ER
flurbiprofen
ibuprofen
indomethacin
indomethacin sodium
indomethacin ER
ketoprofen
QL
ketorolac tromethamine
mefenamic acid
meloxicam
nabumetone
naproxen
naproxen kit
naproxen sodium
naproxen sodium ER
naproxen DR
oxaprozin
piroxicam
sulindac
tolmetin sodium
Fenoprofen Calcium
Indomethacin
Ketoprofen ER
Ketorolac Tromethamine
Meclofenamate Sodium
Meloxicam
Tolmetin Sodium
PENICILLINS
For benefit coverage or restrictions please check
your benefit plan document(s). This listing is revised
periodically as new drugs and new prescribing
information becomes available. It is recommended
that you bring this list of medications when you or a
covered family member sees a physician or other
healthcare provider.
GENERIC
bio-statin
fluconazole
fluconazole IN dextrose
fluconazole IN NACL
flucytosine
griseofulvin microsize
griseofulvin ultramicrosize
PA
itraconazole
ketoconazole
nystatin
QL
terbinafine HCL
voriconazole
Amphotericin B
Fluconazole IN NACL
PREFERRED
Lamisil
Noxafil
PA
Sporanox
Minocin
Tetracycline HCL
CARDIOVASCULAR
ACE-INHIBITORS
GENERIC
benazepril HCL
captopril
enalapril maleate
enalaprilat
fosinopril sodium
lisinopril
moexipril HCL
perindopril erbumine
quinapril HCL
ramipril
trandolapril
ANGIOTENSIN RCPTR BLOCKER
GENERIC
PA,ST
candesartan cilexetil
eprosartan mesylate
irbesartan
losartan potassium
telmisartan
valsartan
PREFERRED
Benicar
TETRACYCLINES
GENERIC
avidoxy
demeclocycline HCL
doxy 100
doxycycline
doxycycline hyclate
doxycycline hyclate DR
doxycycline monohydrate
minocycline HCL
minocycline HCL ER
morgidox 1X100MG
morgidox 2X100MG
BETA BLOCKERS
GENERIC
acebutolol HCL
Effective April 1, 2015 v.2
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
©Catamaran 2015. All Rights Reserved. May not be copied or distributed without authorization.
1
atenolol
betaxolol HCL
bisoprolol fumarate
esmolol HCL
metoprolol succinate ER
metoprolol tartrate
nadolol
pindolol
propranolol HCL
propranolol HCL ER
sorine
sotalol HCL
sotalol HCL (AF)
Propranolol HCL
Timolol Maleate
PREFERRED
Bystolic
PREFERRED
Dilatrate SR
Nitro-bid
Nitrostat
ANTI-HTN COMBINATIONS
GENERIC
amlodipine besylate/benazepril
hydrochloride
amlodipine besylate/benazepril HCL
amlodipine besylate/valsartan
amlodipine/valsartan/hctz
atenolol/chlorthalidone
benazepril HCL/hydrochlorothiazide
bisoprolol
fumarate/hydrochlorothiazide
candesartan
cilexetil/hydrochlorothiazide
enalapril maleate/hydrochlorothiazide
fosinopril sodium/hydrochlorothiazide
irbesartan/hydrochlorothiazide
lisinopril/hydrochlorothiazide
losartan
potassium/hydrochlorothiazide
metoprolol/hydrochlorothiazide
moexipril/hydrochlorothiazide
nadolol/bendroflumethiazide
quinapril/hydrochlorothiazide
telmisartan/amlodipine
telmisartan/hydrochloroth
telmisartan/hydrochlorothiazide
trandolapril/verapamil HCL
trandolapril/verapamil HCL ER
valsartan/hydrochlorothiazide
Captopril/Hydrochlorothiazide
Methyldopa/Hydrochlorothiazide
Propranolol/Hydrochlorothiazide
PREFERRED
Amturnide
Azor
Benicar HCT
Tekamlo
Tekturna HCT
Tribenzor
CALCIUM CHANNEL BLOCKERS
GENERIC
afeditab CR
amlodipine besylate
cartia XT
dilt-CD
dilt-XR
diltiazem CD
diltiazem HCL
diltiazem HCL CD
diltiazem HCL ER
diltzac
felodipine ER
isradipine
matzim LA
nicardipine HCL
nifediac CC
nifedical XL
nifedipine
nifedipine ER
nimodipine
nisoldipine
taztia XT
verapamil HCL
verapamil HCL ER
verapamil HCL SR
Diltiazem HCL
Nisoldipine
Nisoldipine ER
Verapamil HCL
ANTIHYPERLIPIDEMICS
STATINS
GENERIC
atorvastatin calcium
fluvastatin
lovastatin
pravastatin sodium
simvastatin
PREFERRED
Crestor
NITRATES & NITRITES
GENERIC
isoditrate ER
isosorbide dinitrate
isosorbide dinitrate ER
isosorbide mononitrate
isosorbide mononitrate ER
minitran
nitro-time
nitroglycerin
nitroglycerin lingual
nitroglycerin transdermal
nitroglycerin ER
nitroglycerin IN dextrose 5%
nitroglycerin IN 5% dextrose
Isosorbide Dinitrate
Nitroglycerin
Nitroglycerin IN Dextrose 5%
Nitroglycerin Lingual
FIBRATES
GENERIC
fenofibrate
fenofibrate micronized
fenofibric acid DR
gemfibrozil
Fenofibric Acid
PREFERRED
Fenofibrate
Lipofen
BILE ACID SEQUESTRANTS
GENERIC
cholestyramine
cholestyramine light
colestipol HCL
colestipol HCL for oral suspension
micronized colestipol HCL
prevalite
PREFERRED
Welchol
CHOLEST ABS INHBTR/COMBO
PREFERRED
Liptruzet
Vytorin
Zetia
NIACIN/COMBINATIONS
GENERIC
niacin ER
Niacor
PREFERRED
Simcor
OMEGA-3 FATTY ACIDS
GENERIC
omega-3-acid ethyl esters
PREFERRED
Vascepa
DERMATOLOGICALS
ACNE
GENERIC
adapalene
amnesteem
avar cleanser
avar-e emollient
avar-e green
avita
benzepro
benzepro creamy wash
benzepro foaming cloths
benzepro SHORT contact
benziq wash
benzoyl peroxide
benzoyl peroxide wash acne treatment
pack
benzoyl peroxide SHORT contact
bp cleansing wash
bp foam
bp foaming wash
bp wash
bp 10-1
bpo 6% foaming cloths
cerisa wash
claravis
claris clarifying wash
clearplex x
clindacin etz pledgets
clindacin-p
clindamax
clindamycin phosphate
clindamycin/benzoyl peroxide
ery
erythromycin
erythromycin/benzoyl peroxide
lavoclen-4 acne wash kit
lavoclen-8 acne wash kit
metronidazole
myorisan
neuac
oscion cleanser
pr benzoyl peroxide wash
prascion
prascion fc
rosadan
rosanil cleanser
rosula
se bpo wash
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
2
se 10-5 ss
sodium sulfacetamide
sodium sulfacetamide/sulfur
sodium sulfacetamide/sulfur cleanser
sodium sulfacetamide/sulfur cleansing
cloths
sodium sulfacetamide/sulfur green
sodium sulfacetamide/sulfur
w/sunscreen
sodium sulfacetamide/sulfur wash
ss 10-2
sss 10-5
sss 10%-5%
sulfacetamide sodium
sulfacetamide sodium/sulfur cleanser
sulfacleanse 8/4
tretinoin
tretinoin microsphere
tretinoin microsphere P.M.
virti-sulf
zenatane
zencia
Bpo
Bpo 3% Foaming Cloths
Bpo 9% Foaming Cloths
Claravis
Doxycycline
Lavoclen-4 Creamy Wash
Lavoclen-8 Creamy Wash
Sodium Sulfacetamide/Sulfur
Sodium Sulfacetamide/Sulfur Cleanser
IN Urea
Sodium Sulfacetamide/Sulfur IN Urea
Zaclir Cleansing
Zenatane
PREFERRED
Acanya
Atralin
Differin
Epiduo
Finacea
Oracea
Ziana
halobetasol propionate
halonate PAC
hydrocortisone
hydrocortisone acetate/aloe
hydrocortisone acetate/pramoxine
hydrocortisone butyrate
hydrocortisone butyrate (lipid)
hydrocortisone butyrate (lipophilic)
hydrocortisone valerate
hydrocortisone IN absorbase
lokara
mometasone furoate
prednicarbate
scalacort
triamcinolone acetonide
triderm
Amcinonide
Apexicon E
Desoximetasone
Diflorasone Diacetate
Synalar
Triamcinolone Acetonide
Trianex
U-cort
PREFERRED
Pramosone
Pramosone E
QL,PA
Taclonex
Tucks Anti-itch
ENDOCRINE
CONTRACEPTIVE AGENTS
TOPICAL ANTI-INFLAMMATORY
GENERIC
ala cort
alclometasone dipropionate
alphatrex
apexicon
augmented betamethasone
dipropionate
betamethasone dipropionate
betamethasone valerate
calcipotriene/betamethasone
QL,PA
dipropionate
clobetasol propionate
clobetasol propionate e
clobetasol propionate emollient
clodan
cormax scalp application
desonide
desoximetasone
diflorasone diacetate
fluocinolone acetonide
fluocinolone acetonide body
fluocinolone acetonide scalp
fluocinonide
fluocinonide-e
fluticasone propionate
GENERIC
Amethyst
Necon 1/50-28
Necon 10/11-28
Zovia 1/50e
PREVENTIVE
altavera
alyacen 1/35
alyacen 7/7/7
QL
amethia
QL
amethia LO
apri
aranelle
QL
ashlyna
aubra
aviane
azurette
balziva
briellyn
camila
QL
camrese
QL
camrese LO
caziant
cesia
chateal
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
dasetta 1/35
dasetta 7/7/7
QL
daysee
deblitane
delyla
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol
elinest
emoquette
enpresse-28
enskyce
errin
estarylla
falmina
gianvi
gildagia
gildess FE 1.5/30
gildess FE 1/20
gildess 1.5/30
gildess 1/20
gildess 24 FE
heather
QL
introvale
jencycla
QL
jolessa
jolivette
junel FE 1.5/30
junel FE 1/20
junel 1.5/30
junel 1/20
kariva
kelnor 1/35
kurvelo
larin FE 1.5/30
larin FE 1/20
larin 1.5/30
larin 1/20
leena
lessina
levonest
levonorgestrel
QL
levonorgestrel and ethinyl estradiol
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
lomedia 24 FE
loryna
low-ogestrel
lutera
lyza
marlissa
QL
medroxyprogesterone acetate
microgestin FE
microgestin FE 1.5/30
microgestin 1.5/30
microgestin 1/20
mono-linyah
mononessa
my way
myzilra
necon 0.5/35-28
necon 1/35
necon 7/7/7
next choice one dose
nikki
nora-be
norethindrone
norethindrone acetate/ethinyl
estradiol
norethindrone acetate/ethinyl
estradiol/ferrous fumarate
norgestimate/ethinyl estradiol
norlyroc
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
ocella
orsythia
philith
pimtrea
pirmella 1/35
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
3
pirmella 7/7/7
portia-28
previfem
QL
quasense
reclipsen
sharobel
solia
sprintec 28
sronyx
syeda
tarina FE 1/20
tilia FE
tri-estarylla
tri-legest FE
tri-linyah
tri-previfem
tri-sprintec
trinessa
trivora-28
velivet
vestura
viorele
vyfemla
wera
wymzya FE
xulane
zarah
zenchent
zenchent FE
zovia 1/35e
Ogestrel
PREFERRED
Beyaz
Depo-provera
LO Loestrin FE
Minastrin 24 FE
Safyral
PREVENTIVE
Natazia
QL
Nuvaring
ESTROGENS/COMBINATIONS
GENERIC
covaryx
covaryx HS
eemt
eemt HS
esterified
estrogens/methltestosterone
esterified
estrogens/methyltestosterone
esterified estrogens/methyltestosterone
DS
esterified estrogens/methyltestosterone
HS
estradiol
estradiol valerate
estradiol/norethindrone acetate
estropipate
lopreeza
mimvey
mimvey LO
ortho-est
Estropipate
Jinteli
PREFERRED
Cenestin
Combipatch
Enjuvia
Estrace
QL
Estring
Evamist
Minivelle
Premarin
Premphase
Prempro
Vagifem
TESTOSTERONE AGENTS
GENERIC
danazol
PA
testosterone cypionate
PA
testosterone enanthate
PA,ST
Testosterone
PA,ST
Testosterone P.M.
PREFERRED
Androgel
Androgel P.M.
Androxy
Axiron
Methitest
INSULIN
PREFERRED
Lantus
Lantus Solostar
Novolin N
Novolin N Relion
Novolin R
Novolin R Relion
Novolin 70/30
Novolin 70/30 Relion
Novolog
Novolog Flexpen
Novolog Mix 70/30
Novolog Mix 70/30 Prefilled Flexpen
Novolog Penfill
NON-INSULIN HYPOGLYCEMICS
BIGUANIDES
GENERIC
metformin HCL
metformin HCL ER
PREFERRED
Riomet
BIGUAN/SULFONYLUREA COMB.
GENERIC
glipizide/metformin HCL
glyburide/metformin HCL
BIGUAN/THIAZOLIDEINEDIONE
GENERIC
pioglitazone HCL
pioglitazone HCL/metformin HCL
PREFERRED
Actoplus Met XR
DPP-4 INHIBITORS
PREFERRED
Januvia
Onglyza
BIGUANIDE/DPP-4 COMB.
PREFERRED
Janumet
Janumet XR
Kombiglyze XR
SULFONYLUREAS
GENERIC
glimepiride
glipizide
glipizide ER
glipizide XL
glyburide
glyburide micronized
tolazamide
Chlorpropamide
Glyburide
Tolazamide
Tolbutamide
SULFONYLUREA/TZD COMB.
GENERIC
pioglitazone HCL-glimepiride
INCRETINS
PREFERRED
Bydureon
Byetta
Victoza
AMYLIN ANALOGS
PREFERRED
PA
Symlinpen 120
PA
Symlinpen 60
DIABETIC OTHER
PREFERRED
Glucagen
Glucagen Hypokit
Glucagon Emergency Kit
PA
Invokana
Proglycem
GASTROINTESTINAL
PROTON PUMP INHIBITORS
GENERIC
QL
esomeprazole magnesium
esomeprazole sodium
QL
lansoprazole
QL
omeprazole
QL
pantoprazole sodium
QL,PA,ST
rabeprazole sodium
Esomeprazole Sodium
PREFERRED
QL
Nexium
ULCER DRUGS
GENERIC
cimetidine
cimetidine HCL
famotidine
goodsense acid reducer
misoprostol
nizatidine
ranitidine HCL
sucralfate
Famotidine
Famotidine Premixed
PREFERRED
Carafate
NEUROLOGICALS
ALZHEIMER'S DISEASE
GENERIC
donepezil HCL
galantamine
galantamine hydrobromide
rivastigmine tartrate
Galantamine Hydrobromide
PREFERRED
Exelon
Namenda
Namenda Titration PAK
QL
Namenda XR
QL
Namenda XR Titration Pack
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
4
ANTICONVULSANTS
GENERIC
carbamazepine
carbamazepine ER
clonazepam
clonazepam odt
divalproex sodium
divalproex sodium DR
divalproex sodium ER
epitol
ethosuximide
felbamate
fosphenytoin sodium
gabapentin
lamotrigine
lamotrigine odt
lamotrigine ER
levetiracetam
levetiracetam ER
oxcarbazepine
phenytoin
phenytoin infatabs
phenytoin sodium
phenytoin sodium extended
primidone
tiagabine hydrochloride
topiragen
topiramate
valproate sodium
valproic acid
zonisamide
Levetiracetam
PREFERRED
Banzel
Celontin
Diazepam
Dilantin
Fycompa
Gabitril
QL
Lyrica
Onfi
Peganone
Potiga
Tegretol-XR
Vimpat
GENERIC
azelastine HCL
cromolyn sodium
epinastine HCL
PREFERRED
Bepreve
Pataday
Patanol
Pazeo
ANTI-GLAUCOMA AGENTS
GENERIC
apraclonidine
betaxolol HCL
brimonidine tartrate
carteolol HCL
dorzolamide HCL
dorzolamide HCL/timolol maleate
QL
latanoprost
levobunolol HCL
timolol maleate
timolol maleate ophthalmic gel
forming
Istalol
Levobunolol HCL
Metipranolol
PREFERRED
Alphagan P
Combigan
QL
Lumigan
QL
Travatan Z
QL
Travoprost
MIOTICS
GENERIC
pilocarpine HCL
PREFERRED
Phospholine Iodide
Pilopine HS
MISCELLANEOUS
PREFERRED
QL,PA
Restasis
OSTEOPOROSIS
BISPHOSPHONATES
GENERIC
alendronate sodium
QL
ibandronate sodium
QL,PA,ST
risedronate sodium
Alendronate Sodium
Etidronate Disodium
PREFERRED
QL
Fosamax Plus D
ANTI-INFECTIVES
GENERIC
ciprofloxacin HCL
erythromycin
garamycin
gatifloxacin
gentak
gentamicin sulfate
ilotycin
levofloxacin
ofloxacin
romycin
tobramycin sulfate
Bacitracin
PREFERRED
Besivance
Moxeza
Vigamox
MIGRAINE/HEADACHE
GENERIC
dihydroergotamine mesylate
isometheptene
mucate/caffeine/acetaminophen
isometheptene/dichloralphenazone/ace
taminophen
migragesic ida
QL
naratriptan HCL
nodolor
QL
rizatriptan benzoate
QL
rizatriptan benzoate odt
QL
sumatriptan succinate
QL
sumatriptan succinate refill
QL
zolmitriptan
QL
zolmitriptan odt
QL
Dihydroergotamine Mesylate
Isometheptene/Caffeine/Acetaminophe
n
Migralam
QL
Sumatriptan
QL
Sumatriptan Succinate
PREFERRED
QL
Relpax
neo-polycin HC
neomycin/polymyxin/bacitracin/hydroco
rtisone
neomycin/polymyxin/dexamethasone
poly-dex
prednisolone acetate
sulfacetamide sodium/prednisolone
sodium phosphate
tobramycin/dexamethasone
Neomycin/Polymyxin/Hydrocortisone
Prednisolone Sodium Phosphate
PREFERRED
Alrex
FML
Lotemax
Pred Mild
Retisert
Tobradex
Tobradex ST
Zylet
OPHTHALMICS
ANTI-ALLERGIC AGENTS
ANTI-INFLAMMATORY AGENTS
GENERIC
bromfenac
cromolyn sodium
diclofenac sodium
flurbiprofen sodium
ketorolac tromethamine
PREFERRED
QL
Ilevro
QL
Nevanac
QL
Prolensa
CORTICOSTEROIDS/RELATED
GENERIC
dexamethasone sodium phosphate
fluorometholone
SERM
GENERIC
raloxifene hydrochloride
PSYCHOTHERAPEUTICS
ATYPICAL ANTIPSYCHOTICS
GENERIC
chlorpromazine HCL
QL
clozapine
compazine
compro
fluphenazine decanoate
fluphenazine HCL
haloperidol
haloperidol decanoate
haloperidol lactate
lithium carbonate
lithium carbonate ER
loxapine
loxapine succinate
QL
olanzapine
QL
olanzapine odt
perphenazine
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
QL
quetiapine fumarate
Effective April 1, 2015
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
5
QL
risperidone
QL
risperidone odt
QL
risperidone M-TAB
thioridazine HCL
thiothixene
trifluoperazine HCL
QL
ziprasidone HCL
Chlorpromazine HCL
QL
Clozapine Odt
Fluphenazine HCL
Lithium
Lithium Carbonate
PREFERRED
QL
Abilify
QL
Abilify Discmelt
Abilify Maintena
QL
Latuda
Risperdal Consta
QL
Seroquel XR
PSYCHOTHERAPEUTICS, MISC.
GENERIC
QL
amphetamine/dextroamphetamine
clonidine HCL ER
QL
dexedrine
QL
dexmethylphenidate HCL
QL
dexmethylphenidate HCL ER
QL
dextroamphetamine sulfate
QL
dextroamphetamine sulfate ER
guanfacine ER
QL
metadate ER
QL
methamphetamine HCL
methylphenidate hydrochloride
QL
methylphenidate HCL
QL
methylphenidate HCL CD
QL
methylphenidate HCL ER
QL
methylphenidate HCL SR
QL,PA
modafinil
QL
zenzedi
QL
Methylphenidate HCL ER
QL
Procentra
PREFERRED
QL
Daytrana
QL,PA
Nuvigil
QL
Quillivant XR
QL
Strattera
QL
Vyvanse
SNRI ANTIDEPRESSANTS
GENERIC
QL
duloxetine HCL
QL
venlafaxine HCL
QL
venlafaxine HCL ER
QL
Desvenlafaxine ER
Venlafaxine HCL ER
PREFERRED
QL
Pristiq
Fluoxetine HCL
NASAL ANTIHISTAMINES
GENERIC
QL
azelastine HCL
QL
olopatadine HCL
RESPIRATORY
ANAPHYLAXIS TX AGENTS
GENERIC
Epinephrine
PREFERRED
Auvi-q
Epipen 2-PAK
Epipen-JR 2-PAK
NASAL CORTICOSTEROIDS
GENERIC
QL,PA,ST
budesonide
QL
flunisolide
QL
fluticasone propionate
QL
triamcinolone acetonide
QL
Flunisolide
PREFERRED
QL
Nasonex
ANTICHOLINERGICS
GENERIC
QL
ipratropium bromide
PREFERRED
QL
Atrovent HFA
QL
Spiriva Handihaler
QL
Spiriva Respimat
QL
Tudorza Pressair
ANTICHLNRGC/BETA AGONIST
GENERIC
ipratropium bromide/albuterol
QL
sulfate
PREFERRED
Combivent
QL
Combivent Respimat
STEROID/BETA AGONIST
PREFERRED
QL
Dulera
QL
Symbicort
MISCELLANEOUS
PREFERRED
QL
Dymista
UROLOGICALS
BENIGN PRSTATC HYPRPLSIA
GENERIC
alfuzosin HCL ER
finasteride
tamsulosin HCL
PREFERRED
Rapaflo
BETA AGONISTS
GENERIC
albuterol sulfate
albuterol sulfate ER
albuterol TAB 4MG
QL
levalbuterol
QL
levalbuterol HCL
terbutaline sulfate
Metaproterenol Sulfate
PREFERRED
QL
Arcapta Neohaler
QL
Foradil Aerolizer
QL
Perforomist
QL
Proair HFA
QL
Serevent Diskus
ERECTILE DYSFUNCTION
PREFERRED
QL
Cialis
QL
Viagra
URINARY ANTISPASMODICS
GENERIC
bethanechol chloride
flavoxate HCL
oxybutynin chloride
oxybutynin chloride ER
tolterodine tartrate
tolterodine tartrate ER
trospium chloride
trospium chloride ER
PREFERRED
Gelnique
Myrbetriq
QL
Oxytrol
QL
Oxytrol For Women
Toviaz
Vesicare
LEUKOTRIENE RCPTR ANTGNST
GENERIC
montelukast sodium
PA
zafirlukast
PULMONARY CORTICOSTEROIDS
SSRI ANTIDEPRESSANTS
GENERIC
citalopram hydrobromide
escitalopram oxalate
QL
fluoxetine DR
fluoxetine HCL
fluvoxamine maleate
QL
fluvoxamine maleate ER
paroxetine HCL
paroxetine HCL ER
sertraline HCL
GENERIC
budesonide
PREFERRED
QL
Asmanex HFA
Asmanex Twisthaler 120 Metered
QL
Doses
Asmanex Twisthaler 14 Metered
QL
Doses
Asmanex Twisthaler 30 Me Tered
QL
Doses
Asmanex Twisthaler 30 Metered
QL
Doses
Asmanex Twisthaler 60 Metered
QL
Doses
Asmanex Twisthaler 7 Metered
QL
Doses
QL
Pulmicort
QL
Pulmicort Flexhaler
QL
Qvar
Formulary Disclaimer: Coverage for some drugs may be
limited to specific dosage forms and/or strengths. The
benefit design determines what is covered and the
applicable co-payment. The medications listed on this
formulary are subject to change pursuant to the formulary
management activities of Catamaran. The presence of a
medication on this formulary list does not guarantee
coverage. To determine the most up-to-date formulary
status of your medication, please visit your member website
or call member services at the number listed on your ID
card.
Effective April 1, 2015 v.2
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits;
©Catamaran 2015. All Rights Reserved. May not be copied or distributed without authorization.
6