cefuroxime sodium childrens medi-profen

cefuroxime/dextrose childs ibuprofen

cephalexin diclofenac potassium

tazicef diclofenac sodium DR

January 2016 diclofenac sodium ER

diclofenac sodium/misoprostol PENICILLINS UCSHIP CUSTOM FORMULARY GENERIC dyspel TIER 01 PREFERRED DRUG LIST

amoxicillin eq childrens ibuprofen

The Preferred Drug List is a guide identifying amoxicillin trihydrate eq ibuprofen preferred brand-name medicines within select amoxicillin ER eq ibuprofen infants therapeutic categories. The Preferred Drug List may amoxicillin/clavulanate potassium eq ibuprofen junior strength not include all drugs covered by your prescription amoxicillin/clavulanate potassium ER eq naproxen sodium drug benefit. Generic medicines are available within many of the therapeutic categories listed, in addition ampicillin eql all day pain relief

to categories not listed, and should be considered ampicillin sodium eql all day relief

as the first line of prescribing. ampicillin-sulbactam eql childrens ibuprofen

dicloxacillin sodium eql ibuprofen

For benefit coverage or restrictions please check nafcillin sodium eql ibuprofen infants

your benefit plan document(s). This listing is revised oxacillin sodium eql ibuprofen junior strength periodically as new drugs and new prescribing penicillin v potassium eql naproxen sodium information becomes available. It is recommended penicillin G potassium etodolac that you bring this list of medications when you or a penicillin G potassium IN iso-osmotic etodolac ER covered family member sees a physician or other dextrose fenoprofen calcium healthcare provider. penicillin G procaine flanax pain relief

penicillin G sodium flurbiprofen

ANTI-INFECTIVES pfizerpen-G genpril

ANTIFUNGALS piperacillin sodium/ tazobactam gnp all day pain relief

sodium TIER 01 GENERIC gnp childrens ibuprofen

amphotericin b piperacillin sodium/tazobactam gnp ibuprofen

sodium bio-statin gnp ibuprofen infants

piperacillin/tazobactam fluconazole gnp ibuprofen junior strength

fluconazole IN dextrose gnp naproxen sodium

QUINOLONES fluconazole IN NACL hy-vee all day relief

TIER 01 GENERIC flucytosine hyvee ibuprofen childrens

ciprofloxacin griseofulvin microsize i-prin

ciprofloxacin ER griseofulvin ultramicrosize ibu-drops

ciprofloxacin HCL itraconazole ibu-drops infants

ciprofloxacin I.V.-IN D5W ketoconazole ibu-200

levofloxacin miconazole ibuprofen

levofloxacin IN D5W nystatin ibuprofen childrens

moxifloxacin HCL terbinafine HCL ibuprofen junior strength

ofloxacin voriconazole indomethacin

TIER 02 PREFERRED BRAND indomethacin sodium

TETRACYCLINES Bio-statin indomethacin ER

TIER 01 GENERIC infants ibuprofen

avidoxy CEPHALOSPORINS inflammacin demeclocycline HCL TIER 01 GENERIC ketoprofen

doxy 100 cefaclor ketoprofen micronized doxycycline cefaclor ER ketoprofen ultra micronized doxycycline hyclate cefadroxil ketoprofen ER doxycycline hyclate DR cefazolin ketorolac tromethamine doxycycline monohydrate cefazolin sodium kls ibuprofen minocycline HCL cefazolin sodium/dextrose kls ibuprofen IB minocycline HCL ER cefdinir kls naproxen sodium mondoxyne nl cefditoren pivoxil ks ibuprofen morgidox 1X100MG cefepime meclofenamate sodium morgidox 2X100MG cefixime medi-profen oxytetracycline HCL cefotaxime sodium mediproxen tetracycline HCL cefotetan mefenamic acid

cefotetan/dextrose meijer ibuprofen

cefoxitin sodium ANTI-INFLAMMATORY meloxicam

cefpodoxime proxetil NSAIDS midol

cefprozil TIER 01 GENERIC midol extended relief

ceftazidime addaprin motrin IB

ceftazidime/dextrose advil junior strength nabumetone

ceftibuten all day pain relief naproxen

ceftriaxone sodium all day relief naproxen kit

ceftriaxone IN iso-osmotic dextrose celecoxib naproxen sodium

ceftriaxone/dextrose childrens ibuprofen naproxen sodium CR

cefuroxime axetil childrens ibuprofen 100 naproxen sodium ER

naproxen DR

Effective January 1, 2016

1

oxaprozin nimodipine CARDIOVASCULAR pamprin all day maximum strength nisoldipine ACE-INHIBITORS phenylbutazone nisoldipine ER TIER 01 GENERIC

piroxicam taztia XT benazepril HCL provil verapamil HCL captopril px all day relief verapamil HCL ER enalapril maleate px childrens profen IB verapamil HCL SR enalaprilat px ibuprofen fosinopril sodium px ibuprofen junior strength NITRATES & NITRITES lisinopril px infants profen IB GENERIC TIER 01 moexipril HCL qc childrens ibuprofen isosorbide dinitrate

perindopril erbumine qc ibuprofen isosorbide dinitrate ER

quinapril HCL qc ibuprofen infants isosorbide mononitrate

ramipril qc ibuprofen IB isosorbide mononitrate ER

trandolapril qc naproxen sodium minitran

ra ibuprofen nitro-time

ANGIOTENSIN RCPTR BLOCKER ra ibuprofen childrens nitroglycerin

TIER 01 GENERIC

ra ibuprofen infants nitroglycerin lingual

candesartan cilexetil ra ibuprofen junior strength nitroglycerin transdermal

eprosartan mesylate ra naproxen sodium nitroglycerin ER

irbesartan sm all day pain relief nitroglycerin IN dextrose 5%

losartan potassium sm childrens ibuprofen nitroglycerin IN 5% dextrose

telmisartan sm ibuprofen PREFERRED BRAND TIER 02 valsartan sm ibuprofen IB Isordil Titradose

sm ibuprofen JR Nitro-dur

BETA BLOCKERS sm infants ibuprofen Nitrostat

TIER 01 GENERIC sm naproxen sodium

acebutolol HCL sulindac ANTI-HTN COMBINATIONS atenolol tgt childrens ibuprofen TIER 01 GENERIC betaxolol HCL tgt ibuprofen bisoprolol fumarate amlodipine besylate/benazepril tgt ibuprofen childrens hydrochloride carvedilol tgt ibuprofen junior strength amlodipine besylate/benazepril HCL esmolol HCL tgt infants ibuprofen amlodipine besylate/valsartan labetalol HCL tgt naproxen sodium amlodipine/valsartan/hctz metoprolol succinate ER th ibuprofen atenolol/chlorthalidone metoprolol tartrate th naproxen benazepril HCL/hydrochlorothiazide nadolol tolmetin sodium bisoprolol pindolol fumarate/hydrochlorothiazide wal-profen propranolol HCL wal-proxen candesartan propranolol HCL ER cilexetil/hydrochlorothiazide CVS all day pain relief sorine captopril/hydrochlorothiazide

CVS childrens ibuprofen sotalol hydrochloride enalapril maleate/hydrochlorothiazide

CVS ibuprofen sotalol HCL fosinopril sodium/hydrochlorothiazide

CVS ibuprofen infants sotalol HCL (AF) irbesartan/hydrochlorothiazide

CVS ibuprofen junior strength timolol maleate lisinopril/hydrochlorothiazide

CVS ibuprofen liquid filled TIER 02 PREFERRED BRAND losartan CVS ibuprofen IB Coreg CR potassium/hydrochlorothiazide

CVS naproxen sodium Inderal XL methyldopa/hydrochlorothiazide

HM ibuprofen Innopran XL metoprolol/hydrochlorothiazide

HM ibuprofen childrens moexipril/hydrochlorothiazide

HM ibuprofen infants nadolol/bendroflumethiazide CALCIUM CHANNEL BLOCKERS HM ibuprofen IB propranolol/hydrochlorothiazide TIER 01 GENERIC HM naproxen sodium quinapril/hydrochlorothiazide afeditab CR SB childrens ibuprofen telmisartan/amlodipine amlodipine besylate SB ibuprofen telmisartan/hydrochlorothiazide cartia XT SB infants ibuprofen trandolapril/verapamil HCL dilt-CD SB naproxen sodium trandolapril/verapamil HCL ER dilt-XR TIER 02 PREFERRED BRAND valsartan/hydrochlorothiazide diltiazem CD Indocin TIER 02 PREFERRED BRAND diltiazem HCL

Tekturna HCT diltiazem HCL CD AUTO-IMMUNE

diltiazem HCL ER

diltzac ANTIHYPERLIPIDEMICS

TIER 02 PREFERRED BRAND felodipine ER STATINS

Humira isradipine TIER 01 GENERIC

Humira Pediatric Crohns Disease matzim LA atorvastatin calcium

Starter Pack

nicardipine HCL fluvastatin

Humira Pen nifediac CC fluvastatin sodium ER

Humira Pen-crohns Diseasestarter nifedical XL lovastatin

Humira Pen-psoriasis Starter nifedipine pravastatin sodium

nifedipine ER simvastatin

TIER 02

Effective January 1, 2016

2

PREFERRED BRAND bpo 3% foaming cloths sss 10%-5%

Crestor bpo 6% foaming cloths sulfacetamide sodium

FIBRATES bpo 9% foaming cloths sulfacetamide sodium/sulfur cleanser

TIER 01 GENERIC bpo-10 wash sulfacleanse 8/4

fenofibrate bpo-5 wash sulfo-LO

fenofibrate micronized cerisa wash sulfur

fenofibric acid claravis sulfur sublimed

fenofibric acid DR claris clarifying wash sulpho-lac medicated soap

gemfibrozil clean & clear continuous control acne tretinoin cleanser BILE ACID SEQUESTRANTS tretinoin (all-trans retinoic acid)

clean & clear persa-gel extra strength TIER 01 GENERIC tretinoin microsphere

cholestyramine clean & clear persa-gel maximum tretinoin microsphere P.M. strength cholestyramine light virti-sulf clearplex v colestipol HCL zaclir cleansing clearplex x colestipol HCL for oral suspension zenatane clearskin micronized colestipol HCL zencia clindacin etz pledgets prevalite CVS acne clindacin-p TIER 02 PREFERRED BRAND CVS acne cleansing bar

clindamax Welchol CVS acne control cleanser clindamycin phosphate NIACIN/COMBINATIONS CVS acne foaming face wash clindamycin/benzoyl peroxide TIER 01 GENERIC CVS acne treatment

doxycycline niacin ER CVS advanced 3-IN-1 exfoliating ery cleanser niacor erythromycin CVS creamy acne face wash TIER 02 PREFERRED BRAND

erythromycin/benzoyl peroxide Advicor CVS dual action daily cleanser & gnp acne treatment maximum mask OMEGA-3 FATTY ACIDS strength CVS foaming acne face wash TIER 01 GENERIC invisible acne maximum strength CVS targeted acne spot treatment omega-3-acid ethyl esters invisible acne treatment TIER 02 PREFERRED BRAND

kp benzoyl peroxide Acanya DERMATOLOGICALS kp benzoyl peroxide wash Akne-mycin ACNE metronidazole

Differin TIER 01 GENERIC metronidazole benzoate

Finacea acne foaming wash myorisan

acne maximum strength neuac

TOPICAL ANTI-INFLAMMATORY acne medication neutrogena clear pore cleanser/mask

TIER 01 GENERIC

acne medication 10 neutrogena on-the-spot acne ala cort acne medication 5 treatment

alclometasone dipropionate acne pimple medication maximum oscion cleanser alphatrex strength/vanishing panoxyl

amcinonide acne treatment cleansing bar panoxyl wash anti-itch intensive healing maximum strength pr benzoyl peroxide wash anti-itch maximum strength acne-clear prascion apexicon e adapalene prascion fc aquanil HC adapalene P.M. prascion ra with sunscreens amnesteem augmented betamethasone ra acne pads maximum dipropionate avar cleanser ra acne treatment aveeno anti-itch maximum strength avar-e emollient ra renewal medicated acne treatment beta HC avar-e green maximum strength betamethasone dipropionate avita ra vanishing acne treatment/maximum betamethasone valerate bensulfoid strength

benzepro retinoic acid calcipotriene/betamethasone

dipropionate

benzepro creamy wash retinoic acid-all trans

clobetasol propionate benzepro foaming cloths rosadan

clobetasol propionate e benzepro SHORT contact rosanil cleanser

clobetasol propionate emollient benziq wash rosula

clobetasol propionate micronized usp benzoyl peroxide se bpo wash

clobetasol 17 propionate benzoyl peroxide cleanser se 10-5 ss

clocortolone pivalate benzoyl peroxide hydrous sodium sulfacetamide

clocortolone pivalate P.M. benzoyl peroxide wash sodium sulfacetamide/sulfur

clodan benzoyl peroxide wash acne treatment sodium sulfacetamide/sulfur cleanser cormax scalp application pack sodium sulfacetamide/sulfur cleanser

cortaid advanced 12 HOUR anti-itch benzoyl peroxide SHORT contact IN urea

cortaid intensive therapycooling spray bp cleansing wash sodium sulfacetamide/sulfur cleansing cortaid maximum strength cloths bp foam sodium sulfacetamide/sulfur green cortalo

bp foaming wash sodium sulfacetamide/sulfur corticool bp gel w/sunscreen cortizone-10

bp wash sodium sulfacetamide/sulfur wash cortizone-10 eczema

bp 10-1 sodium sulfacetamide/sulfur IN urea cortizone-10 hydratensivehealing

bpo ss 10-2 cortizone-10 hydratensivesoothing

bpo creamy wash complete pack

sss 10-5

Effective January 1, 2016

3

cortizone-10 intensive healing qc hydrocortisone esterified estrogens/methyltestosterone

DS cortizone-10 plus qc hydrocortisone maximumstrength

cortizone-10/aloe ra anti-itch maximum strength esterified estrogens/methyltestosterone HS demarest dricort ra anti-itch/maximum strength estradiol dermarest eczema ra first aid anti-itch spray estradiol micronized desonide ra hydrocortisone maximumstrength estradiol valerate desoximetasone ra hydrocortisone plus estradiol/norethindrone acetate diflorasone diacetate ra hydrocortisone plus 12 estriol eq anti-itch maximum strength recort plus estriol micronized eq hydrocortisone maximu m strength rederm estriol ultra micronized eq hydrocortisone plus sarnol-HC estrone eql anti-itch intensive healing formula scalacort estropipate eql anti-itch maximum strength scalp relief maximum strength ethinyl estradiol eql anti-itch maximum strength plus 10 scalpicin maximum strength jevantique LO healing moisturizers sm hydrocortisone jinteli eql scalp relief maximum strength sm hydrocortisone maximum strength lopreeza fluocinolone acetonide sm hydrocortisone plus mimvey fluocinolone acetonide body sm hydrocortisone/aloe maximum mimvey LO fluocinolone acetonide scalp strength

fluocinonide synalar norethindrone acetate/ethinyl estradiol fluocinonide-e tgt anti-itch maximum strength ortho-est fluticasone propionate tgt anti-itch plus oatmeal TIER 02 PREFERRED BRAND gnp hydro-lotion tgt anti-itch/aloe maximum strength Alora gnp hydrocortisone tgt anti-itch/aloe/vitamin e Cenestin gnp hydrocortisone maximum th hydrocortisone Climara Pro strength th hydrocortisone/aloe Combipatch gnp hydrocortisone plus theracort Duavee gnp hydrocortisone/aloe triamcinolone acetonide Estring gynecort 10 triamcinolone acetonide micronized Evamist halac triamcinolone acetonide usp, Menest halobetasol propionate micronized

Minivelle halonate PAC trianex Prefest hydro skin maximum strength triderm Premarin hydrocortisone Apexicon E Premphase hydrocortisone acetate CVS anti-itch maximum strength Prempro hydrocortisone acetate micronized CVS cortisone cooling relief maximum strength hydrocortisone acetate/aloe

hydrocortisone acetate/pramoxine CVS cortisone intense healing anti- TESTOSTERONE AGENTS

itch hydrocortisone butyrate TIER 01 GENERIC

CVS cortisone long-lasting healing hydrocortisone butyrate (lipid) danazol

CVS cortisone maximum strength hydrocortisone butyrate (lipophilic) methyltestosterone

hydrocortisone intensive healing CVS eczema anti-itch maximum testosterone

strength

hydrocortisone maximum strength testosterone cypionate

CVS hdyrocortisone acetate hydrocortisone maximum strength plus testosterone enanthate CVS hydrocortisone anti-itch 10 moisturizers testosterone P.M.

CVS hydrocortisone maximum hydrocortisone maximum strength plus TIER 02 PREFERRED BRAND strength 12 moisturizers Androgel CVS HC-1% hemorrhoid hydrocortisone micronized Androgel P.M. HM hydrocortisone plus hydrocortisone plus Testim HM hydrocortisone/aloe maximum hydrocortisone valerate Vogelxo strength

hydrocortisone IN absorbase MED-derm hydrocortisone Vogelxo P.M.

hydrocortisone/aloe MG217 psoriasis anti-itch

hydroskin SB hydrocortisone INSULIN instacort 5 SB hydrocortisone maximum strength TIER 02 PREFERRED BRAND

kericort 10 TIER 02 PREFERRED BRAND Humalog

kls hydrocortisone plus Pramosone Humalog Kwikpen kp hydrocortisone Pramosone E Humalog Mix 50/50 kp hydrocortisone maximum strength Humalog Mix 50/50 Kwikpen kp hydrocortisone/aloe Humalog Mix 75/25 ENDOCRINE lanacort 10 Humalog Mix 75/25 Kwikpen ESTROGENS/COMBINATIONS lokara Humulin N TIER 01 GENERIC medi-cortisone Humulin R covaryx medi-first hydrocortisone Humulin R U-500 (concentrated) covaryx HS meijer hydrocortisone Humulin 70/30 eemt mometasone furoate Lantus eemt HS neosporin eczema essentials Lantus Solostar maximum strength esterified

Levemir estrogens/methltestosterone noble formula HC esterified Levemir Flexpen prednicarbate estrogens/methyltestosterone Levemir Flextouch

preparation h hydrocortisone Novolin N

px hydrocream

Effective January 1, 2016

4

Novolin N Relion CVS glucose shot heartburn relief 150 maximum

strength Novolin R TIER 02 PREFERRED BRAND

kls acid controller maximum strength Novolin R Relion Glucagen Hypokit kls acid reducer Novolin 70/30 Glucagon Emergency Kit kls acid reducer maximum strength Novolin 70/30 Relion misoprostol Novolog GASTROINTESTINAL nizatidine Novolog Flexpen PROTON PUMP INHIBITORS pepcid ac maximum strength Novolog Mix 70/30 TIER 01 GENERIC px acid reducer Novolog Mix 70/30 Prefilled Flexpen eq lansoprazole px acid reducer maximum strength Novolog Penfill eq omeprazole magnesium px ranitidine Relion R esomeprazole magnesium qc acid controller

esomeprazole sodium qc acid controller maximum strength NON-INSULIN HYPOGLYCEMICS esomeprazole strontium ra acid reducer BIGUANIDES gnp lansoprazole ra acid reducer maximum strength TIER 01 GENERIC gnp omeprazole ranitidine acid reducer metformin HCL heartburn relief 24 HOUR ranitidine maximum strength metformin HCL ER heartburn treatment 24 HOUR ranitidine HCL BIGUAN/SULFONYLUREA COMB. kls lansoprazole ranitidine 150 maximum strength TIER 01 GENERIC kp omeprazole magnesium ranitidine 75 glipizide/metformin HCL lansoprazole sm acid reducer glyburide/metformin HCL omeprazole sm acid reducer maximum strength BIGUAN/THIAZOLIDEINEDIONE omeprazole magnesium sucralfate TIER 01 GENERIC pantoprazole sodium pioglitazone HCL sw acid reducer 150 maximum qc omeprazole magnesium strength pioglitazone HCL/metformin HCL ra lansoprazole tgt acid reducer TIER 02 PREFERRED BRAND ra omeprazole th famotidine 10 Actoplus Met XR rabeprazole sodium wal-zan 150 maximum strength Avandamet sm lansoprazole wal-zan 75 Avandia CVS lansoprazole CVS acid controller maximum DPP-4 INHIBITORS CVS omeprazole magnesium strength

TIER 02 PREFERRED BRAND HM lansoprazole CVS acid reducer

Januvia TIER 02 PREFERRED BRAND CVS acid reducer maximum strength

Onglyza Nexium CVS heartburn relief

SULFONYLUREAS Prevacid Solutab CVS ranitidine

TIER 01 GENERIC HM acid reducer

chlorpropamide ULCER DRUGS HM famotidine glimepiride TIER 01 GENERIC SB acid controller

glipizide acid control maximum strength SB acid controller maximum strength glipizide ER acid controller SB acid reducer glipizide XL acid controller maximum strength SB acid reducer ranitidine 75 glyburide acid reducer SB cimetidine glyburide micronized acid reducer maximum strength TIER 02 PREFERRED BRAND

tolazamide acid relief Carafate tolbutamide cimetidine SULFONYLUREA/TZD COMB. cimetidine acid reducer HEPATITIS C TIER 01 GENERIC cimetidine HCL ANTIVIRALS pioglitazone HCL-glimepiride cimetidine 200 TIER 01 GENERIC TIER 02 PREFERRED BRAND eq acid reducer ribasphere Avandaryl eq acid reducer maximum strength ribasphere ribapak INCRETINS eq heartburn relief ribatab TIER 02 PREFERRED BRAND eq ranitidine

Byetta eql acid reducer MULTIPLE SCLEROSIS DIABETIC OTHER eql heartburn prevention

TIER 01 GENERIC eql heartburn prevention/maximum TIER 01 GENERIC dex4 fast acting glucose strength

glatopa gluco burst eql heartburn relief

TIER 02 PREFERRED BRAND glucose eql heartburn relief maximum strength

Copaxone glucose liquid famotidine

glutose 15 famotidine premixed

glutose 45 gnp acid control 150 maximum NEUROLOGICALS

kroger glucose gel strength

ALZHEIMER'S DISEASE ra glucose gnp acid control 75 GENERIC TIER 01

relion glucose gnp acid reducer acetyl l-carnitine

relion glucose drink gnp acid reducer maximum strength donepezil HCL

value plus glucose gnp heartburn relief galantamine hydrobromide

value plus glucose gel gnp heartburn relief 200 memantine hydrochloride

walgreens glucose goodsense acid reducer memantine HCL

CVS glucose heartburn relief memantine HCL titration PAK

CVS glucose gel heartburn relief maximum strength rivastigmine tartrate

CVS glucose liquid shot

Effective January 1, 2016

5

rivastigmine transdermal system Zomig Nasal Spray ofloxacin

TIER 02 PREFERRED BRAND romycin

Exelon tobramycin sulfate OPHTHALMICS TIER 02 PREFERRED BRAND ANTI-ALLERGIC AGENTS Azasite ANTICONVULSANTS TIER 01 GENERIC

GENERIC Ciloxan TIER 01 alaway carbamazepine Moxeza

alaway childrens allergy eye itch relief carbamazepine ER Vigamox

allergy eye drops clonazepam

azelastine HCL clonazepam odt ANTI-INFLAMMATORY AGENTS claritin eye diazepam TIER 01 GENERIC cromolyn sodium divalproex sodium bromfenac epinastine HCL divalproex sodium DR cromolyn sodium eq eye itch relief divalproex sodium ER diclofenac sodium eq itchy eye drops epitol flurbiprofen sodium eye itch relief ethosuximide ketorolac tromethamine gnp eye itch relief felbamate TIER 02 PREFERRED BRAND gnp itchy eye fosphenytoin sodium Ilevro ketotifen fumarate gabapentin kp ketotifen fumarate lamotrigine olopatadine HCL CORTICOSTEROIDS/RELATED

lamotrigine odt GENERIC ra antihistamine eye drops TIER 01

lamotrigine titration dexamethasone sodium phosphate ra eye itch relief

lamotrigine ER fluorometholone sm eye itch relief

levetiracetam neo-polycin HC tgt eye itch relief

levetiracetam ER neomycin/polymyxin/bacitracin/hydroco thera tears allergy eye itch relief oxcarbazepine rtisone

wal-zyr phenytoin neomycin/polymyxin/dexamethasone

zyrtec itchy eye phenytoin infatabs neomycin/polymyxin/hydrocortisone

CVS allergy eye drops phenytoin sodium poly-dex

CVS antihistamine eye drops phenytoin sodium extended prednisolone acetate

CVS eye itch relief primidone prednisolone sodium phosphate

HM eye itch relief tiagabine hydrochloride sulfacetamide sodium/prednisolone TIER 02 PREFERRED BRAND

sodium phosphate topiragen Pataday tobramycin/dexamethasone topiramate

TIER 02 PREFERRED BRAND topiramate ER ANTI-GLAUCOMA AGENTS Blephamide valproate sodium TIER 01 GENERIC Blephamide S.o.p. valproic acid apraclonidine Durezol zonisamide betaxolol HCL FML TIER 02 PREFERRED BRAND bimatoprost FML Forte Diastat Acudial brimonidine tartrate Lotemax Diastat Pediatric carteolol HCL Maxidex Dilantin dorzolamide HCL Pred Mild Gabitril dorzolamide HCL/timolol maleate Tobradex Lamictal XR latanoprost

Tegretol-XR levobunolol HCL MIOTICS

metipranolol TIER 01 GENERIC MIGRAINE/HEADACHE timolol maleate pilocarpine HCL TIER 01 GENERIC timolol maleate ophthalmic gel

almotriptan malate forming

MISCELLANEOUS dihydroergotamine mesylate travoprost TIER 02 PREFERRED BRAND ergotamine tartrate TIER 02 PREFERRED BRAND

Restasis isometheptene Alphagan P mucate/caffeine/acetaminophen Azopt

isometheptene/caffeine/acetaminophen Betimol OSTEOPOROSIS

Betoptic-s BISPHOSPHONATES isometheptene/dichloralphenazone/ace Combigan GENERIC TIER 01 taminophen

Lumigan alendronate sodium

migragesic ida etidronate disodium

migralam ANTI-INFECTIVES ibandronate sodium naratriptan HCL TIER 01 GENERIC pamidronate disodium nodolor bacitracin risedronate sodium rizatriptan benzoate ciprofloxacin HCL risedronate sodium DR rizatriptan benzoate odt erythromycin zoledronic acid sumatriptan garamycin TIER 02 PREFERRED BRAND sumatriptan succinate gatifloxacin Fosamax Plus D sumatriptan succinate refill gentak zolmitriptan gentamicin sulfate SERM zolmitriptan odt ilotycin GENERIC TIER 01 TIER 02 PREFERRED BRAND

levofloxacin raloxifene hydrochloride

Treximet

Effective January 1, 2016

6

GENERIC SNRI ANTIDEPRESSANTS PSYCHOTHERAPEUTICS GENERIC budesonide TIER 01 ANTIPSYCHOTICS/ANTIMANIC desvenlafaxine ER flunisolide

TIER 01 GENERIC

duloxetine HCL flunisolide anhydrous

aripiprazole venlafaxine HCL TIER 02 PREFERRED BRAND

aripiprazole odt venlafaxine HCL ER Flovent Diskus

chlorpromazine HCL PREFERRED BRAND Flovent HFA TIER 02 clozapine Pristiq Pulmicort Flexhaler

clozapine odt Qvar

compazine

compro SSRI ANTIDEPRESSANTS

GENERIC NASAL ANTIHISTAMINES fluphenazine decanoate TIER 01

citalopram hydrobromide TIER 01 GENERIC fluphenazine HCL

escitalopram oxalate azelastine HCL haloperidol

fluoxetine DR olopatadine HCL haloperidol decanoate

fluoxetine HCL haloperidol lactate

lithium fluvoxamine maleate NASAL CORTICOSTEROIDS

lithium carbonate fluvoxamine maleate ER TIER 01 GENERIC

lithium carbonate ER paroxetine HCL budesonide

loxapine paroxetine HCL ER flonase allergy relief

loxapine succinate sertraline HCL flunisolide

molindone hydrochloride fluticasone propionate

olanzapine triamcinolone acetonide

RESPIRATORY olanzapine odt TIER 02 PREFERRED BRAND

ANAPHYLAXIS TX AGENTS paliperidone ER Nasonex

TIER 01 GENERIC

perphenazine Veramyst

epinephrine prochlorperazine

TIER 02 PREFERRED BRAND

prochlorperazine edisylate STEROID/BETA AGONIST Adrenaclick prochlorperazine maleate TIER 02 PREFERRED BRAND Auvi-q quetiapine fumarate Advair Diskus Epipen 2-PAK risperidone Advair HFA

risperidone odt Symbicort ANTICHOLINERGICS risperidone M-TAB TIER 01 GENERIC

thioridazine HCL ipratropium bromide UROLOGICALS

thiothixene ipratropium bromide monohydrate BENIGN PRSTATC HYPRPLSIA trifluoperazine HCL TIER 02 PREFERRED BRAND TIER 01 GENERIC

ziprasidone HCL Atrovent HFA alfuzosin HCL ER TIER 02 PREFERRED BRAND Spiriva Handihaler dutasteride Abilify dutasteride/tamsulosin hydrochloride Abilify Discmelt finasteride ANTICHLNRGC/BETA AGONIST Fazaclo GENERIC tamsulosin HCL TIER 01

Seroquel XR ipratropium bromide/albuterol sulfate

TIER 02 PREFERRED BRAND URINARY ANTISPASMODICS

PSYCHOTHERAPEUTICS, MISC. Combivent Respimat TIER 01 GENERIC

TIER 01 GENERIC bethanechol chloride amphetamine/dextroamphetamine flavoxate HCL BETA AGONISTS clonidine HCL ER GENERIC oxybutinin chloride TIER 01

dexedrine albuterol oxybutynin chloride

dexmethylphenidate HCL albuterol sulfate oxybutynin chloride ER

dexmethylphenidate HCL ER albuterol sulfate ER tolterodine tartrate

dextroamphetamine sulfate levalbuterol tolterodine tartrate ER

dextroamphetamine sulfate ER levalbuterol HCL trospium chloride

guanfacine ER metaproterenol sulfate trospium chloride ER

metadate ER terbutaline sulfate TIER 02 PREFERRED BRAND

methamphetamine HCL PREFERRED BRAND Oxytrol TIER 02

methylphenidate hydrochloride Foradil Aerolizer Oxytrol For Women

methylphenidate HCL Perforomist Vesicare

methylphenidate HCL CD Proair HFA

methylphenidate HCL ER Proventil HFA

methylphenidate HCL SR Serevent Diskus Formulary Disclaimer: Coverage for some drugs modafinil Ventolin HFA may be limited to specific dosage forms and/or procentra strengths. The benefit design determines what is

zenzedi covered and the applicable co-payment. The LEUKOTRIENE RCPTR ANTGNST Adderall XR medications listed on this formulary are subject to TIER 01 GENERIC

TIER 02 PREFERRED BRAND change pursuant to the formulary management montelukast sodium Nuvigil activities of Optum. The presence of a medication zafirlukast Strattera on this formulary list does not guarantee coverage.

Vyvanse To determine the most up-to-date formulary status PULMONARY CORTICOSTEROIDS of your medication, please visit your member

TIER 01 website or call member services at the number

listed on your ID card.

Effective January 1, 2016

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