NALC Health Benefit Plan Formulary Drug List with Advanced ...

1 January 2016. NALC Health Benefit Plan Formulary Drug List with Advanced Control Specialty Formulary . The NALC Health Benefit Plan Formulary Drug List with Advanced Control Specialty Formulary is a guide within select therapeutic categories for clients, plan members and Health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These Formulary brand-name medicines are . listed to help identify products that are clinically appropriate and cost-effective. Call CVS/caremark at 1-800-933-NALC (6252) to see if your drug is on the NALC Health Benefit Plan Formulary Drug List with Advanced Control Specialty Formulary . Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list.

2 This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN MEMBER Health CARE PROVIDER. Your Benefit plan provides you with a prescription Benefit program Your patient is covered under a prescription Benefit plan administered by CVS/caremark. Ask your doctor to consider administered by CVS/caremark. As a way to help manage Health prescribing, when medically appropriate, a Formulary medicine from care costs, authorize generic substitution whenever possible. If you this list. Take this list along when you or a covered family member believe a brand-name product is necessary, consider prescribing a sees a doctor. brand name on this list. Please note: Please note: For specific information 1. regarding your prescription Benefit Generics should be considered the first line of prescribing.

3 Coverage and copay information, please visit or contact a CVS/caremark Customer Care This drug list represents a summary of prescription coverage. representative at 1-800-933-NALC (6252). It is not all-inclusive and does not guarantee coverage. CVS/caremark may contact your doctor after receiving your The member's prescription Benefit plan may have a different prescription to request consideration of a drug list product or copay for specific products on the list. generic equivalent. This may result in your doctor prescribing, Unless specifically indicated, drug list products will include all when medically appropriate, a different brand-name product or dosage forms. generic equivalent in place of your original prescription. Log in to to check coverage and copay In most instances, a brand-name drug for which a generic product information for a specific medicine.

4 Becomes available will be designated as a nonformulary option upon release of the generic product to the market. ANALGESICS fentanyl transmucosal cefprozil tetracycline SIVEXTRO. lozenge cefuroxime axetil XIFAXAN 550 MG. NSAIDs hydrocodone-acetaminophen cephalexin ANTIFUNGALS. diclofenac sodium hydromorphone SUPRAX fluconazole CARDIOVASCULAR. meloxicam hydromorphone ext-rel itraconazole ERYTHROMYCINS / ACE INHIBITORS. naproxen methadone terbinafine tablet morphine MACROLIDES fosinopril NSAIDs, COMBINATIONS azithromycin ANTIVIRALS lisinopril morphine ext-rel diclofenac sodium- morphine suppository clarithromycin CYTOMEGALOVIRUS quinapril misoprostol oxycodone clarithromycin ext-rel AGENTS ramipril oxycodone-acetaminophen erythromycins valganciclovir ACE INHIBITOR /. NSAIDs, TOPICAL DIFICID. tramadol DIURETIC COMBINATIONS.

5 Diclofenac sodium solution tramadol ext-rel HERPES AGENTS. VOLTAREN GEL FLUOROQUINOLONES acyclovir fosinopril-hydrochlorothiazide ABSTRAL. ciprofloxacin valacyclovir lisinopril-hydrochlorothiazide COX-2 INHIBITORS BUTRANS. ciprofloxacin ext-rel quinapril-hydrochlorothiazide FENTORA. celecoxib levofloxacin INFLUENZA AGENTS. NUCYNTA ANGIOTENSIN II. NUCYNTA ER moxifloxacin RELENZA. GOUT RECEPTOR ANTAGONISTS /. OPANA ER TAMIFLU. allopurinol PENICILLINS DIURETIC COMBINATIONS. colchicine tablet OXYCONTIN MISCELLANEOUS candesartan / candesartan- SUBSYS amoxicillin probenecid amoxicillin-clavulanate clindamycin hydrochlorothiazide COLCRYS dicloxacillin ivermectin eprosartan ANTI-INFECTIVES. ULORIC penicillin VK metronidazole irbesartan / irbesartan- ANTIBACTERIALS nitrofurantoin hydrochlorothiazide OPIOID ANALGESICS TETRACYCLINES losartan / losartan- CEPHALOSPORINS sulfamethoxazole- codeine-acetaminophen doxycycline hyclate trimethoprim hydrochlorothiazide cefdinir fentanyl transdermal minocycline ALBENZA.

6 For specific information, visit or contact a CVS/caremark Customer Care representative at 1-800-933-NALC (6252). telmisartan / telmisartan- CALCIUM CHANNEL ANTIDEMENTIA ATTENTION DEFICIT VASOMOTOR SYMPTOM. hydrochlorothiazide BLOCKER / ANTILIPEMIC donepezil HYPERACTIVITY DISORDER AGENTS. valsartan / valsartan- COMBINATIONS galantamine amphetamine- BRISDELLE. hydrochlorothiazide amlodipine-atorvastatin galantamine ext-rel dextroamphetamine BENICAR / BENICAR HCT rivastigmine mixed salts ENDOCRINE AND. DIGITALIS GLYCOSIDES EXELON PATCH amphetamine- METABOLIC. ANGIOTENSIN II digoxin NAMENDA dextroamphetamine ANDROGENS. RECEPTOR ANTAGONIST /. NAMENDA XR mixed salts ext-rel CALCIUM CHANNEL DIRECT RENIN INHIBITORS / ANDRODERM. guanfacine ext-rel BLOCKER COMBINATIONS DIURETIC COMBINATIONS ANTIDEPRESSANTS AXIRON. methylphenidate amlodipine-telmisartan TEKTURNA / SELECTIVE SEROTONIN methylphenidate ext-rel amlodipine-valsartan ANTIDIABETICS.

7 TEKTURNA HCT REUPTAKE INHIBITORS DAYTRANA. AZOR (SSRIs) AMYLIN ANALOGS. DIRECT RENIN INHIBITOR / QUILLIVANT XR. citalopram STRATTERA SYMLINPEN. ANGIOTENSIN II CALCIUM CHANNEL. RECEPTOR ANTAGONIST / BLOCKER COMBINATIONS escitalopram VYVANSE BIGUANIDES. CALCIUM CHANNEL fluoxetine TEKAMLO FIBROMYALGIA metformin BLOCKER / DIURETIC paroxetine LYRICA metformin ext-rel COMBINATIONS DIRECT RENIN INHIBITOR / paroxetine ext-rel CALCIUM CHANNEL sertraline SAVELLA BIGUANIDE /. amlodipine-valsartan- BLOCKER / DIURETIC BRINTELLIX SULFONYLUREA. hydrochlorothiazide HYPNOTICS. COMBINATIONS FLUOXETINE 60 MG COMBINATIONS. TRIBENZOR NONBENZODIAZEPINES. AMTURNIDE VIIBRYD glipizide-metformin ANTILIPEMICS eszopiclone DIURETICS SEROTONIN zolpidem DIPEPTIDYL PEPTIDASE-4. BILE ACID RESINS NOREPINEPHRINE. furosemide zolpidem ext-rel (DPP-4) INHIBITORS.

8 Cholestyramine REUPTAKE INHIBITORS. WELCHOL hydrochlorothiazide TRICYCLICS JANUVIA. (SNRIs). metolazone TRADJENTA. duloxetine SILENOR. CHOLESTEROL spironolactone- ABSORPTION INHIBITORS hydrochlorothiazide venlafaxine DIPEPTIDYL PEPTIDASE-4. MIGRAINE. torsemide venlafaxine ext-rel (DPP-4) INHIBITOR. ZETIA SELECTIVE SEROTONIN. triamterene- KHEDEZLA COMBINATIONS. PRISTIQ AGONISTS. FIBRATES hydrochlorothiazide JANUMET. naratriptan JANUMET XR. fenofibrate MISCELLANEOUS. NITRATES rizatriptan JENTADUETO. fenofibric acid AGENTS. nitroglycerin lingual spray sumatriptan HMG-CoA REDUCTASE NITROLINGUAL bupropion zolmitriptan INCRETIN MIMETIC AGENTS. INHIBITORS / NITROSTAT bupropion ext-rel RELPAX TRULICITY. COMBINATIONS mirtazapine ZOMIG NASAL SPRAY VICTOZA. atorvastatin NITRATE / VASODILATOR trazodone COMBINATIONS SELECTIVE SEROTONIN INSULINS.

9 Fluvastatin ANTIPARKINSONIAN AGONIST / NONSTEROIDAL. lovastatin BIDIL HUMULIN R U-500. AGENTS ANTI-INFLAMMATORY LANTUS. pravastatin DRUG (NSAID). MISCELLANEOUS amantadine LEVEMIR. simvastatin COMBINATIONS. RANEXA carbidopa-levodopa NOVOLIN 70/30. CRESTOR. carbidopa-levodopa ext-rel TREXIMET NOVOLIN N. VYTORIN. CENTRAL NERVOUS carbidopa-levodopa- NOVOLIN R. entacapone MUSCULOSKELETAL. NIACINS / COMBINATIONS SYSTEM NOVOLOG. entacapone THERAPY AGENTS. niacin ext-rel NOVOLOG MIX 70/30. ANTICONVULSANTS pramipexole cyclobenzaprine SIMCOR TOUJEO. carbamazepine ropinirole carbamazepine ext-rel NARCOLEPSY INSULIN SENSITIZERS. OMEGA-3 FATTY ACIDS ropinirole ext-rel diazepam rectal gel selegiline NUVIGIL pioglitazone omega-3 acid ethyl esters divalproex sodium AZILECT. divalproex sodium ext-rel POSTHERPETIC INSULIN SENSITIZER /. BETA-BLOCKERS MIRAPEX ER.

10 Ethosuximide NEURALGIA BIGUANIDE COMBINATIONS. atenolol NEUPRO. gabapentin GRALISE pioglitazone-metformin carvedilol lamotrigine ANTIPSYCHOTICS. metoprolol succinate ext-rel PSYCHOTHERAPEUTIC - lamotrigine ext-rel ATYPICALS INSULIN SENSITIZER /. metoprolol tartrate MISCELLANEOUS. levetiracetam SULFONYLUREA. nadolol aripiprazole OPIOID ANTAGONISTS. levetiracetam ext-rel COMBINATIONS. propranolol clozapine propranolol ext-rel oxcarbazepine olanzapine EVZIO pioglitazone-glimepiride BYSTOLIC phenobarbital quetiapine PARTIAL OPIOID AGONIST / MEGLITINIDES. COREG CR phenytoin risperidone OPIOID ANTAGONIST nateglinide phenytoin sodium extended ziprasidone CALCIUM CHANNEL COMBINATIONS repaglinide primidone LATUDA. BLOCKERS tiagabine buprenorphine-naloxone SEROQUEL XR SODIUM-GLUCOSE. amlodipine topiramate sublingual tablet SUBOXONE FILM CO-TRANSPORTER 2.