ceftazidime
Augmentin ES-600
ceftriaxone sodium
Augmentin XR
cefuroxime axetil
Bactocill IN Dextrose
cefuroxime sodium
Bicillin C-R
January 2016
cephalexin
Bicillin L-a
PREFERRED
Moxatag
SELECT/NATIONAL/ADVANTAGE DRUG LIST
Cefaclor
Nafcillin Sodium
Cephalexin
Nallpen Iso-osmotic IN Dextrose
The HealthSmart Rx Drug List is a guide identifying generic, preferred brand name, and non-preferred brand name medicines within select therapeutic categories. The Drug List may not include all drugs covered by your prescription drug benefit. Generic medicines are available within many of the therapeutic categories listed, in addition to categories not listed, and should be considered as the first line of prescribing. For benefit coverage or restrictions please check your benefit plan document(s). This listing is revised periodically as new drugs and new prescribing information becomes available. It is recommended that you bring this list of medications when you or a covered family member sees a physician or other healthcare provider.
NON PREFERRED
Nallpen/Dextrose
Ancef
Penicillin G Potassium IN Iso-osmotic Dextrose
Avycaz
Penicillin G Procaine
Cedax
Penicillin G Sodium
Cefaclor ER
Pfizerpen-G
Cefazolin
Timentin
Cefazolin Sodium
Unasyn
Cefazolin Sodium/Dextrose
Unasyn Bulk Pack
Cefditoren Pivoxil
Zosyn
Cefepime
Cefotetan
QUINOLONES
Cefotetan/Dextrose
GENERIC
Cefoxitin Sodium
ciprofloxacin
Ceftazidime/Dextrose
ciprofloxacin ER
Ceftibuten
ciprofloxacin HCL
Ceftin
ANTI-INFECTIVES
ciprofloxacin I.V.-IN D5W
Ceftriaxone IN Iso-osmotic Dextrose
ANTIFUNGALS
levofloxacin
Ceftriaxone Sodium
GENERIC
levofloxacin IN D5W
Ceftriaxone/Dextrose
fluconazole
moxifloxacin HCL
Cefuroxime Sodium
fluconazole IN dextrose
ofloxacin
Cefuroxime/Dextrose
fluconazole IN NACL
Ciprofloxacin HCL
Claforan
flucytosine
Ofloxacin
Claforan/D5W
griseofulvin microsize
NON PREFERRED
Fortaz
griseofulvin ultramicrosize
Avelox
Keflex
itraconazole
Avelox Abc Pack
Maxipime
ketoconazole
Cipro
Mefoxin
nystatin
Cipro I.V.-IN D5W
Rocephin
terbinafine HCL
Cipro XR
Spectracef
voriconazole
Factive
Suprax
NON PREFERRED
Levaquin
Tazicef
Abelcet
Moxifloxacin HCL
Teflaro
Ambisome
Noroxin
Zerbaxa
Amphotec
Zinacef
Amphotericin B
TETRACYCLINES
Ancobon
GENERIC
PENICILLINS
Cresemba
demeclocycline HCL
GENERIC
Diflucan
doxycycline
amoxicillin
Fluconazole IN NACL
doxycycline hyclate
amoxicillin/clavulanate potassium
Grifulvin V
doxycycline hyclate DR
amoxicillin/clavulanate potassium ER
Gris-peg
doxycycline monohydrate
ampicillin
Lamisil
minocycline HCL
ampicillin sodium
Noxafil
minocycline HCL ER
ampicillin-sulbactam
Onmel
Tetracycline HCL
dicloxacillin sodium
Sporanox
NON PREFERRED
nafcillin sodium
Sporanox Pulsepak
Acticlate
oxacillin sodium
Terbinex
Adoxa
penicillin v potassium
Vfend
Adoxa PAK 1/100
penicillin G potassium
Vfend IV
Adoxa PAK 1/150
piperacillin sodium/ tazobactam sodium
Adoxa PAK 2/100
CEPHALOSPORINS
piperacillin sodium/tazobactam sodium
Alodox Convenience Kit
GENERIC
Doryx
cefaclor
piperacillin/tazobactam
Minocin
cefadroxil
Amoxicillin/Clavulanate Potassium
Minocin Kit
cefazolin sodium
PREFERRED
Monodox
cefdinir
Amoxicillin
Morgidox 1X100MG
cefepime
Ampicillin
Morgidox 2X100MG
cefixime
NON PREFERRED
Nutridox
cefotaxime sodium
Amoxicillin ER
Ocudox
cefoxitin sodium
Ampicillin Sodium
Solodyn
cefpodoxime proxetil
Ampicillin-sulbactam
Targadox
cefprozil
Augmentin
Vibramycin
Effective January 1, 2016 v.3
1
ANTI-INFLAMMATORY
Tivorbex
Edarbi
NSAIDS
Vimovo
Micardis
GENERIC
Vivlodex
Teveten
celecoxib
Voltaren-XR
diclofenac potassium
Zipsor
BETA BLOCKERS
diclofenac sodium DR
Zorvolex
GENERIC
diclofenac sodium ER
acebutolol HCL
diclofenac sodium/misoprostol
AUTO-IMMUNE
atenolol
etodolac
betaxolol HCL
etodolac ER
PREFERRED
bisoprolol fumarate
flurbiprofen
Cimzia
carvedilol
ibuprofen
Cimzia Starter Kit
esmolol HCL
indomethacin
Humira
labetalol HCL
indomethacin ER
Humira Pediatric Crohns Disease Starter Pack
metoprolol succinate ER
ketoprofen
metoprolol tartrate
Humira Pen
ketorolac tromethamine
nadolol
Humira Pen-crohns Diseasestarter
mefenamic acid
pindolol
Humira Pen-psoriasis Starter
meloxicam
propranolol HCL
Remicade
nabumetone
propranolol HCL ER
Simponi
naproxen
sotalol HCL
Simponi Aria
naproxen sodium
sotalol HCL (AF)
NON PREFERRED
naproxen sodium CR
PREFERRED
Actemra
naproxen sodium ER
Bystolic
Enbrel
oxaprozin
Propranolol HCL
Enbrel Sureclick
piroxicam
Timolol Maleate
Kineret
sulindac
NON PREFERRED
Orencia
tolmetin sodium
Betapace
Xeljanz
Meclofenamate Sodium
Betapace AF
Tolmetin Sodium
Brevibloc
CARDIOVASCULAR
PREFERRED
Coreg
ACE-INHIBITORS
Fenoprofen Calcium
Coreg CR
GENERIC
Ketoprofen ER
Corgard
benazepril HCL
Meloxicam
Hemangeol
captopril
Naproxen
Hypertenevide-12.5
enalapril maleate
NON PREFERRED
Inderal LA
enalaprilat
Anaprox
Inderal XL
fosinopril sodium
Anaprox DS
Innopran XL
lisinopril
Arthrotec 50
Kerlone
moexipril HCL
Arthrotec 75
Levatol
perindopril erbumine
Caldolor
Lopressor
quinapril HCL
Cataflam
Sectral
ramipril
Celebrex
Sotalol Hydrochloride
trandolapril
Daypro
Sotylize
NON PREFERRED
Derma Silkrx Anodynexa PAK
Tenormin
Accupril
Derma Silkrx Diclopak
Toprol XL
Aceon
Dermacinrx Inflammatral PAK
Trandate
Altace
Duexis
Zebeta
Epaned
Dyloject
Lotensin
EC-naprosyn
CALCIUM CHANNEL BLOCKERS
Mavik
Feldene
GENERIC
Prinivil
Flanax Pain Relief Kit
amlodipine besylate
Univasc
Ibuprofen Comfort PAC
diltiazem CD
Vasotec
Indocin
diltiazem HCL
Zestril
Indomethacin
diltiazem HCL ER
Indomethacin Sodium
felodipine ER
ANGIOTENSIN RCPTR BLOCKER
IC 400
isradipine
GENERIC
IC 800
nicardipine HCL
candesartan cilexetil
Ketorocaine-l
nifedipine
irbesartan
Ketorocaine-lm
nifedipine ER
losartan potassium
Ketorolac Tromethamine
nimodipine
telmisartan
Meloxicam Comfort PAC
nisoldipine
valsartan
Mobic
verapamil HCL
Eprosartan Mesylate
Nalfon
verapamil HCL ER
PREFERRED
Naprelan
verapamil HCL SR
Benicar
Naprosyn
NON PREFERRED
NON PREFERRED
Naproxen Comfort PAC
Adalat CC
Atacand
Neoprofen
Calan
Avapro
Ponstel
Calan SR
Cozaar
Sprix
Cardene I.v.
Diovan
Effective January 1, 2016
2
Cardene IV
telmisartan/hydrochlorothiazide
gemfibrozil
Cardene SR
trandolapril/verapamil HCL
Fenofibric Acid
Cardizem
trandolapril/verapamil HCL ER
PREFERRED
Cardizem CD
valsartan/hydrochlorothiazide
Fibricor
Cardizem LA
PREFERRED
Lipofen
Cleviprex
Azor
NON PREFERRED
Dilacor XR
Benicar HCT
Antara
Diltiazem HCL
Captopril/Hydrochlorothiazide
Fenofibrate
Nisoldipine
Dutoprol
Fenoglide
Nisoldipine ER
Methyldopa/Hydrochlorothiazide
Lofibra
Norvasc
Propranolol/Hydrochlorothiazide
Lopid
Nymalize
Tekturna HCT
Tricor
Procardia
Tribenzor
Triglide
Procardia XL
NON PREFERRED
Trilipix
Sular
Accuretic
BILE ACID SEQUESTRANTS
Tiazac
Amturnide
GENERIC
Verelan
Atacand HCT
cholestyramine
Verelan PM
Avalide
cholestyramine light
Clorpres
colestipol HCL
NITRATES & NITRITES
Corzide
colestipol HCL for oral suspension
GENERIC
Diovan HCT
PREFERRED
isosorbide dinitrate
Edarbyclor
Welchol
isosorbide mononitrate
Exforge
NON PREFERRED
isosorbide mononitrate ER
Exforge HCT
Colestid
nitroglycerin lingual
Hypertensolol
Colestid Flavored
nitroglycerin transdermal
Hyzaar
Questran
nitroglycerin ER
Lopressor HCT
Questran Light
nitroglycerin IN dextrose 5%
Lotensin HCT
CHOLEST ABS INHBTR/COMBO
nitroglycerin IN 5% dextrose
Lotrel
PREFERRED
Isosorbide Dinitrate
Lytensopril Kit
Vytorin
Nitroglycerin Lingual
Lytensopril-90
NON PREFERRED
PREFERRED
Lytensopril-90 Kit
Zetia
Dilatrate SR
Micardis HCT
NIACIN/COMBINATIONS
Isosorbide Dinitrate ER
Prestalia
GENERIC
Nitro-bid
Tarka
niacin ER
Nitro-dur
Tekamlo
PREFERRED
Nitrostat
Tenoretic 100
Niacor
NON PREFERRED
Tenoretic 50
Simcor
Imdur
Teveten HCT
NON PREFERRED
Isordil Titradose
Twynsta
Advicor
Nitroglycerin
Uniretic
Niaspan
Nitroglycerin IN Dextrose 5%
Vaseretic
OMEGA-3 FATTY ACIDS
Nitrolingual Pumpspray
Zestoretic
GENERIC
Nitromist
Ziac
omega-3-acid ethyl esters
Nitronal
PREFERRED
ANTIHYPERLIPIDEMICS
Vascepa
ANTI-HTN COMBINATIONS
STATINS
NON PREFERRED
GENERIC
GENERIC
Kynamro
amlodipine besylate/benazepril hydrochloride
atorvastatin calcium
Lovaza
fluvastatin
amlodipine besylate/benazepril HCL
fluvastatin sodium ER
DERMATOLOGICALS
amlodipine besylate/valsartan
lovastatin
ACNE
amlodipine/valsartan/hctz
pravastatin sodium
GENERIC
atenolol/chlorthalidone
simvastatin
adapalene
benazepril HCL/hydrochlorothiazide
PREFERRED
benzoyl peroxide
bisoprolol fumarate/hydrochlorothiazide
Crestor
benzoyl peroxide SHORT contact
NON PREFERRED
clindamycin phosphate
candesartan cilexetil/hydrochlorothiazide
Altoprev
clindamycin/benzoyl peroxide
Lescol
erythromycin
enalapril maleate/hydrochlorothiazide
Lescol XL
erythromycin/benzoyl peroxide
fosinopril sodium/hydrochlorothiazide
Lipitor
metronidazole
irbesartan/hydrochlorothiazide
Livalo
sodium sulfacetamide
lisinopril/hydrochlorothiazide
Mevacor
sodium sulfacetamide/sulfur
losartan potassium/hydrochlorothiazide
Pravachol
sodium sulfacetamide/sulfur cleanser
Zocor
sodium sulfacetamide/sulfur cleansing cloths
metoprolol/hydrochlorothiazide
FIBRATES
moexipril/hydrochlorothiazide
sodium sulfacetamide/sulfur green
GENERIC
nadolol/bendroflumethiazide
sodium sulfacetamide/sulfur w/sunscreen
fenofibrate
quinapril/hydrochlorothiazide
fenofibrate micronized
telmisartan/amlodipine
sodium sulfacetamide/sulfur wash
fenofibric acid DR
Effective January 1, 2016
3
sulfacetamide sodium
Rosadan Kit
Cordran
sulfacetamide sodium/sulfur cleanser
Rosanil
Cordran Tape
tretinoin
Rosula
Cortalo
tretinoin microsphere
Sodium Sulfacetamide/Sulfur
Cutivate
tretinoin microsphere P.M.
Sodium Sulfacetamide/Sulfur Cleanser IN Urea
Derma Silkrx Sds PAK
Doxycycline
Derma-smoothe/FS Body
Sodium Sulfacetamide/Sulfur IN Urea
PREFERRED
Derma-smoothe/FS Scalp
Soolantra
Benzamycinpak
Dermasorb HC
Sulfoam
Clindagel
Dermasorb Ta
Sumadan Kit
Finacea
Dermatop
Sumadan Wash
Retinoic Acid
Desonate
Sumadan XLT
Retinoic Acid-all Trans
Desowen
Sumaxin
Tretinoin
Desowen Cream/Cetaphil Lotion
Sumaxin CP Kit
Tretinoin (all-trans Retinoic Acid)
Desowen Lotion/Cetaphil Cream
Sumaxin Ts
NON PREFERRED
Desowen Ointment/Cetaphil Lotion
Sumaxin Wash
Absorica
Diprolene
Tretin-x
Acanya
Diprolene AF
Triseon
Aczone
Elocon
Vanoxide-HC
Adapalene
Epifoam
Veltin
Akne-mycin
First-hydrocortisone
Zacare 4% Kit
Atralin
Halog
Zacare 8% Kit
Avar
Halonate
Ziana
Avar LS
Kenalog
Avar LS Cleanser
Locoid
TOPICAL ANTI-INFLAMMATORY
Avar-e LS
Locoid Lipocream
GENERIC
Azelex
Luxiq
alclometasone dipropionate
Benzac Ac Wash
Nucort
augmented betamethasone dipropionate
Benzac W Wash
Nuzon
Benzaclin
Olux
betamethasone dipropionate
Benzaclin With P.M.
Olux-e
betamethasone valerate
Benzamycin
Pandel
calcipotriene/betamethasone dipropionate
Benzefoam
Pediaderm HC
Benzefoamultra
Pediaderm Ta
clobetasol propionate
Benziq
Scalacort DK
clobetasol propionate emollient
Benziq LS
Silazone Pharmapak
desonide
Clarifoam EF
Synalar
desoximetasone
Cleocin-t
Synalar Cream Kit
fluocinolone acetonide
Clindacin Etz
Synalar Ointment Kit
fluocinonide
Clindacin PAC
Synalar Ts
fluocinonide-e
Clindap-t
Taclonex
fluticasone propionate
Clinoin
Temovate
halobetasol propionate
Dermapak Plus
Temovate E
hydrocortisone
Differin
Texacort
hydrocortisone acetate/aloe
Duac
Topicort
hydrocortisone butyrate
Epiduo
Triamsil Combipak
hydrocortisone butyrate (lipid)
Epiduo Forte
Trianex
hydrocortisone butyrate (lipophilic)
Erygel
Triderma Forte
hydrocortisone valerate
Evoclin
Ultravate
hydrocortisone IN absorbase
Fabior
Ultravate PAC
mometasone furoate
Inova
Ultravate X
prednicarbate
Inova 4/1 Acne Control Therapy
Validerm
triamcinolone acetonide
Inova 8/2 Acne Control Therapy
Vanos
Amcinonide
Klaron
Verdeso
Desoximetasone
Metrocream
Westcort
Diflorasone Diacetate
Metrogel
PREFERRED
Metrolotion
ENDOCRINE
Pramosone
Mirvaso
CONTRACEPTIVE AGENTS
Triamcinolone Acetonide
Neuac Kit
GENERIC
NON PREFERRED
Noritate
desogestrel/ethinyl estradiol
Aclovate
Nuox
drospirenone/ethinyl estradiol
Advanced Allergy Collection Kit
Onexton
levonorgestrel
Ala Scalp
Oracea
levonorgestrel and ethinyl estradiol
Capex
Plexion
levonorgestrel/ethinyl estradiol
Carmol-HC
Plexion Cleanser
norethindrone
Clobex
Plexion Cleansing Cloths
norethindrone & ethinyl estradiol ferrous fumarate
Clocortolone Pivalate
Prascion Ra With Sunscreens
Clocortolone Pivalate P.M.
norethindrone acetate/ethinyl estradiol
Retin-a
Clodan Kit
Retin-a Micro
Cloderm
norethindrone acetate/ethinyl estradiol/ferrous fumarate
Retin-a Micro P.M.
Cloderm P.M.
Riax
Effective January 1, 2016
4
norgestimate/ethinyl estradiol
Cenestin
Humulin 70/30 Kwikpen
Levonorgestrel
Climara
Humulin 70/30 Pen
PREFERRED
Combipatch
Lantus
Natazia
Delestrogen
Lantus Solostar
Necon 1/50-28
Depo-estradiol
Levemir
Necon 10/11-28
Divigel
Levemir Flexpen
Norinyl 1+50
Elestrin
Levemir Flextouch
Nuvaring
Enjuvia
Novolin N
Zovia 1/50e
Estrace
Novolin N Relion
NON PREFERRED
Estradiol
Novolin R
Beyaz
Estrasorb
Novolin R Relion
Brevicon-28
Estring
Novolin 70/30
Cyclessa
Estrogel
Novolin 70/30 Relion
Depo-provera
Evamist
Novolog
Desogen
Femhrt Low Dose
Novolog Flexpen
Ella
Femring
Novolog Mix 70/30
Estrostep FE
Menostar
Novolog Mix 70/30 Prefilled Flexpen
Falessa
Minivelle
Novolog Penfill
Femcon FE
Prefest
Toujeo Solostar
Generess FE
Premarin
NON PREFERRED
Loestrin FE 1.5/30
Vagifem
Afrezza
Loestrin FE 1/20
Vivelle-dot
Apidra
Loestrin 1.5/30-21
Apidra Solostar
Loestrin 1/20-21
TESTOSTERONE AGENTS
Tresiba Flextouch
Loseasonique
GENERIC
LO Loestrin FE
danazol
NON-INSULIN HYPOGLYCEMICS
LO Minastrin FE
methyltestosterone
BIGUANIDES
Minastrin 24 FE
testosterone
GENERIC
Mircette
testosterone cypionate
metformin HCL
Modicon
testosterone enanthate
metformin HCL ER
Nor-QD
testosterone P.M.
NON PREFERRED
Norinyl 1+35
Testosterone
Fortamet
Ortho Evra
Testosterone P.M.
Glucophage
Ortho Micronor
PREFERRED
Glucophage XR
Ortho Tri-cyclen
Androderm
Glumetza
Ortho Tri-cyclen LO
Androgel P.M.
Riomet
Ortho-cept
Androxy
BIGUAN/SULFONYLUREA COMB.
Ortho-cyclen
NON PREFERRED
GENERIC
Ortho-novum 1/35
Androgel
glipizide/metformin HCL
Ortho-novum 7/7/7
Android
glyburide/metformin HCL
Ovcon-35
Aveed
NON PREFERRED
Plan B
Axiron
Glucovance
Plan B One-step
Depo-testosterone
BIGUAN/THIAZOLIDEINEDIONE
Quartette
First-testosterone
GENERIC
Safyral
First-testosterone Mc Compounding Kit
pioglitazone HCL
Seasonique
pioglitazone HCL/metformin HCL
Fortesta
Tri-norinyl 28
NON PREFERRED
Natesto
Yasmin 28
Actoplus Met
Striant
Yaz
Actoplus Met XR
Testim
Actos
Testone Cik
ESTROGENS/COMBINATIONS
Avandamet
Testopel
GENERIC
Avandia
Testred
estradiol
DPP-4 INHIBITORS
Vogelxo
estradiol valerate
PREFERRED
Vogelxo P.M.
estradiol/norethindrone acetate
Januvia
estropipate
Onglyza
INSULIN
norethindrone acetate/ethinyl estradiol
NON PREFERRED
PREFERRED
Nesina
PREFERRED
Humalog
Tradjenta
Alora
Humalog Kwikpen
BIGUANIDE/DPP-4 COMB.
Climara Pro
Humalog Mix 50/50
PREFERRED
Duavee
Humalog Mix 50/50 Kwikpen
Janumet
Estropipate
Humalog Mix 75/25
Janumet XR
Menest
Humalog Mix 75/25 Kwikpen
Kombiglyze XR
Premphase
Humulin N
NON PREFERRED
Prempro
Humulin N Kwikpen
Jentadueto
NON PREFERRED
Humulin N U-100 Pen
Kazano
Activella
Humulin R
SULFONYLUREAS
Angeliq
Humulin R U-500 (concentrated)
GENERIC
Biest/Progesterone
Humulin 70/30
glimepiride
Effective January 1, 2016
5
glipizide
Prevacid
PREFERRED
glipizide ER
Prevacid Solutab
Pegasys
glyburide
Prilosec
Pegasys Proclick
glyburide micronized
Protonix
NON PREFERRED
tolazamide
Infergen
Glyburide
ULCER DRUGS
Peg-intron
PREFERRED
GENERIC
Peg-intron Redipen
Chlorpropamide
cimetidine
Peg-intron Redipen PAK 4
Diabeta
cimetidine HCL
Pegintron
Tolazamide
famotidine
Tolbutamide
misoprostol
PROTEASE INHIBITORS
NON PREFERRED
nizatidine
NON PREFERRED
Amaryl
ranitidine HCL
Olysio
Glucotrol
sucralfate
Victrelis
Glucotrol XL
Famotidine
Glynase
PREFERRED
MULTIPLE SCLEROSIS
SULFONYLUREA/TZD COMB.
Carafate
GENERIC
NON PREFERRED
PREFERRED
pioglitazone HCL-glimepiride
Axid
Ampyra
NON PREFERRED
Cytotec
Avonex
Avandaryl
Deprizine Fusepaq
Avonex Pen
Duetact
Famotidine Premixed
Copaxone
INCRETINS
Pepcid
Plegridy
PREFERRED
Zantac
Plegridy Starter Pack
Bydureon
Tecfidera
Byetta
GROWTH HORMONE
Tecfidera Starter Pack
Victoza
NON PREFERRED
NON PREFERRED
PREFERRED
Aubagio
Tanzeum
Norditropin Cartridge
Betaseron
Trulicity
Norditropin Flexpro
Extavia
AMYLIN ANALOGS
Norditropin Nordiflex Pen
Gilenya
NON PREFERRED
Nutropin AQ Nuspin 10
Lemtrada
Symlinpen 120
Nutropin AQ Nuspin 20
Rebif
Symlinpen 60
Nutropin AQ Nuspin 5
Rebif Rebidose
DIABETIC OTHER
Nutropin AQ Pen
Rebif Rebidose Titration Pack
PREFERRED
Saizen
Rebif Titration Pack
Glucagen Hypokit
Saizen Click.easy
Tysabri
Glucagon Emergency Kit
Serostim
Invokamet
NON PREFERRED
NEUROLOGICALS
Invokana
Genotropin
ALZHEIMER'S DISEASE
Jardiance
Genotropin Miniquick
GENERIC
Proglycem
Humatrope
donepezil HCL
NON PREFERRED
Humatrope Combo Pack
galantamine hydrobromide
Farxiga
Omnitrope
memantine hydrochloride
Synjardy
Tev-tropin
memantine HCL
Xigduo XR
Zomacton
memantine HCL titration PAK
Zorbtive
rivastigmine tartrate
GASTROINTESTINAL
rivastigmine transdermal system
PROTON PUMP INHIBITORS
HEPATITIS C
Galantamine Hydrobromide
GENERIC
ANTIVIRALS
PREFERRED
esomeprazole magnesium
GENERIC
Namenda XR
esomeprazole sodium
ribavirin
Namenda XR Titration Pack
lansoprazole
PREFERRED
NON PREFERRED
omeprazole
Harvoni
Aricept
pantoprazole sodium
Ribatab
Aricept Odt
rabeprazole sodium
Sovaldi
Exelon
Esomeprazole Sodium
NON PREFERRED
Namenda
PREFERRED
Copegus
Namenda Titration PAK
Dexilant
Moderiba
Namzaric
Nexium
Moderiba 1200 Dose Pack
Razadyne
Nexium 24HR
Moderiba 800 Dose Pack
Razadyne ER
NON PREFERRED
Rebetol
Aciphex
Ribasphere
ANTICONVULSANTS
Aciphex Sprinkle
Ribasphere Ribapak
GENERIC
Esomeprazole Strontium
Technivie
carbamazepine
First-lansoprazole
Viekira PAK
carbamazepine ER
First-omeprazole
clonazepam
Nexium I.v.
INTERFERONS
clonazepam odt
Omeprazole + Syrspend SF Alka
divalproex sodium
Effective January 1, 2016
6
divalproex sodium DR
Therapentin-90
ANTI-GLAUCOMA AGENTS
divalproex sodium ER
Topamax
GENERIC
ethosuximide
Topamax Sprinkle
apraclonidine
felbamate
Topiramate ER
betaxolol HCL
fosphenytoin sodium
Trileptal
brimonidine tartrate
gabapentin
Trokendi XR
carteolol HCL
lamotrigine
Vimpat
dorzolamide HCL
lamotrigine odt
Zarontin
dorzolamide HCL/timolol maleate
lamotrigine titration
Zonegran
latanoprost
lamotrigine ER
levobunolol HCL
levetiracetam
MIGRAINE/HEADACHE
timolol maleate
levetiracetam ER
GENERIC
timolol maleate ophthalmic gel forming
oxcarbazepine
almotriptan malate
Bimatoprost
phenytoin
dihydroergotamine mesylate
Metipranolol
phenytoin sodium
naratriptan HCL
PREFERRED
phenytoin sodium extended
rizatriptan benzoate
Alphagan P
primidone
rizatriptan benzoate odt
Azopt
tiagabine hydrochloride
sumatriptan succinate
Betoptic-s
topiramate
sumatriptan succinate refill
Combigan
valproate sodium
zolmitriptan
Levobunolol HCL
valproic acid
zolmitriptan odt
Lumigan
zonisamide
Dihydroergotamine Mesylate
Timoptic Ocudose
PREFERRED
Sumatriptan Succinate
Travatan Z
Diastat Acudial
PREFERRED
Travoprost
Diastat Pediatric
Sumatriptan
NON PREFERRED
Diazepam
Zomig Nasal Spray
Betagan
Lamictal
NON PREFERRED
Betimol
Lamictal Chewable Dispersible
Alsuma
Cosopt
Lamictal Starter/Not Taking Carbamazepine
Amerge
Cosopt PF
Axert
Lamictal Starter/Taking Carbamazepine/Not Taking Valproate
Iopidine
Cafergot
Istalol
Cambia
Lamictal Starter/Taking Valproate
Rescula
D.h.e. 45
Lyrica
Timoptic
Ergomar
NON PREFERRED
Timoptic-xe
Frova
Aptiom
Trusopt
Imitrex
Banzel
Xalatan
Imitrex Statdose Refill
Carbatrol
Zioptan
Imitrex Statdose System
Celontin
Maxalt
Cerebyx
ANTI-INFECTIVES
Maxalt-MLT
Depacon
GENERIC
Migergot
Depakene
ciprofloxacin HCL
Migral
Depakote
erythromycin
Migranal
Depakote ER
gatifloxacin
Relpax
Depakote Sprinkles
gentamicin sulfate
Sumavel Dosepro
Dilantin
levofloxacin
Treximet
Dilantin Infatabs
ofloxacin
Zecuity
Dilantin-125
tobramycin sulfate
Zomig
Fanatrex Fusepaq
PREFERRED
Zomig ZMT
Felbatol
Bacitracin
Fycompa
Moxeza
OPHTHALMICS
Gabitril
Vigamox
ANTI-ALLERGIC AGENTS
Keppra
NON PREFERRED
GENERIC
Keppra XR
Azasite
azelastine HCL
Klonopin
Besivance
cromolyn sodium
Lamictal Odt
Ciloxan
epinastine HCL
Lamictal XR
Garamycin
olopatadine HCL
Levetiracetam
Mitosol
PREFERRED
Mysoline
Ocuflox
Pataday
Neurontin
Tobrex
NON PREFERRED
Onfi
Zymaxid
Alocril
Oxtellar XR
Alomide
Peganone
ANTI-INFLAMMATORY AGENTS
Bepreve
Phenytek
GENERIC
Elestat
Potiga
bromfenac
Emadine
Qudexy XR
cromolyn sodium
Lastacaft
Sabril
diclofenac sodium
Optivar
Stavzor
flurbiprofen sodium
Patanol
Tegretol
ketorolac tromethamine
Pazeo
Tegretol-XR
Therapentin-60
Effective January 1, 2016
7
NON PREFERRED
PREFERRED
Fanapt Titration Pack
Acular
Alendronate Sodium
Fazaclo
Acular LS
NON PREFERRED
Geodon
Acuvail
Actonel
Haldol
Ilevro
Atelvia
Haldol Decanoate 100
Nevanac
Binosto
Haldol Decanoate 50
Ocufen
Boniva
Invega
Prolensa
Etidronate Disodium
Invega Sustenna
Fosamax
Invega Trinza
CORTICOSTEROIDS/RELATED
Fosamax Plus D
Latuda
GENERIC
Pamidronate Disodium
Lithium
dexamethasone sodium phosphate
Reclast
Lithium Carbonate
fluorometholone
Zoledronic Acid
Lithobid
neomycin/polymyxin/bacitracin/hydrocortisone
Zometa
Loxitane
Molindone Hydrochloride
neomycin/polymyxin/dexamethasone
SERM
Rexulti
prednisolone acetate
GENERIC
Risperdal
sulfacetamide sodium/prednisolone sodium phosphate
raloxifene hydrochloride
Risperdal Consta
NON PREFERRED
Risperdal M-TAB
tobramycin/dexamethasone
Evista
Seroquel
PREFERRED
Osphena
Versacloz
Dexamethasone Sodium Phosphate
Zyprexa
FML
PSYCHOTHERAPEUTICS
Zyprexa Relprevv
FML Forte
ANTIPSYCHOTICS/ANTIMANIC
Zyprexa Zydis
Pred Mild
GENERIC
Prednisolone Sodium Phosphate
aripiprazole
PSYCHOTHERAPEUTICS, MISC.
NON PREFERRED
chlorpromazine HCL
GENERIC
Alrex
clozapine
amphetamine/dextroamphetamine
Blephamide
clozapine odt
clonidine HCL ER
Blephamide S.o.p.
fluphenazine decanoate
dexmethylphenidate HCL
Durezol
fluphenazine HCL
dexmethylphenidate HCL ER
Flarex
haloperidol
dextroamphetamine sulfate
FML Liquifilm
haloperidol decanoate
dextroamphetamine sulfate ER
Lotemax
haloperidol lactate
guanfacine ER
Maxidex
lithium carbonate
methamphetamine HCL
Maxitrol
lithium carbonate ER
methylphenidate hydrochloride
Neomycin/Polymyxin/Hydrocortisone
loxapine
methylphenidate HCL
Omnipred
loxapine succinate
methylphenidate HCL CD
Pred Forte
olanzapine
methylphenidate HCL ER
Pred-G
olanzapine odt
methylphenidate HCL SR
Pred-G S.o.p.
paliperidone ER
modafinil
Tobradex
perphenazine
Methylphenidate HCL ER
Tobradex ST
prochlorperazine
PREFERRED
Vexol
prochlorperazine edisylate
Strattera
Zylet
prochlorperazine maleate
Vyvanse
quetiapine fumarate
NON PREFERRED
MIOTICS
risperidone
Adderall
GENERIC
risperidone odt
Adderall XR
pilocarpine HCL
thioridazine HCL
Aptensio XR
PREFERRED
thiothixene
Concerta
Isopto Carbachol
trifluoperazine HCL
Daytrana
Phospholine Iodide
ziprasidone HCL
Desoxyn
NON PREFERRED
Aripiprazole Odt
Dexedrine
Isopto Carpine
Clozapine Odt
Evekeo
PREFERRED
Focalin
MISCELLANEOUS
Abilify Discmelt
Focalin XR
NON PREFERRED
Fluphenazine HCL
Intuniv
Lacrisert
Saphris
Kapvay
Restasis
Seroquel XR
Kapvay Dose Pack
NON PREFERRED
Metadate CD
OSTEOPOROSIS
Abilify
Methylin
BISPHOSPHONATES
Abilify Maintena
Nuvigil
GENERIC
Adasuve
Procentra
alendronate sodium
Aristada
Provigil
ibandronate sodium
Chlorpromazine HCL
Quillivant XR
pamidronate disodium
Clozaril
Ritalin
risedronate sodium
Compazine
Ritalin LA
risedronate sodium DR
Equetro
Ritalin SR
zoledronic acid
Fanapt
Zenzedi
Effective January 1, 2016
8
SNRI ANTIDEPRESSANTS
PREFERRED
olopatadine HCL
GENERIC
Anoro Ellipta
NON PREFERRED
duloxetine HCL
Combivent Respimat
Astelin
venlafaxine HCL
NON PREFERRED
Astepro
venlafaxine HCL ER
Duoneb
Patanase
Venlafaxine HCL ER
PREFERRED
BETA AGONISTS
NASAL CORTICOSTEROIDS
Pristiq
GENERIC
GENERIC
NON PREFERRED
albuterol
budesonide
Cymbalta
albuterol sulfate
flunisolide
Desvenlafaxine ER
albuterol sulfate ER
fluticasone propionate
Duloxetine HCL
albuterol TAB 4MG
triamcinolone acetonide
Effexor XR
levalbuterol
PREFERRED
Fetzima
levalbuterol HCL
Nasonex
Fetzima Titration Pack
terbutaline sulfate
Veramyst
Irenka
PREFERRED
NON PREFERRED
Khedezla
Foradil Aerolizer
Beconase AQ
Metaproterenol Sulfate
Flonase
SSRI ANTIDEPRESSANTS
Proair HFA
Omnaris
GENERIC
Proair Respiclick
Qnasl
citalopram hydrobromide
Serevent Diskus
Qnasl Childrens
escitalopram oxalate
Ventolin HFA
Rhinocort Aqua
fluoxetine DR
NON PREFERRED
Zetonna
fluoxetine HCL
Arcapta Neohaler
fluvoxamine maleate
Brovana
STEROID/BETA AGONIST
fluvoxamine maleate ER
Isuprel
PREFERRED
paroxetine HCL
Maxair Autohaler
Advair Diskus
paroxetine HCL ER
Perforomist
Advair HFA
sertraline HCL
Proventil HFA
Breo Ellipta
PREFERRED
Striverdi Respimat
Symbicort
Fluoxetine HCL
Vospire ER
NON PREFERRED
Paxil
Xopenex
Dulera
NON PREFERRED
Xopenex Concentrate
Celexa
Xopenex HFA
MISCELLANEOUS
Lexapro
NON PREFERRED
Luvox CR
LEUKOTRIENE RCPTR ANTGNST
Dermacinrx Azenase PAK
Paxil CR
GENERIC
Dymista
Pexeva
montelukast sodium
Prozac
zafirlukast
UROLOGICALS
Prozac Weekly
NON PREFERRED
BENIGN PRSTATC HYPRPLSIA
Zoloft
Accolate
GENERIC
Singulair
alfuzosin HCL ER
RESPIRATORY
dutasteride
ANAPHYLAXIS TX AGENTS
PULMONARY CORTICOSTEROIDS
dutasteride/tamsulosin hydrochloride
PREFERRED
GENERIC
finasteride
Epipen 2-PAK
budesonide
tamsulosin HCL
Epipen-JR 2-PAK
PREFERRED
PREFERRED
NON PREFERRED
Flovent Diskus
Rapaflo
Adrenaclick
Flovent HFA
NON PREFERRED
Adrenalin
Pulmicort Flexhaler
Avodart
Auvi-q
Qvar
Cardura XL
Epinephrine
NON PREFERRED
Flomax
Episnap
Aerospan
Jalyn
Alvesco
Proscar
ANTICHOLINERGICS
Arnuity Ellipta
Uroxatral
GENERIC
Asmanex HFA
ipratropium bromide
Asmanex Twisthaler 120 Metered Doses
ERECTILE DYSFUNCTION
PREFERRED
PREFERRED
Asmanex Twisthaler 14 Metered Doses
Incruse Ellipta
Cialis
Spiriva Handihaler
Stendra
Asmanex Twisthaler 30 Metered Doses
Spiriva Respimat
NON PREFERRED
Tudorza Pressair
Levitra
Asmanex Twisthaler 60 Metered Doses
NON PREFERRED
Staxyn
Atrovent HFA
Viagra
Asmanex Twisthaler 7 Metered Doses
Seebri Neohaler
Pulmicort
URINARY ANTISPASMODICS
ANTICHLNRGC/BETA AGONIST
GENERIC
NASAL ANTIHISTAMINES
GENERIC
bethanechol chloride
GENERIC
ipratropium bromide/albuterol sulfate
flavoxate HCL
azelastine HCL
Effective January 1, 2016
9
oxybutynin chloride
oxybutynin chloride ER
tolterodine tartrate
tolterodine tartrate ER
trospium chloride
trospium chloride ER
PREFERRED
Gelnique
Vesicare
NON PREFERRED
Detrol
Detrol LA
Ditropan XL
Enablex
Myrbetriq
Oxytrol
Sanctura
Sanctura XR
Toviaz
Urecholine
Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of HealthSmart Rx. 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 or call member services at the number listed on your ID card.
Effective January 1, 2016 v.3
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