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 itraconazolePA 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 terbinafine HCLQL 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 ceftazidime celecoxibQL,PA 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
fluocinolone acetonide elinest norethindrone acetate/ethinyl 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 mometasone furoate introvaleQL reclipsen
prednicarbate jencycla QL setlakin scalacort jolessaQL 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 TaclonexQL,PA 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 amethiaQL leena velivet amethia LOQL lessina vestura amethyst levonest vienva apri levonorgestrel viorele aranelle levonorgestrel and ethinyl estradiolQL vyfemla ashlynaQL 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 blisovi 24 FE medroxyprogesterone acetateQL Xulane briellyn microgestin FE PREFERRED camila microgestin FE 1.5/30 Depo-provera camreseQL microgestin 1.5/30 LO Loestrin FE camrese LOQL microgestin 1/20 Minastrin 24 FE caziant microgestin 24 FE PREVENTIVE cesia mono-linyah Natazia
chateal mononessa QL Nuvaring cryselle-28 my way
cyclafem 1/35 myzilra ESTROGENS/COMBINATIONS cyclafem 7/7/7 necon 0.5/35-28 GENERIC cyred necon 1/35 estradiol valerate dasetta 1/35 necon 7/7/7 estradiol/norethindrone acetate dasetta 7/7/7 next choice one dose jevantique LO dayseeQL nikki jinteli
nora-be
Effective January 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 3
lopreeza PREFERRED NEUROLOGICALS
mimvey Actoplus Met XR ALZHEIMER'S DISEASE
mimvey LO DPP-4 INHIBITORS GENERIC
norethindrone acetate/ethinyl PREFERRED donepezil HCL
estradiol Januvia galantamine hydrobromide PREFERRED Onglyza memantine hydrochloride Cenestin BIGUANIDE/DPP-4 COMB. memantine HCL Combipatch PREFERRED memantine HCL titration PAK
Enjuvia Janumet rivastigmine tartrate Estrace Janumet XR rivastigmine transdermal system Evamist Kombiglyze XR Galantamine Hydrobromide Premarin SULFONYLUREAS PREFERRED Premphase GENERIC Exelon
Prempro QL tolazamide Namenda XR
Vagifem QL Chlorpropamide Namenda XR Titration Pack LOW COST GENERIC Tolbutamide estradiol LOW COST GENERIC ANTICONVULSANTS
estropipate glimepiride GENERIC ortho-est glipizide carbamazepine ER
glipizide ER clonazepam TESTOSTERONE AGENTS glipizide XL clonazepam odt GENERIC glyburide divalproex sodium danazol glyburide micronized divalproex sodium DR methyltestosterone Glyburide divalproex sodium ER testosterone SULFONYLUREA/TZD COMB. ethosuximide testosterone cypionatePA GENERIC felbamate
testosterone enanthatePA pioglitazone HCL-glimepiride fosphenytoin sodium testosterone P.M. INCRETINS gabapentin Testosterone PREFERRED lamotrigine
Testosterone P.M. Bydureon lamotrigine odt PREFERRED Byetta lamotrigine titration Androgel Victoza lamotrigine ER Androgel P.M. AMYLIN ANALOGS levetiracetam Androxy PREFERRED levetiracetam ER
Axiron PA Symlinpen 120 oxcarbazepine
Methitest PA Symlinpen 60 phenytoin
DIABETIC OTHER phenytoin infatabs INSULIN PREFERRED phenytoin sodium
PREFERRED Glucagen Hypokit phenytoin sodium extended Lantus Glucagon Emergency Kit tiagabine hydrochloride
Lantus Solostar PA Invokana topiragen Novolin N Proglycem topiramate Novolin N Relion zonisamide Novolin R GASTROINTESTINAL PREFERRED Novolin R Relion PROTON PUMP INHIBITORS Banzel Novolin 70/30 GENERIC Celontin
Novolin 70/30 Relion QL esomeprazole magnesium Dilantin Novolog esomeprazole sodium Fycompa
Novolog Flexpen QL lansoprazole Gabitril
Novolog Mix 70/30 QL QL rabeprazole sodium Lyrica Novolog Mix 70/30 Prefilled Flexpen Esomeprazole Sodium Onfi Novolog Penfill LOW COST GENERIC Peganone
Toujeo Solostar QL omeprazole Potiga
QL
pantoprazole sodium Tegretol-XR NON-INSULIN HYPOGLYCEMICS Vimpat BIGUANIDES ULCER DRUGS LOW COST GENERIC GENERIC GENERIC carbamazepine
metformin HCL ER cimetidine epitol PREFERRED cimetidine HCL primidone Riomet famotidine valproate sodium LOW COST GENERIC misoprostol valproic acid metformin HCL nizatidine BIGUAN/SULFONYLUREA COMB. ranitidine HCL MIGRAINE/HEADACHE GENERIC Famotidine GENERIC
glipizide/metformin HCL QL,ST PREFERRED almotriptan malate
glyburide/metformin HCL Carafate dihydroergotamine mesylate
BIGUAN/THIAZOLIDEINEDIONE QL LOW COST GENERIC naratriptan HCL
GENERIC QL sucralfate rizatriptan benzoate
pioglitazone HCL QL rizatriptan benzoate odt pioglitazone HCL/metformin HCL
Effective January 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 4
sumatriptan succinateQL PREFERRED perphenazine
sumatriptan succinate refillQL IlevroQL prochlorperazine
zolmitriptanQL NevanacQL prochlorperazine edisylate
zolmitriptan odtQL prochlorperazine maleate
Dihydroergotamine MesylateQL CORTICOSTEROIDS/RELATED quetiapine fumarateQL
Sumatriptan SuccinateQL GENERIC risperidoneQL
PREFERRED dexamethasone sodium phosphate risperidone odtQL
RelpaxQL fluorometholone risperidone M-TABQL
neo-polycin HC thioridazine HCL
OPHTHALMICS neomycin/polymyxin/bacitracin/hydroco thiothixene rtisone ANTI-ALLERGIC AGENTS trifluoperazine HCL
prednisolone acetate QL GENERIC ziprasidone HCL
azelastine HCL sulfacetamide sodium/prednisolone Aripiprazole OdtQL
sodium phosphate QL cromolyn sodium Clozapine Odt tobramycin/dexamethasone epinastine HCL PREFERRED
PREFERRED QL olopatadine HCL Abilify
Alrex QL PREFERRED Abilify Discmelt FML Bepreve Abilify Maintena
Lotemax QL Pataday Latuda Pred Mild Molindone Hydrochloride Tobradex ANTI-GLAUCOMA AGENTS Risperdal Consta
Tobradex ST QL GENERIC Seroquel XR LOW COST GENERIC apraclonidine LOW COST GENERIC neomycin/polymyxin/dexamethasone betaxolol HCL fluphenazine HCL poly-dex brimonidine tartrate lithium carbonate
carteolol HCL lithium carbonate ER MIOTICS dorzolamide HCL GENERIC dorzolamide HCL/timolol maleate PSYCHOTHERAPEUTICS, MISC.
QL pilocarpine HCL latanoprost GENERIC
PREFERRED QL levobunolol HCL amphetamine/dextroamphetamine Phospholine Iodide timolol maleate ophthalmic gel clonidine HCL ER
QL forming dexedrine
QL MISCELLANEOUS QL Bimatoprost dexmethylphenidate HCL
PREFERRED QL Metipranolol dexmethylphenidate HCL ER QL,PA Restasis QL PREFERRED dextroamphetamine sulfate
QL Alphagan P dextroamphetamine sulfate ER OSTEOPOROSIS Combigan guanfacine ER
QL BISPHOSPHONATES QL Lumigan metadate ER
QL GENERIC QL Travatan Z methamphetamine HCL alendronate sodium LOW COST GENERIC methylphenidate hydrochloride QL ibandronate sodium QL timolol maleate methylphenidate HCL QL,ST risedronate sodium QL
methylphenidate HCL CD QL,ST risedronate sodium DR QL ANTI-INFECTIVES methylphenidate HCL ER
Etidronate Disodium QL GENERIC methylphenidate HCL SR
PREFERRED QL,PA ciprofloxacin HCL modafinil
Alendronate Sodium QL erythromycin zenzedi Fosamax Plus DQL garamycin Methylphenidate HCL ER
QL gatifloxacin Procentra SERM gentak PREFERRED
GENERIC QL gentamicin sulfate Daytrana
raloxifene hydrochloride QL,PA ilotycin Nuvigil
QL levofloxacin Quillivant XR
PSYCHOTHERAPEUTICS QL ofloxacin Strattera
ANTIPSYCHOTICS/ANTIMANIC QL romycin Vyvanse GENERIC Bacitracin
aripiprazoleQL PREFERRED SNRI ANTIDEPRESSANTS chlorpromazine HCL Besivance GENERIC QL clozapine QL Moxeza duloxetine HCL clozapine odtQL Vigamox venlafaxine HCL compazine LOW COST GENERIC venlafaxine HCL ER compro tobramycin sulfate Venlafaxine HCL ER fluphenazine decanoate
PREFERRED
haloperidol QL ANTI-INFLAMMATORY AGENTS Pristiq haloperidol decanoate GENERIC
haloperidol lactate bromfenac SSRI ANTIDEPRESSANTS loxapine cromolyn sodium GENERIC loxapine succinate diclofenac sodium citalopram hydrobromide olanzapineQL flurbiprofen sodium escitalopram oxalate QL olanzapine odt QL ketorolac tromethamine fluoxetine DR paliperidone ERQL,ST
Effective January 1, 2016
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 5
fluvoxamine maleate Asmanex Twisthaler 7 Metered or call member services at the number listed on your ID
QL QL card. Doses fluvoxamine maleate ER Pulmicort FlexhalerQL paroxetine HCL ER QvarQL sertraline HCL
LOW COST GENERIC
NASAL ANTIHISTAMINES fluoxetine HCL GENERIC paroxetine HCL azelastine HCLQL
olopatadine HCLQL RESPIRATORY
ANAPHYLAXIS TX AGENTS NASAL CORTICOSTEROIDS GENERIC
GENERIC Epinephrine budesonideQL PREFERRED
flunisolideQL Auvi-q fluticasone propionateQL Epipen 2-PAK triamcinolone acetonideQL Epipen-JR 2-PAK PREFERRED
NasonexQL ANTICHOLINERGICS
PREFERRED
QL STEROID/BETA AGONIST Atrovent HFA
QL PREFERRED Spiriva Handihaler
QL DuleraQL Spiriva Respimat
QL SymbicortQL Tudorza Pressair
LOW COST GENERIC
QL MISCELLANEOUS ipratropium bromide PREFERRED
DymistaQL ANTICHLNRGC/BETA AGONIST
GENERIC
UROLOGICALS ipratropium bromide/albuterol sulfateQL BENIGN PRSTATC HYPRPLSIA
PREFERRED GENERIC
Combivent RespimatQL alfuzosin HCL ER
dutasteride
BETA AGONISTS dutasteride/tamsulosin hydrochloride
GENERIC PREFERRED
albuterol Rapaflo
albuterol sulfate LOW COST GENERIC
albuterol sulfate ER finasteride
albuterol TAB 4MG tamsulosin HCL
levalbuterolQL
levalbuterol HCLQL ERECTILE DYSFUNCTION
terbutaline sulfate PREFERRED
Metaproterenol Sulfate CialisQL
PREFERRED ViagraQL
Arcapta NeohalerQL
Foradil AerolizerQL URINARY ANTISPASMODICS
PerforomistQL GENERIC
Proair HFAQL bethanechol chloride
Proair RespiclickQL flavoxate HCL
Serevent DiskusQL oxybutynin chloride
oxybutynin chloride ER
LEUKOTRIENE RCPTR ANTGNST tolterodine tartrate
GENERIC tolterodine tartrate ER
montelukast sodium trospium chloride
zafirlukastPA trospium chloride ER
PREFERRED
PULMONARY CORTICOSTEROIDS Gelnique
GENERIC Myrbetriq
budesonide OxytrolQL
PREFERRED Toviaz
Asmanex HFAQL Vesicare
Asmanex Twisthaler 120 Metered
DosesQL
Asmanex Twisthaler 14 Metered Formulary Disclaimer: Coverage for some drugs may be DosesQL limited to specific dosage forms and/or strengths. The
Asmanex Twisthaler 30 Metered benefit design determines what is covered and the DosesQL applicable co-payment. The medications listed on this
Asmanex Twisthaler 60 Metered formulary are subject to change pursuant to the formulary DosesQL management activities of Optum. 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
Effective January 1, 2016 v.4
PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; 6 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.