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Optum Essential Health Benefits Enhanced Formulary PDL January

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Optum Essential Health Benefits Enhanced Formulary PDL January PENICILLINS ketorolac tromethamineQL GENERIC mefenamic acid amoxicillin/clavulanate potassium nabumetone amoxicillin/clavulanate potassium ER naproxen January 2016 ampicillin naproxen sodium ampicillin sodium naproxen sodium CR ESSENTIAL HEALTH BENEFITS ampicillin-sulbactam naproxen sodium ER ENHANCED PREFERRED DRUG LIST nafcillin sodium naproxen DR The Optum Preferred Drug List is a guide identifying oxacillin sodium oxaprozin preferred brand-name medicines within select penicillin G potassium piroxicam therapeutic categories. The Preferred Drug List may piperacillin sodium/ tazobactam sulindac not include all drugs covered by your prescription sodium tolmetin sodium drug benefit. Generic medicines are available within many of the therapeutic categories listed, in addition piperacillin sodium/tazobactam Fenoprofen Calcium sodium to categories not listed, and should be considered Meclofenamate Sodium piperacillin/tazobactam as the first line of prescribing. Tolmetin Sodium Amoxicillin/Clavulanate Potassium LOW COST GENERIC PREFERRED For benefit coverage or restrictions please check indomethacin your benefit plan document(s). This listing is revised Augmentin meloxicam periodically as new drugs and new prescribing LOW COST GENERIC naproxen kit information becomes available. It is recommended amoxicillin that you bring this list of medications when you or a dicloxacillin sodium CARDIOVASCULAR covered family member sees a physician or other penicillin v potassium ACE-INHIBITORS healthcare provider. GENERIC QUINOLONES captopril ANTI-INFECTIVES GENERIC enalaprilat ANTIFUNGALS ciprofloxacin perindopril erbumine GENERIC ciprofloxacin ER LOW COST GENERIC bio-statin ciprofloxacin I.V.-IN D5W benazepril HCL fluconazole IN dextrose levofloxacin enalapril maleate flucytosine levofloxacin IN D5W fosinopril sodium griseofulvin microsize moxifloxacin HCL lisinopril griseofulvin ultramicrosize ofloxacin moexipril HCL PA itraconazole Ciprofloxacin HCL quinapril HCL nystatin Ofloxacin ramipril voriconazole PREFERRED trandolapril Amphotericin B Avelox PREFERRED LOW COST GENERIC ANGIOTENSIN RCPTR BLOCKER Lamisil ciprofloxacin HCL GENERIC Noxafil ST candesartan cilexetil SporanoxPA TETRACYCLINES irbesartan LOW COST GENERIC GENERIC telmisartan fluconazole avidoxy valsartan fluconazole IN NACL demeclocycline HCL Eprosartan Mesylate ketoconazole doxy 100 PREFERRED QL terbinafine HCL doxycycline Benicar doxycycline hyclate LOW COST GENERIC CEPHALOSPORINS doxycycline hyclate DR losartan potassium GENERIC doxycycline monohydrate cefaclor minocycline HCL BETA BLOCKERS cefadroxil minocycline HCL ER GENERIC cefazolin sodium mondoxyne nl acebutolol HCL cefdinir morgidox 1X100MG betaxolol HCL cefepime morgidox 2X100MG esmolol HCL cefixime Tetracycline HCL labetalol HCL cefotaxime sodium metoprolol succinate ER cefoxitin sodium ANTI-INFLAMMATORY nadolol cefpodoxime proxetil NSAIDS pindolol cefprozil GENERIC propranolol HCL QL,PA ceftazidime celecoxib propranolol HCL ER ceftriaxone sodium diclofenac potassium sotalol HCL cefuroxime axetil diclofenac sodium DR sotalol HCL (AF) cefuroxime sodium diclofenac sodium ER Timolol Maleate tazicef diclofenac sodium/misoprostol PREFERRED tazidime etodolac Bystolic Cefditoren Pivoxil etodolac ER Coreg CR Cefotetan flurbiprofen LOW COST GENERIC Cefotetan/Dextrose ibuprofen atenolol Cefuroxime Sodium indomethacin ER bisoprolol fumarate LOW COST GENERIC inflammacin carvedilol cephalexin ketoprofen Effective January 1, 2016 v.4 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 1 All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. © 2015 Optum, Inc. All rights reserved. metoprolol tartrate trandolapril/verapamil HCL ER benzepro foaming cloths sorine valsartan/hydrochlorothiazide benzepro SHORT contact PREFERRED benziq wash CALCIUM CHANNEL BLOCKERS Amturnide benzoyl peroxide GENERIC Azor benzoyl peroxide SHORT contact afeditab CR Benicar HCT bp foam cartia XT Tekamlo bp foaming wash dilt-CD Tekturna HCT bp wash dilt-XR Tribenzor bp 10-1 diltiazem CD LOW COST GENERIC bpo 6% foaming cloths diltiazem HCL atenolol/chlorthalidone cerisa wash diltiazem HCL CD bisoprolol claravis fumarate/hydrochlorothiazide diltiazem HCL ER claris clarifying wash enalapril maleate/hydrochlorothiazide diltzac clearplex x lisinopril/hydrochlorothiazide felodipine ER clindacin etz pledgets isradipine losartan clindacin-p potassium/hydrochlorothiazide matzim LA clindamax nicardipine HCL clindamycin phosphate ANTIHYPERLIPIDEMICS nifediac CC clindamycin/benzoyl peroxide STATINS nifedical XL ery GENERIC nifedipine erythromycin fluvastatin nifedipine ER erythromycin/benzoyl peroxide fluvastatin sodium ER nimodipine metronidazole lovastatin nisoldipine myorisan pravastatin sodium taztia XT neuac PREFERRED verapamil HCL ER oscion cleanser Crestor verapamil HCL SR pr benzoyl peroxide wash LOW COST GENERIC LOW COST GENERIC prascion atorvastatin calcium amlodipine besylate prascion fc simvastatin verapamil HCL rosadan FIBRATES rosanil cleanser GENERIC NITRATES & NITRITES rosula fenofibrate GENERIC se bpo wash fenofibrate micronized isosorbide dinitrate se 10-5 ss fenofibric acid DR isosorbide mononitrate sodium sulfacetamide Fenofibrate minitran sodium sulfacetamide/sulfur Fenofibric Acid nitro-time sodium sulfacetamide/sulfur cleanser LOW COST GENERIC nitroglycerin lingual sodium sulfacetamide/sulfur cleansing gemfibrozil cloths nitroglycerin transdermal BILE ACID SEQUESTRANTS sodium sulfacetamide/sulfur green nitroglycerin ER GENERIC nitroglycerin IN dextrose 5% sodium sulfacetamide/sulfur cholestyramine w/sunscreen nitroglycerin IN 5% dextrose cholestyramine light sodium sulfacetamide/sulfur wash Isosorbide Dinitrate colestipol HCL ss 10-2 Nitroglycerin Lingual micronized colestipol HCL sss 10-5 PREFERRED prevalite sss 10%-5% Dilatrate SR PREFERRED sulfacetamide sodium Nitro-bid Welchol sulfacetamide sodium/sulfur cleanser Nitrostat CHOLEST ABS INHBTR/COMBO sulfacleanse 8/4 LOW COST GENERIC PREFERRED virti-sulf isosorbide mononitrate ER Vytorin zenatane Zetia zencia ANTI-HTN COMBINATIONS NIACIN/COMBINATIONS Doxycycline GENERIC GENERIC PREFERRED amlodipine besylate/benazepril niacin ER Finacea hydrochloride OMEGA-3 FATTY ACIDS Oracea amlodipine besylate/benazepril HCL GENERIC amlodipine besylate/valsartan omega-3-acid ethyl esters TOPICAL ANTI-INFLAMMATORY amlodipine/valsartan/hctz PREFERRED GENERIC benazepril HCL/hydrochlorothiazide Vascepa ala cort candesartan cilexetil/hydrochlorothiazide alclometasone dipropionate fosinopril sodium/hydrochlorothiazide DERMATOLOGICALS alphatrex irbesartan/hydrochlorothiazide ACNE augmented betamethasone dipropionate metoprolol/hydrochlorothiazide GENERIC betamethasone dipropionate moexipril/hydrochlorothiazide amnesteem betamethasone valerate nadolol/bendroflumethiazide avar cleanser quinapril/hydrochlorothiazide avar-e emollient calcipotriene/betamethasone dipropionateQL,PA telmisartan/amlodipine avar-e green clobetasol propionate telmisartan/hydrochlorothiazide benzepro clobetasol propionate e trandolapril/verapamil HCL benzepro creamy wash Effective January 1, 2016 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 2 clobetasol propionate emollient deblitane norethindrone clodan delyla norethindrone & ethinyl estradiol ferrous fumarate cormax scalp application desogestrel/ethinyl estradiol desonide drospirenone/ethinyl estradiol norethindrone acetate/ethinyl estradiol desoximetasone econtra EZ norethindrone acetate/ethinyl fluocinolone acetonide elinest estradiol/ferrous fumarate fluocinolone acetonide body emoquette norgestimate/ethinyl estradiol fluocinolone acetonide scalp enpresse-28 norlyroc fluocinonide enskyce nortrel 0.5/35 (28) fluocinonide-e errin nortrel 1/35 fluticasone propionate estarylla nortrel 7/7/7 halobetasol propionate fallback solo ocella halonate PAC falmina opcicon one-step hydrocortisone gianvi orsythia hydrocortisone acetate/aloe gildagia philith hydrocortisone butyrate gildess FE 1.5/30 pimtrea hydrocortisone butyrate (lipid) gildess FE 1/20 pirmella 1/35 hydrocortisone butyrate (lipophilic) gildess 1.5/30 pirmella 7/7/7 hydrocortisone valerate gildess 1/20 portia-28 hydrocortisone IN absorbase gildess 24 FE previfem lokara heather QL quasense QL mometasone furoate introvale reclipsen prednicarbate jencycla QL setlakin QL scalacort jolessa sharobel Amcinonide jolivette solia Apexicon E juleber sprintec 28 Desoximetasone junel FE 1.5/30 sronyx Diflorasone Diacetate junel FE 1/20 syeda PREFERRED junel FE 24 take action QL,PA Taclonex junel 1.5/30 tarina FE 1/20 LOW COST GENERIC junel 1/20 tilia FE triamcinolone acetonide kariva tri-estarylla triderm kelnor 1/35 tri-legest FE kimidess tri-linyah ENDOCRINE kurvelo tri-previfem CONTRACEPTIVE AGENTS larin FE 1.5/30 tri-sprintec PREVENTIVE larin FE 1/20 tri-LO-estarylla aftera larin 1.5/30 tri-LO-sprintec altavera larin 1/20 trinessa alyacen 1/35 larin 24 FE trinessa LO alyacen 7/7/7 layolis FE trivora-28 QL amethia leena velivet QL amethia LO lessina vestura amethyst levonest vienva apri levonorgestrel viorele QL aranelle levonorgestrel and ethinyl estradiol vyfemla QL ashlyna levonorgestrel/ethinyl estradiol wera aubra levora 0.15/30-28 wymzya FE aviane lomedia 24 FE zarah azurette loryna zenchent balziva low-ogestrel zenchent FE bekyree lutera zovia 1/35e blisovi FE 1.5/30 lyza Levonorgestrel blisovi FE 1/20 marlissa Ogestrel QL blisovi 24 FE medroxyprogesterone acetate Xulane briellyn microgestin FE PREFERRED camila microgestin
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