Advantage Choice Pharmacy Benefit Guide€¦ · The most commonly prescribed Advantage Choice drugs...

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


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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

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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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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

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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



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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

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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)


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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

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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



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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

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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



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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

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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)

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dexmethylphenidate ER QL (PA < 4 and ≥ 18 years of age)

1



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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

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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



12

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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

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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



13

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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

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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



14

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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

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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



15

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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

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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



16


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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

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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


17


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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


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

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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/hydrochlorothiazide 5

lithium 1

lithium ER 1


18


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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


Lomedia 24 FE 6

Lo Minastrin FE 3


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

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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


19


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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

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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


20


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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

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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


21


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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

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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


22


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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

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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


23


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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

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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 ER 1

propranolol/hydrochlorothiazide 1


24


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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

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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


25


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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


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


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

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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)


26


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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

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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


27


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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

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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


28


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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

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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


29


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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

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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


30

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.

31

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

32

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

U.S. Steel Tower, 600 Grant StreetPittsburgh, PA 15219www.upmchealthplan.com

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Advantage Choice Pharmacy Benefit Guide€¦ · The most commonly prescribed Advantage Choice drugs...

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