2016 Optum Select Formulary Reference Guide

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2016 Optum Select FormularyReference GuideList of Covered drugs

SHIP Drug BenefitIf you have any questions about your SHIP drug benefit please contact:CHP Student Health Pharmacy Help Desk: 1-877-657-5031The SHIP drug benefit has 4 tiers of drug coverage:1st Tier-Formulary Generic drug2nd Tier-Formulary Brand drug3rd Tier-Non-formulary Brand drug4th Tier-Specialty drugsGeneric drugs (1st Tier) have the lowest member copayment. Copayments for tiers 1, 2 and 3, are listed next to “RXCOPAY” on the SHIP membership card. Member cost-sharing for specialty drugs is detailed in the online SHIP PlanDocumentFDA-approved contraceptive medications are fully covered under the SHIP contraceptive benefit. For a supply of more than 30days please call CHP Student Health at 1-877-657-5031. Note: unless a brand name contraceptive is prescribed as medicallynecessary, a copayment will apply if a member receives a brand name contraceptive when a generic equivalent is available.USING THIS FORMULARY REFERENCE GUIDE TO HELP CONTAIN COSTSMany health plans use the Optum formulary to help manage the overall cost of providing prescription drug benefits. Thisformulary offers a wide range of medications from which to choose. We realize that this formulary reference guide maynot include every drug from every manufacturer. However, choosing a generic or preferred drug when it is appropriatecan provide access to the necessary medications to stay healthy, at a cost that is more affordable.SAVING ON OUT-OF-POCKET COSTSSHIP sets the co-payments for each formulary drug status which include generic, preferred brand-name, and nonpreferred brand-name medications. Health plans often design prescription drug plans to encourage the use of genericand preferred brand-name drugs. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses.Patients may also pay less for generic drugs, or they may be asked to pay the cost difference between brand-namedrugs and their generic alternatives.PLEASE NOTE: Brand-name drugs may move to non-preferred status if a generic version becomes available.KNOWING HOW THE FORMULARY INFORMATION IS ORGANIZEDThe following formulary reference guide is designed so that generic products are listed first in each drug category. Thepreferred brand name products are listed next.

July 2016SELECT FORMULARYPREFERRED DRUG LISTThe Optum Preferred Drug List is a guide identifyingpreferred brand-name medicines within selecttherapeutic categories. The Preferred Drug List maynot include all drugs covered by your prescriptiondrug benefit. Generic medicines are available withinmany of the therapeutic categories listed, in additionto categories not listed, and should be consideredas the first line of prescribing.For benefit coverage or restrictions please checkyour benefit plan document(s). This listing is revisedperiodically as new drugs and new prescribinginformation becomes available. It is recommendedthat you bring this list of medications when you or acovered family member sees a physician or otherhealthcare clavulanate potassiumamoxicillin/clavulanate potassium ERampicillinampicillin sodiumampicillin-sulbactampiperacillin icillin/Clavulanate inciprofloxacin ERciprofloxacin HCLciprofloxacin I.V.-IN D5Wlevofloxacinlevofloxacin IN D5Wmoxifloxacin HCLofloxacinCiprofloxacin HCLOfloxacinTETRACYCLINESGENERICdemeclocycline HCLdoxycyclinedoxycycline hyclatedoxycycline hyclate DRdoxycycline monohydrateminocycline HCLminocycline HCL ERtetracycline hydrochlorideTetracycline n sodiumcefdinircefepimecefiximecefotaxime sodiumcefotetancefoxitin sodiumcefpodoxime proxetilcefprozilceftazidimeceftriaxone sodiumcefuroxime axetilcefuroxime sodiumcephalexinCeftriaxone IN Iso-osmotic DextroseCefuroxime SodiumPREFERREDCefaclorCephalexinMeclofenamate SodiumNaproxenTolmetin SodiumPREFERREDFenoprofen CalciumIndocinKetoprofen nazolefluconazole IN dextrosefluconazole IN NACLflucytosinegriseofulvin microsizegriseofulvin inafine HCLvoriconazoledicloxacillin sodiumnafcillin sodiumoxacillin sodiumpenicillin v potassiumpenicillin G potassiumpiperacillin sodium/ coxibdiclofenac potassiumdiclofenac sodium DRdiclofenac sodium ERdiclofenac sodium/misoprostoletodolacetodolac ERflurbiprofenibuprofenibuprofen lysineindomethacinindomethacin ERketoprofenketorolac tromethaminemefenamic acidmeloxicamnabumetonenaproxennaproxen sodiumnaproxen sodium CRnaproxen sodium ERoxaprozinpiroxicamsulindactolmetin sodiumAUTO-IMMUNEPREFERREDCimziaCimzia Starter KitHumiraHumira Pediatric Crohns DiseaseStarter PackHumira PenHumira Pen-crohns DiseasestarterHumira Pen-psoriasis StarterRemicadeSimponiSimponi AriaCARDIOVASCULARACE-INHIBITORSGENERICbenazepril HCLcaptoprilenalapril maleateenalaprilatfosinopril sodiumlisinoprilmoexipril HCLperindopril erbuminequinapril HCLramipriltrandolaprilANGIOTENSIN RCPTR BLOCKERGENERICcandesartan cilexetilirbesartanlosartan potassiumtelmisartanvalsartanEprosartan MesylatePREFERREDBenicarBETA BLOCKERSGENERICacebutolol HCLatenololbetaxolol HCLbisoprolol fumaratecarvedilolesmolol HCLlabetalol HCLmetoprolol succinate ERmetoprolol tartratenadololpindololpropranolol HCLpropranolol HCL ERsotalol HCLsotalol HCL (AF)Metoprolol TartrateEffective July 1, 2016 v.2All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. 2016 Optum, Inc. All rights reserved.TM1

PREFERREDBystolicPropranolol HCLTimolol MaleatePREFERREDAzorBenicar eTekturna HCTTribenzorCALCIUM CHANNEL BLOCKERSGENERICamlodipine besylatediltiazem CDdiltiazem HCLdiltiazem HCL ERfelodipine ERisradipinenicardipine HCLnifedipinenifedipine ERnimodipinenisoldipineverapamil HCLverapamil HCL ERverapamil HCL SRNITRATES & NITRITESGENERICisosorbide dinitrateisosorbide mononitrateisosorbide mononitrate ERnitroglycerin lingualnitroglycerin transdermalnitroglycerin ERnitroglycerin IN dextrose 5%nitroglycerin IN 5% dextroseIsosorbide DinitrateNitroglycerin LingualPREFERREDDilatrate SRIsordil TitradoseIsosorbide Dinitrate ERNitro-bidNitro-durNitrostatANTI-HTN COMBINATIONSGENERICamlodipine besylate/benazeprilhydrochlorideamlodipine besylate/benazepril HCLamlodipine l/chlorthalidonebenazepril eenalapril maleate/hydrochlorothiazidefosinopril ril/verapamil HCLtrandolapril/verapamil HCL STATINSGENERICatorvastatin calciumfluvastatinfluvastatin sodium ERlovastatinpravastatin sodiumrosuvastatin brate micronizedfenofibric acid DRgemfibrozilFenofibrateFenofibric AcidPREFERREDFibricorLipofenBILE ACID SEQUESTRANTSGENERICcholestyraminecholestyramine lightcolestipol HCLPREFERREDWelcholCHOLEST ABS ERICniacin ERPREFERREDNiacorSimcorOMEGA-3 FATTY ACIDSGENERIComega-3-acid ethyl apaleneadapalene P.M.benzoyl peroxidebenzoyl peroxide SHORT contactclindamycin phosphateclindamycin/benzoyl peroxideerythromycinerythromycin/benzoyl peroxidemetronidazolesodium sulfacetamidesodium sulfacetamide/sulfursodium sulfacetamide/sulfur cleansersodium sulfacetamide/sulfur cleansingclothssodium sulfacetamide/sulfur greensodium sulfacetamide/sulfurw/sunscreensodium sulfacetamide/sulfur washsulfacetamide sodiumsulfacetamide sodium/sulfursulfacetamide sodium/sulfur cleansertretinointretinoin microspheretretinoin microsphere ceaRetin-a Micro P.M.Retinoic AcidRetinoic Acid-all TransTretin-xTretinoinTretinoin (all-trans Retinoic Acid)TOPICAL ANTI-INFLAMMATORYGENERICalclometasone dipropionateaugmented betamethasonedipropionatebetamethasone dipropionatebetamethasone betasol propionateclobetasol propionate emollientdesonidedesoximetasonefluocinolone fluticasone propionatehalobetasol propionatehydrocortisonehydrocortisone acetate/aloehydrocortisone butyratehydrocortisone butyrate (lipid)hydrocortisone butyrate (lipophilic)hydrocortisone valeratehydrocortisone IN absorbasemometasone furoateprednicarbatetriamcinolone acetonideAmcinonideDesoximetasoneDiflorasone DiacetatePREFERREDPramosoneTopicortTriamcinolone AcetonideENDOCRINECONTRACEPTIVE AGENTSGENERICdesogestrel/ethinyl estradioldrospirenone/ethinyl estradiollevonorgestrellevonorgestrel and ethinyl estradiollevonorgestrel/ethinyl estradiolnorethindroneEffective July 1, 20162

norethindrone & ethinyl estradiolferrous fumaratenorethindrone acetate/ethinylestradiolnorethindrone acetate/ethinylestradiol/ferrous fumaratenorgestimate/ethinyl estradiolLevonorgestrelPREFERREDNataziaNecon 1/50-28Necon 10/11-28Norinyl 1 50NuvaringZovia ol valerateestradiol/norethindrone acetatenorethindrone limara E testosterone cypionatetestosterone enanthatetestosterone P.M.TestosteroneTestosterone P.M.PREFERREDAndrodermAndrogelAndrogel P.M.AndroxyINSULINPREFERREDHumalogHumalog KwikpenHumalog Mix 50/50Humalog Mix 50/50 KwikpenHumalog Mix 75/25Humalog Mix 75/25 KwikpenHumulin NHumulin N KwikpenHumulin RHumulin R U-500 (concentrated)Humulin R U-500 KwikpenHumulin 70/30Humulin 70/30 KwikpenLantusLantus SolostarLevemirLevemir FlexpenLevemir FlextouchNovolin NNovolin N RelionNovolin RNovolin R RelionNovolin 70/30Novolin 70/30 RelionNovologNovolog FlexpenNovolog Mix 70/30Novolog Mix 70/30 Prefilled FlexpenNovolog PenfillNON-INSULIN HYPOGLYCEMICSBIGUANIDESGENERICmetformin HCLmetformin HCL ERBIGUAN/SULFONYLUREA COMB.GENERICglipizide/metformin HCLglyburide/metformin HCLBIGUAN/THIAZOLIDEINEDIONEGENERICpioglitazone HCLpioglitazone HCL/metformin HCLDPP-4 BIGUANIDE/DPP-4 COMB.GENERICAlogliptin/Metformin HCLPREFERREDJanumetJanumet XRKombiglyze e ERglyburideglyburide lorpropamideDiabetaTolbutamideSULFONYLUREA/TZD COMB.GENERICpioglitazone licityVictozaDIABETIC OTHERPREFERREDGlucagen HypokitGlucagon Emergency ROINTESTINALPROTON PUMP INHIBITORSGENERICesomeprazole magnesiumesomeprazole sodiumlansoprazoleomeprazolepantoprazole sodiumrabeprazole sodiumEsomeprazole SodiumPREFERREDDexilantULCER DRUGSGENERICcimetidinecimetidine HCLfamotidinemisoprostolnizatidineranitidine GROWTH HORMONEPREFERREDNorditropin CartridgeNorditropin FlexproNorditropin Nordiflex PenNutropin AQ Nuspin 10Nutropin AQ Nuspin 20Nutropin AQ Nuspin 5Nutropin AQ PenSaizenSaizen Click.easySerostimHEPATITIS SovaldiZepatierINTERFERONSPREFERREDPegasysPegasys ProclickMULTIPLE SCLEROSISGENERICglatopaPREFERREDAmpyraAvonexAvonex PenCopaxonePlegridyPlegridy Starter PackTecfideraTecfidera Starter PackEffective July 1, 20163

NEUROLOGICALSALZHEIMER'S DISEASEGENERICdonepezil HCLgalantamine hydrobromidememantine hydrochloridememantine HCLmemantine HCL titration PAKrivastigmine tartraterivastigmine transdermal systemGalantamine HydrobromidePREFERREDNamenda XRNamenda XR Titration ne ERclonazepamclonazepam odtdivalproex sodiumdivalproex sodium DRdivalproex sodium ERethosuximidefelbamatefosphenytoin sodiumgabapentinlamotriginelamotrigine odtlamotrigine titrationlamotrigine ERlevetiracetamlevetiracetam ERoxcarbazepinephenytoinphenytoin sodiumphenytoin sodium extendedprimidonetiagabine hydrochloridetopiramatevalproate sodiumvalproic acidzonisamidePREFERREDDiastat AcudialDiastat PediatricDiazepamLamictalLamictal Chewable DispersibleLamictal Starter/Not TakingCarbamazepineLamictal Starter/TakingCarbamazepine/Not Taking ValproateLamictal Starter/Taking ValproateLyricaMIGRAINE/HEADACHEGENERICalmotriptan malatedihydroergotamine mesylatefrovatriptan succinatenaratriptan HCLrizatriptan benzoaterizatriptan benzoate odtsumatriptan succinatesumatriptan succinate refillzolmitriptanzolmitriptan odtDihydroergotamine MesylateSumatriptan SuccinatePREFERREDImitrexSumatriptanZomigZomig Nasal eomycin/polymyxin/dexamethasoneprednisolone acetatesulfacetamide sodium/prednisolonesodium asone Sodium PhosphateFMLFML FortePred MildPrednisolone Sodium PhosphateOPHTHALMICSANTI-ALLERGIC AGENTSGENERICazelastine HCLcromolyn sodiumepinastine HCLolopatadine HCLPREFERREDPatadayMIOTICSGENERICpilocarpine HCLPREFERREDIsopto CarbacholPhospholine IodideANTI-GLAUCOMA AGENTSGENERICapraclonidinebetaxolol HCLbrimonidine tartratecarteolol HCLdorzolamide HCLdorzolamide HCL/timolol maleatelatanoprostlevobunolol HCLtimolol maleatetimolol maleate ophthalmic gelformingBimatoprostMetipranololPREFERREDAlphagan PAzoptBetoptic-sCombiganLevobunolol HCLLumiganTimoptic OcudoseTravatan ZTravoprostANTI-INFECTIVESGENERICciprofloxacin HCLerythromycingatifloxacingentamicin sulfatelevofloxacinofloxacintobramycin MATORY AGENTSGENERICbromfenaccromolyn sodiumdiclofenac sodiumflurbiprofen sodiumketorolac asone sodium SGENERICalendronate sodiumibandronate sodiumpamidronate disodiumrisedronate sodiumrisedronate sodium DRzoledronic acidPREFERREDAlendronate SodiumSERMGENERICraloxifene MANICGENERICaripiprazolechlorpromazine HCLclozapineclozapine odtfluphenazine decanoatefluphenazine HCLhaloperidolhaloperidol decanoatehaloperidol lactatelithium carbonatelithium carbonate ERloxapineloxapine succinateolanzapineolanzapine odtpaliperidone ERperphenazineprochlorperazineprochlorperazine edisylateprochlorperazine maleatequetiapine fumaraterisperidonerisperidone odtthioridazine HCLthiothixenetrifluoperazine HCLziprasidone HCLAripiprazole OdtClozapine OdtEffective July 1, 20164

PREFERREDAbilifyAbilify DiscmeltFluphenazine HCLSaphrisSeroquel XRANTICHLNRGC/BETA AGONISTGENERICipratropium bromide/albuterol sulfatePREFERREDAnoro ElliptaCombivent Respimatdutasteride/tamsulosin HCLfinasteridetamsulosin HCLPREFERREDRapafloERECTILE DYSFUNCTIONPSYCHOTHERAPEUTICS, ilclonidine HCL ERdexmethylphenidate HCLdexmethylphenidate HCL ERdextroamphetamine sulfatedextroamphetamine sulfate ERguanfacine ERmethamphetamine HCLmethylphenidate hydrochloridemethylphenidate HCLmethylphenidate HCL CDmethylphenidate HCL ERmethylphenidate HCL SRmodafinilMethylphenidate HCL ERPREFERREDStratteraVyvanseSNRI ANTIDEPRESSANTSGENERICduloxetine HCLvenlafaxine HCLvenlafaxine HCL ERVenlafaxine HCL ERPREFERREDPristiqBETA AGONISTSGENERICalbuterolalbuterol sulfatealbuterol sulfate ERalbuterol TAB 4MGlevalbuterollevalbuterol HCLterbutaline sulfatePREFERREDForadil AerolizerMetaproterenol SulfateProair HFAProair RespiclickSerevent DiskusVentolin HFALEUKOTRIENE RCPTR ANTGNSTGENERICmontelukast sodiumzafirlukastPULMONARY CORTICOSTEROIDSGENERICbudesonidePREFERREDArnuity ElliptaFlovent DiskusFlovent HFAPulmicort FlexhalerQvarPREFERREDCialisStendraURINARY ANTISPASMODICSGENERICbethanechol chloridedarifenacin hydrobromide ERdarifenacin ERflavoxate HCLoxybutynin chlorideoxybutynin chloride ERtolterodine tartratetolterodine tartrate ERtrospium chloridetrospium chloride ERPREFERREDGelniqueVesicareFormulary Disclaimer: Coverage for some drugs may belimited to specific dosage forms and/or strengths. Thebenefit design determines what is covered and theapplicable co-payment. The medications listed on thisformulary are subject to change pursuant to the formularymanagement activities of Optum. The presence of amedication on this formulary list does not guaranteecoverage. To determine the most up-to-date formularystatus of your medication, please visit your member websiteor call member services at the number listed on your IDcard.SSRI ANTIDEPRESSANTSGENERICcitalopram hydrobromideescitalopram oxalatefluoxetine DRfluoxetine HCLfluvoxamine maleatefluvoxamine maleate ERparoxetine HCLparoxetine HCL ERsertraline HCLPREFERREDFluoxetine HCLPaxilNASAL ANTIHISTAMINESGENERICazelastine HCLolopatadine HCLNASAL sone propionatemometasone furoatetriamcinolone acetonideSTEROID/BETA AGONISTRESPIRATORYANAPHYLAXIS TX AGENTSGENERICEpinephrinePREFERREDEpipen 2-PAKEpipen-JR 2-PAKANTICHOLINERGICSGENERICipratropium bromidePREFERREDIncruse ElliptaSpiriva HandihalerSpiriva RespimatTudorza PressairPREFERREDAdvair DiskusAdvair HFABreo GICALSBENIGN PRSTATC HYPRPLSIAGENERICalfuzosin HCL ERdutasteridedutasteride/tamsulosin hydrochlorideEffective July 1, 2016 v.2All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. 2016 Optum, Inc. All rights reserved.TM5

Norditropin Cartridge Prempro GENERIC Norditropin Flexpro A logliptin/Metformin HCL Norditropin Nordiflex Pen TESTOSTERONE AGENTS PREFERRED Nutropin AQ Nuspin 10 GENERIC Janumet Nutropin AQ Nuspin 20 danazol Janumet XR Nutropin AQ Nuspin 5 methyltestosterone Ko

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