Select Drug Formulary

HMSA Select Drug List

The drugs in this brochure have a fixed copayment and are covered by your drug plan. If your prescription drug isn't listed here, that means your plan doesn't pay for it or it's an Other Brand drug that may be covered but at a higher cost.

Prescription drugs are listed in alphabetical order. Generic names are in lowercase (e.g., acyclovir) and brand names are uppercase (e.g., ADVAIR DISKUS).

This drug list is subject to change and drugs may be added or removed without notice. Please contact HMSA to confirm your drug plan coverage. This list is effective April 1, 2016.

A ARNUITY ELLIPTA buspirone ciprofloxacin ASMANEX butalbital/acetaminophen/caffeine ciprofloxacin ointment abacavir ASMANEX HFA butalbital/aspirin/caffeine citalopram abacavir/lamivudine/zidovudine atenolol butorphanol clarithromycin acarbose atenolol/chlorthalidone BYDUREON clarithromycin ext-rel acebutolol atorvastatin QL clindamycin acetazolamide atovaquone C clobetasol acetazolamide ext-rel ATRIPLA clocortolone crm 0.1% cabergoline acetylcysteine ATROVENT HFA clomipramine calcipotriene acitretin AUVI-Q clonazepam calcitonin-salmon nasal acyclovir azathioprine clonidine calcitriol acyclovir ointment azelastine clopidogrel calcitriol ointment adapalene AZILECT clorazepate calcium acetate adefovir dipivoxil azithromycin clotrimazole CANASA ADVAIR DISKUS QL clozapine capecitabine SP ADVAIR HFA QL B codeine captopril ADVICOR codeine/acetaminophen QL bacitracin/neomycin/polymyxin B captopril/hydrochlorothiazide albuterol codeine/aspirin QL ointment CARAC albuterol/ipratropium solution codeine/promethazine bacitracin/neomycin/polymyxin B/ carbamazepine alendronate colchicine tablets QL hydrocortisone ointment carbamazepine ext-rel ALKERAN colchicine/probenecid bacitracin/polymyxin B ointment CARBATROL allopurinol colestipol baclofen carbidopa/levodopa alosetron COMBIVENT RESPIMAT balsalazide carbidopa/levodopa ext-rel ALPHAGAN P 0.1% COMPLERA BARACLUDE carbidopa/levodopa/entacapone alprazolam CORDARONE benazepril carisoprodol QL ALREX CORDRAN TAPE benazepril/amlodipine carteolol amantadine COREG CR benazepril/hydrochlorothiazide carvedilol amcinonide CORTISPORIN CREAM benzonatate cefaclor amiloride CREON benzoyl peroxide cefdinir amiloride/hydrochlorothiazide CRIXIVAN benztropine cefixime aminophylline cromolyn sodium betamethasone cefpodoxime amiodarone cyclobenzaprine BETAPACE AF cefprozil amitriptyline CYCLOPHOSPHAMIDE CAPSULES bethanechol cefuroxime amlodipine cyclosporine bexarotene capsules SP celecoxib amlodipine/benazepril cyclosporine, modified bicalutamide CELLCEPT amlodipine/telmisartan cyproheptadine bimatoprost cephalexin amlodipine/valsartan CYSTADANE bisoprolol CHANTIX QL amlodipine/valsartan/ bisoprolol/hydrochlorothiazide CHEMET hydrochlorothiazide D BLEPHAMIDE chlordiazepoxide ammonium lactate 12% BREO ELLIPTA chlordiazepoxide/amitriptyline danazol amoxapine BRILINTA chlorhexidine gluconate dantrolene amoxicillin brimonidine chloroquine dapsone amoxicillin/clavulanate bromfenac sodium eye drops chlorpromazine DELZICOL amoxicillin/clavulanate ext-rel bromocriptine chlorpropamide DEPAKENE ampicillin budesonide inhalation suspension chlorthalidone DEPAKOTE anagrelide bumetanide chlorzoxazone DEPAKOTE ER anastrozole BUPHENYL SP cholestyramine desipramine ANDRODERM QL buprenorphine ciclopirox desmopressin ANDROGEL QL bupropion cilostazol desonide APRISO bupropion ext-rel CILOXAN OINTMENT desoximetasone APTIVUS bupropion SR cimetidine desvenlafaxine ext-rel aripiprazole

NOTE: Generic - Lowercase Preferred Brand Name - Uppercase

PA = Prior Authorization Required QL = Quantity Limits G = Generic Copayment SP = Specialty Drug ST = Step Therapy Required 0 = Zero Copayment ** = Coverage is Subject to Plan Benefits

dexamethasone ethinyl estradiol/levonorgestrel H lansoprazole + amoxicillin + DIASTAT ethosuximide clarithromycin halobetasol diazepam etodolac LANTUS G haloperidol diazepam rectal gel EVAMIST latanoprost HEPSERA diclofenac potassium leflunomide HUMALOG G diclofenac sodium 0.1% soln F LETAIRIS PA, SP HUMULIN G diclofenac sodium delayed-rel leucovorin famciclovir hydralazine diclofenac sodium ext-rel LEVEMIR G famotidine hydrochlorothiazide dicyclomine levetiracetam FARESTON hydrocodone/acetaminophen didanosine delayed-rel levetiracetam ext-rel FAST TAKE TEST STRIPS 0 hydrocodone/ibuprofen diflorasone levobunolol felbamate hydrocortisone diflunisal levocarnitine felodipine hydrocortisone butyrate lipid cream digoxin levocetirizine fenofibrate 0.1% DILANTIN levothyroxine fenoprofen hydromorphone ext-rel diltiazem LEXIVA fentanyl oral PA, QL hydroxychloroquine diltiazem ext-rel lidocaine fentanyl transdermal QL hydroxyzine diphenoxylate/atropine liothyronine FINACEA dipyridamole lisinopril finasteride I dipyridamole ext-rel/aspirin lisinopril/hydrochlorothiazide flecainide disopyramide ibuprofen lithium carbonate FLOVENT DISKUS divalproex imatinib SP LITHOBID FLOVENT HFA divalproex sodium delayed-rel imipramine lomustine fluconazole divalproex sodium ext-rel imiquimod loperamide fludrocortisone DIVIGEL indapamide lorazepam flunisolide nasal spray donepezil INTELENCE losartan fluocinolone dorzolamide INVIRASE losartan/hydrochlorothiazide fluocinolone acetonide oil 0.01% dorzolamide/timolol INVOKAMET ST LOTEMAX fluocinonide doxazosin INVOKANA ST lovastatin fluorometholone doxepin ipratropium loxapine fluorouracil doxercalciferol irbesartan LUMIGAN fluoxetine doxycycline irbesartan/hydrochlorothiazide LYRICA QL fluphenazine DULERA ISENTRESS SP flurbiprofen duloxetine delayed-rel isoniazid M flutamide dutasteride isosorbide dinitrate fluticasone maprotiline isosorbide mononitrate fluvoxamine meclizine E isotretinoin folic acid meclofenamate isradipine econazole fosinopril medroxyprogesterone acetate itraconazole EDURANT fosinopril/hydrochlorothiazide mefloquine ivermectin EFFIENT FREESTYLE INSULINX TEST megestrol

ELIDEL STRIPS 0 J meloxicam ELIQUIS FREESTYLE LITE TEST STRIPS 0 memantine tablets ELMIRON FREESTYLE TEST STRIPS 0 JANUMET MEPHYTON EMCYT furosemide JANUMET XR meprobamate EMEND QL JANUVIA mercaptopurine EMTRIVA G mesalamine enalapril K mesalamine rectal enema gabapentin enalapril/hydrochlorothiazide metaproterenol GABITRIL KALETRA entacapone metformin galantamine KEPPRA entecavir metformin ext-rel gatifloxacin eye drops KEPPRA XR EPIPEN methadone gemfibrozil ketoprofen EPIPEN JR. methazolamide gentamicin ketoprofen ext-rel eplerenone methenamine hippurate glimepiride ketorolac EPZICOM methenamine mandelate glipizide KLONOPIN ERGOMAR methimazole glipizide ext-rel KOMBIGLYZE XR ERY-TAB methotrexate glipizide/metformin erythromycin methoxsalen oral GLUCAGEN L erythromycin/benzoyl peroxide methyldopa GLUCAGON EMERGENCY KIT labetalol esomeprazole methyldopa/hydrochlorothiazide glyburide lactulose

ESTRACE VAGINAL CREAM methylphenidate QL glyburide/metformin LAMICTAL estradiol methylphenidate ext-rel QL GLYSET lamivudine estropipate methylprednisolone granisetron lamotrigine eszopiclone metoclopramide griseofulvin microsize lamotrigine ext-rel ethambutol metolazone griseofulvin ultramicrosize lamotrigine orally disintegrating ethinyl estradiol/desogestrel metoprolol succinate ext-rel guanfacine tablets ethinyl estradiol/drospirenone metoprolol tartrate guanfacine ext-rel lansoprazole

NOTE: Generic - Lowercase Preferred Brand Name - Uppercase

PA = Prior Authorization Required QL = Quantity Limits G = Generic Copayment SP = Specialty Drug ST = Step Therapy Required 0 = Zero Copayment ** = Coverage is Subject to Plan Benefits

metoprolol/hydrochlorothiazide omeprazole PROAIR HFA SORIATANE metronidazole ondansetron probenecid sotalol metronidazole gel 1% ONETOUCH TEST STRIPS 0 prochlorperazine SPIRIVA HANDIHALER minocycline ONETOUCH ULTRA PROGRAF SPIRIVA RESPIMAT minoxidil TEST STRIPS 0 PROMACTA SP spironolactone mirtazapine ONGLYZA promethazine spironolactone/hydrochlorothiazide misoprostol ORAPRED ODT propafenone stavudine moexipril orphenadrine ext-rel propantheline STIMATE montelukast oxcarbazepine propranolol STRIBILD morphine OXSORALEN-ULTRA propranolol ext-rel STRIVERDI RESPIMAT morphine ext-rel oxybutynin propranolol/hydrochlorothiazide SUBOXONE FILM moxifloxacin oxybutynin ext-rel propylthiouracil sucralfate multivitamins/fluoride ** oxycodone protriptyline sulfacetamide mupirocin oxycodone/acetaminophen QL PULMICORT sulfacetamide/prednisolone mycophenolate mofetil oxycodone/aspirin QL pyrazinamide sulfadiazine mycophenolate sodium delayed-rel OXYCONTIN QL pyridostigmine sulfamethoxazole/trimethoprim MYFORTIC pyridostigmine ext-rel sulfasalazine MYLERAN P sulindac MYSOLINE Q sumatriptan QL pantoprazole SURESTEP TEST STRIPS 0 paromomycin quetiapine N SURMONTIL paroxetine quinapril SUSTIVA nabumetone paroxetine ext-rel quinapril/hydrochlorothiazide SYMBICORT nadolol penicillin VK QVAR SYNAREL naltrexone pentoxifylline SYNTHROID NAMENDA XR perindopril R naphazoline permethrin rabeprazole delayed-rel T naproxen perphenazine raloxifene naproxen sodium ext-rel phenazopyridine tacrolimus ramipril NASCOBAL phenelzine TAMIFLU QL ranitidine nateglinide phenobarbital tamoxifen RELENZA QL NEBUPENT phenylephrine tamsulosin RELPAX QL neomycin phenytoin TARGRETIN CAPSULES SP RENVELA NEORAL phenytoin sodium extended TAZORAC repaglinide NEURONTIN pilocarpine TEGRETOL RESCRIPTOR nevirapine PILOPINE HS TEGRETOL-XR RESTASIS QL nevirapine ext-rel pindolol telmisartan REYATAZ niacin ext-rel pioglitazone telmisartan/amlodipine ribavirin PA, SP NIASPAN pioglitazone/glimepiride telmisartan/hydrochlorothiazide rifabutin nicardipine pioglitazone/metformin temazepam rifampin nifedipine ext-rel piroxicam terazosin RILUTEK nimodipine podofilox terbinafine riluzole NITRO-DUR polyethylene glycol terbutaline risedronate nitrofurantoin potassium chloride testosterone gel QL risperidone nitroglycerin potassium chloride/potassium tetrabenazine SP rivastigmine transdermal nitroglycerin lingual spray bicarbonate/citrate tetracycline rizatriptan QL nitroglycerin transdermal PRADAXA THEO-24 ropinirole NITROSTAT pramipexole theophylline ext-rel RYTHMOL nizatidine pramipexole ext-rel thioridazine RYTHMOL SR norelgestromin/ethinyl estradiol PRANDIMET thiothixene norethindrone pravastatin QL S THYROLAR NORPACE prazosin tiagabine SANDIMMUNE NORPACE CR PRED FORTE timolol SAVELLA nortriptyline PRED MILD timolol maleate gel selegiline NORVIR prednisolone TIVICAY selenium sulfide NOVOLIN G prednisolone acetate 1% tizanidine SELZENTRY NOVOLOG G prednisolone sodium phosphate TOBI SP SENSIPAR SP NUVARING prednisone TOBRADEX OINTMENT SEROQUEL XR nystatin PREMARIN tobramycin sertraline PREMARIN VAGINAL CREAM tobramycin inhalation solution SP sildenafil SP O PREMPHASE tobramycin/dexamethasone silver sulfadiazine PREMPRO TOBREX OINTMENT ofloxacin SIMCOR prenatal vitamins ** tolbutamide olanzapine simvastatin QL PREVPAC tolmetin olopatadine nasal spray sirolimus PREZISTA tolterodine olopatadine ophth sodium fluoride primidone tolterodine ext-rel omega-3 acid ethyl esters sodium polystyrene sulfonate

NOTE: Generic - Lowercase Preferred Brand Name - Uppercase

PA = Prior Authorization Required QL = Quantity Limits G = Generic Copayment SP = Specialty Drug ST = Step Therapy Required 0 = Zero Copayment ** = Coverage is Subject to Plan Benefits

TOPAMAX TRILEPTAL VECTICAL X topiramate trimethobenzamide venlafaxine XARELTO torsemide trimethoprim venlafaxine ext-rel XENAZINE SP TRACLEER PA, SP trimethoprim/polymyxin B VENTOLIN HFA tramadol trimipramine verapamil Z tramadol ext-rel TRUVADA verapamil ext-rel tramadol/acetaminophen QL VICTOZA zaleplon QL trandolapril U VIDEX SOLUTION ZARONTIN trandolapril/verapamil ext-rel VIGAMOX zidovudine ursodiol trazodone VIRACEPT ziprasidone tretinoin gel V VIREAD ZIRGAN triamcinolone VORTEX zolpidem QL VAGIFEM triamterene/hydrochlorothiazide VYVANSE ZONEGRAN valacyclovir triazolam zonisamide valganciclovir trifluoperazine W ZYLET valproic acid trifluridine warfarin valsartan trihexyphenidyl

NOTE: Generic - Lowercase Preferred Brand Name - Uppercase

PA = Prior Authorization Required QL = Quantity Limits G = Generic Copayment SP = Specialty Drug ST = Step Therapy Required 0 = Zero Copayment ** = Coverage is Subject to Plan Benefits

NOTE

The status of a drug on this list is current as of the date of this publication.

The list serves as a guide to product selection for our providers and members. The list is subject to change. Participating pharmacies have the most up-to-date formulary information at the time prescriptions are filled. New drugs, strengths, forms, and/or therapeutic categories introduced in the marketplace will be reflected in the formulary, as applicable, following the completion of HMSA’s review process.

Brand-name drugs not listed should be considered Other Brand drugs. Not all generic drugs may be listed.

Coverage of a drug will depend on your drug plan.

HMSA's mission is to provide the people of Hawaii access to a sustainable, quality health care system that improves the overall health and well-being of our state.

HMSA CENTERS Convenient evening and Saturday hours:

HMSA Center @ Honolulu 818 Keeaumoku St. | Monday through Saturday, 8 a.m. - 6 p.m.

HMSA Center @ Pearl City Pearl City Gateway | 1132 Kuala St., Suite 400 Monday through Saturday, 9 a.m. - 7 p.m.

HMSA Center @ Hilo Waiakea Center | 303A E. Makaala St. Monday through Saturday, 9 a.m. - 7 p.m.

OFFICES Visit your local HMSA office Monday through Friday, 8 a.m. - 4 p.m.:

PHONE 948-6111 on Oahu

If you are calling from the U.S. Mainland, please call 1 (800) 776-4672. If you need to call a local Hawaii telephone number from the Mainland, the area code is 808.

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.