2020 FOURTH QUARTER Quick Reference Preferred Drug List - … · 2020. 9. 14. · AMRIX ANDROGEL 1%...
Transcript of 2020 FOURTH QUARTER Quick Reference Preferred Drug List - … · 2020. 9. 14. · AMRIX ANDROGEL 1%...
QUICK REFERENCE DRUG LIST
A
abacavir tabletabacavir-lamivudine ABILIFY MAINTENA**
abirateroneACCU-CHEK AVIVA PLUS
STRIPS AND KITS 11
ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11
ACCU-CHEK GUIDE STRIPS AND KITS 11
ACCU-CHEK SMARTVIEW STRIPS AND KITS 11
acitretin
ACUVAILacyclovir capsule, tabletadapaleneADEMPASADVAIR DISKUS
ADVAIR HFAADYNOVATE
AFINITOR
AIMOVIGAJOVY
albuterol inhalation solutionalbuterol sulfate CFC-free
aerosolalendronatealfuzosin ext-relaliskiren
allopurinolalosetronALPHAGAN P
alprazolamamantadineambrisentanamilorideAMITIZA
2020 FOURTH QUARTERQuick Reference Preferred Drug List - Tiers 1&2
The 2020 Quick Reference Preferred Drug List is an alphabetical listing of preferred and generic drugs. Generics should be considered the first line of prescribing. The preferred medicines are listed to help identify products that are clinically appropriate and cost effective. This is not an all-inclusive list and is subject to change. This list represents brand products in CAPS and generic products in lowercase.
The Preferred Alternatives Drug List, lists non-preferred brand-name drugs with their preferred and/or generic alternatives.
Please note that specific prescription benefit plan designs may not cover certain medicines, regardless of their appearance in this document. Please read the prescription drug section of your Group Plan Booklet- certificate. Also please note that some of the drugs listed may be on one of the pharmacy programs; Dose Optimization, Prior Authorization or Quantity limits - those drugs are identified with an asterisk (*).
We encourage you to register and use the Caremark website that is linked to the www.nipponlifebenefits.com website. Use the “Check Drug Coverage and Cost” tool on the CVS Caremark website for the most up to date information. If you do not have access to the website, or would prefer to talk to a customer service representative, have your ID card available and call CVS Caremark customer service at 866-644-7527.
We Cover family planning services which consist of FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage section of your Nippon Life Insurance Company of America Booklet-Certificate, counseling on use of contraceptives and related topics, and sterilization procedures for women. Such services are not subject to Copayments, Deductibles or Coinsurance when provided in accordance with the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF and when provided by a Participating Provider. Please see page 11-12 for the additional information.
NOTHING HEREIN IS A GUARANTEE OF BENEFITS OR ELIGIBILITY. ALL TERMS, PROVISIONS, CONDITIONS, LIMITITATIONS AND EXCLUSIONS SHOWN IN YOUR NIPPON LIFE INSURANCE COMPANY OF AMERICA CERTIFICATE AND MASTER POLICY WILL GOVERN.
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amlodipineamlodipine-atorvastatinamlodipine-olmesartanamlodipine-telmisartanamlodipine-valsartanamlodipine-valsartan-
hydrochlorothiazide
amoxicillinamoxicillin-clavulanateamphetamine-
dextroamphetamine mixed salts
amphetamine-dextroamphetamine mixed salts ext-rel †
ANDRODERM* ANORO ELLIPTA
ARANESP aripiprazole ARISTADA ARISTADA INITIO armodafinil* ARNUITY ELLIPTA
atazanavir atenolol atomoxetine atorvastatin ATRIPLA AUBAGIO AUSTEDO azelaic acid gel azelastine azithromycin
AZOPT
B
balsalazideBAQSIMIBASAGLARBD ULTRAFINE INSULIN
SYRINGES AND NEEDLES
BELBUCA* BELSOMRA
benzonatate (except NDCs^
69336012615, 69499032915)
benzoyl peroxide BESIVANCE BETASERON BETHKISBETIMOLBETOPTIC S BEVESPI AEROSPHERE
bicalutamideBIDILBIKTARVY
bosentanBOSULIFBREO ELLIPTA BRILINTAbrimonidinebromfenacBRYHALI*budesonide capsule budesonide ext-rel budesonide inhalation
suspension
buprenorphine transdermal buprenorphine-naloxone
sublingualbupropionbupropion ext-rel 7
BYSTOLIC*
C
CABOMETYX calcipotriene ointment,
solutioncalcitonin-salmoncalcium acetate candesartan candesartan-
hydrochlorothiazide
carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopa-
entacaponecarvedilolcarvedilol phosphate ext-rel cefdinircefprozilcefuroxime axetil celecoxibcephalexinCERDELGACEREZYME CETROTIDE cholestyramineciclopirox*CILOXAN OINTMENT
CIMDUOcinacalcetCIPRODEXciprofloxacincitalopramCITRANATAL
clarithromycin clarithromycin ext-rel CLIMARA PRO clindamycinclindamycin gel (except NDC^
68682046275)
clindamycin solution clindamycin-benzoyl
peroxideclobazamclobetasol cream, foam, gel,
lotion, ointment, shampoo clonazepamclopidogrelclotrimazoleclozapinecodeine-acetaminophen* colchicine tablet colesevelamCOMBIGAN COMBIPATCH
COMPLERA COPAXONE
COPIKTRACORLANOR CORTIFOAM
COSENTYX
CREON
CRINONE
cromolyn sodiumcyclobenzaprine 8
D
DALIRESPdarifenacin ext-rel DESCOVY
desonide desoximetasone desvenlafaxine ext-rel* dexamethasone DEXCOM CONTINUOUS
GLUCOSE MONITORING SYSTEMDEXILANT* diazepamdiazepam rectal gel diclofenacdiclofenac sodium diclofenac sodium gel 1%
(except NDC^ 69499031866)
diclofenac sodium solution diclofenac sodium-
misoprostoldicloxacillindicyclomineDIFICIDdigoxindiltiazem ext-rel 5
dipyridamole ext-rel-aspirin divalproex sodium divalproex sodium ext-rel DIVIGELdonepezildorzolamidedorzolamide-timolol DOVATOdoxazosindoxepindoxycycline hyclate 20 mg doxycycline hyclate capsule doxycycline monohydrate
delayed-rel capsule doxylamine-pyridoxine
delayed-reldronabinolDUAVEEduloxetineDUPIXENT
DUREZOLDUROLANE
dutasteridedutasteride-tamsulosin DYMISTA
E
econazoleeletriptanELIGARDELIQUIS
EMGALITYEMVERM*ENBREL
ENDOMETRINentacapone
entecavirENTRESTOEPCLUSA
EPIDUOepinephrine auto-injector EPIPENEPIPEN JR
EPISILERLEADAerythromycinerythromycin solution erythromycin-benzoyl
peroxideerythromycinsESBRIETescitalopram esomeprazoleestradiolestradiol-norethindrone ESTRINGeszopicloneethinyl estradiol-
drospirenoneethinyl estradiol-
drospirenone-levomefolate ethinyl estradiol-etonogestrel ethinyl estradiol-
levonorgestrel ethinyl estradiol-
norelgestromin ethinyl estradiol-
norethindrone acetate ethinyl estradiol-
norethindrone acetate-iron ethinyl estradiol-norgestimate ethosuximideEUCRISA* EVAMISTeverolimusEVOTAZ
EYLEAezetimibeezetimibe-simvastatin
F
famotidine FARXIGA* FASENRA
fenofibrate 4
fenofibric acid delayed-relfentanyl transdermalfentanyl transmucosal
lozengeFIASPFINACEA FOAMfinasterideFIRAZYRFLOVENT DISKUS
FLOVENT HFA
fluconazolefludrocortisoneflunisolidefluocinonide 12
fluorouracil cream 5%
fluorouracil solution
fluoxetine 6
fluticasonefluvastatin
FML FORTEFML S.O.P.folic acidFORTEOfosinoprilfosinopril-hydrochlorothiazidefurosemideFYCOMPA
G
gabapentingalantaminegalantamine ext-rel GEL-ONEGELSYN-3GENOTROPIN
gentamicinGENVOYA
GILENYAglatiramerglimepirideglipizideglipizide ext-relglipizide-metforminGLUCAGEN HYPOKITGLUCAGON EMERGENCY
KITGLYXAMBIGONAL-F
GRALISEgranisetronGRASTEKguanfacine ext-relGVOKE
H
HARVONIHUMATROPE
HUMIRAHUMULIN R U-500 hydrochlorothiazide hydrocodone ext-rel hydrocodone-acetaminophen hydrocortisone hydrocortisone butyrate
cream, lotion, ointment, solution
hydrocortisone enema hydromorphone* hydromorphone ext-rel*
I
ibandronate IBRANCE
ibuprofenILEVROimatinib mesylate imiquimod INCRUSE ELLIPTA
INGREZZA* ipratropium inhalation
solution ipratropium-albuterol
inhalation solution irbesartan irbesartan-
hydrochlorothiazide
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IRESSA
ISENTRESS
itraconazole*ivermectin
J
JANUMET
JANUMET XRJANUVIA*JARDIANCE
JIVI
K
ketoconazole cream 2%ketoconazole shampoo 2%
ketorolacKISQALIKISQALI FEMARA CO-
PACKKOGENATE FSKOVALTRY
KYLEENA
L
lactulose solution lamivudinelamotriginelamotrigine ext-rel lansoprazoleLASTACAFTlatanoprostLATUDA*levalbuterol tartrate CFC-free
aerosolLEVEMIRlevetiracetam levetiracetam ext-rel levocarnitinelevocetirizinelevofloxacinlevothyroxinelidocaine-prilocainelinezolidLINZESS*liothyroninelisinoprillisinopril-hydrochlorothiazide LO LOESTRIN FE LOKELMAlorazepamlosartanlosartan-hydrochlorothiazide loteprednollovastatinLUCENTISluliconazoleLUMIGANLUPRON DEPOT
LYNPARZA
M
MAXIDEXMAYZENTmeclizinemedroxyprogesteronemegestrol acetatemeloxicam
memantinemesalamine delayed-rel mesalamine ext-rel mesalamine suppository mesalamine suspension metforminmetformin ext-rel 10
methadone*methoxsalen methylphenidate methylphenidate ext-rel †methylprednisolone
metoclopramide metolazonemetoprolol succinate ext-rel metoprolol tartrate metronidazole minocyclineMIRENAmirtazapine mometasone montelukastmorphine*morphine ext-rel* morphine suppository MOVANTIK*moxifloxacinMUGARDMULPLETAMULTAQmupirocin ointment MUSE*MYDAYISMYRBETRIQ
N
nadololNAFTINnaloxone injectionNAMZARICnaproxen 2
naratriptanNARCAN NASAL SPRAY
nateglinideneomycin-polymyxin B-
bacitracin-hydrocortisone neomycin-polymyxin B-
dexamethasone NEULASTANEUPRONEVANACniacin ext-relnifedipine ext-rel nitrofurantoin nitroglycerin lingual spray nitroglycerin sublingual NIVESTYMNORVIRNOVOEIGHTNOVOLIN 70/30 NOVOLIN NNOVOLIN RNOVOLOGNOVOLOG MIX 70/30 NUBEQANUCALANUCYNTA*NUCYNTA ER*
NUEDEXTA
NURTEC ODT
NUWIQnystatin
O
ODEFSEY
ODOMZOOFEVofloxacinolanzapineolmesartanolmesartan-amlodipine-
hydrochlorothiazide
olmesartan-hydrochlorothiazide
olopatadineomega-3 acid ethyl estersomeprazoleOMNIPOD INSULIN
INFUSION PUMPondansetronONEXTONONZETRA XSAIL
OPSUMIT
ORALAIRORENITRAM
ORFADIN* ORILISSA oseltamivir OSPHENA
OTEZLAOVIDRELoxazepam oxcarbazepine OXTELLAR XR oxybutyninoxybutynin ext-rel oxycodone*oxycodone-acetaminophen* OZEMPIC
P
pantoprazoleparoxetine HClparoxetine HCl ext-relparoxetine mesylatePAZEOpeg 3350-electrolytespenicillin VKPENTASAPERFOROMIST
phenobarbitalphenytoinphenytoin sodium extendedPHOSLYRA
PICATOpimecrolimuspindololpioglitazonepioglitazone-glimepiridepioglitazone-metforminpotassium chloride liquidPRALUENTpramipexolepramipexole ext-rel prasugrel
pravastatinPRED MILDprednisolone acetate 1%
prednisolone solutionprednisonepregabalinPREMARINPREMARIN CREAM
PREMPHASE
PREMPROprenatal vitaminsPREZCOBIX
PREZISTA
primidoneprobenecidprochlorperazinePROCTOFOAM-HCprogesterone, micronizedPROLASTIN-CPROLIApromethazinepropranololpropranolol ext-relPULMICORT FLEXHALERPYLERA
Q
quetiapinequetiapine ext-relquinaprilquinapril-hydrochlorothiazideQVAR REDIHALER
R
RAGWITEK
raloxifeneramelteonramiprilranolazine ext-rel rasagilineRASUVO
REBIFREBINYN*RELENZA*repaglinide RESTASIS RETACRIT
REYVOW RHOPRESSA ribavirinRINVOQrisedronate risperidone rivastigmine rivastigmine transdermal rizatriptan ROCKLATAN ropiniroleropinirole ext-rel rosuvastatin RUBRACA RUCONEST RYBELSUS*
RYDAPT
S
SANCUSO
SAXENDAscopolamine transdermal selegilineselenium sulfide lotion 2.5%
SEREVENTsertralinesevelamer carbonate sildenafilsilodosinSIMBRINZAsimvastatinSKYLASKYRIZIsolifenacinSOLIQUASOMATULINE DEPOTSOMAVERT SOOLANTRAsotalolSPIRIVAspironolactone-
hydrochlorothiazide
SPRYCELSTELARA
SUBCUTANEOUS STIOLTO RESPIMAT STRIBILDSTRIVERDI RESPIMAT SUBSYS*sucralfate tablet sulfacetamide sulfamethoxazole-
trimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptanSUNOSISUPARTZ FXSUPRAX
SUPREPSYMBICORT
SYMFISYMFI LOSYMJEPISYMLINPEN SYMPROICSYMTUZASYNJARDYSYNJARDY XRSYNTHROID
T
tacrolimustadalafil TAKHZYRO tamsulosin TAZORAC* TECFIDERATEGSEDI TEKTURNA HCT* telmisartan telmisartan-
hydrochlorothiazideTEMIXYS terazosin terbinafine tablet* testosterone gel 9testosterone solution
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tetrabenazinetetracyclinetiagabinetimolol maleate solution TIVICAYTOBRADEX OINTMENT
TOBRADEX STtobramycintobramycin inhalation
solutiontobramycin-dexamethasone TOLAKtolterodinetolterodine ext-rel topiramatetorsemideTOVIAZ*tramadol* (except NDC^ 52817019610)
tramadol ext-rel*travoprosttrazodoneTRELEGY ELLIPTATREMFYA
TRESIBAtretinoin*triamcinolone cream, lotion,
ointmenttriamterenetriamterene-
hydrochlorothiazide
TRIJARDY XR trimethobenzamide TRINTELLIX*TRIUMEQTROKENDI XR
trospiumtrospium ext-rel TRULICITY
TRUVADATYMLOSTYSABRI
U
UBRELVY
UDENYCA
UPTRAVI
V
valacyclovirvalganciclovirvalproic acidvalsartanvalsartan-hydrochlorothiazide vancomycin capsuleVARUBIVASCEPAVELPHOROVELTASSAVEMLIDYvenlafaxinevenlafaxine ext-rel capsule verapamil ext-relV-GO INSULIN INFUSION
PUMPVIBERZI VICTOZA
vigabatrinVIIBRYD*VIMPAT
VIOKACE
VISCO-3
VISTOGARD
VOSEVI 3
VRAYLAR*VUMERITY
VYVANSE
W
warfarin
X
XARELTOXELJANZ
XELJANZ XRXIFAXAN 550 MGXIGDUO XR* XIIDRA
XOLAIRXTAMPZA ER*XTANDI XULTOPHY
Y
YONSA
YUPELRI
Z
zafirlukastZEJULAZEMBRACE SYMTOUCHZENPEPzileuton ext-rel ziprasidonezolmitriptanzolpidemzolpidem ext-rel zolpidem sublingual ZOMIG NASAL SPRAY* zonisamideZUBSOLVZYCLARA
PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S)*
ABILIFY
ACANYA
ACIPHEX, ACIPHEX SPRINKLE
ACTEMRA
ACTICLATE
Activite
ACTOS
acyclovir cream
aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA*, VRAYLAR*
adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin* , EPIDUO, ONEXTON, TAZORAC*
esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT*
ENBREL, HUMIRA, RINVOQ, XELJANZ, XELJANZ XR
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
folic acid
pioglitazone
acyclovir capsule, acyclovir tablet, valacyclovir
ALCORTIN A desonide, hydrocortisone
ALEVICYN GEL, ALEVICYN SG, ALEVICYN SOLUTION
desonide, hydrocortisone
ALIQOPA COPIKTRA
ALLISON MEDICAL INSULIN SYRINGES 13 BD ULTRAFINE INSULIN SYRINGES
ALORA estradiol, DIVIGEL, EVAMIST
ALPROLIX Consult doctor
ALREX azelastine, cromolyn sodium, olopatadine, LASTACAFT, PAZEO
ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
DRUG NAME(S) PREFERRED OPTION(S)*
ALVESCO
AMRIX
ANDROGEL 1%
ANGELIQ
ANTARA
APEXICON E
APIDRA
APLENZIN
ARMOUR THYROID
ARTHROTEC
ASACOL HD
ASCENSIA STRIPS AND KITS 14
ASMANEX, ASMANEX HFA
ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM*
estradiol-norethindrone, PREMPHASE, PREMPRO
fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel
desoximetasone, fluocinonide (except fluocinonide cream 0.1%), BRYHALI*
FIASP, NOVOLOG
bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg)
levothyroxine, liothyronine, SYNTHROID
celecoxib; diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT*
balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11
ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR REDIHALER
NC2019-38 (10/20)
DRUG NAME(S) PREFERRED OPTION(S)*
ATACAND, ATACAND HCT
ATOPADERM
ATROVENT HFA
AVENOVA
AVONEX
AZELEX
BARACLUDE TABLET
BEAU RX
BECONASE AQ
BENICAR, BENICAR HCT
BENSAL HP
BENZAC AC
BENZACLIN
BENZIQ
benzonatate (NDCs^ 69336012615, 69499032915 only)
BERINERT
BETAPACE, BETAPACE AF
BEYAZ
candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
desonide, hydrocortisone
ipratropium inhalation solution, INCRUSE ELLIPTA, SPIRIVA, YUPELRI
Consult doctor
glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA, MAYZENT, REBIF, TECFIDERA, TYSABRI, VUMERITY
adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin*, EPIDUO, ONEXTON, TAZORAC*
entecavir, lamivudine, VEMLIDY
Consult doctor
flunisolide, fluticasone, mometasone, DYMISTA
candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
desonide, hydrocortisone
adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin*, EPIDUO, ONEXTON, TAZORAC*
adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin*, EPIDUO, ONEXTON, TAZORAC*
adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin*, EPIDUO, ONEXTON, TAZORAC*
benzonatate (except NDCs^ 69336012615, 69499032915)
FIRAZYR, RUCONEST
sotalol
ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron
DRUG NAME(S) PREFERRED OPTION(S)*
bimatoprost solution 0.03%
BREEZE 2 STRIPS AND KITS 14
Bupap
bupropion ext-rel tablet 450 mg
butalbital-acetaminophen tablet 50-300 mg, BUTALBITAL-ACETAMINOPHEN (NDC^ 69499034230 only)
butalbital-acetaminophen-caffeine capsule
BUTRANS
BYDUREON
BYETTA
CAFERGOT
calcipotriene cream
calcitriol ointment
CAMBIA
CARAC
CARAFATE
CARBINOXAMINE TABLET 6 MG
CARDIZEM, CARDIZEM CD, CARDIZEM LA
CARNITOR, CARNITOR SF
chlordiazepoxide-clidinium (NDC^ 42494040901 only)
chlorzoxazone 375 mg, chlorzoxazone 500 mg (NDC^ 73007001303 only), chlorzoxazone 750 mg, CHLORZOXAZONE 250 MG
CIALIS
CICATRACE
CIMZIA
CLINDAGEL
clindamycin gel (NDC^ 68682046275 only)
latanoprost, travoprost, LUMIGAN
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11
diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension)
bupropion, bupropion ext-rel (except bupropion ext-rel tablet 450 mg)
diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension)
diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension)
buprenorphine transdermal, BELBUCA
OZEMPIC, RYBELSUS*, TRULICITY, VICTOZA
OZEMPIC, RYBELSUS*, TRULICITY, VICTOZA
eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY*
calcipotriene ointment, calcipotriene solution
calcipotriene ointment, calcipotriene solution
diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension)
fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA
sucralfate tablet
levocetirizine
diltiazem ext-rel (except generics for CARDIZEM LA)
levocarnitine
dicyclomine
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
sildenafil, tadalafil
Consult doctor
COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, SKYRIZI, STELARA SUBCUTANEOUS, TREMFYA, XELJANZ, XELJANZ XR
erythromycin solution
adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-
NC2019-38 (10/20)
DRUG NAME(S) PREFERRED OPTION(S)*
clobetasol spray
CLOBEX SPRAY
COLAZAL
COLCRYS
CONSENSI
CONTOUR NEXT STRIPS AND KITS 14
CONTOUR STRIPS AND KITS 14
CONTRAVE
CORDRAN OINTMENT
CoreMino
COUMADIN
CRESTOR
cyclobenzaprine ext-rel capsule, cyclobenzaprine tablet 7.5 mg
CYMBALTA
DaVite
DELZICOL
DETROL LA
dexchlorpheniramine
Dexifol
Dexpak
diclofenac sodium gel 1% (NDC^ 69499031866 only)
benzoyl peroxide, tretinoin*, EPIDUO, ONEXTON, TAZORAC*
clobetasol foam
clobetasol foam
balsalazide
colchicine tablet
amlodipine WITH celecoxib
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11
SAXENDA
hydrocortisone butyrate cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
warfarin
atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
desvenlafaxine ext-rel*, duloxetine, venlafaxine, venlafaxine ext-rel capsule
folic acid
balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA
darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ*
levocetirizine
folic acid
dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, prednisone
diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
DRUG NAME(S) PREFERRED OPTION(S)*
Diclofex DC (NDC^ 51021037201 only)
Diclosaicin
diflorasone cream, diflorasone ointment
dihydroergotamine spray
diltiazem ext-rel (generics for CARDIZEM LA only)
DIOVAN, DIOVAN HCT
Diphen Elixir
DORAL
DORYX, DORYX MPC
doxepin cream
diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
desoximetasone, fluocinonide (except fluocinonide cream 0.1%), BRYHALI*
eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY*
diltiazem ext-rel (except generics for CARDIZEM LA)
candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
levocetirizine
doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
desonide, hydrocortisone, pimecrolimus, tacrolimus, EUCRISA*
doxycycline hyclate delayed-rel tablet 200 mg doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
doxycycline hyclate tablet 50 mg (NDC^ 72143021160 only), doxycycline hyclate tablet 75 mg, doxycycline hyclate tablet 150 mg
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
doxycycline monohydrate capsule 75 mg, doxycycline monohydrate capsule 150 mg
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
DULERA ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, SYMBICORT
DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide
DYRENIUM amiloride, triamterene
EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
EDLUAR doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA
E.E.S. GRANULES erythromycins
NC2019-38 (10/20)
DRUG NAME(S) PREFERRED OPTION(S)*
EFFEXOR XR
ELELYSO
ELOCTATE
ENABLEX
ENLITE CONTINUOUS GLUCOSE MONITORING SYSTEM
ENTERAGAM
ENTYVIO
EPICERAM
EPOGEN
ergotamine-caffeine
ERYPED
EUFLEXXA
EVEKEO
EVERSENSE CONTINUOUS GLUCOSE MONITORING SYSTEM
EVZIO
EXFORGE
EXFORGE HCT
EXTAVIA
FANAPT
FEMRING
fenofibrate tablet 120 mg
FENOGLIDE TABLET 120 MG
fenoprofen, FENOPROFEN CAPSULE
FERIVA 21/7
FETZIMA
Fexmid
desvenlafaxine ext-rel* , duloxetine, venlafaxine, venlafaxine ext-rel capsule
CERDELGA, CEREZYME
ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ
darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ*
DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
alosetron, VIBERZI, XIFAXAN 550 MG
HUMIRA, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR
desonide, hydrocortisone
ARANESP, RETACRIT
eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY*
erythromycins
DUROLANE, GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3
amphetamine-dextroamphetamine mixed salts, methylphenidate
DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
naloxone injection, NARCAN NASAL SPRAY
amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan
amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide
glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA, MAYZENT, REBIF, TECFIDERA, TYSABRI, VUMERITY
aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA*, VRAYLAR*
estradiol, ESTRING, PREMARIN CREAM
fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel
fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel
diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
folic acid
desvenlafaxine ext-rel* , duloxetine, venlafaxine, venlafaxine ext-rel capsule
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
FINACEA GEL azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA
FIORICET CAPSULE diclofenac sodium, ibuprofen,
DRUG NAME(S) PREFERRED OPTION(S)*
naproxen (except naproxen CR or naproxen suspension)
FLAREX dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD
flucytosine capsule 500 mg fluconazole
fluocinonide cream 0.1% clobetasol cream
fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, TOLAK, ZYCLARA
fluoxetine tablet (generics for SARAFEM only) fluoxetine (except fluoxetine tablet 60 mg,
fluoxetine tablet 60 mg
flurandrenolide lotion (NDC^ 24470092112 only)
flurandrenolide ointment
FML LIQUIFILM
FOLIC-K
FOLLISTIM AQ
Folvik-D
Folvite-D
FORTAMET
FORTESTA
FOSAMAX PLUS D
FOSRENOL
FOSTEUM, FOSTEUM PLUS
FREESTYLE LIBRE CONTINUOUS GLUCOSE MONITORING SYSTEM
FREESTYLE STRIPS AND KITS 14
FROVA
FULPHILA
fluoxetine tablet [generics for SARAFEM]), paroxetine HCl ext-rel, sertraline
citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX*, VIIBRYD*
desonide, hydrocortisone
hydrocortisone butyrate cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment
dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD
folic acid
GONAL-F
folic acid
folic acid
metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA)
testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM*
alendronate, ibandronate, risedronate
calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO
alendronate, ibandronate, risedronate
DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11
eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY*
NEULASTA, UDENYCA
NC2019-38 (10/20)
DRUG NAME(S) PREFERRED OPTION(S)*
Genicin Vita-S folic acid
GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL
GLUMETZA metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA)
GLYCOPYRROLATE TABLET 1.5 MG dicyclomine
GRANIX NIVESTYM
GUARDIAN CONNECT CONTINUOUS GLUCOSE MONITORING SYSTEM
DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM
HORIZANT gabapentin, GRALISE
HUMALOG FIASP, NOVOLOG
HUMALOG MIX 50/50 NOVOLOG MIX 70/30
HUMALOG MIX 75/25 NOVOLOG MIX 70/30
HUMULIN 70/30 NOVOLIN 70/30
HUMULIN N NOVOLIN N
HUMULIN R NOVOLIN R
HYALGAN DUROLANE, GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3
hydrocortisone butyrate lipophilic cream 0.1% hydrocortisone butyrate
HylaVite
HYSINGLA ER
INDERAL LA, INDERAL XL
INDOCIN
indomethacin capsule 20 mg
Inflammacin
INNOPRAN XL
INTERMEZZO
INTUNIV
INVOKAMET, INVOKAMET XR
cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment
folic acid
fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel*, methadone*, morphine ext-rel*, NUCYNTA ER*, XTAMPZA ER
atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC*
diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC*
doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA
amphetamine-dextroamphetamine mixed salts ext-rel †, atomoxetine, guanfacine ext-rel, methylphenidate ext-rel †, MYDAYIS, VYVANSE
SYNJARDY, SYNJARDY XR, XIGDUO XR*
DRUG NAME(S) PREFERRED OPTION(S)*
INVOKANA
ISTALOL
JALYN
FARXIGA*, JARDIANCE
timolol maleate solution, BETIMOL, BETOPTIC S
dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, silodosin, tamsulosin or terazosin
JENTADUETO, JENTADUETO XR JANUMET, JANUMET XR
KAMDOY desonide, hydrocortisone
KAZANO JANUMET, JANUMET XR
ketoconazole foam 2% ketoconazole shampoo 2%, selenium sulfide lotion 2.5%
Ketodan ketoconazole shampoo 2%, selenium sulfide lotion 2.5%
ketoprofen capsule 25 mg diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
ketoprofen ext-rel capsule diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
KINERET ENBREL, HUMIRA, RINVOQ, XELJANZ, XELJANZ XR
KOMBIGLYZE XR JANUMET, JANUMET XR
LACTULOSE PAK lactulose solution
LAMICTAL, LAMICTAL ODT, LAMICTAL XR carbamazepine, carbamazepine ext-rel,
LANOXIN TABLET (125 MCG and 250 MCG only)
lanthanum carbonate
LANTUS
LAZANDA
LESCOL XL
LETAIRIS
levorphanol
LEXAPRO
LIALDA
LIDOCAINE-TETRACAINE CREAM (NDC^ 71800063115 only)
LIDOTREX
divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT
digoxin
calcium acetate, sevelamer carbonate, PHOSLYRA, VELPHORO
BASAGLAR, LEVEMIR
fentanyl transmucosal lozenge, SUBSYS*
atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
ambrisentan, bosentan, OPSUMIT
fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel* , methadone* , morphine ext-rel* , NUCYNTA ER*, XTAMPZA ER*
citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX*, VIIBRYD*
balsalazide, mesalamine delayed-rel, mesalamine ext-rel, sulfasalazine, sulfasalazine delayed-rel, PENTASA
lidocaine-prilocaine
lidocaine-prilocaine
NC2019-38 (10/20)
DRUG NAME(S) PREFERRED OPTION(S)*
LIPITOR
LIVALO
Lorid
Lorzone
LOTEMAX, LOTEMAX SM
LUNESTA
MACRODANTIN
Matzim LA
MAVYRET
mefenamic acid (NDC^ 69336012830 only)
MENEST
MENOSTAR
metformin ext-rel (generics for FORTAMET and GLUMETZA only)
methocarbamol 750 mg (NDCs^ 69036093090, 70868090190 only)
MIACALCIN INJECTION
MIACALCIN NASAL SPRAY
MICARDIS, MICARDIS HCT
Migergot
MILLIPRED
MINASTRIN 24 FE
MINIVELLE
MINOCIN
minocycline ext-rel
atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin
folic acid
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD
doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA
nitrofurantoin
diltiazem ext-rel (except generics for CARDIZEM LA)
EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 3
diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
estradiol, PREMARIN
estradiol
metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA)
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO, PROLIA, TYMLOS
calcitonin-salmon
candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide
eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY*
dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, prednisone
ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron
estradiol, DIVIGEL, EVAMIST
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline,
DRUG NAME(S) PREFERRED OPTION(S)*
Mondoxyne NL capsule 75 mg
MONOVISC
MOVIPREP
MultiPro
mupirocin cream
MYTESI
NAPRELAN
naproxen-esomeprazole
naproxen CR
naproxen suspension
NATAZIA
NATESTO
NESINA
NEUPOGEN
NEXIUM
tetracycline
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
DUROLANE, GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3
peg 3350-electrolytes, SUPREP
Consult doctor
gentamicin, mupirocin ointment
Consult doctor
diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
diclofenac sodium, ibuprofen, meloxicam or naproxen (except naproxen CR or naproxen suspension) WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT*
diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-levonorgestrel, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron, ethinyl estradiol-norgestimate, LO LOESTRIN FE
testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM*
JANUVIA*
NIVESTYM
esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT*
niacin tablet 500 mg niacin ext-rel
Niacor niacin ext-rel
NICADAN folic acid
NICAPRIN folic acid
NICAZEL, NICAZEL FORTE folic acid
NICOMIDE folic acid
NILANDRON abiraterone, bicalutamide, XTANDI, YONSA
NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual
NORDITROPIN GENOTROPIN, HUMATROPE
NORGESIC FORTE cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
NORITATE azelaic acid gel, metronidazole, FINACEA FOAM, SOOLANTRA
NORVASC amlodipine
NOVACORT desonide, hydrocortisone
NOVO NORDISK NEEDLES 13 BD ULTRAFINE NEEDLES
NC2019-38 (10/20)
DRUG NAME(S) PREFERRED OPTION(S)*
NuDiclo SoluPak, NuDiclo TabPak
NUTROPIN AQ
NUVIGIL
Okebo
OLEPTRO
OLUX-E
omeprazole-sodium bicarbonate
OMNARIS
OMNITROPE
OMNIVEX
ONETOUCH ULTRA STRIPS AND KITS 14
ONETOUCH VERIO STRIPS AND KITS 14
ONFI
ONGLYZA
ORENCIA CLICKJECT, ORENCIA INTRAVENOUS, ORENCIA SUBCUTANEOUS
orphenadrine-aspirin-caffeine
Orphengesic Forte
ORTHO D
ORTHO DF
ORTHO TRI-CYCLEN LO
ORTHOVISC
OSENI
OSMOPREP
OWEN MUMFORD NEEDLES 13
oxiconazole (NDCs^ 00168035830, 51672135902 only)
OXYCONTIN
diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
GENOTROPIN, HUMATROPE
armodafinil, SUNOSI
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
trazodone
clobetasol foam
esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT*
flunisolide, fluticasone, mometasone, DYMISTA
GENOTROPIN, HUMATROPE
folic acid
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11
clobazam, lamotrigine, topiramate, TROKENDI XR
JANUVIA*
COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg)
folic acid
folic acid
ethinyl estradiol-norgestimate
DUROLANE, GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3
JANUMET, JANUMET XR; JANUVIA* WITH pioglitazone
peg 3350-electrolytes, SUPREP
BD ULTRAFINE NEEDLES
ciclopirox*, clotrimazole, econazole, ketoconazole cream 2%, luliconazole
fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel*, methadone*, morphine ext-rel*, NUCYNTA ER*, XTAMPZA ER*
DRUG NAME(S) PREFERRED OPTION(S)*
OXYTROL
PANCREAZE
PENNSAID
PERCOCET
PERRIGO NEEDLES 13
PERTZYE
PEXEVA
PLAVIX
PLEGRIDY
POLYTOZA
posaconazole delayed-rel tablet
PRADAXA
PRECISION XTRA STRIPS AND KITS 14
PRED FORTE
PREFEST
PRENATAL PLUS
PREVACID
PREVIDENT
PRIMLEV
PRISTIQ
PROAIR HFA, PROAIR RESPICLICK
PROCRIT
PRODIGEN
PROTONIX
PROTOPIC
PROVENTIL HFA
darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ*
CREON, VIOKACE, ZENPEP
diclofenac sodium, diclofenac sodium gel 1% (except NDC^ 69499031866), diclofenac sodium solution, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
hydrocodone-acetaminophen, hydromorphone* , morphine* , oxycodone-acetaminophen, NUCYNTA*
BD ULTRAFINE NEEDLES
CREON, VIOKACE, ZENPEP
citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX*, VIIBRYD*
clopidogrel, prasugrel, BRILINTA
glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA, MAYZENT, REBIF, TECFIDERA, TYSABRI, VUMERITY
Consult doctor
fluconazole, itraconazole*
warfarin, ELIQUIS, XARELTO
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11
dexamethasone, loteprednol, prednisolone acetate 1%, DUREZOL, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD
estradiol-norethindrone, PREMPHASE, PREMPRO
generic prenatal vitamins, CITRANATAL
esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT*
Consult doctor
hydrocodone-acetaminophen, hydromorphone* , morphine* , oxycodone-acetaminophen, NUCYNTA*
desvenlafaxine ext-rel* , duloxetine, venlafaxine, venlafaxine ext-rel capsule
albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol
ARANESP, RETACRIT
Consult doctor
esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT*
pimecrolimus, tacrolimus, EUCRISA*
albuterol sulfate CFC-free aerosol,
NC2019-38 (10/20)
DRUG NAME(S) PREFERRED OPTION(S)*
PROZAC
PSORCON
QNASL
QSYMIA
QTERN
quazepam
RAPAFLO
RAYOS
RECEDO
RELION INSULIN
REPATHA
RHEUMATE
RIBOZEL
RIMSO-50
RIOMET
ROZEREM
RyClora
SABRIL
SAIZEN
SCARSILK PAD
SEROQUEL XR
SIL-K PAD
SILIVEX
SILTREX
SIMPONI
SINGULAIR
SORILUX
SPRIX
STENDRA
STRIANT
levalbuterol tartrate CFC-free aerosol
citalopram, escitalopram, fluoxetine (except fluoxetine tablet 60 mg, fluoxetine tablet [generics for SARAFEM]), paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX*, VIIBRYD*
desoximetasone, fluocinonide (except fluocinonide cream 0.1%), BRYHALI*
flunisolide, fluticasone, mometasone, DYMISTA
SAXENDA
GLYXAMBI
doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA
alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin
dexamethasone, hydrocortisone, methylprednisolone, prednisolone solution, prednisone
Consult doctor
NOVOLIN INSULIN
PRALUENT
folic acid
folic acid
Consult doctor
metformin, metformin ext-rel (except generics for FORTAMET and GLUMETZA)
doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA
levocetirizine
vigabatrin
GENOTROPIN, HUMATROPE
Consult doctor
aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA*, VRAYLAR*
Consult doctor
Consult doctor
Consult doctor
COSENTYX, ENBREL, HUMIRA, OTEZLA, RINVOQ, STELARA SUBCUTANEOUS, XELJANZ, XELJANZ XR
montelukast, zafirlukast, zileuton ext-rel
calcipotriene ointment, calcipotriene solution
diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
sildenafil, tadalafil
testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM*
DRUG NAME(S) PREFERRED OPTION(S)*
SUBOXONE
sucralfate suspension
sumatriptan-naproxen
SURE-TEST STRIPS AND KITS 14
SYNERDERM
SYNVISC, SYNVISC-ONE
TALIVA
TALTZ
TARGADOX
TASIGNA
TAYTULLA
TESTIM
testosterone gel 1% (authorized generics for TESTIM and VOGELXO only)
TIMOPTIC OCUDOSE
TIROSINT
TOBI, TOBI PODHALER
TOPROL-XL
TOUJEO
TRADJENTA
tramadol* (NDC^ 52817019610 only)
TRANSDERM SCOP
TREXIMET
buprenorphine-naloxone sublingual, ZUBSOLV
sucralfate tablet
diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY*
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11
desonide, hydrocortisone
DUROLANE, GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3
folic acid
COSENTYX, ENBREL, HUMIRA, OTEZLA, SKYRIZI, STELARA SUBCUTANEOUS, TREMFYA, XELJANZ, XELJANZ XR
doxycycline hyclate 20 mg, doxycycline hyclate capsule, minocycline, tetracycline
imatinib mesylate, BOSULIF, SPRYCEL
ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron
testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM*
testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM*
timolol maleate solution, BETIMOL, BETOPTIC S
levothyroxine, SYNTHROID
tobramycin inhalation solution, BETHKIS
atenolol, carvedilol, carvedilol phosphate ext-rel, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, pindolol, propranolol, propranolol ext-rel, BYSTOLIC*
TRESIBA
JANUVIA*
tramadol* (except NDC^ 52817019610), tramadol ext-rel*
meclizine, scopolamine transdermal
diclofenac sodium, ibuprofen or naproxen (except naproxen CR or naproxen suspension) WITH eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, NURTEC ODT, ONZETRA XSAIL, REYVOW, UBRELVY, ZEMBRACE SYMTOUCH or ZOMIG NASAL SPRAY*
NC2019-38 (10/20)
DRUG NAME(S) PREFERRED OPTION(S)*
triamcinolone acetonide aerosol 0.2%
TRICOR
TRIGLIDE
TRILIPIX
TRIVIDIA INSULIN SYRINGES 13
TronVite
TRUETEST STRIPS AND KITS 14
TRUETRACK STRIPS AND KITS 14
TUDORZA
ULTIMED INSULIN SYRINGES 13
ULTIMED NEEDLES 13
UROXATRAL
VALCYTE
VALTREX
Vanatol LQ, Vanatol S
Vanoxide-HC
VASCULERA
VECTICAL
VELTIN
venlafaxine ext-rel tablet (except 225 mg)
VENTOLIN HFA
hydrocortisone butyrate cream, hydrocortisone butyrate lotion, hydrocortisone butyrate ointment, hydrocortisone butyrate solution, mometasone, triamcinolone cream, triamcinolone lotion, triamcinolone ointment
fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel
fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel
fenofibrate (except fenofibrate tablet 120 mg), fenofibric acid delayed-rel
BD ULTRAFINE INSULIN SYRINGES
folic acid
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 11, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 11, ACCU-CHEK GUIDE STRIPS AND KITS 11, ACCU-CHEK SMARTVIEW STRIPS AND KITS 11
ELLIPTA,INCRUSE SPIRIVA, YUPELRI
BD ULTRAFINE INSULIN SYRINGES
BD ULTRAFINE NEEDLES
alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin
valganciclovir
acyclovir capsule, acyclovir tablet, valacyclovir
diclofenac sodium, ibuprofen, naproxen (except naproxen CR or naproxen suspension)
adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin*, EPIDUO, ONEXTON, TAZORAC*
Consult doctor
calcipotriene ointment, calcipotriene solution
adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin*, EPIDUO, ONEXTON, TAZORAC*
desvenlafaxine ext-rel*, duloxetine, venlafaxine, venlafaxine ext-rel capsule
albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol
DRUG NAME(S) PREFERRED OPTION(S)*
VEREGEN
VIAGRA
VIEKIRA PAK
VITAFOL-ONE
Vitasure
VIVELLE-DOT
VOGELXO
XANAX, XANAX XR
XENAZINE
XOLEGEL
XOPENEX HFA
Xvite
XYZBAC
YAZ
ZARXIO
ZEGERID
ZEMAIRA
ZEPATIER
ZETIA
ZETONNA
ZIANA
ZOHYDRO ER
ZOLPIMIST
ZONEGRAN
ZONTIVITY
ZORTRESS
imiquimod
sildenafil, tadalafil
EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)
generic prenatal vitamins, CITRANATAL
folic acid
estradiol, DIVIGEL, EVAMIST
testosterone gel (except authorized generics for TESTIM and VOGELXO), testosterone solution, ANDRODERM*
alprazolam, clonazepam, diazepam, lorazepam, oxazepam
tetrabenazine, AUSTEDO
ciclopirox*, ketoconazole cream 2%
albuterol sulfate CFC-free aerosol, levalbuterol tartrate CFC-free aerosol
folic acid
folic acid
ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-norethindrone acetate, ethinyl estradiol-norethindrone acetate-iron
NIVESTYM
esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT*
PROLASTIN-C
EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)
ezetimibe
flunisolide, fluticasone, mometasone, DYMISTA
adapalene, benzoyl peroxide, clindamycin gel (except NDC^ 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin*, EPIDUO, ONEXTON, TAZORAC*
fentanyl transdermal, hydrocodone ext-rel, hydromorphone ext-rel*, methadone*, morphine ext-rel*, NUCYNTA ER*, XTAMPZA ER*
doxepin, eszopiclone, ramelteon, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA
carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT
Consult doctor
everolimus
NC2019-38 (10/20)
DRUG NAME(S) PREFERRED OPTION(S)*
ZORVOLEX diclofenac sodium, ibuprofen, meloxicam, naproxen (except naproxen CR or naproxen suspension)
ZUPLENZ granisetron, ondansetron, SANCUSO
ZYDELIG COPIKTRA
ZYFLO montelukast, zafirlukast, zileuton ext-rel
ZYLET neomycin-polymyxin B-bacitracin-
DRUG NAME(S) PREFERRED OPTION(S)*
hydrocortisone, neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone, TOBRADEX OINTMENT, TOBRADEX ST
ZYTIGA abiraterone, bicalutamide, XTANDI, YONSA
ZYVIT folic acid
FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay1 for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to Caremark.com to check coverage and copay1 information for a specific medicine.
An exception process may exist for specific clinical or regulatory circumstances that may require coverage of an excluded medication.
§ Generics are available in this class and should be considered the first line of prescribing. ^ Drug products are identified by unique numerical product identifiers, called National Drug Codes (NDC), which identify the manufacturer, strength, dosage form, formulation and package
size. † Listing does not include certain NDCs^. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription
price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 Listing does not include naproxen CR or naproxen suspension. 3 For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). 4 Listing does not include fenofibrate tablet 120 mg. 5 Listing does not include generics for CARDIZEM LA. 6 Listing does not include fluoxetine tablet 60 mg, fluoxetine tablet (generics for SARAFEM). 7 Listing does not include bupropion ext-rel tablet 450 mg. 8 Listing does not include cyclobenzaprine tablet 7.5 mg. 9 Listing does not include the authorized generics for TESTIM and VOGELXO. 10 Listing does not include generics for FORTAMET and GLUMETZA. 11 An ACCU-CHEK blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK. For more information on
how to obtain a blood glucose meter, call: 1-877-418-4746. 12 Listing does not include fluocinonide cream 0.1%. 13 BD ULTRAFINE syringes and needles are the only preferred options. 14 ACCU-CHEK brand test strips are the only preferred options.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.
The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.
©2020. All rights reserved. 106-1046481 100120
NC2019-38 (10/20)