2015 Catamaran National

Formulary Reference Guide

List of covered drugs

SHIP Drug Benefit

If you have any questions about your SHIP drug benefit please contact:
AIG Student Health Pharmacy Help Desk: 1-888-722-1668
The SHIP drug benefit has 4 tiers of drug coverage:
1st Tier2nd Tier3rd Tier4th Tier-

Formulary Generic drug

Formulary Brand drug
Non-formulary Brand drug
Specialty drugs

Generic drugs (1st Tier) have the lowest member copayment. Copayments for tiers 1, 2 and 3, are listed
next to RX COPAY on the SHIP membership card. Member cost-sharing for specialty drugs is detailed in
the online SHIP Plan Document
FDA-approved contraceptive medications are fully covered under the SHIP contraceptive benefit. For
a supply of more than 30 days please call AIG Student Health at 1-888-722-1668. Note: unless a
brand name contraceptive is prescribed as medically necessary, 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 COSTS
Many health plans use the Catamaran formulary to help manage the overall cost of providing
prescription drug benefits. This formulary offers a wide range of medications from which to choose. We
realize that this formulary reference guide may not include every drug from every manufacturer.
However, choosing a generic or preferred drug when it is appropriate can provide access to the
necessary medications to stay healthy, at a cost that is more affordable.
SAVING ON OUT-OF-POCKET COSTS
SHIP sets the co-payments for each formulary drug status which include generic, preferred brand-name,
and non-preferred brand-name medications. Health plans often design prescription drug plans to
encourage the use of generic and 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-name drugs 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 ORGANIZED
The following formulary reference guide is designed so that generic products are listed first in each drug
category. The preferred brand name products are listed next.

oxacillin sodium
penicillin v potassium
penicillin G potassium
piperacillin sodium/ tazobactam
sodium
piperacillin sodium/tazobactam
sodium
piperacillin/tazobactam
PREFERRED
Augmentin

NATIONAL FORMULARY PREFERRED

DRUG LIST
The Catamaran 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.

QUINOLONES
GENERIC
ciprofloxacin
ciprofloxacin ER
ciprofloxacin HCL
ciprofloxacin I.V.-IN D5W
levofloxacin
levofloxacin IN D5W
moxifloxacin HCL
ofloxacin
Ciprofloxacin HCL
Ofloxacin
PREFERRED
Avelox

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
GENERIC
fluconazole
fluconazole IN dextrose
fluconazole IN NACL
flucytosine
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole
ketoconazole
nystatin
terbinafine HCL
voriconazole
PREFERRED
Lamisil
Noxafil
Sporanox

CEPHALOSPORINS
GENERIC
cefaclor
cefadroxil
cefazolin sodium
cefdinir
cefepime
cefotaxime sodium
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium
cephalexin

PENICILLINS
GENERIC
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium ER
ampicillin
ampicillin sodium
ampicillin-sulbactam
dicloxacillin sodium
nafcillin sodium

PREFERRED
Cimzia
Cimzia Starter Kit
Humira
Humira Pediatric Crohns Disease
Starter Pack
Humira Pen
Humira Pen-crohns Diseasestarter
Humira Pen-psoriasis Starter

CARDIOVASCULAR
ACE-INHIBITORS
GENERIC
benazepril HCL
captopril
enalapril maleate
enalaprilat
fosinopril sodium
lisinopril
moexipril HCL
perindopril erbumine
quinapril HCL
ramipril
trandolapril

TETRACYCLINES
GENERIC
demeclocycline HCL
doxycycline
doxycycline hyclate
doxycycline hyclate DR
doxycycline monohydrate
minocycline HCL
minocycline HCL ER
Tetracycline HCL

ANGIOTENSIN RCPTR BLOCKER

GENERIC
candesartan cilexetil
eprosartan mesylate
irbesartan
losartan potassium
telmisartan
valsartan
PREFERRED
Benicar

ANTI-INFLAMMATORY
NSAIDS
GENERIC
celecoxib
diclofenac potassium
diclofenac sodium DR
diclofenac sodium ER
diclofenac sodium/misoprostol
etodolac
etodolac ER
flurbiprofen
ibuprofen
indomethacin
indomethacin sodium
indomethacin ER
ketoprofen
ketorolac tromethamine
mefenamic acid
meloxicam
nabumetone
naproxen
naproxen sodium
oxaprozin
piroxicam
sulindac
tolmetin sodium
Meclofenamate Sodium
Tolmetin Sodium
PREFERRED
Zorvolex

BETA BLOCKERS
GENERIC
acebutolol HCL
atenolol
betaxolol HCL
bisoprolol fumarate
esmolol HCL
metoprolol succinate ER
metoprolol tartrate
nadolol
pindolol
propranolol HCL
propranolol HCL ER
sotalol HCL
sotalol HCL (AF)
PREFERRED
Bystolic

CALCIUM CHANNEL BLOCKERS

AUTO-IMMUNE

GENERIC
amlodipine besylate
diltiazem CD
diltiazem HCL
diltiazem HCL ER
felodipine ER
nicardipine HCL
nifedipine
nifedipine ER
nimodipine
nisoldipine
verapamil HCL
verapamil HCL ER

Effective April 1, 2015 v.1

Catamaran 2015. All Rights Reserved. May not be copied or distributed without authorization.
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verapamil HCL SR
Verapamil HCL

NITRATES & NITRITES

GENERIC
isosorbide dinitrate
isosorbide dinitrate ER
isosorbide mononitrate
isosorbide mononitrate ER
nitroglycerin
nitroglycerin lingual
nitroglycerin transdermal
nitroglycerin IN dextrose 5%
nitroglycerin IN 5% dextrose
Isosorbide Dinitrate
PREFERRED
Dilatrate SR
Nitro-bid
Nitrostat

ANTI-HTN COMBINATIONS
GENERIC
amlodipine besylate/benazepril
hydrochloride
amlodipine besylate/benazepril HCL
amlodipine besylate/valsartan
amlodipine/valsartan/hctz
atenolol/chlorthalidone
benazepril HCL/hydrochlorothiazide
bisoprolol
fumarate/hydrochlorothiazide
candesartan
cilexetil/hydrochlorothiazide
enalapril maleate/hydrochlorothiazide
fosinopril sodium/hydrochlorothiazide
irbesartan/hydrochlorothiazide
lisinopril/hydrochlorothiazide
losartan
potassium/hydrochlorothiazide
metoprolol/hydrochlorothiazide
moexipril/hydrochlorothiazide
nadolol/bendroflumethiazide
quinapril/hydrochlorothiazide
telmisartan/amlodipine
telmisartan/hydrochloroth
telmisartan/hydrochlorothiazide
valsartan/hydrochlorothiazide
PREFERRED
Amturnide
Azor
Benicar HCT
Tarka
Tekamlo
Tekturna HCT
Tribenzor

ANTIHYPERLIPIDEMICS
STATINS
GENERIC
atorvastatin calcium
fluvastatin
lovastatin
pravastatin sodium
simvastatin
PREFERRED
Crestor
FIBRATES
GENERIC
fenofibrate
fenofibrate micronized

fenofibric acid DR
gemfibrozil
PREFERRED
Fenofibrate
Lipofen
BILE ACID SEQUESTRANTS
GENERIC
cholestyramine
cholestyramine light
colestipol HCL
colestipol HCL for oral suspension
PREFERRED
Welchol
CHOLEST ABS INHBTR/COMBO
PREFERRED
Liptruzet
Vytorin
Zetia
NIACIN/COMBINATIONS
GENERIC
niacin ER
PREFERRED
Simcor
OMEGA-3 FATTY ACIDS
GENERIC
omega-3-acid ethyl esters
PREFERRED
Vascepa

DERMATOLOGICALS
ACNE
GENERIC
adapalene
benzoyl peroxide
benzoyl peroxide SHORT contact
clindamycin phosphate
clindamycin/benzoyl peroxide
erythromycin
erythromycin/benzoyl peroxide
metronidazole
sodium sulfacetamide
sodium sulfacetamide/sulfur
sodium sulfacetamide/sulfur cleanser
sodium sulfacetamide/sulfur cleansing
cloths
sodium sulfacetamide/sulfur green
sodium sulfacetamide/sulfur
w/sunscreen
sodium sulfacetamide/sulfur wash
sulfacetamide sodium
sulfacetamide sodium/sulfur cleanser
tretinoin
tretinoin microsphere
tretinoin microsphere P.M.
Claravis
Doxycycline
PREFERRED
Acanya
Atralin
Differin
Epiduo
Finacea
Mirvaso
Oracea
Ziana

TOPICAL ANTI-INFLAMMATORY
GENERIC
alclometasone dipropionate

augmented betamethasone
dipropionate
betamethasone dipropionate
betamethasone valerate
calcipotriene/betamethasone
dipropionate
clobetasol propionate
clobetasol propionate emollient
desonide
desoximetasone
diflorasone diacetate
fluocinolone acetonide
fluocinonide
fluocinonide-e
fluticasone propionate
halobetasol propionate
hydrocortisone
hydrocortisone acetate/aloe
hydrocortisone butyrate
hydrocortisone butyrate (lipid)
hydrocortisone butyrate (lipophilic)
hydrocortisone valerate
hydrocortisone IN absorbase
mometasone furoate
prednicarbate
triamcinolone acetonide
Amcinonide
Apexicon E
Desoximetasone
PREFERRED
Pramosone
Pramosone E
Taclonex
Tucks Anti-itch

ENDOCRINE
CONTRACEPTIVE AGENTS
GENERIC
desogestrel/ethinyl estradiol
drospirenone/ethinyl estradiol
levonorgestrel
levonorgestrel and ethinyl estradiol
levonorgestrel/ethinyl estradiol
norethindrone
norethindrone acetate/ethinyl
estradiol
norethindrone acetate/ethinyl
estradiol/ferrous fumarate
norgestimate/ethinyl estradiol
Ogestrel
PREFERRED
Beyaz
Depo-provera
LO Loestrin FE
Minastrin 24 FE
Natazia
Safyral

ESTROGENS/COMBINATIONS
GENERIC
estradiol
estradiol valerate
estradiol/norethindrone acetate
estropipate
Jinteli
PREFERRED
Alora
Cenestin
Combipatch
Duavee

Effective April 1, 2015

2

Enjuvia
Estrace
Estring
Evamist
Minivelle
Premarin
Premphase
Prempro
Vagifem

TESTOSTERONE AGENTS
GENERIC
danazol
testosterone cypionate
testosterone enanthate
Testosterone
Testosterone P.M.
PREFERRED
Androgel
Androgel P.M.
Androxy
Axiron

INSULIN
PREFERRED
Humalog
Humalog Kwikpen
Humalog Mix 50/50
Humalog Mix 50/50 Kwikpen
Humalog Mix 75/25
Humalog Mix 75/25 Kwikpen
Humulin N
Humulin N Kwikpen
Humulin N U-100 Pen
Humulin R
Humulin R U-500 (concentrated)
Humulin 70/30
Humulin 70/30 Kwikpen
Humulin 70/30 Pen
Lantus
Lantus Solostar
Levemir
Levemir Flexpen
Levemir Flextouch
Novolin N
Novolin N Relion
Novolin R
Novolin R Relion
Novolin 70/30
Novolin 70/30 Relion
Novolog
Novolog Flexpen
Novolog Mix 70/30
Novolog Mix 70/30 Prefilled Flexpen
Novolog Penfill

NON-INSULIN HYPOGLYCEMICS
BIGUANIDES
GENERIC
metformin HCL
metformin HCL ER
PREFERRED
Riomet
BIGUAN/SULFONYLUREA COMB.
GENERIC
glipizide/metformin HCL
glyburide/metformin HCL
BIGUAN/THIAZOLIDEINEDIONE
GENERIC
pioglitazone HCL

pioglitazone HCL/metformin HCL

PREFERRED
Actoplus Met XR
DPP-4 INHIBITORS
PREFERRED
Januvia
Onglyza
Tradjenta
BIGUANIDE/DPP-4 COMB.
PREFERRED
Janumet
Janumet XR
Jentadueto
Kombiglyze XR
SULFONYLUREAS
GENERIC
glimepiride
glipizide
glipizide ER
glyburide
glyburide micronized
tolazamide
Glyburide
SULFONYLUREA/TZD COMB.
GENERIC
pioglitazone HCL-glimepiride
INCRETINS
PREFERRED
Bydureon
Byetta
Victoza
AMYLIN ANALOGS
PREFERRED
Symlinpen 120
Symlinpen 60
DIABETIC OTHER
PREFERRED
Farxiga
Glucagen
Glucagen Hypokit
Glucagon Emergency Kit
Invokamet
Invokana
Jardiance
Proglycem

GASTROINTESTINAL
PROTON PUMP INHIBITORS
GENERIC
esomeprazole sodium
lansoprazole
omeprazole
pantoprazole sodium
rabeprazole sodium
Esomeprazole Sodium
PREFERRED
Nexium
Nexium 24HR

ULCER DRUGS
GENERIC
cimetidine
cimetidine HCL
famotidine
misoprostol
nizatidine
ranitidine HCL
sucralfate
Famotidine

PREFERRED
Carafate

GROWTH HORMONE
PREFERRED
Norditropin Cartridge
Norditropin Flexpro
Norditropin Nordiflex Pen
Nutropin
Nutropin AQ Nuspin 10
Nutropin AQ Nuspin 20
Nutropin AQ Nuspin 5
Nutropin AQ Pen

HEPATITIS C
ANTIVIRALS
GENERIC
ribavirin
PREFERRED
Harvoni
Moderiba
Moderiba 1200 Dose Pack
Moderiba 800 Dose Pack
Ribasphere
Ribasphere Ribapak
Ribatab
Sovaldi

INTERFERONS
PREFERRED
Peg-intron
Peg-intron Redipen
Peg-intron Redipen PAK 4
Pegasys
Pegasys Proclick
Pegintron

PROTEASE INHIBITORS
PREFERRED
Olysio
Victrelis

MULTIPLE SCLEROSIS
PREFERRED
Ampyra
Aubagio
Avonex
Avonex Pen
Betaseron
Copaxone
Gilenya
Lemtrada
Plegridy
Plegridy Starter Pack
Rebif
Rebif Rebidose
Rebif Rebidose Titration Pack
Rebif Titration Pack
Tecfidera
Tecfidera Starter Pack
Tysabri

NEUROLOGICALS
ALZHEIMER'S DISEASE
GENERIC
donepezil HCL
galantamine

Effective April 1, 2015

3

galantamine hydrobromide
rivastigmine tartrate
Galantamine Hydrobromide
PREFERRED
Exelon
Namenda
Namenda Titration PAK
Namenda XR
Namenda XR Titration Pack

ANTICONVULSANTS
GENERIC
carbamazepine
carbamazepine ER
clonazepam
clonazepam odt
divalproex sodium
divalproex sodium DR
divalproex sodium ER
ethosuximide
felbamate
fosphenytoin sodium
gabapentin
lamotrigine
lamotrigine odt
lamotrigine ER
levetiracetam
levetiracetam ER
oxcarbazepine
phenytoin
phenytoin sodium
phenytoin sodium extended
primidone
tiagabine hydrochloride
topiramate
valproate sodium
valproic acid
zonisamide
PREFERRED
Banzel
Celontin
Diazepam
Dilantin
Fycompa
Gabitril
Lyrica
Onfi
Oxtellar XR
Peganone
Potiga
Tegretol-XR
Vimpat

MIGRAINE/HEADACHE
GENERIC
dihydroergotamine mesylate
naratriptan HCL
rizatriptan benzoate
rizatriptan benzoate odt
sumatriptan succinate
sumatriptan succinate refill
zolmitriptan
zolmitriptan odt
Isometheptene/Caffeine/Acetaminophe
n
Sumatriptan Succinate
PREFERRED
Relpax

Sumavel Dosepro
Treximet
Zomig
Zomig Nasal Spray

neomycin/polymyxin/bacitracin/hydroco
rtisone
neomycin/polymyxin/dexamethasone
prednisolone acetate
sulfacetamide sodium/prednisolone
sodium phosphate
tobramycin/dexamethasone
PREFERRED
Alrex
FML
Lotemax
Ozurdex
Pred Mild
Retisert
Tobradex
Tobradex ST
Zylet

OPHTHALMICS
ANTI-ALLERGIC AGENTS
GENERIC
azelastine HCL
cromolyn sodium
epinastine HCL
PREFERRED
Bepreve
Pataday
Patanol

ANTI-GLAUCOMA AGENTS
GENERIC
apraclonidine
betaxolol HCL
brimonidine tartrate
carteolol HCL
dorzolamide HCL
dorzolamide HCL/timolol maleate
latanoprost
levobunolol HCL
timolol maleate
timolol maleate ophthalmic gel
forming
Metipranolol
PREFERRED
Alphagan P
Combigan
Lumigan
Travatan Z
Travoprost

MIOTICS
GENERIC
pilocarpine HCL
PREFERRED
Phospholine Iodide
Pilopine HS

MISCELLANEOUS
PREFERRED
Restasis

OSTEOPOROSIS
BISPHOSPHONATES
GENERIC
alendronate sodium
ibandronate sodium
pamidronate disodium
risedronate sodium
zoledronic acid
PREFERRED
Alendronate Sodium
Atelvia
Fosamax Plus D

ANTI-INFECTIVES
GENERIC
ciprofloxacin HCL
erythromycin
gatifloxacin
gentamicin sulfate
levofloxacin
ofloxacin
tobramycin sulfate
Bacitracin
PREFERRED
Besivance
Moxeza
Vigamox

ANTI-INFLAMMATORY AGENTS
GENERIC
bromfenac
cromolyn sodium
diclofenac sodium
flurbiprofen sodium
ketorolac tromethamine
PREFERRED
Bromday
Ilevro
Nevanac
Prolensa

CORTICOSTEROIDS/RELATED
GENERIC
dexamethasone sodium phosphate
fluorometholone

SERM
GENERIC
raloxifene hydrochloride

PSYCHOTHERAPEUTICS
ATYPICAL ANTIPSYCHOTICS
GENERIC
chlorpromazine HCL
clozapine
fluphenazine decanoate
fluphenazine HCL
haloperidol
haloperidol decanoate
haloperidol lactate
lithium carbonate
lithium carbonate ER
loxapine
loxapine succinate
olanzapine
olanzapine odt
perphenazine
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
quetiapine fumarate
risperidone
risperidone odt
thioridazine HCL

Effective April 1, 2015

4

thiothixene
trifluoperazine HCL
ziprasidone HCL
PREFERRED
Abilify
Abilify Discmelt
Abilify Maintena
Latuda
Risperdal Consta
Seroquel XR

PSYCHOTHERAPEUTICS, MISC.
GENERIC
amphetamine/dextroamphetamine
clonidine HCL ER
dexmethylphenidate HCL
dexmethylphenidate HCL ER
dextroamphetamine sulfate
dextroamphetamine sulfate ER
guanfacine ER
methamphetamine HCL
methylphenidate hydrochloride
methylphenidate HCL
methylphenidate HCL CD
methylphenidate HCL ER
methylphenidate HCL SR
modafinil
Methylphenidate HCL ER
Procentra
PREFERRED
Daytrana
Nuvigil
Quillivant XR
Strattera
Vyvanse

PREFERRED
Atrovent HFA
Spiriva Handihaler
Spiriva Respimat
Tudorza Pressair

PREFERRED
Nasonex
Qnasl
Qnasl Childrens

STEROID/BETA AGONIST
PREFERRED
Advair Diskus
Advair HFA
Breo Ellipta
Dulera
Symbicort

ANTICHLNRGC/BETA AGONIST
GENERIC
ipratropium bromide/albuterol sulfate
PREFERRED
Anoro Ellipta
Combivent
Combivent Respimat

MISCELLANEOUS
PREFERRED
Dymista

BETA AGONISTS
GENERIC
albuterol sulfate
albuterol sulfate ER
albuterol TAB 4MG
levalbuterol
levalbuterol HCL
terbutaline sulfate
PREFERRED
Arcapta Neohaler
Foradil Aerolizer
Perforomist
Proair HFA
Serevent Diskus
Ventolin HFA

UROLOGICALS
BENIGN PRSTATC HYPRPLSIA
GENERIC
alfuzosin HCL ER
finasteride
tamsulosin HCL
PREFERRED
Rapaflo

ERECTILE DYSFUNCTION
PREFERRED
Cialis
Viagra

LEUKOTRIENE RCPTR ANTGNST

GENERIC
montelukast sodium
zafirlukast

URINARY ANTISPASMODICS
GENERIC
bethanechol chloride
flavoxate HCL
oxybutynin chloride
oxybutynin chloride ER
tolterodine tartrate
tolterodine tartrate ER
trospium chloride
trospium chloride ER
PREFERRED
Gelnique
Myrbetriq
Oxytrol
Oxytrol For Women
Toviaz
Vesicare

PULMONARY CORTICOSTEROIDS
SNRI ANTIDEPRESSANTS
GENERIC
duloxetine HCL
venlafaxine HCL
venlafaxine HCL ER
Venlafaxine HCL ER
PREFERRED
Pristiq

SSRI ANTIDEPRESSANTS
GENERIC
citalopram hydrobromide
escitalopram oxalate
fluoxetine DR
fluoxetine HCL
fluvoxamine maleate
fluvoxamine maleate ER
paroxetine HCL
paroxetine HCL ER
sertraline HCL

GENERIC
budesonide
PREFERRED
Asmanex HFA
Asmanex Twisthaler 120 Metered
Doses
Asmanex Twisthaler 14 Metered
Doses
Asmanex Twisthaler 30 Me Tered
Doses
Asmanex Twisthaler 30 Metered
Doses
Asmanex Twisthaler 60 Metered
Doses
Asmanex Twisthaler 7 Metered Doses
Flovent Diskus
Flovent HFA
Pulmicort
Pulmicort Flexhaler
Qvar

NASAL ANTIHISTAMINES
RESPIRATORY
ANAPHYLAXIS TX AGENTS
GENERIC
Epinephrine
PREFERRED
Auvi-q
Epipen 2-PAK
Epipen-JR 2-PAK

ANTICHOLINERGICS
GENERIC
ipratropium bromide

GENERIC
azelastine HCL
olopatadine HCL

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 Catamaran. 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 listed on your ID
card.

NASAL CORTICOSTEROIDS
GENERIC
budesonide
flunisolide
fluticasone propionate
triamcinolone acetonide
Flunisolide

Effective April 1, 2015 v.1

Catamaran 2015. All Rights Reserved. May not be copied or distributed without authorization.
5