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2018 Prime Preferred Drug List the Universal Rx Prime Drug Formulary Identifies Commonly Prescribed Generic and Brand Drugs

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2018 Prime Preferred Drug List the Universal Rx Prime Drug Formulary Identifies Commonly Prescribed Generic and Brand Drugs 2018 Prime Preferred Drug List The Universal Rx Prime Drug Formulary identifies commonly prescribed generic and brand drugs. While this document does not identify a specific copay tier for each medicine, drugs on this list are preferred for use and will generally be assigned lower copays defined by your drug benefit plan. If your prescription drug plan includes a three-tier copay structure, these drugs would go through at the preferred copayment tiers. Your plan documents may have coverage requirements or limitations that may exclude certain drugs or drug classes. Please review your benefit documents for information about specific medicines, and if you have questions please call the phone number printed on your member ID card. Also, when you are with your doctor and a prescribed medicine is going to be part of your treatment, please ask your doctor to prescribe a generic drug when it is appropriate. Please note that a brand name drug may move to nonpreferred status if a generic becomes available during the year. KEY: CAPITAL letters – Preferred BRAND drugs, lower case letters – generic drugs, [INJ] – Injectable medicines A B C D E F G H I J K L M N O P Q R S T U V W X Z A aripiprazole BYETTA [INJ] COMBIVENT RESPIMAT doxycycline hyclate ABILIFY MAINTENA [INJ] ARISTADA [INJ] BYSTOLIC COMPLERA doxycycline monohydrate ABSORICA ARNUITY ELLIPTA BYVALSON COPAXONE 40 MG (INJ ) DUAVEE ACANYA ASACOL HD COREG CR DULERA acetaminophen/codeine ASMANEX HFA C CORLANOR duloxetine delayed-release ACTEMRA [INJ] ASMANEX TWISTHALER CORTIFOAM DUPIXET [INJ] atenolol CANASA COSENTYX [INJ] DYMISTA ACTHAR H.P. [INJ] CARAC acyclovir atenolol/chlorthalidone CREON atorvastatin carbidopa/levodopa CRINONE ADCIRCA carvedilol E ADEMPAS ATRIPLA cyanocobalamin [INJ] ATROVENT HFA cefdinir cyclobenzaprine EDARBI ADVAIR DISKUS cefuroxime axetil EDARBYCLOR ADVAIR HFA AVONEX [INJ] AZASITE celecoxib EFFIENT ADVATE CELONTIN D ELIDEL AFSTYLA azelastine nasal spray DAKLINZA azithromycin cephalexin ELIGARD AKYNZEO CERDELGA DALIRESP ELIQUIS ALBENZA CETROTIDE [INJ] DAYTRANA ELMIRON albuterol nebulization solution B chlorhexidine gluconate DELZICOL EMVERM alendronate baclofen chlorthalidone DESCOVY enalapril ALINIA BANZEL CHANTIX desloratadine ENBREL [INJ] allopurinol benazepril CIALIS desonide enoxaparin [INJ] ALPHAGAN P 0.1% benzonatate CIPRODEX dexamethasone ENSTILAR alprazolam BEPREVE ciprofloxacin dexmethylphenidate ext- ENTRESTO ALREX BETASERON [INJ] citalopram release ENTYVIO amiodarone dextroamphetamine- BETHKIS clarithromycin EPCLUSA AMITIZA BEVESPI AEROSPHERE clindamycin hcl amphetamine EPIDUO amitriptyline BILTRICIDE clindamycin phosphate dextroamphetamine- EPIDUO FORTE amlodipine bisoprolol/hctz clindamycin phosphate/benzoyl amphetamine ext-release EPINEPHRINE AUTOINJECTOR(by amlodipine/benazepril BREO ELLIPTA peroxide diazepam Mylan) [INJ] amlodipine/valsartan BRILINTA clobetasol propionate diclofenac sodium EPIPEN amoxicillin dicyclomine BRISDELLE clomiphene citrate EPIPEN JR [INJ] amoxicillin/potassium clavulanate budesonide nebulization susp. clonazepam digoxin ergocalciferol AMPYRA bupropion clonidine DILANTIN 30MG CAPSULE erythromycin eye ointment anastrozole diltiazem ext-release bupropion ext-release clopidogrel ESBRIET ANDRODERM diphenoxylate/atropine buspirone clotrimazole/betamethasone escitalopram ANDROGEL 1.62% divalproex delayed-release butalbital/acetaminophen/ dipropionate esomeprazole divalproex ext-release ANORO ELLIPTA caffeine COLCRYS magnesium-delayed-release DIVIGEL apri BUTRANS COMBIGAN ESTRACE CREAM donepezil ARANESP [INJ] BYDUREON [INJ] COMBIPATCH estradiol ARCAPTA NEOHALER doxazosin Disclaimer: This information is confidential and proprietary and may not be reproduced or disclosed in whole or part unless authorized in writing by an authorized representative of Universal Rx. v.2017-11 This document is in effect January 1, 2018. 2018 Prime Preferred Drug List estradiol patch gildess fe INVOKAMET losartan N estradiol/norethindrone acetate GILENYA INVOKAMET XR losartan/hctz nabumetone ESTRING GILOTRIF INVOKANA LOTEMAX NAMENDA XR eszopiclone glimepiride irbesartan lovastatin NAMZARIC etodolac glipizide IRESSA LUMIGAN naproxen glipizide ext-release EUFLEXXA ISENTRESS LYRICA naproxen sodium EVEKEO GLUCAGEN [INJ] isosorbide mononitrate NARCAN NASAL SPRAY EXTAVIA GLUCAGON [INJ] ext-release M NASCOBAL glyburide ezetimibe MAKENA [INJ] NATACYN GLYXAMBI ezetimibe / simvastatin J meclizine NATAZIA GONAL-F JAKAFI medroxyprogesterone neomycin/polymyxin/ HC ear F GONAL-F RFF JANUMET meloxicam drops GONAL-F RFF REDI-JECT [INJ] famotidine JANUMET XR MEPHYTON NEULASTA [INJ] GRALISE FARESTON JANUVIA MENOPUR [INJ] NEUPOGEN [INJ] GRANIX [INJ] FARXIGA JARDIANCE MESTINON SYRUP NEVANAC GRASTEK fenofibrate JENTADUETO metaxalone NEXIUM PACKETS guanfacine ext-release fenofibrate micronized JENTADUETO XR metformin niacin ext-release fenofibric acid delayed-release junel fe metformin ext-release nifedipine ext-release fentanyl patches H methimazole NINLARO FETZIMA HARVONI methocarbamol nitrofurantoin mono/macrocrystal FINACEA HELIXATE FS [INJ] K methotrexate NORDITROPIN [INJ] finasteride HIZENTRA ketoconazole topical methylphenidate nortriptyline FLECTOR HUMALOG [INJ] ketorolac methylphenidate ext-release NORVIR FLOVENT DISKUS HUMATROPE [INJ] KITABIS PAK methylprednisolone NOVOEIGHT FLOVENT HFA HUMIRA [INJ] KOGENATE metoclopramide hcl NOVOLIN fluconazole HUMULIN [INJ] KOVALTRY metoprolol succinate ext-release NOVOLOG [INJ] fluocinonide HUMULIN R U-500 KYLEENA metoprolol tartrate NOVOTWIST NEEDLES fluoxetine KWIKPEN metronidazole NOXAFIL [INJ] fluticasone nasal spray hydralazine L metronidazole topical NUCYNTA hydrochlorothiazide metronidazole vaginal gel NUCYNTA ER folic acid labetalol hydrocodone/acetaminophen microgestin fe NUEDEXTA FORTEO [INJ] lamotrigine hydrocodone/chlorpheniramine MINIVELLE NUVARING FRAGMIN [INJ] lansoprazole delayed-release polistirex ext-release minocycline nystatin oral susp. FREESTYLE KITS/METERS LANTUS [INJ] hydrocortisone topical MIRENA nystatin topical FREESTYLE FREEDOM latanoprost eye solution FREESTYLE FREEDOM LITE hydromorphone LATUDA mirtazapine FREESTYLE INSULINX hydroxychloroquine LETAIRIS MIRVASO FREESTYLE LITE hydroxyzine hcl MITIGARE O LEVEMIR [INJ] ODEFSEY FREESTYLE TEST STRIPS hydroxyzine pamoate levetiracetam moderiba FREESTYLE, HYSINGLA ER mometasone OFEV levocetirizine ofloxacin FREESTYLE INSULINX levofloxacin mononessa FREESTYLE LITE MONOVISC [INJ] olanzapine I levothyroxine sodium olmesartan furosemide ibandronate lidocaine patches montelukast FYCOMPA morphine sulfate ext-release olmesartan/hctz IBRANCE LINZESS omega-3 acid ethyl esters ibuprofen MOVANTIK liothyronine omeprazole delayed-release ILARIS MOXEZA G LIPOFEN ondansetron ILEVRO multivitamins/fluoride gabapentin lisinopril ondansetron orally- disintegrating IMBRUVICA lisinopril/hctz mupirocin GELNIQUE tablets INCRUSE ELLIPTA LIVALO MUSE gemfibrozil ONETOUCH KITS/METERS; ULTRA indomethacin LO LOESTRIN FE MYRBETRIQ GENOTROPIN [INJ] 2, ULTRAMINI, VERIO, VERIO FLEX, INLYTA lorazepam GENVOYASP VERIO IQ, VERIO SYNC Disclaimer: This information is confidential and proprietary and may not be reproduced or disclosed in whole or part unless authorized in writing by an authorized representative of Universal Rx. v.2017-11 This document is in effect January 1, 2018. 2018 Prime Preferred Drug List ONETOUCH TEST STRIPS; ULTRA, progesterone micronized SEREVENT DISKUS terconazole vaginal VIAGRA VERIO PROLENSA SEROSTIM [INJ] testosterone cypionate [INJ] VIBERZI ONEXTON promethazine sertraline timolol maleate eye solution VICTOZA [INJ] ONFI promethazine/dextromethorphan SIMPONI 100 MG [INJ] TIVICAY VIEKIRA PAK OPSUMIT propranolol simvastatin tizanidine VIEKIRA XR ORACEA propranolol ext-release SKYLA TOBI PODHALER VIIBRYD ORKAMBI PULMICORT FLEXHALER SOLIQUA [INJ] TOBRADEX OINTMENT VIMPAT ORTHOVISC [INJ] PULMOZYME SOLODYN TOBRADEX ST VIOKACE OTEZLA PURIXAN SOMATULINE DEPOT-[INJ] tobramycin eye solution VIREAD OTOVEL PYLERA SOOLANTRA tobramycin/dexamethasone eye VOTRIENT OTREXUP [INJ] SOVALDI suspension VYVANSE oxcarbazepine Q SPIRIVA HANDIHALER topiramate oxybutynin ext-release QNASL SPIRIVA RESPIMAT TOUJEO SOLOSTAR [INJ] W oxycodone QUDEXY SPORANOX SOL TOVIAZ warfarin oxycodone/acetaminophen spironolactone TRACLEER quetiapine WELCHOL OXYCONTIN sprintec TRADJENTA QUILLICHEW ER SPRYCEL tramadol QUILLIVANT XR X Quinapril STELARA [INJ] TRAVATAN Z P XALKORI QVAR STIOLTO RESPIMAT trazodone pantoprazole delayed-release STIVARGA TRESIBA [INJ] XARELTO paroxetine R STRENSIQ [INJ] triamcinolone topical XELJANZ PAZEO rabeprazole delayed-release STRIBILD triamterene/hctz XELJANZ XR penicillin v potassium RAGWITEK STRIVERDI RESPIMAT trinessa XIFAXAN PENTASA raloxifene SUBOXONE SL FILM tri-sprintec XIGDUO XR PERFOROMIST ramipril sulfamethoxazole/trimethoprim TRIUMEQ XIIDRA PHOSLYRA RANEXA sumatriptan TRUVADA XTANDI PICATO ranitidine SUPREP TUDORZA PRESSAIR XULTOPHY [INJ] pioglitazone RAPAFLO SUSTIVA TRULICITY XYREM PLEGRIDY [INJ] RASUVO [INJ] SUTENT TYKERB polymyxin/trimethoprim REBIF [INJ] SYMBICORT TYMLOS [INJ] solution RECTIV SYMLINPEN [INJ] Z ZARXIO [INJ] POMALYST REGRANEX GEL SYNAGIS [INJ] U potassium chloride ext- RELENZA ZELBORAF SYNJARDY UCERIS TABLETS release RELISTOR [INJ] ZENPEP SEEBRI ULORIC POTIGA REMICADE [INJ] ZEPATIER UPTRAVI PRALUENT [INJ] RENVELA zolpidem UTIBRON pramipexole REPATHA [INJ] T zolpidem ext-release TACLONEX SUSP pravastatin RESTASIS ZOMIG NASAL TAGRISSO prednisolone acetate eye REVLIMID V ZONTIVITY suspension REYATAZ tamoxifen valacyclovir ZORTRESS tamsulosin
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