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ampicillin PREFERRED Timolol Maleate
ampicillin sodium Fenoprofen Calcium
ampicillin-sulbactam Indocin CALCIUM CHANNEL BLOCKERS dicloxacillin sodium Ketoprofen ER GENERIC
January 2016 nafcillin sodium Meloxicam amlodipine besylate
oxacillin sodium Mobic diltiazem CD
penicillin v potassium Naproxen diltiazem HCL
penicillin G potassium diltiazem HCL ER
piperacillin sodium/ tazobactam sodium
AUTO-IMMUNE felodipine ER
isradipine piperacillin sodium/tazobactam sodium
PREFERRED nicardipine HCL
Cimzia nifedipine piperacillin/tazobactam
Cimzia Starter Kit nifedipine ER PREFERRED
Humira nimodipine Amoxicillin
Humira Pediatric Crohns Disease Starter Pack
nisoldipine Ampicillin
verapamil HCL Augmentin Humira Pen verapamil HCL ER
Humira Pen-crohns Diseasestarter
verapamil HCL SR QUINOLONES Verapamil HCL
GENERIC Humira Pen-psoriasis Starter ciprofloxacin
NITRATES & NITRITES Remicade ciprofloxacin ER GENERIC
Simponi ciprofloxacin HCL isosorbide dinitrate
Simponi Aria ciprofloxacin I.V.-IN D5W isosorbide mononitrate
levofloxacin isosorbide mononitrate ER
CARDIOVASCULAR levofloxacin IN D5W nitroglycerin lingual
ACE-INHIBITORS moxifloxacin HCL nitroglycerin transdermal
GENERIC ofloxacin nitroglycerin ER
benazepril HCL Ciprofloxacin HCL nitroglycerin IN dextrose 5%
captopril Ofloxacin nitroglycerin IN 5% dextrose
SELECT/NATIONAL/ADVANTAGE PREFERRED DRUG LIST
The HealthSmart Rx Preferred Drug List is a guide identifying preferred brand-name medicines within select therapeutic categories. The Preferred 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.
ANTI-INFECTIVES ANTIFUNGALS
enalapril maleate Isosorbide Dinitrate GENERIC enalaprilat TETRACYCLINES Nitroglycerin Lingual fluconazole fosinopril sodium GENERIC PREFERRED fluconazole IN dextrose lisinopril demeclocycline HCL Dilatrate SR fluconazole IN NACL moexipril HCL doxycycline Isordil Titradose flucytosine perindopril erbumine doxycycline hyclate Isosorbide Dinitrate ER griseofulvin microsize quinapril HCL doxycycline hyclate DR Nitro-bid griseofulvin ultramicrosize ramipril doxycycline monohydrate Nitro-dur itraconazole trandolapril minocycline HCL Nitrostat ketoconazole
minocycline HCL ER nystatin ANGIOTENSIN RCPTR
BLOCKER Tetracycline HCL
ANTI-HTN COMBINATIONS terbinafine HCL GENERIC voriconazole GENERIC ANTI-INFLAMMATORY amlodipine besylate/benazepril hydrochloride
candesartan cilexetil NSAIDS CEPHALOSPORINS irbesartan GENERIC
GENERIC losartan potassium celecoxib amlodipine besylate/benazepril HCL cefaclor telmisartan diclofenac potassium
cefadroxil valsartan amlodipine besylate/valsartan
diclofenac sodium DR cefazolin sodium Eprosartan Mesylate diclofenac sodium ER cefdinir amlodipine/valsartan/hctz PREFERRED diclofenac
sodium/misoprostol cefepime atenolol/chlorthalidone Benicar cefixime benazepril
HCL/hydrochlorothiazide etodolac
cefotaxime sodium etodolac ER BETA BLOCKERS bisoprolol fumarate/hydrochlorothiazide
cefoxitin sodium flurbiprofen GENERIC cefpodoxime proxetil ibuprofen acebutolol HCL cefprozil indomethacin atenolol
candesartan cilexetil/hydrochlorothiazide
ceftazidime indomethacin ER betaxolol HCL ceftriaxone sodium ketoprofen bisoprolol fumarate enalapril
maleate/hydrochlorothiazide cefuroxime axetil ketorolac tromethamine carvedilol cefuroxime sodium mefenamic acid esmolol HCL fosinopril
sodium/hydrochlorothiazide cephalexin meloxicam labetalol HCL PREFERRED irbesartan/hydrochlorothiazid
e nabumetone metoprolol succinate ER
Cefaclor naproxen metoprolol tartrate lisinopril/hydrochlorothiazide Cephalexin naproxen sodium nadolol losartan potassium/hydrochlorothiazide
naproxen sodium CR pindolol PENICILLINS naproxen sodium ER propranolol HCL
GENERIC oxaprozin propranolol HCL ER metoprolol/hydrochlorothiazide amoxicillin piroxicam sotalol HCL
amoxicillin/clavulanate potassium
sulindac sotalol HCL (AF) moexipril/hydrochlorothiazide tolmetin sodium PREFERRED
amoxicillin/clavulanate potassium ER
nadolol/bendroflumethiazide Meclofenamate Sodium Bystolic
Tolmetin Sodium Propranolol HCL
Effective January 1, 2016
1
quinapril/hydrochlorothiazide GENERIC triamcinolone acetonide PREFERRED adapalene Amcinonide Humalog
telmisartan/amlodipine benzoyl peroxide Desoximetasone Humalog Kwikpen telmisartan/hydrochloroth benzoyl peroxide SHORT
contact Diflorasone Diacetate Humalog Mix 50/50
telmisartan/hydrochlorothiazide
PREFERRED Humalog Mix 50/50 Kwikpen clindamycin phosphate Pramosone Humalog Mix 75/25
trandolapril/verapamil HCL clindamycin/benzoyl peroxide
Topicort Humalog Mix 75/25 Kwikpen trandolapril/verapamil HCL ER
Triamcinolone Acetonide Humulin N erythromycin
Humulin N Kwikpen valsartan/hydrochlorothiazide erythromycin/benzoyl
peroxide ENDOCRINE Humulin N U-100 Pen
CONTRACEPTIVE AGENTS Humulin R PREFERRED metronidazole GENERIC Humulin R U-500
(concentrated) Azor sodium sulfacetamide
desogestrel/ethinyl estradiol Benicar HCT sodium sulfacetamide/sulfur Humulin 70/30 drospirenone/ethinyl
estradiol Captopril/Hydrochlorothiazide sodium sulfacetamide/sulfur
cleanser Humulin 70/30 Kwikpen
levonorgestrel Humulin 70/30 Pen Dutoprol sodium sulfacetamide/sulfur cleansing cloths levonorgestrel and ethinyl
estradiol Lantus Methyldopa/Hydrochlorothiazi
de Lantus Solostar sodium sulfacetamide/sulfur green levonorgestrel/ethinyl
estradiol Propranolol/Hydrochlorothiazide
Levemir
sodium sulfacetamide/sulfur w/sunscreen
Levemir Flexpen norethindrone Tekturna HCT Levemir Flextouch norethindrone & ethinyl estradiol ferrous fumarate
Tribenzor sodium sulfacetamide/sulfur wash
Novolin N
Novolin N Relion norethindrone acetate/ethinyl estradiol
sulfacetamide sodium ANTIHYPERLIPIDEMICS Novolin R sulfacetamide sodium/sulfur cleanser
STATINS Novolin R Relion norethindrone acetate/ethinyl estradiol/ferrous fumarate GENERIC Novolin 70/30
tretinoin atorvastatin calcium norgestimate/ethinyl
estradiol Novolin 70/30 Relion
tretinoin microsphere fluvastatin Novolog
tretinoin microsphere P.M. fluvastatin sodium ER Levonorgestrel Novolog Flexpen
Doxycycline lovastatin PREFERRED Novolog Mix 70/30
PREFERRED pravastatin sodium Natazia Novolog Mix 70/30 Prefilled
Flexpen Benzamycinpak
simvastatin Necon 1/50-28 Clindagel
PREFERRED Necon 10/11-28 Novolog Penfill Finacea
Crestor Norinyl 1+50 Toujeo Solostar Retin-a Micro P.M.
FIBRATES Nuvaring Retinoic Acid
GENERIC Zovia 1/50e NON-INSULIN HYPOGLYCEMICS Retinoic Acid-all Trans
fenofibrate BIGUANIDES Tretin-x
fenofibrate micronized ESTROGENS/COMBINATIONS GENERIC Tretinoin
fenofibric acid DR GENERIC metformin HCL Tretinoin (all-trans Retinoic Acid)
gemfibrozil estradiol metformin HCL ER
Fenofibrate estradiol valerate BIGUAN/SULFONYLUREA COMB. Fenofibric Acid estradiol/norethindrone
acetate GENERIC
TOPICAL ANTI-INFLAMMATORY PREFERRED glipizide/metformin HCL
GENERIC estropipate Fibricor glyburide/metformin HCL
alclometasone dipropionate norethindrone acetate/ethinyl estradiol
Lipofen BIGUAN/THIAZOLIDEINEDIONE augmented betamethasone dipropionate BILE ACID SEQUESTRANTS GENERIC
PREFERRED GENERIC pioglitazone HCL betamethasone dipropionate
Alora cholestyramine pioglitazone HCL/metformin
HCL betamethasone valerate
Climara Pro cholestyramine light calcipotriene/betamethasone
dipropionate Duavee DPP-4 INHIBITORS colestipol HCL Estropipate PREFERRED colestipol HCL for oral
suspension clobetasol propionate
Menest Januvia clobetasol propionate emollient Premarin PREFERRED Onglyza
Premphase Welchol desonide BIGUANIDE/DPP-4 COMB. Prempro CHOLEST ABS INHBTR/COMBO desoximetasone PREFERRED
PREFERRED fluocinolone acetonide Janumet TESTOSTERONE AGENTS Vytorin fluocinonide Janumet XR
GENERIC NIACIN/COMBINATIONS fluocinonide-e Kombiglyze XR danazol GENERIC fluticasone propionate SULFONYLUREAS testosterone niacin ER halobetasol propionate GENERIC testosterone cypionate PREFERRED hydrocortisone glimepiride testosterone enanthate Niacor hydrocortisone acetate/aloe glipizide Testosterone Simcor hydrocortisone butyrate glipizide ER Testosterone P.M. OMEGA-3 FATTY ACIDS hydrocortisone butyrate
(lipid) glyburide
PREFERRED GENERIC glyburide micronized hydrocortisone butyrate (lipophilic)
Androderm omega-3-acid ethyl esters tolazamide Androgel PREFERRED Glyburide
hydrocortisone valerate Androgel P.M. Vascepa PREFERRED hydrocortisone IN absorbase
Androxy Chlorpropamide
DERMATOLOGICALS Diabeta mometasone furoate
INSULIN ACNE Tolazamide prednicarbate
Tolbutamide
Effective January 1, 2016
2
SULFONYLUREA/TZD COMB.
MULTIPLE SCLEROSIS
Phenytek
ANTI-INFLAMMATORY AGENTS
GENERIC
GENERIC
pioglitazone HCL-glimepiride
PREFERRED
MIGRAINE/HEADACHE
bromfenac
Ampyra
GENERIC
cromolyn sodium
INCRETINS
Avonex
almotriptan malate
diclofenac sodium
PREFERRED
Copaxone
dihydroergotamine mesylate
flurbiprofen sodium
Bydureon
Plegridy
naratriptan HCL
ketorolac tromethamine
Byetta
Plegridy Starter Pack
rizatriptan benzoate
Victoza
Tecfidera
rizatriptan benzoate odt
CORTICOSTEROIDS/RELATED
DIABETIC OTHER
Tecfidera Starter Pack
sumatriptan succinate
GENERIC
PREFERRED
sumatriptan succinate refill
dexamethasone sodium phosphate
Glucagen Hypokit
NEUROLOGICALS
zolmitriptan
Glucagon Emergency Kit
fluorometholone
ALZHEIMER'S DISEASE
zolmitriptan odt
Invokamet
neomycin/polymyxin/bacitracin/hydrocortisone
GENERIC
Dihydroergotamine Mesylate
Invokana
donepezil HCL
neomycin/polymyxin/dexamethasone
Jardiance
Sumatriptan Succinate
galantamine hydrobromide
Proglycem
PREFERRED
memantine HCL
prednisolone acetate
Imitrex
memantine HCL titration PAK
sulfacetamide sodium/prednisolone sodium phosphate
GASTROINTESTINAL
Sumatriptan
PROTON PUMP INHIBITORS
rivastigmine tartrate
Zomig
GENERIC
rivastigmine transdermal system
Zomig Nasal Spray
tobramycin/dexamethasone
esomeprazole magnesium
PREFERRED
Galantamine Hydrobromide
esomeprazole sodium
OPHTHALMICS
FML
PREFERRED
lansoprazole
ANTI-ALLERGIC AGENTS
FML Forte
Namenda
omeprazole
GENERIC
Pred Mild
Namenda XR
pantoprazole sodium
azelastine HCL
Prednisolone Sodium Phosphate
Namenda XR Titration Pack
rabeprazole sodium
cromolyn sodium
Esomeprazole Sodium
epinastine HCL
ANTICONVULSANTS
PREFERRED
PREFERRED
MIOTICS
GENERIC
Dexilant
Pataday
GENERIC
carbamazepine
Nexium
Patanol
pilocarpine HCL
carbamazepine ER
Nexium 24HR
PREFERRED
clonazepam
ANTI-GLAUCOMA AGENTS
Isopto Carbachol
clonazepam odt
ULCER DRUGS
GENERIC
Phospholine Iodide
divalproex sodium
GENERIC
apraclonidine
divalproex sodium DR
cimetidine
betaxolol HCL
OSTEOPOROSIS
divalproex sodium ER
cimetidine HCL
brimonidine tartrate
BISPHOSPHONATES
ethosuximide
famotidine
carteolol HCL
GENERIC
felbamate
misoprostol
dorzolamide HCL
alendronate sodium
fosphenytoin sodium
nizatidine
dorzolamide HCL/timolol maleate
ibandronate sodium
gabapentin
ranitidine HCL
pamidronate disodium
lamotrigine
latanoprost
sucralfate
risedronate sodium
lamotrigine odt
levobunolol HCL
Famotidine
risedronate sodium DR
lamotrigine ER
timolol maleate
PREFERRED
zoledronic acid
levetiracetam
timolol maleate ophthalmic gel forming
Carafate
PREFERRED
levetiracetam ER
Alendronate Sodium
Bimatoprost
oxcarbazepine
GROWTH HORMONE
Metipranolol
phenytoin
SERM
PREFERRED
phenytoin sodium
PREFERRED
GENERIC
Alphagan P
phenytoin sodium extended
Nutropin AQ Nuspin 10
raloxifene hydrochloride
Azopt
primidone
Nutropin AQ Nuspin 20
Betoptic-s
tiagabine hydrochloride
Nutropin AQ Nuspin 5
PSYCHOTHERAPEUTICS
Combigan
topiramate
Nutropin AQ Pen
ANTIPSYCHOTICS/ANTIMANIC
Levobunolol HCL
valproate sodium
Saizen
GENERIC
Lumigan
valproic acid
Saizen Click.easy
aripiprazole
Timoptic Ocudose
zonisamide
Serostim
chlorpromazine HCL
Travatan Z
PREFERRED
clozapine
Travoprost
Diastat Acudial
HEPATITIS C
fluphenazine decanoate
Diastat Pediatric
ANTIVIRALS
fluphenazine HCL
ANTI-INFECTIVES
Diazepam
GENERIC
haloperidol
GENERIC
Lamictal
ribavirin
haloperidol decanoate
ciprofloxacin HCL
Lamictal Chewable Dispersible
PREFERRED
haloperidol lactate
erythromycin
Harvoni
lithium carbonate
Lamictal Odt
gatifloxacin
Ribatab
lithium carbonate ER
Lamictal Starter/Not Taking Carbamazepine
gentamicin sulfate
Sovaldi
loxapine
levofloxacin
loxapine succinate
Lamictal Starter/Taking Carbamazepine/Not Taking Valproate
ofloxacin
INTERFERONS
olanzapine
tobramycin sulfate
PREFERRED
olanzapine odt
PREFERRED
Pegasys
Lamictal Starter/Taking Valproate
paliperidone ER
Bacitracin
Pegasys Proclick
perphenazine
Moxeza
Lyrica
prochlorperazine
Vigamox
Effective January 1, 2016
3
prochlorperazine edisylate Epipen-JR 2-PAK UROLOGICALS prochlorperazine maleate BENIGN PRSTATC HYPRPLSIA quetiapine fumarate ANTICHOLINERGICS GENERIC risperidone GENERIC alfuzosin HCL ER
risperidone odt ipratropium bromide finasteride
thioridazine HCL PREFERRED tamsulosin HCL
thiothixene Incruse Ellipta PREFERRED trifluoperazine HCL Spiriva Handihaler Avodart
ziprasidone HCL Spiriva Respimat Jalyn
Clozapine Odt Tudorza Pressair Rapaflo
PREFERRED Abilify ANTICHLNRGC/BETA AGONIST ERECTILE DYSFUNCTION Abilify Discmelt GENERIC PREFERRED Fluphenazine HCL ipratropium bromide/albuterol
sulfate Cialis
Saphris Stendra PREFERRED Seroquel XR Combivent Respimat URINARY ANTISPASMODICS
PSYCHOTHERAPEUTICS, MISC. GENERIC BETA AGONISTS GENERIC bethanechol chloride
GENERIC amphetamine/dextroamphetamine
flavoxate HCL albuterol sulfate oxybutynin chloride
clonidine HCL ER albuterol sulfate ER oxybutynin chloride ER dexmethylphenidate HCL albuterol TAB 4MG tolterodine tartrate dexmethylphenidate HCL ER
levalbuterol tolterodine tartrate ER levalbuterol HCL trospium chloride
dextroamphetamine sulfate terbutaline sulfate trospium chloride ER dextroamphetamine sulfate ER
PREFERRED PREFERRED Foradil Aerolizer Gelnique
guanfacine ER Metaproterenol Sulfate Vesicare
methamphetamine HCL Proair HFA
methylphenidate hydrochloride
Proair Respiclick
Serevent Diskus methylphenidate HCL
Ventolin HFA methylphenidate HCL CD
methylphenidate HCL ER LEUKOTRIENE RCPTR ANTGNST
methylphenidate HCL SR
modafinil GENERIC
Methylphenidate HCL ER montelukast sodium
PREFERRED zafirlukast
Strattera
Vyvanse PULMONARY CORTICOSTEROIDS SNRI ANTIDEPRESSANTS
GENERIC GENERIC
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 list
ed on your ID card.
budesonide duloxetine HCL
PREFERRED venlafaxine HCL
Flovent Diskus venlafaxine HCL ER
Flovent HFA Venlafaxine HCL ER
Pulmicort Flexhaler PREFERRED
Qvar Pristiq
NASAL ANTIHISTAMINES SSRI ANTIDEPRESSANTS GENERIC
GENERIC azelastine HCL
citalopram hydrobromide olopatadine HCL
escitalopram oxalate
fluoxetine DR NASAL CORTICOSTEROIDS fluoxetine HCL
GENERIC fluvoxamine maleate
budesonide fluvoxamine maleate ER
flunisolide paroxetine HCL
fluticasone propionate paroxetine HCL ER
triamcinolone acetonide sertraline HCL
PREFERRED PREFERRED
Nasonex Fluoxetine HCL
Veramyst Paxil
STEROID/BETA AGONIST RESPIRATORY PREFERRED
ANAPHYLAXIS TX AGENTS Advair Diskus
GENERIC Advair HFA
Epinephrine Breo Ellipta
PREFERRED Symbicort
Epipen 2-PAK
Effective January 1, 2016
4