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transcript
Advantage ChoicePharmacy Benefit Guide
Effective January 1, 2016
www.upmchealthplan.com
TABLE OF CONTENTS
Advantage Choice Overview ............................................. 1Advantage Choice Contact Numbers ............................. 1Understanding Coverage and Cost-sharing ................ 2 About Generic Drugs ............................................... 2Formulary Overview .......................................................... 2 For Prospective Members ........................................ 3Understanding Our Symbols .......................................... 3 Prior Authorization ..................................................... 3 Step Therapy ................................................................ 3 Quantity Limits ............................................................ 3Filling Your Prescription ................................................... 3 Retail .............................................................................. 3 Mail Order .................................................................... 3 Specialty Medications ...............................................4 Specialty Provider .......................................................4 Filling Your Prescription When Traveling ............4 Medication Supplies Not Covered by UPMC Health Plan .....................................................4Advantage Choice Formulary .......................................... 5Medications Not Covered by Advantage Choice .... 30Advantage Choice Brand/Generic Reference Guide ...................................................... 31
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ADVANTAGE CHOICE OVERVIEWThe Advantage Choice pharmacy program offers a variety of high-quality, effective generic and brand-name prescription drugs. This guide provides information that is applicable to most members. For information specific to your plan, refer to your plan’s prescription drug rider.
When you need a prescription medication, you and your doctor can choose from five different levels, or “tiers.” Each tier has a different copayment. This gives you and your doctor the freedom to choose the medication that is right for you. At the same time, this will help you to better budget your health care dollars.
This guide provides an overview of your pharmacy benefit with UPMC Health Plan. It explains the copayment structure, the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more.
ADVANTAGE CHOICE CONTACT NUMBERSCurrent Members:UPMC Health Plan Health Care Concierge Team: 1-855-489-3494
UPMC Health Plan Pharmacy Services (for doctors and pharmacies): 1-800-396-4139
TTY Services: 1-800-361-2629
Prospective Members:Prospective members should direct their questions to their company’s benefits administrator or to the UPMC Health Plan Health Care Concierge team at 1-855-489-3494.
Online information is available at www.upmchealthplan.com/pharmacy.
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UNDERSTANDING COVERAGE AND COST-SHARING
Our formulary is the list of Food and Drug Administration (FDA)-approved drugs that we cover. UPMC Health Plan’s Pharmacy and Therapeutics (P&T) Committee researches and evaluates medications it may cover. Committee members include local doctors and pharmacists who meet regularly during the year to review and update the formulary. Committee members base their decision on the drug’s safety, effectiveness, and cost.
Advantage Choice prescription drugs are organized into five copayment tiers on the formulary:
Tier 1 is for generic medications. Generic drugs offer the same level of safety and quality as their brand-name equivalents. They have the same amount of active ingredients as brand-name medications.
Advantage Choice requires you to use a generic version of the drug if one is available. This means that if you receive a brand-name drug when a generic is available, you must pay the brand copayment in addition to the retail cost difference between the brand-name and generic forms of the drug.
Tier 2 is for preferred-brand medications. UPMC Health Plan classifies these drugs as “preferred” because of their value and effectiveness.
Tier 3 is for non-preferred brand medications.
Tier 4 is for specialty medications, for which you will have the highest level of cost-sharing.
Specialty medications usually treat complex and rare conditions. These drugs are created because of advancements in drug development. These drugs can be high-cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant).
Specialty drugs require close management by a physician. Physicians need to monitor these drugs due to potential side effects and the need for frequent dosage adjustments.
Tier 5 is for select generic medications.
Select generic medications are offered at no additional cost-share to you. Many of these medications can help you to avoid getting sick and to improve your overall health.
Tier 6 is for zero cost-share preventive drugs.
In accordance with the Patient Protection and Affordable Care Act of 2010 (PPACA), many select preventive medications are covered at no cost to you.
About Generic Drugs Generic drugs have the same active ingredients as their brand-name equivalents, but cost significantly less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand-name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you.
Generic drugs have the same active ingredients as brand-name drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brand-name drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works.
The FDA regulates generic drug manufacturers just as it regulates the makers of brand-name medications. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand-name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brand-name drug.
FORMULARY OVERVIEW
The most commonly prescribed Advantage Choice drugs are listed in the formulary section of this booklet. Please note that there are other drugs that Advantage Choice covers in addition to the ones listed in this booklet. For the latest information on the complete Advantage Choice formulary and other pharmacy benefits, visit our website at www.upmchealthplan.com/pharmacy. Select “Advantage Choice” to access the searchable drug list.
You may also call our Health Care Concierge team at the number listed on the back of your member ID card or on page 1 of this booklet.
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If you are a current UPMC Health Plan member, refer to your Schedule of Benefits for your copayment amounts. If you did not receive a Schedule of Benefits in your Welcome Kit, contact our Health Care Concierge team at the number on the back of your member ID card. Your member ID card should also list your copayment amounts.
For Prospective MembersIf you are thinking about joining UPMC Health Plan and would like information about copayment amounts, review the Schedule of Benefits. You may have received one from your company’s Benefits Administrator or Human Resources Department. If you did not receive a Schedule of Benefits, contact the UPMC Health Plan Health Care Concierge team at the number listed on page 1 of this booklet.
UNDERSTANDING OUR SYMBOLS
Prior AuthorizationYou will see the symbol PA next to certain drugs on our formulary tables in this booklet. PA stands for Prior Authorization.
If a drug requires prior authorization, the UPMC Health Plan Pharmacy Services Department must authorize the use of this drug before it will be covered.
Drugs that require prior authorization are often:• Newer drugs for which UPMC Health Plan wants to
track usage. • Drugs not used as a standard first option in treating a
medical condition. • Drugs with potential side effects that UPMC Health Plan
wants to monitor for patient safety. • Drugs categorized as specialty medications.
All compounded medications require prior authorization.
Step TherapyYou will see the symbol ST next to certain drugs on the formulary tables in this booklet. ST stands for Step Therapy.
Step therapy is the practice of using specific medications first when beginning drug therapy for a medical condition. The preferred first course of treatment may be generic medications or drugs that are considered as the standard first-line treatment.
Step therapy is built into the electronic system that checks your medication history. A drug with step therapy will be automatically approved if there is a record that you have
already tried the preferred drug(s). If there is no record that you tried the preferred drug(s) in your medication history, your physician must submit relevant clinical information to the UPMC Health Plan Pharmacy Services Department before it will be covered.
Quantity LimitsYou will see the symbol QL next to certain drugs on the formulary tables in this booklet. QL stands for Quantity Limits.
Quantity limits are drug-specific and limit the amount of certain drugs that can be dispensed during a specified period of time. These limits are based on FDA guidelines, clinical literature, and manufacturer’s instructions. Quantity limits promote appropriate use of the drug, prevent waste, and help control costs.
For some drugs, the dosing guidelines may recommend that patients take the drug one time a day in a larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and cover one larger dose per day. Your physician can request an exception to the quantity limit through the UPMC Health Plan Pharmacy Services Department.
Prescriptions for controlled substances and specialty medications are limited to a 30-day supply.
FILLING YOUR PRESCRIPTION
RetailUPMC Health Plan’s network of retail pharmacies includes hundreds of locations — independent pharmacies as well as multistore chains — throughout the region. You can take your prescription to any pharmacy in the network. You must use 75 percent of your medication before you can get a refill.
For specific pharmacy names, locations, and telephone numbers, visit www.upmchealthplan.com/pharmacy or call our Health Care Concierge team. The phone number is listed on the back of your member ID card and on page 1 of this booklet.
Mail OrderIf you take maintenance medications for a chronic condition, you can get them through a mail-order pharmacy. Maintenance medications are drugs that are taken on a regular, long-term basis. This may include drugs to treat high blood pressure, diabetes, asthma, high cholesterol, and more.
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With convenient mail-order service:• You receive a 90-day supply of most drugs, plus refills, as
prescribed by your doctor.• You usually pay a lower out-of-pocket cost for a 90-day
supply at a mail-order pharmacy than you would pay at a retail pharmacy.
• You get these drugs delivered right to your door.
Most mail-order prescriptions are written for a 90-day supply. If your doctor writes for a 30-day supply with two refills, the mail-order facility may combine the prescription to make a 90-day supply. If you do not want a 90-day supply, you should indicate this on the mail-order form.
For a first-time prescription or a new medication, UPMC Health Plan recommends that you try a 30-day supply of the drug from a retail pharmacy. That way your doctor has a chance to make sure that it is the right dose for you and that it does not cause any side effects.
Once you’re confident that the medication is appropriate, ask your doctor to write a prescription for a 90-day supply of each maintenance drug that you need (plus refills if appropriate). Then order the supply through the mail-order pharmacy.
To avoid running out of your mail-order prescription, reorder your medication while you still have an adequate supply remaining, allowing a few weeks for processing and delivery. To request refills, you may order online or over the telephone.
You can request a mail-order form by calling our Health Care Concierge team or requesting the form on the UPMC Health Plan website at www.upmchealthplan.com/pharmacy.
Specialty MedicationsIf your medication is on our Specialty Tier (Tier 4), you are required to fill your prescription at our designated specialty pharmacy.
Specialty ProviderMost specialty medications must be obtained through our designated specialty provider. When you are prescribed a specialty medication and use a specialty provider, you get
mail-order delivery and improved access to drugs, as many retail pharmacies do not carry these types of medications.
Specialty providers also improve care by providing education for our members and expanded access to health care professionals trained in the proper use of these specialty medications. A specialty provider offers cost-effective health care and medication management and compliance programs.
Filling Your Prescription When TravelingWhen you travel outside of the western Pennsylvania area, thousands of pharmacies across the country will honor your UPMC Health Plan member ID card.
To locate a participating pharmacy, contact our Health Care Concierge team at the phone number listed on the back of your member ID card or on 1 page of this booklet.
To fill a prescription at a participating out-of-area pharmacy, present your UPMC Health Plan member ID card. Some pharmacies may ask you to pay the full price of the medication. If that happens and your claim is approved, you will be reimbursed the amount that you paid for the medication, less the appropriate copayment.
You can request a “Pharmacy Program Direct Reimbursement Claim Form” by calling our Health Care Concierge team or requesting the form on the UPMC Health Plan website at www.upmchealthplan.com/pharmacy.
If you will be away from home for an extended period of time, or if you will be traveling outside of the country, you may want to use our mail-order service so that you receive a 90-day supply before you leave home.
Medication Supplies Not Covered by UPMC Health Plan• No authorizations will be provided for medications that are
reported by the member, provider, or pharmacy to be lost, misplaced, stolen, destroyed, or damaged.
• Medications received at no charge to the member (workers’ compensation, medications purchased with a manufacturer’s coupon, etc.) will not be covered.
• Prescriptions that are written more than a year ago will not be covered. Your doctor will need to write a new prescription.
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KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
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entiv
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SuggestedAlternative(s)
8-MOP PA 4 Specialty medication
abacavir QL 1
abacavir/lamivudine/zidovudine QL 1
Abilify Maintena PA, QL (ST < 12 years of age) 4 Specialty medication
Abstral PA, QL 4 Specialty medication
acarbose 1
acebutolol 1
acetaminophen/caffeine/dihydrocodeine QL 1
acetaminophen/codeine QL 1
acetazolamide 1
acetazolamide ER 1
acetic acid 1
acetic acid/hydrocortisone 1
acetylcysteine 1
acitretin ST 4 Specialty medication
Actemra PA, QL 4 Specialty medication
Acthar gel PA, QL 4 Specialty medication
Actimmune PA 4 Specialty medication
Acuvail QL 3 bromfenac, diclofenac, ketorolac
acyclovir 1
acyclovir ointment 1
Adagen PA 4 Specialty medication
adapalene (PA > 35 years of age) 1
Adcirca PA, QL 4 Specialty medication
Adderall XR QL (PA < 4 and ≥ 18 years of age) 1
adefovir PA 4 Specialty medication
Adempas PA, QL 4 Specialty medication
Advair 2
Aerospan ST 3 Asmanex, Flovent
afeditab CR 1
Afrezza PA 3 Apidra (ST), Humalog, Novolog
Drug Name
Gen
eric
Pref
erre
dN
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SuggestedAlternative(s)
Afinitor PA, QL 4 Specialty medication
Akynzeo QL 2
Alamast ST 3 azelastine, cromolyn, epinastine
Albenza 2
albuterol solution QL 1
albuterol ER tablets 1
alclometasone dipropionate 1
Aldurazyme PA 4 Specialty medication
alendronate 1
Alferon N PA 4 Specialty medication
alfuzosin ER 1
Alimta 4 Specialty medication
Alinia 2
Alkeran 2
allopurinol 1
almotriptan ST, QL 1naratriptan, rizatriptan, sumatriptan, zolmitriptan
Alocril ST 3 azelastine, cromolyn, epinastine
Alomide ST 3 azelastine, cromolyn, epinastine
alosetron PA 4 Specialty medication
Aloxi ST, QL 3 ondansetron
Alphagan P 0.1% 2
alprazolam 1
alprazolam ODT ST 1 alprazolam
Alrex 3 fluorometholone, prednisolone
Altabax 3 mupirocin
Altavera 6
Alvesco ST 3 Asmanex, Flovent
Alyacen 6
amantadine 1
amcinonide ST 1 betamethasone, fluocinonide
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Drug Name
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Pref
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dN
on-p
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SuggestedAlternative(s)
Amethia 6
Amethia Lo 6
Amethyst 6
amiloride 1
amiloride/HCTZ 1
amiodarone 1
Amitiza QL 2
amitriptyline 1
amlodipine besylate 1
amlodipine/atorvastatin 1
amlodipine/benazepril 1
ammonium lactate 1
Amnesteem 1
amoxapine 1
amoxicillin 1
amoxicillin 250 mg 5
amoxicillin 500 mg 5
amoxicillin/clavulanate 1
amoxicillin/clavulanate ER 1
amphetamine salts QL (PA < 4 and ≥ 18 years of age)
1
ampicillin capsule 5
Ampyra PA, QL 4 Specialty medication
Anadrol PA 3
anagrelide 1
anastrozole 1
Androderm PA, ST 3testosterone injection (PA), Androgel 1.62% (PA)
Androgel 1% PA, ST 3testosterone injection (PA), Androgel 1.62% (PA)
Androgel 1.62% PA 2
androxy PA, ST 1 Androgel 1.62% (PA)
Anoro Ellipta 2
Anucort-HC 1
Drug Name
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erre
dN
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SuggestedAlternative(s)
Anzemet ST, QL 3 ondansetron
Apidra ST, QL 3 Humalog, Novolog
Apokyn PA, QL 4 Specialty medication
apraclonidine 1
Apri 6
Apriso ER 2
Aptiom PA, QL 3
carbamazepine, oxcarazepine, lamotrigine, valproic acid, levetiracetam, phenytoin, zonisamide
Aptivus QL 4 Specialty medication
Aralast NP PA 4 Specialty medication
Aranelle 6
Aranesp PA 4 Specialty medication
arbinoxa 1
Arcalyst PA, QL 4 Specialty medication
Arcapta ST 3 Foradil, Serevent
aripiprazole PA, QL (ST <12 years of age) 1
Armour Thyroid 3 levothyroxine, liothyronine
Arnuity Ellipta 2
Asacol HD 2
Asmanex 2
aspirin/dipyridamole 1
atenolol 5
atenolol/chlorthalidone 5
atorvastatin 1
atovaquone/proguanil PA 1
atovaquone suspension 1
Atripla QL 4 Specialty medication
atropine drops 1
Atrovent HFA 3 Incruse Ellipta, Spiriva
Aubagio PA, QL 4 Specialty medication
Aubra 6
Auryxia 2
Auvi-Q QL 2
Effective January 1, 2016
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
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Effective January 1, 2016
Drug Name
Gen
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Pref
erre
dN
on-p
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Spec
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SuggestedAlternative(s)
Aveed PA, ST 3testosterone injection (PA), Androgel 1.62% (PA)
Aviane 6
Avodart 2
Avonex QL 4 Specialty medication
Axiron ST, PA 3testosterone injection (PA), Androgel 1.62% (PA)
Azasite 3 erythromycin
azathioprine 1
azelastine 1
Azilect 2
azithromycin QL 1
Azopt ST 3 dorzolamide
Azurette 6
bacitracin eye ointment 1
baclofen 1
balsalazide disodium 1
Balziva 6
Banzel PA 3 felbamate, lamotrigine, topiramate, valproate
benazepril 5
benazepril/hydrochlorothiazide 1
Benicar PA 3candesartan, eprosartan, irbesartan, losartan, telmisartan, valsartan
Benlysta PA 4 Specialty medication
benzonatate 1
benzoyl peroxide 1
benztropine 1
Bepreve ST 3 azelastine, cromolyn, epinastine
Berinert PA 4 Specialty medication
Besivance 3ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin
betamethasone 1
Betaseron ST, QL 4 Specialty medication
Drug Name
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SuggestedAlternative(s)
betaxolol 1
bethanechol 1
Bethkis QL 4 Specialty medication
Betoptic S 3 betaxolol, carteolol, timolol
bexarotene PA 4 Specialty medication
Beyaz 2
bicalutamide 1
Biltricide 2
bisoprolol 1
bisoprolol/hydrochlorothiazide 5
Bivigam PA 4 Specialty medication
Blephamide 3sulfacetamide sodium/prednisolone sodium phosphate
Bosulif PA, QL 4 Specialty medication
Botox PA, QL 4 Specialty medication
Breo Ellipta 2
Briellyn 6
Brilinta QL 3 clopidogrel, Effient
brimonidine tartrate 1
Brintellix PA, QL 3citalopram, duloxetine, paroxetine, sertraline, venlafaxine ER capsules
bromfenac ophthalmic solution 1
bromocriptine 1
Brovana 3 Foradil, Serevent
budeprion XL 1
budesonide EC 1
budesonide nasal spray 1
budesonide respules 1
bumetanide 0.5 mg tablet 5
bumetanide 1 mg tablet 5
Bunavail PA, QL 3 Suboxone film (PA), Zubsolv (PA)
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
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Drug Name
Gen
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Pref
erre
dN
on-p
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SuggestedAlternative(s)
Buphenyl tablet PA 4 Specialty medication
buprenorphine PA, QL 1
buprenorphine/naloxone tablet PA, QL 3 Suboxone film (PA),
Zubsolv (PA)
buproban 6
bupropion 1
bupropion XL 1
buspirone 1
butalbital/acetaminophen/caffeine 1
butorphanol nasal spray QL 1
Butrans PA, QL 3
hydrocodone/acetaminophen, oxycodone/acetaminophen, tramadol
Bydureon QL 3 Trulicity, Victoza
Byetta ST, QL 3 Trulicity, Victoza
Bystolic ST 3 atenolol, metoprolol, propranolol
cabergoline 1
calcipotriene 1
calcitonin nasal spray 1
calcitriol 1
calcitriol ointment QL 1
calcium acetate 1
Camila 6
Camrese 6
Camrese Lo 6
Canasa 3
Apriso, Asacol HD, balsalazide disodium, Delzicol, mesalamine, sulfasalazine, sulfasalazine EC
candesartan 1
candesartan/hydrochlorothiazide 1
capecitabine PA 4 Specialty medication
Caphosol 2
Drug Name
Gen
eric
Pref
erre
dN
on-p
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ialty
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SuggestedAlternative(s)
Caprelsa PA, QL 4 Specialty medication
captopril/hydrochlorothiazide 1
captopril tablet 5
Carbaglu PA 4 Specialty medication
carbamazepine 1
carbamazepine ER 1
carbidopa ST 1
carbidopa/levodopa 1
carbidopa/levodopa/entacapone 1
carbinoxamine 1
Carimune NF PA 4 Specialty medication
carisoprodol 1
carisoprodol-aspirin 1
carteolol 1
cartia XT 1
carvedilol tablet 5
Cayston QL 4 Specialty medication
Caziant 6
cefaclor 1
cefaclor ER 1
cefadroxil 1
cefdinir 1
cefditoren 1
cefpodoxime 1
cefprozil 1
ceftibuten 1
Ceftin 3 cefaclor, cefprozil
cefuroxime 1
celecoxib ST, QL 1Generic NSAIDS (diclofenac, etodolac, ibuprofen, meloxicam, naproxen)
Cenestin ST 3 estradiol, estropipate, Premarin
cephalexin 1
Effective January 1, 2016
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
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Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
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ct G
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ic
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entiv
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SuggestedAlternative(s)
cephalexin 250 mg capsule 5
cephalexin 500 mg capsule 5
Cerdelga PA, QL 4 Specialty medication
Cerezyme PA 4 Specialty medication
Cesamet ST 3 ondansetron
cevimeline 1
Chantix ST, QL 6 generic nicotine replacement products
Chateal 6
Chemet PA 3
chlordiazepoxide 1
chlordiazepoxide/amitriptyline 1
chlordiazepoxide/clindinium 1
chlorhexidine rinse 1
chloroquine PA 1
chlorpromazine (PA < 12 years of age) 1
chlorpropamide 1
chlorthalidone 1
chlorzoxazone 1
cholestyramine 1
chorionic gonadotropin PA 4 Specialty medication
ciclopirox 1
cilostazol 1
Ciloxan 3ciprofloxacin, gatifloxin, levofloxacin, ofloxacin
cimetidine 1
Cimzia PA, QL 4 Specialty medication
Cinryze PA, QL 4 Specialty medication
Cipro HC 2 ciprofloxacin
Ciprodex 2 ciprofloxacin, dexamethasone
Drug Name
Gen
eric
Pref
erre
dN
on-p
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SuggestedAlternative(s)
ciprofloxacin 1
ciprofloxacin 250 mg tablet 5
ciprofloxacin 500 mg tablet 5
ciprofloxacin ER QL 1
ciprofloxacin 0.2% ear drops 1
ciprofloxacin 0.3% eye drops 1
citalopram QL 1
Claravis 1
clarithromycin 1
clarithromycin ER 1
clindamycin 1
clindamycin/benzoyl peroxide gel PA 1
clobetasol 1
clomipramine ST 1citalopram, escitalopram, fluoxetine, paroxetine, sertraline
clonazepam 1
clonazepam ODT ST 1 clonazepam
clonidine 1
clonidine ER ST, QL 1 clonidine
clopidogrel 1
clorazepate 1
clotrimazole 1
clotrimazole/betamethasone 1
clozapine (PA < 12 years of age) 1
clozapine ODT ST, QL (PA < 12 years of age) 1 clozapine
Coartem 2
codeine sulfate 1
Colcrys 2
colestipol 1
Effective January 1, 2016
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
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Drug Name
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erre
dN
on-p
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SuggestedAlternative(s)
Combigan 2
Combipatch QL 3norethindrone-estradiol, Jinteli, Prempro, Premphase
Combivent Respimat 2
Cometriq PA, QL 4 Specialty medication
Complera 4 Specialty medication
constulose 1
Copaxone QL 4 Specialty medication
Corlanor PA, QL 3
cortisone tablet 1
Cortisporin topical 3
Cosentyx PA, QL 4 Specialty medication
Cosopt PF ST 3 dorzolamide-timolol
Creon 2
Cresemba QL 4 Specialty medication
Crestor PA 3atorvastatin, lovastatin, pravastatin, simvastatin
Crinone 4% gel 3
Crixivan QL 2
cromolyn 1
Cryselle 6
Cuvposa (PA > 16 years of age) 4 Specialty medication
Cyclafem 6
cyclobenzaprine 1
cyclopentolate 1
cyclophosphamide capsules 4 Specialty medication
Cycloset 3 bromocriptine
cyclosporine 1
cyclosporine modified 1
cyproheptadine 1
Cystadane powder PA 4 Specialty medication
Cystagon 4 Specialty medication
Cystaran PA, QL 4 Specialty medication
Drug Name
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SuggestedAlternative(s)
Daliresp PA 3Advair, Breo Ellipta, Foradil, Incruse Ellipta, Serevent, Spiriva
danazol PA 1
dantrolene 1
Dapsone 2
Daraprim PA 3
Dasetta 6
Delyla 6
Delzicol 2
demeclocycline 1
Demser PA 4 Specialty medication
Depen PA 4 Specialty medication
desipramine 1
desloratadine ST 1 levocetirizine
desmopressin tablets 1
desmopressin nasal spray 1
desogestrel/ethinyl estradiol 6
desonide 1
desoximetasone ST 1 betamethasone, fluocinonide
desvenlafaxine ER ST, QL 3citalopram, duloxetine, fluoxetine, paroxetine, sertraline, venlafaxine ER capsules
dexamethasone 1
dexedrine QL (PA < 4 and ≥18 years of age) 1
Dexilant PA, QL 3esomeprazole, lansoprazole, omeprazole, pantoprazole
dexmethylphenidate QL (PA < 4 and ≥ 18 years of age)
1
dexmethylphenidate ER QL (PA < 4 and ≥ 18 years of age)
1
Effective January 1, 2016
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
11
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
dextroamphetamine QL (PA < 4 and ≥ 18 years of age)
1
dextroamphetamine ER QL (PA < 4 and ≥18 years of age)
1
diazepam 1
diazepam rectal gel 1
Dibenzyline PA 4 Specialty medication
diclofenac 1
diclofenac/misoprostol 1
diclofenac ophthalmic solution 1
dicloxacillin 1
dicyclomine 1
didanosine QL 1
Dificid ST, QL 4 Specialty medication
diflorasone ST 1
diflunisal 1
digoxin 1
dihydroergotamine 1
diltiazem 1
diltiazem ER 1
Dipentum ST 3balsalazide disodium, Apriso, Asacol HD, Delzicol
diphenoxylate/atropine 1
dipyridamole 1
disopyramide 1
disulfuram 1
divalproex sodium 1
divalproex sodium ER 1
donepezil PA 1
dorzolamide 1
dorzolamide/timolol 1
doxazosin 1
doxepin 1
doxercalciferol 1
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
doxycycline 1
drithocreme 1
dronabinol 1
drysol 1
Duavee 3estradiol-norethindrone, Jinteli, Prempro, Premphase
Dulera 2
duloxetine QL 1
Durezol 2
Dyrenium ST 3
triamterene/hydrochlorothiazide, spironolactone, spironolactone/hydrochlorothiazide
Dysport PA, QL 4 Specialty medication
econazole cream 1
Edarbi ST 3candesartan, eprosartan, irbesartan, losartan, telmisartan, valsartan
Edurant QL 4 Specialty medication
Effient QL 2
Elaprase PA 4 Specialty medication
Elelyso PA 4 Specialty medication
Elidel PA, ST 3generic topical steroids, tacrolimus ointment (PA)
Eligard PA, QL 4 Specialty medication
Elinest 6
eliphos 1
Eliquis QL 2
Ella 3 levonorgestrel, Next Choice
Elmiron 3
Emadine ST 3 azelastine, cromolyn, epinastine
Embeda PA, QL 3morphine sulfate ER, fentanyl patches, oxymorphone ER, Opana ER
Emcyt PA 4 Specialty medication
Emend capsule QL 2
Effective January 1, 2016
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
12
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Emend vial QL 3
Emoquette 6
Emsam PA, QL 3 phenelzine, tranylcypromine
Emtriva QL 2
Enablex ST 3
oxybutynin, oxybutynin ER, tolterodine, tolterodine ER, trospium, trospium ER, Toviaz, Vesicare
enalapril 1
enalapril/hydrochlorothiazide 1
Enbrel PA, QL 4 Specialty medication
Endocet QL 1
Enjuvia ST 3 estradiol, estropipate, Premarin
enoxaparin QL 4 Specialty medication
Enpresse 6
Enskyce 6
entacapone 1
entecavir PA 4 Specialty medication
Entyvio PA, QL 4 Specialty medication
epiklor 1
epinastine ophthalmic solution 1
epinephrine 1
EpiPen QL 2
eplerenone 1
Epogen PA 4 Specialty medication
epoprostenol PA 4 Specialty medication
eprosartan 1
Epzicom QL 4 Specialty medication
Ergomar PA, QL 3ergotamine/caffeine, isometheptine/acetaminophen/dichloralphenazone
ergotamine/caffeine 1
Erivedge PA, QL 4 Specialty medication
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Errin 6
EryPed 3 erythromycin
Ery-tab EC 250 mg tablet 1
Ery-tab EC 333 mg tablet 1
erythromycin 1
erythromycin/benzoyl peroxide gel PA 1
Esbriet PA, QL 4 Specialty medication
escitalopram QL 1
esomeprazole ST, QL 1lansoprazole, omeprazole, pantoprazole
Estarylla 6
estazolam 1
Estrace cream 3 estradiol, estropipate, Premarin
estradiol 1
estradiol/norethindrone 1
estradiol patch QL 1
Estrogel QL 3 Premarin
estropipate 1
eszopiclone ST, QL 1
ethambutol 1
ethosuximide 1
etidronate 1
etodolac 1
etodolac ER 1
etoposide PA 4 Specialty medication
Euflexxa PA, QL 4 Specialty medication
Eurax 3 permethrin
Evotaz QL 4 Specialty medication
Evzio PA, QL 4 Specialty medication
Exalgo PA, QL 3morphine sulfate ER, fentanyl patches, oxymorphone ER, Opana ER
Exelderm 3 ketoconazole, metronidazole
Effective January 1, 2016
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
13
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
exemestane 1
Exjade PA 4 Specialty medication
Eylea PA 4 Specialty medication
Fabior PA (PA > 35 years of age) 3 generic topical acne
agents
Fabrazyme PA 4 Specialty medication
Factive QL 3 ciprofloxacin, levofloxacin
Falmina 6
famciclovir QL 1
famotidine 1
Fanapt PA, QL (PA < 12 years of age) 3
aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone
Fareston PA 4 Specialty medication
Farydak PA, QL 4 Specialty medication
felbamate 1
felodipine 1
Femring QL 3 estradiol, estropipate, Premarin
fenofibrate 1
fenofibric acid ST 1 fenofibrate
fenoprofen 1
fentanyl citrate PA, QL 4 Specialty medication
fentanyl transdermal QL 1
Fentora PA, QL 4 Specialty medication
Ferriprox PA 4 Specialty medication
Fetzima PA, QL 3citalopram, duloxetine, fluoxetine, paroxetine, sertraline, venlafaxine ER capsules
Finacea PA 3 adapalene, tretinoin
finasteride 1
Firazyr PA, QL 4 Specialty medication
Firmagon PA, QL 4 Specialty medication
Flarex 3 fluorometholone, prednisolone
Flebogamma PA 4 Specialty medication
flecainide 1
Flovent HFA 2
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
fluconazole QL 1
flucytosine 4 Specialty medication
fludrocortisone 1
flunisolide 1
fluocinolone 1
fluocinonide 1
fluoride 0.25 mg tablet 6
fluoride 0.5 mg tablet 6
fluoride 1 mg tablet 1
fluorometholone 1
fluoxetine 1
fluphenazine (PA < 12 years of age) 1
flurazepam 1
flurbiprofen 1
fluticasone 1
fluvastatin 1
fluvoxamine 1
FML Forte 3 fluorometholone, prednisolone
FML S.O.P. 3 fluorometholone
folic acid 0.4 mg tablet 6
folic acid 0.8 mg tablet 6
folic acid 1 mg tablet 1
fondaparinux QL 4 Specialty medication
Foradil 2
Forteo ST, QL 4 Specialty medication
Fortesta PA, ST 3testosterone injection (PA), Androgel 1.62% (PA)
fortical 1
fosinopril 1
fosinopril/hydrochlorothiazide 1
Fosrenol ST 3 calcium acetate, Renvela, Auryxia
Fragmin QL 4 Specialty medication
Effective January 1, 2016
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
14
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Frova ST, QL 3almotriptan (ST), naratriptan, rizatriptan, sumatriptan, zolmitriptan
Fulyzaq PA, QL 4 Specialty medication
furosemide solution 1
furosemide tablets 5
Fuzeon QL 4 Specialty medication
Fycompa PA, QL 3 felbamate, lamotrigine, topiramate, valproate
gabapentin 1
Gablofen 3
galantamine PA 1
galantamine ER PA 1
Galzin PA 2
Gammagard PA 4 Specialty medication
Gammaked PA 4 Specialty medication
Gammaplex PA 4 Specialty medication
Gamunex PA 4 Specialty medication
Gamunex-C PA 4 Specialty medication
ganciclovir 1
gatifloxacin 1
Gattex PA, QL 4 Specialty medication
gavilyte-g 6
gavilyte-h 6
Gelclair 3
gemfibrozil 1
Generess FE 3
generic oral contraceptives, Beyaz, Natazia, Nuvaring, Safyral, Ortho Tri Cyclen Lo
generlac 1
gentamicin 1
Geodon vial PA 3 olanzapine vial
Gianvi 6
Gildagia 6
Gildess 6
Gildess FE 6
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Gildess 24 FE 6
Gilenya PA, QL 4 Specialty medication
Gilotrif PA, QL 4 Specialty medication
Glassia PA 4 Specialty medication
Gleevec PA, QL 4 Specialty medication
Gleostine PA 4 Specialty medication
glimepiride 1
glipizide 1
glipizide/metformin 1
glipizide ER 1
Glucagon QL 2
glyburide 1
glyburide/metformin 1
glycopyrrolate 1
Glyset 3 acarbose
Glyxambi QL 2
Gralise PA, QL 3 gabapentin
granisetron ST, QL 1 ondansetron
granisol ST, QL 1 ondansetron
Granix PA 4 Specialty medication
Grastek PA, QL 4 Specialty medication
griseofulvin 1
guanfacine 1
guanfacine ER ST, QL 1 guanfacine
halobetasol 1
haloperidol (PA < 12 years of age) 1
Harvoni PA, QL 4 Specialty medication
Heather 6
Hetlioz PA, QL 4 Specialty medication
Hexalen 3
Hizentra PA 4 Specialty medication
homatropine drops 1
Horizant PA, QL 3 gabapentin, pramipexole, ropinirole
Effective January 1, 2016
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
15
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Humalog QL 2
Humalog 50/50 QL 2
Humalog 75/25 QL 2
Humira PA, QL 4 Specialty medication
Humulin 50/50 QL 2
Humulin 70/30 QL 2
Humulin N QL 2
Humulin R QL 2
Hycamtin PA 4 Specialty medication
hydralazine 1
hydrochlorothiazide 1
hydrochlorothiazide 12.5 mg capsule 5
hydrochlorothiazide 25 mg tablet 5
hydrochlorothiazide 50 mg tablet 5
hydrocodone/acetaminophen 5 mg/325 mg QL
1
hydrocodone/acetaminophen 7.5 mg/325 mg QL
1
hydrocodone/acetaminophen 10 mg/325 mg QL
1
hydrocodone/chlorpheniramine 1
hydrocodone/homatropine 1
hydrocodone/ibuprofen 7.5mg/200mg QL 1
hydrocortisone 1
hydrocortisone/pramoxine cream 1
hydromorphone 1
hydroxychloroquine 1
hydroxyurea 1
hydroxyzine 1
hyoscyamine 1
HyQvia PA 4 Specialty medication
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
ibandronate syringe ST, QL 1 alendronate,
ibandronate
ibandronate IV ST, QL 3 alendronate, ibandronate
ibandronate tablet QL 1
Ibrance PA, QL 4 Specialty medication
ibuprofen 1
Iclusig PA, QL 4 Specialty medication
Ilaris PA, QL 4 Specialty medication
Ilevro 3 bromfenac, diclofenac, ketorolac
Iluvien PA, QL 4 Specialty medication
Imbruvica PA, QL 4 Specialty medication
imipramine 1
imiquimod 1
Increlex PA 4 Specialty medication
Incruse Ellipta 2
indapamide 1
indomethacin 1
Infergen PA, QL 4 Specialty medication
Inlyta PA, QL 4 Specialty medication
Intelence PA, QL 4 Specialty medication
Intron A PA 4 Specialty medication
Introvale 6
Invega PA, QL (PA < 12 years of age) 3
aripiprazole (PA), olanzapine, quetiapine (PA), risperidone, ziprasidone
Invega Sustenna PA, QL (ST< 12 years of age) 4 Specialty medication
Invirase QL 4 Specialty medication
Invokana QL 2
Invokamet QL 2
ipratropium 1
ipratropium/albuterol solution 1
Iquix 3 ciprofloxacin, levofloxacin, ofloxacin
irbesartan 1
Effective January 1, 2016
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
16
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
irbesartan/hydrochlorothiazide 1
Isentress QL 4 Specialty medication
isoniazid 1
Isopto Carbachol 3betaxolol, brimonidine, caretolol, dorzolamide, latanoprost, levobunolol, timolol
Isopto Homatropine 3homatropine, atropine, cyclopentolate, tropicamide
isosorbide 1
isosorbide ER 1
isradipine 1
itraconazole capsule PA, QL 1
ivermectin 1
Jadenu PA 4 Specialty medication
Jakafi PA, QL 4 Specialty medication
Jalyn 2
Jantoven 1
Janumet 2
Janumet XR 2
Januvia 2
Jardiance QL 2
Jentadueto 2
Jetrea PA, QL 4 Specialty medication
Jinteli 1
Jolessa 6
Jolivette 6
Junel 6
Junel FE 6
Juxtapid PA, QL 4 Specialty medication
Kalbitor PA 4 Specialty medication
Kaletra QL 4 Specialty medication
Kalydeco PA, QL 4 Specialty medication
Kariva 6
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Kazano ST 3Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta
Kelnor 6
Ketek QL 3azithromycin, clarithromycin ER, erythromycin
ketoconazole 1
ketoprofen 1
ketorolac QL 1
ketorolac ophthalmic solution 1
Khedezla ER ST, QL 3citalopram, duloxetine, fluoxetine, paroxetine, sertraline, venlafaxine ER capsules
Kineret PA, QL 4 Specialty medication
Klor-Con 1
Kombiglyze XR ST 3Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta
Korlym PA, QL 4 Specialty medication
Krystexxa PA, QL 4 Specialty medication
Kurvelo 6
Kuvan PA 4 Specialty medication
Kynamro PA, QL 4 Specialty medication
labetalol 1
Lacrisert PA 3 generic artificial tears, Restasis
lactic acid 1
lactulose 1
lamivudine QL 1
lamivudine/zidovudine QL 1
lamivudine HBV PA 1
lamotrigine 1
lansoprazole QL 1
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
17
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
lansoprazole/amoxicillin/clarithromycin pack 1
Lantus QL 2
Lantus Solostar QL 2
Larin 6
Larin FE 6
Lastacaft ST 3 azelastine, cromolyn, epinastine
latanoprost 1
Latuda ST, QL (PA < 12 years of age) 3
aripiprazole (PA), olanzapine, quetiapine (PA), risperidone, ziprasidone
Layolis FE 6
Lazanda PA, QL 4 Specialty medication
Leena 6
leflunomide 1
Lemtrada PA 4 Specialty medication
Lenvima PA, QL 4 Specialty medication
Lessina 6
Letairis PA, QL 4 Specialty medication
letrozole 1
leucovorin calcium tablet 1
Leukeran 2
Leukine PA 4 Specialty medication
leuprolide PA 4 Specialty medication
levalbuterol 1
Levatol ST 3 atenolol, metoprolol, propranolol
Levemir QL 2
levetiracetam 1
levetiracetam ER QL 1
levobunolol 1
levocetirizine 1
levofloxacin 1
levofloxacin ophthalmic 1
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Levonest 6
levonorgestrel 1
levonorgestrel/estradiol 6
Levora 6
Levothroid 5
Levothroid 300 mg tablet 1
levothyroxine 5
levothyroxine 300 mg tablet 1
Levoxyl 5
Lexiva QL 4 Specialty medication
Lialda ST 3balsalazide disodium, Apriso, Asacol HD, Delzicol
lidocaine cream 1
lidocaine patch ST, QL 1
lidocaine-hc gel 1
lidocaine jelly 1
Lifescan Blood Glucose Meters 2
Lifescan Blood Glucose Test Strips (QL > 18 years of age)
2
Lifescan Lancets (QL > 18 years of age) 2
lindane 1
linezolid QL 1
liothyronine 1
lisinopril 1
lisinopril 10 mg tablet 5
lisinopril 2.5 mg tablet 5
lisinopril 20 mg tablet 5
lisinopril 5 mg tablet 5
lisinopril/hydrochlorothiazide 5
lithium 1
lithium ER 1
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
18
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Livalo PA 3atorvastatin, lovastatin, pravastatin, simvastatin
Loestrin 24 FE 3
Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Safyral, Ortho Tri Cyclen Lo
Lo Loestrin FE 3
Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Safyral, Ortho Tri Cyclen Lo
Lomedia 24 FE 6
Lo Minastrin FE 3
Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Safyral, Ortho Tri Cyclen Lo
loperamide capsules 1
lorazepam 1
Lorcet HD QL 1
Lorcet plus QL 1
Lortab QL 1
Loryna 6
losartan 1
losartan/hydrochlorothiazide 1
Lotemax 3 fluorometholone, prednisolone
lovastatin 1
Low-ogestrel 6
loxapine (PA < 12 years of age) 1
Lucentis PA 4 Specialty medication
Lufyllin ST 3 aminophylline, theophylline
Lumigan 2
Lumizyme PA 4 Specialty medication
Lupaneta PA, QL 4 Specialty medication
Lupron PA, QL 4 Specialty medication
Lutera 6
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Lynparza PA, QL 4 Specialty medication
Lyrica PA, QL 3amitriptyline, cyclobenzaprine, duloxetine, gabapentin
Lysodren PA 4 Specialty medication
Lyza 6
Macugen PA 4 Specialty medication
Makena PA 4 Specialty medication
malathion 1
Marlissa 6
Marplan ST 3 phenelzine, tranylcypromine
Matulane 4 Specialty Medication
Maxidex 3
mebendazole 1
meclizine 1
medroxyprogesterone acetate injection QL 6
mefenamic acid PA 1
mefloquine PA 1
megestrol 1
meloxicam 1
memantine PA 1
Menest 3 estradiol, estropipate, Premarin
Menostar QL 3 estradiol
meperidine 1
Mephyton 3
meprobamate 1
mercaptopurine 1
mesalamine enema 1
Mesnex tablets 4 Specialty medication
metaxalone 1
metformin 1
metformin ER 1
methadone 1
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
19
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
methamphetamine QL (PA < 4 and ≥ 18 years of age)
1
methazolamide 1
methenamine 1
methimazole 1
Methitest PA 3testosterone injection (PA), Androgel 1.62% (PA)
methocarbamol 1
methotrexate tablet 1
methotrexate vial 4 Specialty medication
methoxsalen PA 4 Specialty medication
methscopolamine 1
methylin QL (PA < 4 and ≥ 18 years of age) 1
methylin ER QL (PA < 4 and ≥ 18 years of age) 1
methylphenidate QL (PA < 4 and ≥ 18 years of age)
1
methylphenidate CD QL (PA < 4 and ≥ 18 years of age)
1
methylphenidate ER QL (PA < 4 and ≥ 18 years of age)
1
methylphenidate SR QL (PA < 4 and ≥ 18 years of age)
1
methylprednisolone 1
metipranolol 1
metoclopramide 1
metolazone 1
metoprolol/hydrochlorothiazide 1
metoprolol succinate ER 1
metoprolol tartrate tablet 5
metronidazole 1
mexiletine 1
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Microgestin 6
Microgestin FE 6
midazolam 1
midodrine 1
Mimvey 1
Mimvey Lo 1
Minastrin 24 Fe 3
Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen Lo, Safyral
minocycline 1
minoxidil 1
mirtazapine 1
Mirvaso PA 3
adapalene, metronidazole, sodium sulfacetamide-sulfur 10-5% cleanser, tretinoin
misoprostol 1
modafinil PA, QL 1
Moderiba QL 4 Specialty medication
moexipril 1
moexipril/hydrochlorothiazide 1
mometasone 1
Mono-linyah 6
MonoNessa 6
montelukast QL 1
morphine sulfate IR 1
morphine sulfate ER tablet QL 1
Movantik PA, QL 3
Moviprep 2
Moxeza 3 ciprofloxacin, levofloxacin, ofloxacin
moxifloxacin 1
Mozobil PA, QL 4 Specialty medication
Multaq 2
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
20
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
mupirocin 1
Myalept PA, QL 4 Specialty medication
mycophenolate mofetil 1
mycophenolate sodium 1
mycophenolate suspension 4 Specialty medication
Myleran 2
Myobloc PA, QL 4 Specialty medication
myorisan 1
Myozyme PA 4 Specialty medication
Myrbetriq ER ST, QL 3
oxybutynin, oxybutynin ER, trospium, trospium ER, tolterodine, tolterodine ER, Toviaz, Vesicare
Myzilra 6
nabumetone 1
nadolol 1
nadolol/bendroflumethiazide 1
Naglazyme PA 4 Specialty medication
Namenda XR PA, QL 2
naproxen 1
naratriptan QL 1
Natazia 2
nateglinide 1
Natpara PA, QL 4 Specialty medication
Nature-throid 1
Nebupent 2
Necon 6
nefazodone 1
neomycin 1
Nesina ST 3Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta
Neulasta PA 4 Specialty medication
Neumega 4 Specialty medication
Neupogen PA 4 Specialty medication
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Nevanac 3 bromfenac, diclofenac, ketorolac
nevirapine QL 1
nevirapine ER QL 1
Nexavar PA, QL 4 Specialty medication
Next Choice 6
Next Choice One Dose 6
niacin ER 1
nicardipine 1
nicotine gum QL 6
nicotine lozenges QL 6
nicotine patches QL 6
Nicotrol inhaler ST, QL 6 generic nicotine replacement products
Nicotrol nasal spray ST, QL 6 generic nicotine
replacement products
nifediac CC 1
nifedipine 1
nifedipine ER 1
Nikki 6
Nilandron PA 4 Specialty medication
nimodipine 1
nisoldipine ER ST 1
Nitro-dur 3 nitroglycerin
nitrofurantoin 1
nitroglycerin 1
Nitrostat 3 nitroglycerin
nizatidine 1
nodolor 1
Nora-BE 6
Norditropin PA 4 Specialty medication
norgestimate/estradiol 6
Norlyroc 6
Noroxin 3 ciprofloxacin, levofloxacin
Northera PA, QL 4 Specialty medication
Nortrel 6
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
21
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
nortriptyline 1
Norvir QL 2
Novofine 2
Novolin 70/30 QL 2
Novolin N QL 2
Novolin R QL 2
Novolog QL 2
Novolog Mix 70/30 QL 2
Novotwist 2
Noxafil PA, QL 4 Specialty medication
Nplate PA 4 Specialty medication
Nuedexta PA, QL 4 Specialty medication
Nulojix PA 4 Specialty medication
Numoisyn 3 Caphosol
Nuvaring QL 6
Nuvigil PA, QL 3
Adderall XR (PA), amphetamine salts (PA), dexmethylphenidate (PA), methylphenidate (PA), methylphenidate ER (PA), modafinil (PA)
nystatin 1
nystatin/triamcinolone 1
nystop 1
Ocella 6
octreotide 4 Specialty medication
Ofev PA, QL 4 Specialty medication
ofloxacin 1
Oforta PA 4 Specialty medication
Ogestrel 6
olanzapine QL (PA < 12 years of age) 1
olanzapine vial 1
olanzapine/fluoxetine PA, QL (PA < 12 years of age)
1
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
olopatadine 0.6% nasal spray ST 1 azelastine, flunisolide,
fluticasone
Olysio PA, QL 4 Specialty medication
omega-3 acid ethyl esters 1
omeprazole QL 1
omeprazole/sodium bicarbonate PA, QL 1
ondansetron QL 1
One Touch Blood Glucose Meters 2
One Touch Blood Glucose Lancets (QL > 18 years of age)
2
One Touch Blood Glucose Test Strips (QL > 18 years of age)
2
Onfi PA 3 felbamate, lamotrigine, topiramate, valproate
Onglyza ST 3Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta
Onsolis PA, QL 4 Specialty medication
Opana ER QL 2
Opsumit PA, QL 4 Specialty medication
Oralair PA, QL 4 Specialty medication
OramagicRx 3 lidocaine, First-Mouthwash
Orap (PA < 12 years of age) 3
Oravig PA, QL 3 fluconazole
Orencia PA, QL 4 Specialty medication
Orenitram PA 4 Specialty medication
Orfadin PA 4 Specialty medication
Orkambi PA, QL 4 Specialty medication
orphenadrine 1
Orsythia 6
Ortho Tri-Cyclen Lo 2
Oseni 3Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
22
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Osmoprep 3 peg-3350, Suprep, Moviprep
Otezla PA, QL 4 Specialty medication
Otrexup PA, ST, QL 4 Specialty medication
oxandrolone PA 1
oxaprozin 1
oxazepam 1
oxcarbazepine 1
Oxsoralen PA 4 Specialty medication
oxybutynin 1
oxybutynin ER 1
oxycodone IR 1
oxycodone/acetaminophen 2.5 mg/325 mg QL
1
oxycodone/acetaminophen 5 mg/325 mg QL
1
oxycodone/acetaminophen 7.5 mg/325 mg QL
1
oxycodone/acetaminophen 10 mg/325 mg QL
1
oxycodone/aspirin QL 1
oxycodone/ibuprofen QL 1
Oxycontin PA, QL 3morphine sulfate ER, fentanyl patches, oxymorphone ER, Opana ER
oxymorphone 1
oxymorphone ER QL 1
pamidronate vial 1
Panretin PA 4 Specialty medication
pantoprazole QL 1
paricalcitol 1
paroxetine 1
Pataday ST 3 azelastine, cromolyn, epinastine
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Patanol ST 3 azelastine, cromolyn, epinastine
Pazeo 3 azelastine, cromolyn, epinastine
peg-3350 6
Peganone PA 3
carbamazepine, lamotrigine, oxcarbazepine, phenytoin, topiramate, valproic acid
Pegasys PA, QL 4 Specialty medication
Peg-Intron PA, QL 4 Specialty medication
penicillin 1
penicillin VK 250 mg tablet 5
Pentasa 3Apriso, Asacol HD, balsalazide disodium, Delzicol, sulfasalazine, sulfasalazine EC
pentazocine/acetaminophen QL 1
pentazocine/naloxone 1
pentoxifylline 1
Perforomist 3 Foradil, Serevent
perindopril 1
permethrin cream 1
perphenazine (PA < 12 years of age) 1
perphenazine/amitriptyline 1
phenazopyridine 1
phenelzine 1
phenobarbital 1
phenytoin 1
Philith 6
Phospholine Iodide 3 pilocarpine
Picato PA 3 5-fluorouracil, imiquimod
pilocarpine 1
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
23
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Pilopine HS 3 pilocarpine
Pimtrea 6
pindolol 1
pioglitazone 1
pioglitazone/glimepiride 1
pioglitazone/metformin 1
Pirmella 6
piroxicam 1
Plegridy QL 4 Specialty medication
podofilox 1
Pomalyst PA, QL 4 Specialty medication
Portia 6
potassium chloride 1
Potiga PA, QL 3
carbamazepine, levetiracetam, oxcarbazepine, phenytoin, tiagabine, topiramate, valproic acid, zonisamide
Pradaxa QL 3 Eliquis, Xarelto
pramipexole 1
Prandimet 3 metformin, repaglinide
pravastatin 1
prazosin 1
Pred Mild 3 fluorometholone, prednisolone
prednicarbate 1
prednisolone oral solution 1
prednisone 1
Premarin 2
Premarin Vaginal Cream 2
Premphase 2
Prempro 2
Prepopik 3 peg-3350, Suprep, Moviprep
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Prezcobix QL 4 Specialty medication
Prezista QL 4 Specialty medication
Primaquine PA 3
primidone 1
Pristiq ST, QL 3citalopram, duloxetine, fluoxetine, paroxetine, sertraline, venlafaxine ER capsules
Privigen PA 4 Specialty medication
ProAir HFA PA, QL 3 Ventolin HFA
probenecid 1
probenecid/colchicine 1
prochlorperazine 1
Procrit PA 4 Specialty medication
proctosol-hc 1
proctozone-hc 1
Procysbi PA, QL 4 Specialty medication
progesterone 1
Prolastin PA 4 Specialty medication
Prolastin-C PA 4 Specialty medication
Proleukin 4 Specialty medication
Prolia PA, QL 4 Specialty medication
Promacta PA, QL 4 Specialty medication
promethazine 1
promethazine/codeine 1
propafenone 1
propafenone ER 1
propranolol 1
propranolol 10 mg tablet 5
propranolol 20 mg tablet 5
propranolol 40 mg tablet 5
propranolol 80 mg tablet 5
propranolol ER 1
propranolol/hydrochlorothiazide 1
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
24
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
propylthiouracil 1
protriptyline 1
Proventil HFA PA, QL 3 Ventolin HFA
prudoxin ST 1
Pulmicort Flexhaler ST 3 Asmanex, Flovent
Pulmozyme PA, QL 4 Specialty medication
pyridostigmine bromide 1
Quartette 3
Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen Lo, Safyral
Quasense 6
quetiapine PA, QL (PA < 12 years of age) 1
quinapril 1
quinapril/hydrochlorothiazide 1
quinidine 1
Qutenza PA, QL 4 Specialty medication
QVAR ST 3 Asmanex, Flovent HFA
rabeprazole PA, QL 1
Ragwitek PA, QL 4 Specialty medication
raloxifene 1
ramipril 1
Ranexa 2
ranitidine 1
ranitidine 150 mg tablet 5
Rapaflo ST 3alfuzosin er, doxazosin, prazosin, tamsulosin, terazosin
Rasuvo PA, QL 4 Specialty medication
Ravicti PA, QL 4 Specialty medication
Rebif ST, QL 4 Specialty medication
Reclipsen 6
Rectiv PA 3compounded topical diltiazem, compounded nifedipine
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Regranex QL 3
Relenza QL 3 amantadine
Relistor syringe PA 4 Specialty medication
Relpax ST, QL 3almotriptan (ST), naratriptan, rizatriptan, sumatriptan, zolmitriptan
Remeven (urea) 50% cream 1
Remicade PA 4 Specialty medication
Remodulin PA 4 Specialty medication
Renvela 2
Renvela powder packet 2
repaglinide 1
Rescriptor QL 2
Rescula ST 3 latanoprost
reserpine 1
Restasis QL 2
Revlimid PA, QL 4 Specialty medication
Reyataz QL 4 Specialty medication
Ribasphere QL 4 Specialty medication
ribavirin QL 4 Specialty medication
rifabutin 1
rifampin 1
riluzole PA, QL 4 Specialty medication
risedronate ST, QL 1 alendronate, ibandronate
risedronate DR ST, QL 1 alendronate, ibandronate
risedronate monthly ST, QL 1 alendronate,
ibandronate
Risperdal Consta PA, QL (ST < 12 years of age) 4 Specialty medication
risperidone QL (PA < 12 years of age) 1
risperidone ODT QL (PA < 12 years of age) 1
Rituxan PA, QL 4 Specialty medication
rivastigmine PA 1
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
25
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
rizatriptan QL 1
ropinirole 1
ropinirole ER ST 1 ropinirole, pramipexole
Roxicet solution 3 oxycodone/acetaminophen tablet
Rozerem PA 3 zolpidem, zaleplon
Ruconest PA 4 Specialty medication
Sabril PA, QL 4 Specialty medication
Safyral 2
salicylic acid 1
salsalate 1
Samsca PA, QL 4 Specialty medication
Sancuso ST, QL 3 ondansetron
Sandostatin LAR PA, QL 4 Specialty medication
Santyl 3
Saphris ST, QL (PA < 12 years of age) 3
aripiprazole (PA), olanzapine, quetiapine (PA), risperidone, ziprasidone
Savella PA, QL 3amitriptyline, cyclobenzaprine, duloxetine, gabapentin,
selegiline 1
selenium sulfide 1
Selzentry PA, QL 4 Specialty medication
Sensipar 2
Serevent 2
Seroquel XR PA, ST, QL (PA < 12 years of age) 3
aripiprazole (PA), olanzapine, quetiapine (PA), risperidone, ziprasidone
Serostim PA 4 Specialty medication
sertraline 1
Signifor PA 4 Specialty medication
Signifor LAR PA, QL 4 Specialty medication
sildenafil 20 mg PA, QL 4 Specialty medication
silver nitrate 1
silver sulfadiazine cream (SSD) 1% 1
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Simbrinza 2
Simcor ST 3 simvastatin, niacin ER
Simponi PA, QL 4 Specialty medication
Simponi Aria PA, QL 4 Specialty medication
simvastatin 1
sirolimus PA 1
Sirturo PA 4 Specialty medication
Sivextro QL 4 Specialty medication
Sklice PA 3 spinosad
sodium fluoride gel 1
sodium phenylbutyrate powder PA 4 Specialty medication
sodium sulfacetamide-sulfur 10-5% cleanser 1
Soliris PA 4 Specialty medication
Somatuline PA, QL 4 Specialty medication
Somavert PA, QL 4 Specialty medication
sotalol 1
Sovaldi PA, QL 4 Specialty medication
Spectracef 3 cefpodoxime, cefdinir
spinosad 1
Spiriva 2
spironolactone 1
spironolactone 25 mg tablet 5
spironolactone/hydrochlorothiazide 1
Sporanox solution PA 3 itraconazole capsule (PA)
Sprintec 6
Sprycel PA, QL 4 Specialty medication
Sronyx 6
stavudine QL 1
Stelara PA, QL 4 Specialty medication
Stivarga PA, QL 4 Specialty medication
Strattera QL 2
Striant PA, ST 3testosterone injection (PA), Androgel 1.62% (PA)
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
26
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Stribild QL 4 Specialty medication
Stiolto Respimat 2 Anoro Ellipta
Striverdi Respimat 3 Foradil, Serevent
Suboxone film PA, QL 2
Subsys PA, QL 4 Specialty medication
Suclear 3 peg-3350, Suprep, Moviprep
Sucraid PA 4 Specialty medication
sucralfate 1
sulfacetamide sodium 1
sulfadiazine 1
sulfamethoxazole/trimethoprim 1
sulfasalazine 1
sulfasalazine EC 1
sulfisoxazole 1
sulindac 1
sumatriptan QL 1
Supprelin LA PA, QL 4 Specialty medication
Suprax 3 cefpodoxime, cefdinir
Suprep 2
Sustiva QL 4 Specialty medication
Sutent PA, QL 4 Specialty medication
Syeda 6
Sylatron PA 4 Specialty medication
Sylvant PA 4 Specialty medication
Symbicort 2
Symlin ST, QL 2
Synagis PA, QL 4 Specialty medication
Synarel PA, QL 4 Specialty medication
Synera PA 3 lidocaine/prilocaine cream
Synthroid 3 levothyroxine, liothyronine
Syprine PA 4 Specialty medication
Tabloid PA 2
Taclonex suspension PA 3 generic topical steroids
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
tacrolimus capsule 1
tacrolimus ointment PA, QL 1
Tamiflu QL 3 amantadine
tamoxifen 1
tamsulosin 1
Tanzeum ST, QL 3 Trulicity, Victoza
Tarceva PA, QL 4 Specialty medication
Tasigna PA, QL 4 Specialty medication
Tazorac ST (PA > 35 years of age) 3 generic topical acne
agents
taztia XT 1
Tecfidera PA, QL 4 Specialty medication
Tecfidera Starter Pack PA, QL 4 Specialty medication
Tekturna ST 2
lisinopril, enalapril, candesartan, eprosartan, irbesartan, losartan, telmisartan, valsartan
Tekturna HCT ST 2
lisinopril/HCTZ, enalapril/HCTZ, candesartan/HCTZ, irbesartan/HCTZ, losartan/HCTZ, telmisartan/HCTZ, valsartan/HCTZ
telmisartan 1
telmisartan/amlodipine 1
telmisartan/HCTZ 1
temazepam 1
temozolomide PA 4 Specialty medication
Tencon 1
terazosin 1
terbinafine QL 1
terconazole 1
testosterone injection PA 1
tetracaine ophthalmic 1
tetracycline 1
Thalomid PA, QL 4 Specialty medication
theophylline ER 1
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
27
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
thermazene cream 1
thioridazine (PA < 12 years of age) 1
thiothixene (PA < 12 years of age) 1
Thyrogen 4 Specialty medication
tiagabine 1
ticlopidine 1
Tikosyn 3
Tilia FE 6
timolol 1
tinidazole 1
Tirosint 3 levothyroxine, liothyronine
Tivicay 2
tizanidine tablet 1
TOBI Podhaler QL 4 Specialty medication
Tobradex ST 3 tobramycin/dexamethasone
tobramycin 1
tobramycin/dexamethasone 1
Tobrex 3 tobramycin
tolazamide 1
tolbutamide 1
tolcapone ST 1 entacapone
tolmetin 1
tolterodine 1
tolterodine ER 1
topiramate 1
topiramate sprinkle QL 1
torsemide 1
Toviaz 2
Tracleer PA, ST, QL 4 Specialty medication
Tradjenta 2
tramadol QL 1
tramadol ER tablet QL 1
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
tramadol/acetaminophen QL 1
trandolapril 1
tranexamic acid PA, QL 1
Transderm-Scop 3 meclizine
tranylcypromine 1
Travatan Z ST 3 latanoprost
travoprost ST 1 latanoprost
trazodone 1
Trelstar PA, QL 4 Specialty medication
tretinoin oral 4 Specialty medication
tretinoin topical 1
triamcinolone 1
triamterene/hydrochlorothiazide 5
triazolam 1
triderm cream 1
Tri-estarylla 6
trifluoperazine (PA < 12 years of age) 1
trifluridine eye drops 1
trihexyphenidyl 1
Tri-legest FE 6
Tri-linyah 6
Trilyte with flavor packets 6
trimethobenzamide 1
trimethoprim 1
trimipramine 1
Trinessa 6
Tri-previfem 6
Tri-sprintec 6
Triumeq QL 4 Specialty medication
Trivora 6tropicamide drops 1trospium 1trospium ER 1
Trulicity QL 2
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
28
Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Truvada QL 4 Specialty medication
Tudorza Pressair ST 3 Incruse Ellipta, Spiriva
Tybost QL 4 Specialty medication
Tykerb PA, QL 4 Specialty medication
Tysabri PA, QL 4 Specialty medication
Tyvaso PA 4 Specialty medication
Tyzeka PA 4 Specialty medication
Uceris PA 3 budesonide
Uceris Rectal Foam PA 3
Ulesfia 3 lindane, malathion, permethrin, spinosad
Uloric ST, QL 2 allopurinol
unithroid 1
urea 40% cream 1
urea 40% lotion 1
urea 50% cream 1
ursodiol 1
Vagifem 3 estradiol, estropipate, Premarin
valacyclovir QL 1
Valchlor PA 4 Specialty medication
valganciclovir 1
valproic acid 1
valsartan 1
valsartan/hydrochlorothiazide 1
vancomycin capsules 1
vandazole vaginal gel 1
Vantas PA, QL 4 Specialty medication
Vasolex 1
Veletri PA 4 Specialty medication
Velivet 6
Velphoro ST 3 calcium acetate, Renvela, Auryxia
venlafaxine 1
venlafaxine ER capsule QL 1
Ventavis PA 4 Specialty medication
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Ventolin HFA QL 2
Veramyst 2
verapamil 1
verapamil ER 1
Veregen 3 imiquimod, podofilox
Vesicare 2
Vestura 6
Vexol 3 fluorometholone, prednisolone
Victoza ST, QL 2
Videx solution QL 2
Viekira Pak PA, QL 4 Specialty medication
Vigamox 3 ciprofloxacin, levofloxacin, ofloxacin
Viibryd PA, QL 3citalopram, duloxetine, fluoxetine, paroxetine, sertraline, venlafaxine ER capsules
Vimizim PA 4 Specialty medication
Vimpat PA 3
divalproex sodium, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, topiramate, zonisamide
Viorele 6
Viracept QL 4 Specialty medication
Viread QL 4 Specialty medication
Visicol 3 peg-3350, Suprep, Moviprep
vitamins, generic pediatric 1
vitamins, generic prenatal 6
Vitekta QL 4 Specialty medication
Vivitrol PA 4 Specialty medication
Voltaren Gel QL 3Generic oral NSAIDS (such as diclofenac, etodolac, ibuprofen, meloxicam, naproxen)
voriconazole QL 1
Votrient PA, QL 4 Specialty medication
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
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Effective January 1, 2016
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
VPRIV PA 4 Specialty medication
Vyfemla 6
Vyvanse PA, QL 3
amphetamine salts, Adderall XR, dexmethylphenidate, methylphenidate, methylphenidate ER, Strattera
warfarin 1
Welchol 2
Wera 6
westhroid 1
WP Thyroid 3 levothyroxine
Wymzya Fe 6
Xalkori PA, QL 4 Specialty medication
Xarelto QL 2
Xeljanz PA, QL 4 Specialty medication
Xenazine PA, QL 4 Specialty medication
Xeomin PA, QL 4 Specialty medication
Xerac AC 3 Hypercare solution
Xgeva PA, QL 4 Specialty medication
Xifaxan 200 mg QL 3 ciprofloxacin, loperamide
Xifaxan 550 mg PA, QL 4 Specialty medication
Xolair PA, QL 4 Specialty medication
Xopenex HFA PA, QL 3 Ventolin HFA
Xtandi PA, ST, QL 4 Specialty medication
Xulane QL 6
Xyrem PA, QL 4 Specialty medication
Yodoxin 2
zafirlukast 1
zaleplon 1
Zarah 6
Zavesca PA 4 Specialty medication
Zelboraf PA, QL 4 Specialty medication
Zemaira PA 4 Specialty medication
Zenatane 1
Zenchent 6
Drug Name
Gen
eric
Pref
erre
dN
on-p
refe
rred
Spec
ialty
Sele
ct G
ener
ic
Prev
entiv
e
SuggestedAlternative(s)
Zenchent Fe 6
zenieva 1
Zenpep ST 3 Creon
Zeosa 6
Zetia 2
Ziana gel ST (PA > 35 years of age) 3
adapalene, benzoyl peroxide, clindamycin, erythromycin, tretinoin
zidovudine QL 1
Zioptan ST 3 latanoprost
ziprasidone QL (PA < 12 years of age) 1
Zirgan gel 2
Zoladex PA, QL 4 Specialty medication
zoledronic acid 4 mg 4 Specialty medication
zoledronic acid 5 mg ST, QL 4 Specialty medication
Zolinza PA, QL 4 Specialty medication
zolmitriptan QL 1
zolpidem tartrate QL 1
Zomig nasal spray QL 3almotriptan (ST), naratriptan, rizatriptan, sumatriptan, zolmitriptan
zonisamide 1
Zontivity PA, QL 3 clopidogrel, Effient
Zorbtive PA 4 Specialty medication
Zortress PA 4 Specialty medication
Zovia 6
Zubsolv PA, QL 2
Zydelig PA, QL 4 Specialty medication
Zyflo CR ST 3 montelukast
Zyflo ST 3 montelukast
Zykadia PA, QL 4 Specialty medication
Zylet 3 tobramycin/dexamethasone
Zyprexa Relprevv PA, QL (ST < 12 years of age) 4 Specialty medication
Zytiga PA, QL 4 Specialty medication
KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications PA = Prior Authorization required 2 = Preferred-Brand Medications ST = Step Therapy required 3 = Non-Preferred Brand Medications 4 = Specialty Medications * Age restrictions apply to some medications. 5 = Select Generic Medications 6 = Preventive Medications
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MEDICATIONS NOT COVERED BY ADVANTAGE CHOICE
The following medications are benefit exclusions and will not be covered under the pharmacy benefit:
Antimalarial agents when used for prevention
Antiobesity medications, including, but not limited to, appetite suppressants and lipase inhibitors
Blood or blood plasma products*
Compounded products containing excluded ingredients (examples are compounded hormone replacement therapies and compounded narcotic analgesics)
Drugs labeled for investigational use
Drugs used for cosmetic purposes or hair growth
Drugs used to treat sexual dysfunction (examples are Viagra, Levitra, Cialis, Muse, Caverject, Osphena, Stendra)
Fertility agents
Legend vitamins (other than prenatal, fluoride, and certain therapeutic vitamins)
Most over-the-counter medications**
Needles/syringes (other than insulin)*
Nutrition and dietary supplements*
Ostomy supplies*
Therapeutic devices/appliances*
Urine strips (Because our doctors feel blood glucose strips are more accurate than urine test strips in measuring blood glucose, urine strips are not a covered benefit.)
This is not a complete list and there may be other medications that are not covered. For more information, please contact Member Services.
*Please note that, under certain circumstances, your medical benefits may cover the items marked with an asterisk (*). For information on these items, you can contact our Health Care Concierge team at the number listed on the back of your member ID card. If you have not yet received an ID card, call the Health Care Concierge team number listed on page 1 of this booklet.
**Additional over-the-counter medications may be covered in accordance with the Patient Protection and Affordable Care Act. The Preventive Service Guide available on the UPMC Health Plan website contains information regarding this coverage.
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ADVANTAGE CHOICE BRAND/GENERIC REFERENCE GUIDE Brand Generic
Abilify AripiprazoleAccolate ZafirlukastAccupril QuinaprilAceon Perindopril Aciphex RabeprazoleActiq Fentanyl CitrateActivella Estradiol-Norethindrone, Mimvey,
LopreezaActonel RisedronateActoPlus Met Pioglitazone/MetforminActos PioglitazoneAcular KetorolacAdderall Amphetamine salts Aggrenox Aspirin/DipyridamoleAldactazide Spironolactone/hydrochlorothiazideAldactone SpironolactoneAldara Imiquimod Alesse Aviane, DelylaAlphagan Brimonidine Altace RamiprilAmaryl GlimepirideAmbien Zolpidem TartrateAmerge Naratriptan Amoxil AmoxicillinAnalpram HC cream Hydrocortisone-Pramoxine creamAntabuse DisulfuramAntara FenofibrateAntivert MeclizineArava LeflunomideAricept DonepezilArimidex AnastrozoleArixtra FondaparinuxAromasin ExemestaneArthrotec Diclofenac/MisoprostolAstelin AzelastineAtacand Candesartan Atacand HCT Candesartan/hydrochlorothiazideAtelvia Risedronate DRAtivan LorazepamAugmentin Amoxicillin/ClavulanateAvalide Irbesartan/hydrochlorothiazideAvapro IrbesartanAvelox MoxifloxacinAxert AlmotriptanAzulfidine, Sulfazine SulfasalazineBactrim Sulfamethoxazole/TrimethoprimBactroban Mupirocin Baraclude EntecavirBiaxin ClarithromycinBoniva Ibandronate Buphenyl powder Sodium Phenylbutyrate powder
Brand GenericBuspar BuspironeCaduet Amlodipine/AtorvastatinCalan VerapamilCampral AcamprosateCardizem CD Diltiazem ERCardizem LA Diltiazem ERCasodex Bicalutamide Catapres ClonidineCeclor CefaclorCedax CeftibutenCeftin CefuroximeCefzil CefprozilCelebrex CelecoxibCelexa Citalopram Cellcept Mycophenolate MofetilCetraxal Ciprofloxacin 0.2% ear dropsCipro CiprofloxacinClarinex DesloratadineClaritin OTC Loratadine OTCCleocin ClindamycinClimara Estradiol Patch Clobex ClobetasolCogentin BenztropineColazal Balsalazide DisodiumColestid ColestipolCombivir Lamivudine/ZidovudineComtan EntacaponeConcerta Methylphenidate ER Condylox PodofiloxCoreg CarvedilolCosopt Dorzolamide/TimololCoumadin WarfarinCozaar LosartanCutivate (topical) FluticasoneCyclocort Amcinonide Cyclogyl 2% eye drops Cyclopentolate 2% dropsCymbalta DuloxetineCytomel LiothyronineCytotec MisoprostolDepakote, Depakote ER Divalproex Sodium, Divalproex Sodium ERDepo-Provera Medroxyprogesterone acetate injectionDerma-Smoothe/FS FluocinoloneDesoxyn Methamphetamine Desyrel TrazodoneDetrol TolterodineDetrol LA Tolterodine ERDexedrine Dextroamphetamine Diabeta, Micronase GlyburideDiamox Sequels Acetazolamide ERDifferin Adapalene
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Brand GenericDiflucan Fluconazole Diovan ValsartanDiovan HCT Valsartan/HydrochlorothiazideDitropan OxybutyninDovonex CalcipotrieneDuac gel Clindamycin/Benzoyl Peroxide 1%-5% gelDuetact Pioglitazone/GlimepirideDuoneb Ipratropium/Albuterol solutionDuragesic Fentanyl transdermalDuricef Cefadroxil HydrateEffexor VenlafaxineEffexor XR Venlafaxine ER capsulesElavil AmitriptylineElestat Epinastine Eliphos Calcium AcetateElocon MometasoneEntocort EC Budesonide ECEpivir LamivudineEpivir HBV Lamivudine HBVEvista RaloxifeneEvoxac CevimelineExelon Rivastigmine Famvir Famciclovir Fazaclo Clozapine ODT Feldene PiroxicamFemara LetrozoleFemcon Fe Zeosa, Wymzia Fe, Zenchent FeFemhrt 1/5 Jinteli, Ethinyl Estradiol-Norethindrone
AcetateFemhrt Lo Ethinyl Estradiol-Norethindrone AcetateFlagyl MetronidazoleFlexeril CyclobenzaprineFlolan EpoprostenolFlomax TamsulosinFlonase FluticasoneFocalin Dexmethylphenidate Focalin XR Dexmethylphenidate ERFortamet Metformin ERFortaz CeftazidimeFosamax AlendronateGabitril TiagabineGeneress Fe Layolis FeGengraf Cyclosporine modifiedGeodon Ziprasidone Glucophage MetforminGlucotrol GlipizideGlucovance Glyburide/MetforminGolytely GaviLyte-GHalfLytely GaviLyte-HHectorol DoxercalciferolHepsera AdefovirHyzaar Losartan/HydrochlorothiazideIlotycin Erythromycin
Brand GenericImitrex Sumatriptan Inderal PropranololIndocin IndomethacinInspra EplerenoneIntuniv Guanfacine ERIopidine ApraclonidineKapvay Clonidine ERKeflex CephalexinKenalog (topical) TriamcinoloneKeppra LevetiracetamKeppra XR Levetiracetam ER Klonopin ClonazepamKytril Granisetron Lamictal Lamotrigine Lamisil TerbinafineLariam Mefloquine Lasix FurosemideLescol FluvastatinLevaquin LevofloxacinLexapro Escitalopram Lidoderm Lidocaine PatchLipitor AtorvastatinLodine EtodolacLodosyn CarbidopaLoestrin Fe Gildess Fe, Junel Fe, Larin Fe, Microgestin
Fe, Tarina FeLoestrin 24 Fe Lomedia 24 Fe, Glidess 24 FeLofibra FenofibrateLomotil Diphenoxylate/AtropineLopid GemfibrozilLopressor MetoprololLoprox, Penlac CiclopiroxLoSeasonique Amethia Lo, Camrese LoLotrel Amlodipine Besylate/BenazeprilLotronex AlosetronLovaza Omega-3 Acid Ethyl EstersLovenox EnoxaparinLunesta EszopicloneLybrel AmethystLysteda Tranexamic AcidMacrodantin NitrofurantoinMalarone Atovaquone/Proguanil Marinol DronabinolMaxalt Rizatriptan Metadate CD Methylphenidate ERMetadate ER Methylphenidate ERMetaglip Glipizide/MetforminMevacor LovastatinMiacalcin Calcitonin Nasal SprayMicardis TelmisartanMicardis HCT Telmisartan/HCTZMicronor Camila, Heather, Jencycla, Lyza, Norlyroc,
Sharobel
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Brand GenericMigranal DihydroergotamineMinocin MinocyclineMirapex PramipexoleMobic MeloxicamMotrin IbuprofenMS Contin Morphine Sulfate ER Myfortic Mycophenolate SodiumNamenda MemantineNaprosyn NaproxenNasacort AQ Triamcinolone Acetonide Natroba SpinosadNeoral Cyclosporine modifiedNeurontin GabapentinNexium EsomeprazoleNiaspan Niacin ERNizoral KetoconazoleNordette Portia, Chateal, KurveloNorvasc Amlodipine BesylateNulytely Peg-3350Ocupress Carteolol ophthalmicOmnicef CefdinirOmnipred 1% drops Prednisolone Acetate 1% dropsOpana OxymorphoneOpana ER Oxymorphone ER Optivar AzelastineOrtho-Cept Apri, Enskyce, Desogestrel-Ethinyl
EstradiolOrtho-Cyclen Mono-Linyah, Mononessa, Estarylla,
SprintecOrtho Evra XulaneOrtho Tri-Cyclen Tri-Linyah, Trinessa, Tri-Estarylla,
Tri-SprintecOvcon Briellyn, Gildagia, Philith, Pirmella,
VyfemlaOvide MalathionOxsoralen Ultra MethoxsalenPalgic ArbinoxaParcopa Carbidopa/LevodopaPatanase OlopatadinePaxil ParoxetinePepcid FamotidinePercocet Oxycodone/Acetaminophen Peridex, Periogard Chlorhexidine PhosLo Calcium AcetatePlan B Levonorgestrel, Next ChoicePlan B One-Step Next Choice One DosePlavix ClopidogrelPlendil FelodipinePletal CilostazolPonstel Mefenamic AcidPrandin RepaglinidePravachol Pravastatin
Brand GenericPrecose AcarbosePrevacid Lansoprazole Prevident Sodium fluoride gelPrevpac Lansoprazole/Amoxicillin/Clarithromycin
packPrilosec Omeprazole Prinivil, Zestril LisinoprilPrinzide, Zestoretic Lisinopril/HydrochlorothiazideProcardia NifedipinePrograf Tacrolimus Prometrium Progesterone capsuleProscar FinasterideProtonix Pantoprazole Protopic Tacrolimus ointmentProvigil ModafinilProzac FluoxetineProzac Weekly Fluoxetine DRPulmicort respules Budesonide respulesQuestran CholestyramineQuixin Levofloxacin opthalmicRapamune SirolimusRazadyne Galantamine Reclast Zoledronic Acid 5 mgReglan MetoclopramideRelafen NabumetoneRemeron MirtazapineRenvela Sevelamer carbonateRequip RopiniroleRequip XL Ropinirole XLRestoril TemazepamRetin A TretinoinRetrovir ZidovudineRevatio SildenafilRhinocort Aqua Budesonide nasal sprayRilutek Riluzole Risperdal Risperidone Ritalin MethylphenidateRitalin LA Methylphenidate ERRowasa MesalamineRythmol SR Propafenone ERSanctura TrospiumSanctura XR Trospium ERSandimmune CyclosporineSeasonale Jolessa, QuasenseSeasonique Amethia, Ashlyna, CamreseSeroquel Quetiapine Singulair Montelukast Sodium Skelaxin MetaxaloneSoma CarisoprodolSonata Zaleplon
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UPMC Health Plan Inc. administers group and individual products for UPMC Health Coverage Inc., UPMC Health Network Inc., UPMC Health Options Inc., and UPMC Health Plan Inc. Please note that throughout this document, we use the terms “UPMC Health Plan” and “the Health Plan” to refer to UPMC Health Coverage Inc., UPMC Health Network Inc., UPMC Health Options Inc., and UPMC Health Plan Inc., as well as plans administered by UPMC Benefit Management Services Inc.
This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered.
This Pharmacy Benefit Guide is current as of January 1, 2016. For the latest information on the Advantage Choice drug formulary and other pharmacy benefits, visit www.upmchealthplan.com/pharmacy. Select “Advantage Choice” to access the searchable drug list. You may also call our Health Care Concierge team at the number listed on the back of your member ID card and on page 1 of this booklet.
Brand GenericSoriatane AcitretinSporanox Itraconazole Stalevo Carbidopa/Levodopa/EntacaponeStarlix NateglinideStromectol IvermectinSuboxone Buprenorphine/NaloxoneSubutex Buprenorphine Sular Nisoldipine ERSulfamylon Mafenide PowderSymbyax Olanzapine/Fluoxetine Tagamet CimetidineTargrentin BexaroteneTarka Trandolapril/VerapamilTasmar TolcaponeTegretol CarbamazepineTegretol XR Carbamazepine ERTemodar TemozolomideTemovate ClobetasolTenex GuanfacineTenormin AtenololTeveten EprosartanTindamax TinidazoleTOBI Tobramycin solution for nebulizationTobradex Tobramycin-DexamethasoneTopamax TopiramateTopicort Desoximetasone Toprol XL Metoprolol ERTravatan TravoprostTrexall MethotrexateTricor FenofibrateTridesilon DesonideTrileptal OxcarbazepineTrilipix Fenofibric acidTrizivir Abacavir/Lamivudine/ZidovudineTrusopt Dorzolamide Twynsta Telmisartan/AmlodipineTylenol # 3 Acetaminophen/Codeine Ultram Tramadol Uroxatral Alfuzosin ERUrso UrsodiolValcyte Valganciclovir
Brand GenericValium DiazepamValtrex ValacyclovirVancocin VancomycinVasotec EnalaprilVectical Ointment Calcitriol OintmentVeetids PenicillinVermox MebendazoleVfend Voriconazole Vibramycin DoxycyclineVicodin, Vicodin ES Hydrocodone/Acetaminophen Vicoprofen Hydrocodone/IbuprofenVidex EC DidanosineViramune NevirapineVivactil ProtriptylineVoltaren DiclofenacWellbutrin BupropionWellbutrin XL Budeprion XLXalatan LatanoprostXanax AlprazolamXeloda CapecitabineXibrom Bromfenac Xopenex LevalbuterolXyzal LevocetirizineYasmin Ocella, Syeda, ZarahYaz Gianvi, Loryna, Vestura, NikkiZantac RanitidineZemplar ParicalcitolZerit StavudineZiagen AbacavirZithromax AzithromycinZocor SimvastatinZofran Ondansetron Zoloft SertralineZometa Zoledronic Acid 4 mgZomig ZolmitriptanZonegran ZonisamideZovirax AcyclovirZyloprim AllopurinolZymaxid GatifloxacinZyprexa Olanzapine Zyvox Linezolid
Copyright 2015 UPMC Health Plan Inc. All Rights Reserved. AC_PHARM_GD_POD_15PHID0032 (MCG) 12/24/15 PDF
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