Effective April 1, 2015 v.2 ©Catamaran 2015. All Rights Reserved
oxacillin sodium penicillin v potassium penicillin G potassium piperacillin sodium/ tazobactam sodium piperacillin sodium/tazobactam sodium piperacillin/tazobactam PREFERRED Augmentin April 2015 VALUE 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. QUINOLONES GENERIC ciprofloxacin ciprofloxacin ER ciprofloxacin HCL ciprofloxacin I.V.-IN D5W levofloxacin levofloxacin IN D5W moxifloxacin HCL ofloxacin Ciprofloxacin HCL Ofloxacin PREFERRED Avelox 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. ANTI-INFECTIVES ANTIFUNGALS GENERIC fluconazole fluconazole IN dextrose fluconazole IN NACL flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole nystatin terbinafine HCL voriconazole PREFERRED Lamisil Noxafil Sporanox CEPHALOSPORINS GENERIC cefaclor cefadroxil cefazolin sodium cefdinir cefepime cefotaxime sodium cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime ceftriaxone sodium cefuroxime axetil cefuroxime sodium cephalexin PENICILLINS GENERIC amoxicillin amoxicillin/clavulanate potassium amoxicillin/clavulanate potassium ER ampicillin ampicillin sodium ampicillin-sulbactam dicloxacillin sodium nafcillin sodium TETRACYCLINES GENERIC demeclocycline HCL doxycycline doxycycline hyclate doxycycline hyclate DR doxycycline monohydrate minocycline HCL minocycline HCL ER Tetracycline HCL ANTI-INFLAMMATORY NSAIDS GENERIC celecoxib diclofenac potassium diclofenac sodium DR diclofenac sodium ER diclofenac sodium/misoprostol etodolac etodolac ER flurbiprofen ibuprofen indomethacin indomethacin sodium indomethacin ER ketoprofen ketorolac tromethamine mefenamic acid meloxicam nabumetone naproxen naproxen sodium naproxen sodium ER oxaprozin piroxicam sulindac tolmetin sodium Meclofenamate Sodium Tolmetin Sodium PREFERRED Zorvolex PREFERRED Cimzia Cimzia Starter Kit Humira Humira Pediatric Crohns Disease Starter Pack Humira Pen Humira Pen-crohns Diseasestarter Humira Pen-psoriasis Starter 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 candesartan cilexetil eprosartan mesylate irbesartan losartan potassium telmisartan valsartan PREFERRED Benicar BETA BLOCKERS GENERIC acebutolol HCL atenolol betaxolol HCL bisoprolol fumarate esmolol HCL metoprolol succinate ER metoprolol tartrate nadolol pindolol propranolol HCL propranolol HCL ER sotalol HCL sotalol HCL (AF) PREFERRED Bystolic CALCIUM CHANNEL BLOCKERS AUTO-IMMUNE GENERIC amlodipine besylate diltiazem CD diltiazem HCL diltiazem HCL ER felodipine ER isradipine nicardipine HCL nifedipine nifedipine ER nimodipine nisoldipine verapamil HCL verapamil HCL ER Effective April 1, 2015 v.2 ©Catamaran 2015. All Rights Reserved. May not be copied or distributed without authorization. 1 verapamil HCL SR Verapamil HCL NITRATES & NITRITES GENERIC isosorbide dinitrate isosorbide dinitrate ER isosorbide mononitrate isosorbide mononitrate ER nitroglycerin nitroglycerin lingual nitroglycerin transdermal nitroglycerin IN dextrose 5% nitroglycerin IN 5% dextrose Isosorbide Dinitrate Nitroglycerin Lingual 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 PREFERRED Amturnide Azor Benicar HCT Tekamlo Tekturna HCT Tribenzor ANTIHYPERLIPIDEMICS STATINS GENERIC atorvastatin calcium fluvastatin lovastatin pravastatin sodium simvastatin PREFERRED Crestor FIBRATES GENERIC fenofibrate fenofibrate micronized fenofibric acid DR gemfibrozil PREFERRED Fenofibrate Lipofen BILE ACID SEQUESTRANTS GENERIC cholestyramine cholestyramine light colestipol HCL colestipol HCL for oral suspension PREFERRED Welchol CHOLEST ABS INHBTR/COMBO PREFERRED Liptruzet Vytorin Zetia NIACIN/COMBINATIONS GENERIC niacin ER PREFERRED Simcor OMEGA-3 FATTY ACIDS GENERIC omega-3-acid ethyl esters PREFERRED Vascepa DERMATOLOGICALS ACNE GENERIC adapalene benzoyl peroxide benzoyl peroxide SHORT contact clindamycin phosphate clindamycin/benzoyl peroxide erythromycin erythromycin/benzoyl peroxide metronidazole 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 sulfacetamide sodium sulfacetamide sodium/sulfur cleanser tretinoin tretinoin microsphere tretinoin microsphere P.M. Claravis Doxycycline Zenatane PREFERRED Acanya Atralin Differin Epiduo Finacea Mirvaso Oracea Ziana TOPICAL ANTI-INFLAMMATORY GENERIC alclometasone dipropionate augmented betamethasone dipropionate betamethasone dipropionate betamethasone valerate calcipotriene/betamethasone dipropionate clobetasol propionate clobetasol propionate emollient desonide desoximetasone diflorasone diacetate fluocinolone acetonide fluocinonide fluocinonide-e fluticasone propionate halobetasol propionate hydrocortisone hydrocortisone acetate/aloe hydrocortisone butyrate hydrocortisone butyrate (lipid) hydrocortisone butyrate (lipophilic) hydrocortisone valerate hydrocortisone IN absorbase mometasone furoate prednicarbate triamcinolone acetonide Amcinonide Desoximetasone PREFERRED Pramosone Pramosone E Taclonex Tucks Anti-itch ENDOCRINE CONTRACEPTIVE AGENTS GENERIC desogestrel/ethinyl estradiol drospirenone/ethinyl estradiol levonorgestrel levonorgestrel and ethinyl estradiol levonorgestrel/ethinyl estradiol medroxyprogesterone acetate norethindrone norethindrone acetate/ethinyl estradiol norethindrone acetate/ethinyl estradiol/ferrous fumarate norgestimate/ethinyl estradiol Ogestrel PREFERRED Beyaz Depo-provera Implanon LO Loestrin FE Minastrin 24 FE Mirena Natazia Nexplanon Nuvaring Safyral ESTROGENS/COMBINATIONS GENERIC estradiol estradiol valerate estradiol/norethindrone acetate estropipate Effective April 1, 2015 2 Jinteli PREFERRED Alora Cenestin Combipatch Enjuvia Estrace Estring Evamist Minivelle Premarin Premphase Prempro Vagifem TESTOSTERONE AGENTS GENERIC danazol testosterone cypionate testosterone enanthate Testosterone Testosterone P.M. PREFERRED Androgel Androgel P.M. Androxy Axiron 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 glyburide glyburide micronized tolazamide Glyburide SULFONYLUREA/TZD COMB. GENERIC pioglitazone HCL-glimepiride INCRETINS PREFERRED Bydureon Byetta Victoza AMYLIN ANALOGS PREFERRED Symlinpen 120 Symlinpen 60 DIABETIC OTHER PREFERRED Farxiga Glucagen Glucagen Hypokit Glucagon Emergency Kit Invokamet Invokana Jardiance Proglycem GASTROINTESTINAL PROTON PUMP INHIBITORS GENERIC esomeprazole magnesium esomeprazole sodium lansoprazole omeprazole pantoprazole sodium rabeprazole sodium Esomeprazole Sodium PREFERRED Nexium Nexium 24HR ULCER DRUGS GENERIC cimetidine cimetidine HCL famotidine misoprostol nizatidine ranitidine HCL sucralfate Famotidine PREFERRED Carafate Nutropin AQ Pen HEPATITIS C ANTIVIRALS GENERIC ribavirin PREFERRED Harvoni Moderiba Moderiba 1200 Dose Pack Moderiba 800 Dose Pack Ribasphere Ribasphere Ribapak Ribatab Sovaldi INTERFERONS PREFERRED Peg-intron Peg-intron Redipen Peg-intron Redipen PAK 4 Pegasys Pegasys Proclick Pegintron MULTIPLE SCLEROSIS PREFERRED Ampyra Aubagio Avonex Avonex Pen Betaseron Copaxone Gilenya Plegridy Plegridy Starter Pack Rebif Rebif Rebidose Rebif Rebidose Titration Pack Rebif Titration Pack Tecfidera Tecfidera Starter Pack Tysabri NEUROLOGICALS ALZHEIMER'S DISEASE GENERIC donepezil HCL galantamine galantamine hydrobromide rivastigmine tartrate Galantamine Hydrobromide PREFERRED Exelon Namenda Namenda Titration PAK Namenda XR Namenda XR Titration Pack GROWTH HORMONE ANTICONVULSANTS PREFERRED Norditropin Cartridge Norditropin Flexpro Norditropin Nordiflex Pen Nutropin Nutropin AQ Nuspin 10 Nutropin AQ Nuspin 20 Nutropin AQ Nuspin 5 GENERIC carbamazepine carbamazepine ER clonazepam clonazepam odt divalproex sodium divalproex sodium DR divalproex sodium ER Effective April 1, 2015 3 ethosuximide felbamate fosphenytoin sodium gabapentin lamotrigine lamotrigine odt lamotrigine ER levetiracetam levetiracetam ER oxcarbazepine phenytoin phenytoin sodium phenytoin sodium extended primidone tiagabine hydrochloride topiramate valproate sodium valproic acid zonisamide PREFERRED Banzel Celontin Diazepam Dilantin Fycompa Gabitril Lyrica Onfi Oxtellar XR Peganone Potiga Tegretol-XR Vimpat latanoprost levobunolol HCL timolol maleate timolol maleate ophthalmic gel forming Metipranolol PREFERRED Alphagan P Combigan Lumigan Travatan Z Travoprost GENERIC ciprofloxacin HCL erythromycin gatifloxacin gentamicin sulfate levofloxacin ofloxacin tobramycin sulfate Bacitracin PREFERRED Besivance Moxeza Vigamox ANTI-INFLAMMATORY AGENTS GENERIC bromfenac cromolyn sodium diclofenac sodium flurbiprofen sodium ketorolac tromethamine PREFERRED Ilevro Nevanac Prolensa CORTICOSTEROIDS/RELATED GENERIC dexamethasone sodium phosphate fluorometholone neomycin/polymyxin/bacitracin/hydroco rtisone neomycin/polymyxin/dexamethasone prednisolone acetate sulfacetamide sodium/prednisolone sodium phosphate tobramycin/dexamethasone PREFERRED Alrex FML Lotemax Ozurdex Pred Mild Retisert Tobradex Tobradex ST Zylet OPHTHALMICS ANTI-ALLERGIC AGENTS 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 PREFERRED Restasis OSTEOPOROSIS BISPHOSPHONATES GENERIC alendronate sodium ibandronate sodium pamidronate disodium risedronate sodium zoledronic acid PREFERRED Alendronate Sodium Fosamax Plus D ANTI-INFECTIVES MIGRAINE/HEADACHE GENERIC dihydroergotamine mesylate naratriptan HCL rizatriptan benzoate rizatriptan benzoate odt sumatriptan succinate sumatriptan succinate refill zolmitriptan zolmitriptan odt Isometheptene/Caffeine/Acetaminophe n Sumatriptan Succinate PREFERRED Relpax MISCELLANEOUS MIOTICS GENERIC pilocarpine HCL PREFERRED Phospholine Iodide Pilopine HS SERM GENERIC raloxifene hydrochloride PSYCHOTHERAPEUTICS ATYPICAL ANTIPSYCHOTICS GENERIC chlorpromazine HCL clozapine fluphenazine decanoate fluphenazine HCL haloperidol haloperidol decanoate haloperidol lactate lithium carbonate lithium carbonate ER loxapine loxapine succinate olanzapine olanzapine odt perphenazine prochlorperazine prochlorperazine edisylate prochlorperazine maleate quetiapine fumarate risperidone risperidone odt thioridazine HCL thiothixene trifluoperazine HCL ziprasidone HCL Clozapine Odt PREFERRED Abilify Abilify Discmelt Abilify Maintena Latuda Risperdal Consta Seroquel XR PSYCHOTHERAPEUTICS, MISC. GENERIC amphetamine/dextroamphetamine clonidine HCL ER dexmethylphenidate HCL dexmethylphenidate HCL ER dextroamphetamine sulfate dextroamphetamine sulfate ER guanfacine ER methamphetamine HCL methylphenidate hydrochloride methylphenidate HCL methylphenidate HCL CD Effective April 1, 2015 4 methylphenidate HCL ER methylphenidate HCL SR modafinil Methylphenidate HCL ER Procentra PREFERRED Daytrana Nuvigil Quillivant XR Strattera Vyvanse SNRI ANTIDEPRESSANTS GENERIC duloxetine HCL venlafaxine HCL venlafaxine HCL ER Venlafaxine HCL ER PREFERRED Pristiq SSRI ANTIDEPRESSANTS GENERIC citalopram hydrobromide escitalopram oxalate fluoxetine DR fluoxetine HCL fluvoxamine maleate fluvoxamine maleate ER paroxetine HCL paroxetine HCL ER sertraline HCL RESPIRATORY ANAPHYLAXIS TX AGENTS GENERIC Epinephrine PREFERRED Auvi-q Epipen 2-PAK Epipen-JR 2-PAK ANTICHOLINERGICS GENERIC ipratropium bromide PREFERRED Atrovent HFA Spiriva Handihaler Spiriva Respimat Tudorza Pressair ANTICHLNRGC/BETA AGONIST GENERIC ipratropium bromide/albuterol sulfate PREFERRED Anoro Ellipta Combivent Combivent Respimat BETA AGONISTS GENERIC albuterol sulfate albuterol sulfate ER albuterol TAB 4MG levalbuterol levalbuterol HCL terbutaline sulfate PREFERRED Arcapta Neohaler Foradil Aerolizer Perforomist Proair HFA Serevent Diskus GENERIC bethanechol chloride flavoxate HCL oxybutynin chloride oxybutynin chloride ER tolterodine tartrate tolterodine tartrate ER trospium chloride trospium chloride ER PREFERRED Gelnique Myrbetriq Oxytrol Oxytrol For Women Toviaz Vesicare LEUKOTRIENE RCPTR ANTGNST GENERIC montelukast sodium zafirlukast PULMONARY CORTICOSTEROIDS GENERIC budesonide PREFERRED Asmanex HFA Asmanex Twisthaler 120 Metered Doses Asmanex Twisthaler 14 Metered Doses Asmanex Twisthaler 30 Me Tered Doses Asmanex Twisthaler 30 Metered Doses Asmanex Twisthaler 60 Metered Doses Asmanex Twisthaler 7 Metered Doses Pulmicort Pulmicort Flexhaler 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. NASAL ANTIHISTAMINES GENERIC azelastine HCL olopatadine HCL NASAL CORTICOSTEROIDS GENERIC budesonide flunisolide fluticasone propionate triamcinolone acetonide Flunisolide PREFERRED Nasonex STEROID/BETA AGONIST PREFERRED Dulera Symbicort MISCELLANEOUS PREFERRED Dymista UROLOGICALS BENIGN PRSTATC HYPRPLSIA GENERIC alfuzosin HCL ER finasteride tamsulosin HCL PREFERRED Rapaflo ERECTILE DYSFUNCTION PREFERRED Cialis Viagra URINARY ANTISPASMODICS Effective April 1, 2015 v.2 ©Catamaran 2015. All Rights Reserved. May not be copied or distributed without authorization. 5
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