Prescription Drug Formulary [pdf]

TESTOSTERONE AGENTStestosterone cypionate, testosteroneenanthateANDRODERM, ANDROGEL, ANDROXY, AXIRON,FORTESTA, METHITESTINSULINAPIDRA, HUMALOG, HUMULIN R U-500,LANTUS, LEVEMIR, NOVOLOGNON-INSULIN HYPOGLYCEMIC AGENTSBIGUANIDE/THIAZOLIDINEDIONE (TZDs)pioglitazone, pioglitazone-metforminSULFONYLUREA/TZDs COMBINATIONSDUETACTDIPEPTIDYL PEPTIDASE-4 INHIBITORS (DPP-4)JANUVIA, ONGLYZA, TRADJENTADPP-4/HMG-COA REDUCTASE INHIBITORCOMBINATIONSJUVISYNCBIGUANIDESmetformin, metformin ERRIOMETBIGUANIDE/DPP-4 COMBINATIONSJANUMET, JANUMET XR, JENTADUETO,KOMBIGLYZE XRBIGUANIDE/SULFONYLUREA COMBINATIONSglipizide-metforminBIGUANIDE/ INSULIN SECRETAGOGUECOMBINATIONSPRANDIMETINCRETIN MIMETICSBYDUREON, BYETTA, VICTOZAAMYLIN ANALOGSSYMLINANTIHYPOGLYCEMIC AGENTSGLUCAGONSULFONYLUREASglimiperide, glipizide, glipizide ERGASTROINTESTINALPROTON PUMP INHIBITORSlansoprazole, omeprazole, pantoprazoleNEXIUMULCER DRUGSnizatidine, sucralfateAXID SOLUTION, CARAFATE SUSPENSION,PYLERAGROWTH HORMONENORDITROPIN, NUTROPINANTIVIRALSribavirinRIBAPAKHEPATITIS CINTERFERONSPEGASYS, PEG-INTRONPROTEASE INHIBITORSINCIVEK, VICTRELISMULTIPLE SCLEROSISAMPYRA, AVONEX, COPAXONE, REBIFNEUROLOGICALSALZHEIMER’S DISEASEdonepezil, rivastigmineEXELON PATCH, NAMENDAANTICONVULSANTS/ANTI-SEIZUREcarbamazepine, carbamazepine ER,divalproex, gabapentin, lamotrigine,levetiracetam, levetiracetam ER,oxcarbazepineBANZEL, CELONTIN, DIASTAT PEDIATRIC,DILANTIN INFATABS, GABITRIL, LAMICTALODT, LAMICTAL STARTER KIT, LAMICTAL XR,LYRICA, PEGANONE, TEGRETOL XR, TRILEPTALSUSPENSION, VIMPATMIGRAINE/HEADACHEnaratriptan, sumatriptanCAFERGOT, ERGOMAR, MAXALT,RELPAX, TREXIMET, ZOMIGOPHTHALMICSANTI-ALLERGIC AGENTSazelastine, ketotifenPATADAY, PATANOLANTI-GLAUCOMA AGENTSbetaxolol, brimonidine, latanoprostALPHAGAN P, AZOPT, BETOPTIC-S, COMBIGAN,LUMIGAN, TRAVATAN ZANTI-INFECTIVESciprofloxacin, ofloxacin, tobramycinBESIVANCE, CILOXAN, MOXEZA, NATACYN,TOBREX, VIGAMOX, ZYMAXIDANTI-INFLAMMATORY AGENTScromolyn sodium, diclofenac sodium,ketorolacACUVAIL, BROMDAY, NEVANACCORTICOSTEROIDS/RELATED AGENTSprednisolone acetate,tobramycin/dexmethasoneALREX, BLEPHAMIDE S.O.P., DUREZOL, FML,LOTEMAX, OZURDEX, PRED MILD, RETISERT,TOBRADEX, TOBRADEX ST, ZYLETMIOTICSpilocarpineISOPTO CARBACHOL, PHOSPHOLINE IODINE,PILOPINE HSMISCELLANEOUSLACRISERT, RESTASISOSTEOPOROSIS THERAPYBISPHOSPHONATESalendronate, ibandronate, ACTONEL, ATELVIASELECTIVE ESTROGEN RECEPTORMODULATOREVISTAPSYCHOTHERAPEUTICSATYPICAL ANTIPSYCHOTICSclozapine, olanzapine, quetiapine,risperidone, ziprasidoneABILIFY, CLOZARIL, LATUDA, SEROQUEL XRCNS STIMULANTSamphetamine-dextroamphetamine,methylphenidate, methylphenidate ERDAYTRANA, INTUNIV, METADATE CD, VYVANSESNRI ANTIDEPRESSANTSvenlafaxine, venlafaxine ERCYMBALTA, PRISTIQSSRI ANTIDEPRESSANTScitalopram, escitalopram, fluoxetine,paroxetine, paroxetine ER, sertralinePAXIL SUSPENSION, VIIBRYDRESPIRATORYANAPHYLAXIS TREATMENT AGENTSEPIPEN, TWINJECTANTICHOLINERGICSipratropiumATROVENT HFA, SPIRIVAANTICHOLINERGIC/BETA AGONISTCOMBINATIONSipratropium-albuterolCOMBIVENTBETA AGONIST BRONCHODILATORSalbuterol, levalbuterol solutionFORADIL, PERFOROMIST, PROAIR, SEREVENT,VENTOLIN HFALEUKOTRIENE RECEPTOR ANTAGONISTSmontelukast, zafirlukastPULMONARY CORTICOSTEROIDSbudesonideALVESCO, ASMANEX, PULMICORT, QVARNASAL ANTIHISTAMINESazelastineASTEPRO, ASTELINNASAL CORTICOSTEROIDSfluticasone, triamcinoloneNASONEX, QNASL, RHINOCORT, VERAMYSTSTEROID/BETA AGONIST COMBINATIONSADVAIR, DULERA, SYMBICORTUROLOGICALSBENIGN PROSTATIC HYPERPLASIA (BPH)finasteride, tamsulosinRAPAFLOURINARY ANTISPASMODICSoxybutynin, oxybutynin ER, tolterodineDETROL LA, ENABLEX, GELNIQUE, OXYTROL,SANCTURA XR, TOVIAZ, VESICARECatamaran Preferred Drug List - Effective January 1, 2013214-091112-3 © 2012 Catamaran Inc. All rights reserved. Catamaran is a registered trademark of Catamaran Inc.

TRAVEL MEDICATIONSTRAVEL MEDICATIONS- Below is a list of thetravel medications covered under the SHIP drugbenefit. Medications that are covered at ageneric copay appear in lowercase whilemedications covered at a brand copay appear inCAPS.VIVOTIF, cipro, ciprofloxin er, ciprofloxin hcl,doxycycline, doxycycline monohydrate,doxycycline hyclate, vibramycin, oraxyl,azithromycin, zmax, chloroquine phosphate,hydroxychloroquine sulfate, mefloquine hcl,primaquine phosphate, daraprim, qualquin,coartem, atovaquone/proguanil hclFormulary Disclaimer: Coverage for some drugs may be limited tospecific dosage forms and/or strengths. The benefit designdetermines what is covered and the applicable co-payment. Themedications listed on this formulary are subject to changepursuant to the formulary management activities of Catamaran.The presence of a medication on this formulary list does notguarantee coverage.Catamaran Preferred Drug List - Effective January 1, 2013214-091112-3 © 2012 Catamaran Inc. All rights reserved. Catamaran is a registered trademark of Catamaran Inc.

IsentressKaletraLexivaNorvirPrezistaRescriptorRetrovirReyatazSelzentrystavudineSustivaTrizivirTruvadaVidexViraceptViramuneVireadZeritZiagenzidovudineHIV (CONT.)Additional Information:General Specialty Questions1.800.850.9122Compounded SpecialtyMedication Questions1.800.951.0175HORMONAL THERAPIESEligardleuprolide acetateLupron DepotLupron Depot-PEDMakena*Supprelin LASynarelTrelstarVantasZoladexSpecialty medications may require prior authorization to ensure appropriate usage. Coverage for these medications may vary with respect tobenefit design. This list is subject to change without notice to accommodate the introduction, removal and availability of new drugs andclinical information. * Limited Distribution Product - Contact BriovaRx for more information.Catamaran Preferred Drug List - Effective January 1, 2013214-091112-3 © 2012 Catamaran Inc. All rights reserved. Catamaran is a registered trademark of Catamaran Inc.