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