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Your prescription drug program 2015
Your prescription drug program 2015 This information is also available in large print. Call 1-800-286-4242. TTY users should call toll-free 1-800-361-2629. Table of Contents Your Prescription Drug Program................................................................................................................................................................ 1 Pharmacy Copayments................................................................................................................................................................................. 1 Plan Exclusions............................................................................................................................................................................................... 2 Dispensing Limitations................................................................................................................................................................................. 2 Coverage and Prior Authorization Review Process.............................................................................................................................. 2 Temporary Supplies...................................................................................................................................................................................... 3 Generic Medications..................................................................................................................................................................................... 3 Step Therapy................................................................................................................................................................................................... 4 Step Therapy Medications.......................................................................................................................................................................... 4 Prior Authorization........................................................................................................................................................................................ 5 Prior Authorization Medications................................................................................................................................................................ 5 Quantity Limits............................................................................................................................................................................................... 7 Pharmacies for Prescriptions.....................................................................................................................................................................15 Complaints, Grievances, and Fair Hearings...........................................................................................................................................15 Pharmacy Benefit Questions......................................................................................................................................................................15 UPMC for You Prescription Drug Formulary..........................................................................................................................................16 UPMC for You Over-the-Counter Formulary........................................................................................................................................30 Brand/Generic Reference Guide..............................................................................................................................................................33 Your Prescription Drug Program If you have any questions, call Member Services. Pharmacy Copayments The UPMC for You Prescription Drug Formulary is a list of Food and Drug Administration (FDA) approved medications. This list has been developed by UPMC for You doctors and pharmacists. UPMC for You provides coverage (pays for) for medications on the formulary (drug list). The drugs on the formulary were selected because they are safe, work well, and cost less than other drugs that have the same level of effectiveness. For your convenience, there is a list of prescription medications and a list of over-the-counter (OTC) medications. These lists are in alphabetical order. The UPMC for You formulary includes the most commonly used drugs. It does not include every medication your doctor might prescribe. UPMC for You covers many other drugs besides the ones listed in the formulary. Some members may need to pay a small amount to the pharmacist for their medications. This is called a copayment. The pharmacist will let you know if a copayment applies to you. If you need a medication and truly cannot pay the copayment amount at the time you pick up the prescription, the pharmacy will give you the prescribed medication and bill you for the copayment. You will still owe the pharmacy the copayment for that prescription and the pharmacy will require you to pay the copayment. Pharmacy copayments do not apply to pregnant women (including through the postpartum period), recipients under the age of 18, nursing facility residents, and those who reside in an Intermediate Care Facility for the Intellectually Disabled and Other Related Conditions (ICF/ID/ORC) and recipients eligible under the Breast and Cervical Cancer Prevention and Treatment coverage group and Titles IV-B Foster Care and IV-E Foster Care and Adoption Assistance. Pharmacy copayments also do not apply to emergency supplies and family planning supplies. To find out if your medication is covered, ask your pharmacist or call UPMC for You Member Services. Your doctor should order medications for you from the formulary. A non-formulary medication is one that is not on the list of medications covered by UPMC for You. If your doctor writes you a prescription for a non-formulary medicine, he or she will need to contact Pharmacy Services at 1-800-979-UPMC (8762) for a medical exception. You will not be able to get the medication until we authorize the exception. Copayment Information If you have pharmacy benefits, brand-name prescription drugs and brand-name over-the-counter drugs are $3 for each new prescription or refill. Some prescription medications have to be approved by UPMC for You. This is called “prior authorization.” The medication your provider is asking for is reviewed for medical necessity. This means we need to understand why the medication is needed to treat your specific condition. All requests for medications requiring a prior authorization are reviewed by the UPMC for You Pharmacy Department. Decisions to approve or deny will be made within 24 hours of the request. If the request is denied, you will receive a letter explaining why it was denied. The letter will also tell you how to file a grievance if you are not satisfied with the decision. For more information about how to file a grievance see Section 6 of your member handbook. If you have pharmacy benefits, generic prescription drugs and generic over-the-counter drugs are $1 for each new prescription or refill. Drugs, including immunizations, dispensed by a physician are excluded from copayments. You do not have to pay a copayment for certain drugs: anti-hypertensives (high blood pressure drugs), antineoplastics (cancer drugs), anti-diabetics (diabetes drugs), anti-convulsants (epilepsy drugs), cardiovascular preparations (heart disease drugs), anti-Parkinson’s agents (Parkinson’s disease drugs), HIV/AIDS drugs, anti-glaucoma agents (glaucoma drugs), anti-psychotics You can get some over-the-counter medications when your doctor writes a prescription for them. Please refer to the UPMC for You Over-the-Counter formulary in this book for a listing of covered products. If you have any questions, call UPMC for You Member Services at 1-800-286-4242. Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free at 1-800-361-2629. 1 (drugs for psychosis), and anti-depressants (drugs for depression). Please ask your pharmacist or call our Member Services representatives to determine which drugs can be filled for a 90-day supply. If you have questions about copayments, please call Member Services. A medication may be refilled when 85% of the medication has been used. Authorizations for medications that are lost/misplaced, stolen, or destroyed/damaged must be reviewed by the UPMC for You Pharmacy Services Department. Plan Exclusions The following medications are not covered under the Medical Assistance Program: Coverage and Prior Authorization Review Process • DESI drugs. DESI (Drug Efficacy Study Implementation) drugs are classified by the FDA as being safe but not effective since these drugs did not have the appropriate studies done to prove they are effective. Your medication may require a review prior to coverage by UPMC for You. The types of review for coverage or exception include the following: • Drugs from manufacturers not participating in the Medicaid Drug Rebate Program. • Prior authorization (requires your medication be review for medical necessity) • Erectile dysfunction medications. • Experimental/investigational medications. • Step therapy (requires that you must try another medication first) • Drugs used for cosmetic purposes. • Drugs used for fertility purposes. • Non-formulary (requires that you try formulary medications) • Weight loss drugs. • Quantity limits (requires you to take the recommended amounts of the medication) Dispensing Limitations If your medication requires a review, then your doctor or other health care provider must contact Pharmacy Services. Your doctor or health care provider can do the following: Prescriptions must be dispensed by a network pharmacy. Some network pharmacies can provide up to a 90-day supply of maintenance drug for one copayment. Please ask your pharmacist or call our Member Services representatives to see if your pharmacy participates in this program. • Fax a prior authorization request form to Pharmacy Services at 412-454-7722. Your doctor can find the form on the UPMC Health Plan website at www.upmchealthplan.com • A maintenance medication is one that you take on a regular basis for a chronic or long-term condition. Antibiotics, controlled substances, and specialty medications are limited to a maximum 30-day supply per copayment. • Call 1-800-979-UPMC (8762) for urgent requests. • Controlled substances are drugs with high abuse potential and have a schedule II-V classification according to the Drug Enforcement Agency (DEA) and Food and Drug Administration (FDA). UPMC for You will respond to all requests for coverage or exception within 24 hours. You and your doctor will get a written notice of the decision. If the request is denied, the written notice will explain how to appeal the denial. • Specialty drugs are high-cost medications used to treat complex diseases. These medications usually require specialized handling and close monitoring by a doctor. If you have been receiving the medication and your request is denied, you can file a complaint, grievance, or request a fair hearing. If your request is hand delivered or postmarked within 10 days of the written notice of the If you have any questions, call UPMC for You Member Services at 1-800-286-4242. Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free at 1-800-361-2629. 2 Generic Medications decision, you can get your medication while you wait for a decision about your appeal. Additional information on how to file an appeal can be found in your member handbook. UPMC for You requires that generic medications be given to you when available. Generic drugs have the same active ingredients as their brand-name counterparts and are just as safe and effective. Doctors are encouraged to prescribe generic medications whenever clinically appropriate. If your doctor prescribes a drug by brand name, your pharmacist will give you a generic version of that drug. If your doctor thinks you need the brand-name version of the drug, your doctor will need to call Pharmacy Services at 1-800-979-UPMC (8762). Representatives are available Monday through Friday from 8 a.m. to 5 p.m. Your medication may be approved for a certain time period. After that time, your doctor will need to make sure your medication is still covered for you. Temporary Supplies While UPMC for You is reviewing the request for an exception, the pharmacist may give you a 15-day supply of the medication if your prescription qualifies as an ongoing medication that you have been taking. If it is a new medication, the pharmacist will give you a 72hour supply if you have an immediate need for it. If the pharmacist feels that taking the requested medication alone or along with other medications you are taking will hurt your health or safety, the prescribing provider will be contacted before giving you the medication. If you have any questions, call UPMC for You Member Services at 1-800-286-4242. Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free at 1-800-361-2629. 3 Step Therapy Step therapy medications require that you try specific medications first. The step therapy medications are automatically covered if we have a record that the required medication has been tried first. If there is no record that the required medication has been tried, your doctor is required to consult with UPMC for You Pharmacy Services before your pharmacy plan will cover the step therapy medication. The drugs in the following table require step therapy: Step Therapy Medications Acitretin Irbesartan/HCTZ Alprazolam ODT Januvia Avandia Juvisync Celebrex Levalbuterol Clonazepam ODT Olanzapine-fluoxetine Clozapine ODT Symlin Dificid Tradjenta Granisetron Valsartan Irbesartan Valsartan/HCTZ 4 Prior Authorization Some medications listed on the UPMC for You formulary require additional information from your doctor. Your doctor is required to consult with UPMC for You Pharmacy Services the first time he or she prescribes these drugs for you and before your pharmacy plan will cover them. The drugs are as follows: Prior Authorization Medications 8-MOP Abilify (2 mg, 5 mg <12 years of age) Abilify Maintena Abstral Actemra Acthar Gel Actimmune Adagen Adcirca Adderall XR (<4 or >18 years of age) Adefovir Adempas Afinitor Aldurazyme Alferon N Amevive Amphetamine salts (<4 or >18 years of age) Ampyra Androgel Apokyn Aptiom Aralast Aranesp NP Arcalyst Aubagio Banzel Baraclude Benlysta Berinert Bivigam Bosulif Botox Buphenyl Buprenorphine Buprenorphine/naloxone tablets Capecitabine Caprelsa Exjade Eylea Fabrazyme Fanapt Fareston Fentanyl citrate lozenge Fentora Ferriprox Firazyr Firmagon Flolan/epoprostenol Fluphenazine (<12 years of age) Forteo Fulyzaq Fycompa Galantamine/ Galantamine ER Galzin Gammaked Gattex Gilenya Gilotrif Glassia Gleevec Gralise ER Granix Grastek Haloperidol (<12 years of age) Harvoni Hetlioz Horizant Humira Hycamtin Iclusig Ilaris Imbruvica Increlex Infergen Inlyta Carbaglu Cerezyme Chlorpromazine (<12 years of age) Cimzia Cinryze Clozapine (<12 years of age) Clozapine ODT (<12 years of age) Cometriq Cuprimine Cystadane Cystagon Cystaran Daliresp Danazol Demsar Depen Dexmethylphenidate (<4 or >18 years of age) Dextroamphetamine (<4 or >18 years of age) Dextroamphetamine SA (<4 or >18 years of age) Dibenzyline Donepezil Dysport Egrifta Elaprase Elelyso Elidel Eligard Enbrel Entyvio Epivir-HBV Epogen Erivedge Etoposide Euflexxa Evzio 5 Intron-A Invega Sustenna Iressa Itraconazole IVIG (intravenous immune globulin) Jakafi Jetrea Juxtapid Kalbitor Kalydeco Kineret Korlym Krystexxa Kuvan Kynamro Lazanda Letairis Leukine Lidocaine patch Lotronex Loxapine (<12 years of age) Lucentis Lumizyme Lupaneta Pack Lupron Lupron Depot Lupron Depot-Ped Lyrica Lysodren Makena Mekinist Methylphenidate (<4 or >18 years of age) Methylphenidate ER (<4 or >18 years of age) Methylphenidate LA (<4 or >18 years of age) Methylphenidate SR (<4 or >18 years of age) Modafnil Mozobil Myalept Myobloc Myozyme Naglazyme Namenda Neulasta Neupogen Nexavar Norditropin Northera Noxafil Nplate Nuedexta Nulojix Nuvigil Oforta Olanzapine (<12 years of age) Olysio Omontys Onfi Onmel Onsolis Opsumit Orap (<12 years of age) Orencia Orenitram Orfadin Otezla Otrexup Oxsorelen Panretin Peg-Intron Perphenazine (<12 years of age) Pomalyst Potiga Procrit Procysbi Prolastin Prolastin-C Prolia Promacta Protopic Provenge Pulmozyme Quetiapine Quetiapine (<12 years of age) Qutenza Ragwitek Rapamune Rasuvo Ravicti Relistor Remicade Remodulin Revlimid Riluzole Risperdal Consta Risperidone (<12 years of age) Rituxan Rivastigmine Sabril Samsca Sandostain LAR Depot Savella Serostim Signifor Sildenafil Simponi Sirturo Soliris Somatuline Depot Somavert Sovaldi Sprycel SQIG Stelara Stivarga Suboxone film Sucraid Supprelin LA Sutent Sylatron Sylvant Syprine Synagis Synarel Synvisc Syprine Tafinlar Tarceva Targretin Tasigna Tecfidera Temozolomide Testosterone Thalomid Thioridazine (<12 years of age) Thiothixene (<12 years of age) Tracleer Tranexamic acid Trelstar Tretinoin (age 35 and older) Trifluoperazine (<12 years of age) Tykerb Tysabri Tyvaso 6 Tyzeka Valchlor Vantas Veletri Ventavis Viadur Vimizim Vivitrol Votrient VPRIV Vyvanse (<4 or >18 years of age) Xalkori Xeljanz Xenazine Xeomin Xgeva Xifaxan Xofigo Xolair Xtandi Xyrem Zavesca Zelboraf Zemaira Ziprasidone (<12 years of age) Zoladex Zoledronic acid Zolinza Zontivity Zorbtive Zortress Zubsolv Zydelig Zykadia Zytiga Quantity Limits The UPMC for You Pharmacy and Therapeutics Committee has established quantity limits on certain drugs to encourage the appropriate use of these drugs. Quantity limits are drug-specific and limit the amount of certain drugs that can be dispensed in a specified period of time. These limits are based on the Food and Drug Administration’s recommended dosing, clinical literature, and manufacturer’s instructions. For some drugs, the dosing guidelines may recommend taking 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. For example, a prescription for tramadol is limited to 240 tablets per month, a prescription for Prolia is limited to two vials per year, and a prescription for quetiapine is limited to three tablets per day. Your doctor is required to consult with UPMC for You Pharmacy Services if you require more than the quantity limit of your medication. The drugs in the following table have quantity limits: Medication Class Quantity Limits Allergic Rhinitis Medications Grastek 30 tablets per 30 days Ragwitek 30 tablets per 30 days Anticoagulant (blood thinner) Medications Effient 30 tablets per month Eliquis 2.5 mg: 60 tablets per 30 days 5 mg: 74 tablets per 30 days Enoxaparin, Fragmin, and Fondaparinux 2-month supply per year Pradaxa 60 capsules per 30 days Xarelto 10 mg: 2-month supply per year 15 mg: 42 tablets per 30 days 20 mg: 30 tablets per 30 days Starter pack: 1 pack per year Zontivity 30 tablets per 30 days Antiviral Medications famciclovir 125 mg: 21 tablets per month 250 mg: 70 tablets per month 500 mg: 21 tablets per month Relenza 1 kit per season Synagis PA 1 vial per month Maximum of 5 doses per season Tamiflu 10 capsules per season 6 mg/mL suspension: 120 mL per season valacyclovir 500 mg: 42 tablets per month 1000 mg: 21 tablets per month Asthma montelukast 30 tablets or oral packets per 30 days ADHD and Stimulant Medications Adderall XR PA 5 mg, 10 mg, 15 mg: 30 capsules per 30 days 20 mg, 25 mg, 30 mg: 60 capsules per 30 days amphetamine salt combo PA 5 mg, 7.5 mg, 10 mg, 12.5 mg, 20 mg: 90 tablets per 30 days 15 mg, 30 mg: 60 tablets per 30 days dexmethylphenidate PA 60 tablets per 30 days dextroamphetamine PA 120 tablets per 30 days dextroamphetamine SA PA 5 mg: 30 capsules per 30 days 10 mg, 15 mg: 120 capsules per 30 days PA = Prior Authorization Required ST = Step Therapy Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 7 Medication Class Quantity Limits methylphenidate PA 2.5 mg, 5 mg, 10 mg, 20 mg: 30 tablets per 90 days 5 mg/5 mL solution: 1,800 mL per 30 days 10 mg/5 mL solution: 900 mL per 30 days methylphenidate ER PA 18 mg, 27 mg, 54 mg: 30 tablets per 30 days 36 mg: 60 tablets per 30 days methylphenidate ER PA 30 tablets per 30 days methylphenidate SR PA 90 capsules per 30 days modafinil PA 100 mg: 30 tablets per 30 days 200 mg: 60 tablets per 30 days Nuvigil PA 30 tablets per 30 days Strattera 10 mg, 40 mg, 60 mg, 80 mg, 100 mg: 30 tablets per month 18 mg: 60 tablets per month 25 mg: 90 tablets per month Vyvanse PA 30 capsules per 30 days Bronchodilators Proair HFA 2 inhalers per month Ventolin HFA 2 inhalers per month Contraceptive Agents Medroxyprogesterone injection 1 vial/syringe per 90 days Nuvaring 1 ring per 28 days Oral contraceptive tablets 28 tablets per 28 days 91 tablets per 90 days for extended cycle tablets Cystic Fibrosis Agents Kalydeco PA 60 tablets per month Dermatological Agents Regranex 3 tubes per year Diabetes Medications Symlin ST 4 vials/pens per month Victoza 3 pens per month Insulin U-100: 5 vials per 30 days U-500: 1 vial per 30 days 3 boxes of pens/cartridges per 30 days Lancets 200 lancets per 30 days Test Strips 150 test strips per month Fibromyalgia Medications Savella PA 60 tablets per month Savella titration pack 1 package per lifetime Gastrointestinal Medications Emend 40 mg: 1 tablet per month 80 mg: 4 tablets per month 125 mg: 2 tablets per month Tri-fold: 2 packs per month 1 vial per 30 days granisetron ST Tablets: 14 per month Suspension: 90 mL per month lansoprazole 30 capsules per month omeprazole OTC 60 tablets per month PA = Prior Authorization Required ST = Step Therapy Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 8 Medication Class Quantity Limits ondansetron 4 mg, 8 mg: 90 tablets per month 24 mg: 7 tablets per month pantoprazole 60 tablets per month Hormone Replacement Therapy estradiol transdermal patches 4 patches per month Injectable & Biotech Medications Actemra PA Intravenous infusion 800 mg (40 mL) per 28 days Subcutaneous injection: 4 syringes per 28 days Acthar gel PA 3 vials per month Adcirca PA 60 tablets per month Adempas PA 90 tablets per 30 days Amevive PA 2 treatment courses per year Ampyra PA 60 tablets per month Apokyn 30 syringes/cartridges per month Arcalyst PA 4 vials per month Aubagio PA 30 tablets per 30 days Bethkis 56 ampules per 56 days Botox PA Four 100-unit vials per 84 days Two 200-unit vials per 84 days Cayston 84 vials per 56 days Cimzia PA 2 vials/syringes per month Cinryze PA 16 vials per month Cystaran PA 4 bottles per 30 days Dysport PA Two vials per 84 days Egrifta PA 60 vials per 30 days Eligard PA One 7.5 mg kit per 28 days One 22.5 mg kit per 84 days One 30 mg kit per 112 days One 45 mg kit per 168 days Enbrel PA 25 mg: 8 vials per month 50 mg: 4 vials per month Firazyr PA 3 syringes per 30 days Firmagon PA Two 120 mg vials per lifetime One 80 mg vial per 28 days Forteo PA 1 pen per 28 days Maximum of 2 years of therapy per lifetime Fulyzaq PA 60 tablets per 30 days Gattex PA 30 vials per 30 days Gilenya PA 30 capsules per 30 days Harvoni PA 30 tablets per 30 days Hetlioz PA 30 capsules per 30 days Humira PA 2 syringes per month Crohn’s Starter Pack: 1 pack per lifetime Psoriasis Starter Pack: 1 pack per lifetime Ilaris PA 2 vials per 28 days Infergen PA 30 vials per month PA = Prior Authorization Required ST = Step Therapy Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 9 Medication Class Quantity Limits Jetrea PA 2 injections per lifetime Juxtapid PA 5 mg and 10 mg: 30 capsules per 30 days 20 mg: 90 capsules per 30 days Kineret PA 30 syringes per month Korlym PA 120 tablets per 30 days Krystexxa PA 2 vials per 28 days Kynamro PA 4 vials per 28 days Letairis PA 30 tablets per month Lupron PA 2 kits per 28 days Lupron Depot PA One 3.75-mg kit per 28 days One 7.5-mg kit per 28 days One 11.25-mg kit per 84 days One 22.5-mg kit per 84 days One 30-mg kit per 112 days One 45-mg kit per 168 days Lupron Depot-Ped PA One 7.5-mg kit per 28 days One 11.25-mg 1-month kit per 28 days One 11.25-mg 3-month kit per 84 days One 15-mg kit per 28 days One 30-mg kit per 84 days Lupaneta Pack PA One 1-month pack per 28 days One 3-month pack per 84 days Mozobil PA 8 vials per 4 days Myalept PA 30 vials per 30 days Myobloc PA Four 2,500-unit vials per 84 days Two 5,000-unit vials per 84 days One 10,000-unit vials per 84 days Northera PA 100 mg: 540 capsules per lifetime 200 mg and 300 mg: 180 capsules per month Nuedexta PA 60 capsules per month Olysio PA 30 tablets per 30 days Opsumit PA 30 tablets per 30 days Orencia PA 4 syringes per month Otezla PA 60 tablets per 30 days 1 starter pack per lifetime Otrexup PA 1 package (4 auto-injectors) per 28 days Peg-Intron PA 4 kits per month Procysbi PA 900 capsules per 30 days Prolia PA 1 vial per 180 days Promacta PA 12.5 mg and 25 mg: 30 tablets per 30 days 50 mg and 75 mg: 60 tablets per 30 days Provenge PA 1 course per lifetime Pulmozyme PA 30 ampules per month Rasuvo PA 1 package (4 auto-injectors) per 28 days Ravicti PA 525 mL per month Rebetol solution 900 mL per 30 days Reclast PA 1 infusion per year PA = Prior Authorization Required ST = Step Therapy Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 10 Medication Class Quantity Limits Ribasphere 200 mg tablet/capsule: 180 tablets/capsules per 30 days 400 mg: 90 tablets per 30 days 600 mg: 60 tablets per 30 days ribavirin 200 mg tablet/capsule: 180 tablets/capsules per 30 days 400 mg tablet: 90 tablets per 30 days 600 mg: 60 tablets per 30 days Riluzole PA 60 tablets per month Rituxan PA 1 treatment course (two 1000 mg doses given on day 1 and 15) Samsca PA 15 mg: 30 tablets per month 30 mg: 60 tablets per month Sandostatin LAR Depot PA 10 mg and 30 mg: 1 kit per 28 days 20 mg: 2 kits per 28 days Signifor PA 60 ampules per 30 days sildenafil PA 90 tablets per 30 days 1,125 mL per 30 days (IV solution) Simponi PA 1 syringe/autoinjector per 28 days Sivextro 6 tablets per 30 days Somatuline Depot PA 60 mg, 90 mg, and 120 mg: 1 syringe per 28 days Somavert PA 30 vials per 30 days Sovaldi PA 30 tablets per 30 days Stelara PA 1 vial/syringe per 12 weeks Supprelin LA PA 1 implant per 365 days Synarel PA 5 bottles per 30 days Tecfidera PA 60 capsules per 30 days Starter pack: 1 pack per lifetime TOBI 56 vials per 56 days TOBI Podhaler 224 capsules per 56 days Tracleer PA 60 tablets per month tranexamic acid PA 30 tablets per 28 days Trelstar PA 3.75 mg: 1 vial every 28 days 11.25 mg: 1 vial every 84 days 22.5 mg: 1 vial every 168 days Tysabri PA 1 vial per 28 days Vantas PA 1 implant per 365 days Xeljanz PA 60 tablets per month Xenazine PA 12.5 mg: 90 tablets per 30 days 25 mg: 60 tablets per 30 days Xeomin PA 50 U vial: 8 vials per 84 days 100 U vial: 4 vials per 84 days Xgeva PA 1 vial per 28 days Xofigo PA 1 course per lifetime Xolair PA 6 vials per 28 days Zoladex PA One 3.6-mg implant per 28 days One 10.8-mg implant per 84 days Migraine Medications naratriptan 9 tablets per month rizatriptan 9 tablets per month PA = Prior Authorization Required ST = Step Therapy Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 11 Medication Class Quantity Limits sumatriptan Injection: 4 boxes per month Nasal spray: 6 bottles per month Tablets: 9 tablets per month Monthly Fill Limitations Benzodiazepines 2 fills per month Narcotic analgesics 4 fills per month Multiple Sclerosis Injectable Medications Avonex 1 package (each containing 4 vials) per month Copaxone 20 mg: 30 syringes per 30 days 40 mg: 12 syringes per 30 days Muscle Relaxants carisoprodol 120 tablets per year Narcolepsy Medication Xyrem PA 540 mL per month Non-steroidal Anti-inflammatory Medications (NSAIDs) Celebrex ST 60 capsules per month ketorolac 5-day supply Oral Antibiotic Medications azithromycin 250 mg: 10 tablets per month 500 mg: 4 tablets per month 600 mg: 8 tablets per month 2 gr per 60 mL bottle: 1 bottle per month ciprofloxacin ER 500 mg: 3 tablets per prescription 1,000 mg: 14 tablets per prescription Dificid ST 20 tablets per 10 days Xifaxan PA 200 mg: 9 tablets per prescription 550 mg: 60 tablets per 30 days Zyvox 56 tablets per year 1,650 mL per year Oral Antifungal Medications fluconazole 150 mg: 2 tablets per prescription 50 mg, 100 mg, 200 mg: 10 tablets per month itraconazole PA 60 capsules per month Noxafil PA 93 tablets per 30 days Onmel PA 30 tablets per 30 days terbinafine 90 tablets per year voriconazole 30 day supply for esophageal infections 100-day supply per year Oral Oncology Medications Afinitor PA 30 tablets per 30 days Bosulif PA 100 mg: 120 tablets per 30 days 500 mg: 30 tablets per 30 days Caprelsa PA 100 mg: 60 tablets per 30 days 300 mg: 30 tablets per 30 days Cometriq PA 60 mg/day pack: 84 capsules per 28 days 100 mg/day pack: 56 capsules per 28 days 140 mg/day pack: 112 capsules per 28 days Erivedge PA 30 tablets per 30 days PA = Prior Authorization Required ST = Step Therapy Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 12 Medication Class Quantity Limits Gilotrif PA 30 tablets per 30 days Gleevec PA 100 mg: 90 tablets per 30 days 400 mg: 60 tablets per 30 days Iclusig PA 15 mg: 60 tablets per 30 days 45 mg: 30 tablets per 30 days Imbruvica PA 120 capsules per 30 days Inlyta PA 1 mg: 180 tablets per 30 days 5 mg: 120 tablets per 30 days Iressa PA 30 tablets per 30 days Jakafi PA 60 tablets per 30 days Mekinist PA 30 tablets per 30 days Nexavar PA 120 tablets per 30 days Pomalyst PA 21 capsules per 28 days Revlimid PA 30 tablets per 30 days Sprycel PA 30 tablets per 30 days Stivarga PA 84 tablets per 28 days Sutent PA 12.5 mg: 90 capsules per 30 days 25 mg, 37.5 mg, 50 mg: 30 capsules per 30 days Tafinlar PA 120 tablets per 30 days Tarceva PA 100 mg and 150 mg: 30 tablets per 30 days Tasigna PA 120 tablets per 30 days Thalomid PA 50 mg and 100 mg: 30 tablets per 30 days 150 mg and 200 mg: 60 tablets per 30 days Tykerb PA 180 tablets per 30 days Votrient PA 120 tablets per 30 days Xalkori PA 60 capsules per 30 days Xtandi PA 120 tablets per 30 days Zelboraf PA 240 tablets per 30 days Zolinza PA 120 tablets per 30 days Zydelig PA 60 tablets per 30 days Zykadia PA 150 capsules per 30 days Zytiga PA 120 tablets per 30 days Osteoarthritis of the Knee Injections Euflexxa PA Twice-yearly injection course per knee Synvisc PA Twice-yearly injection course per knee Pain Medications Combination drugs containing acetaminophen 4 grams daily Combination drugs containing aspirin 4 grams daily Abstral PA 120 tablets per month fentanyl citrate lozenge PA 120 units per month fentanyl transdermal patch 100 mcg: 30 patches per month 12 mcg, 25 mcg, 50 mcg, 75 mcg: 10 patches per month Fentora PA 120 tablets per month Gralise PA 300 mg: 30 tablets per 30 days 600 mg: 90 tablets per 30 days 1 starter pack per lifetime PA = Prior Authorization Required ST = Step Therapy Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 13 Medication Class Quantity Limits hydrocodone/ibuprofen 50 tablets per 10 days Horizant PA 60 tablets per 30 days Lazanda PA 120 doses per 30 days Lidoderm PA 3 patches per day morphine sulfate sustained release 90 tablets per month Narcotic analgesics 30-day supply Onsolis PA 120 units per month oxymorphone ER 60 tablets per month oxycodone/ibuprofen 28 tablets per month Qutenza PA 4 patches per 90 days tramadol 240 tablets per month tramadol/acetaminophen 40 tablets per month Psychiatric Medications Abilify PA 1 tablet per day 2 orally disintegrating tablets per day Solution: 750 mL per 30 days buprenorphine PA 2 mg: 60 tablets per 30 days 8 mg: 60 tablets per 30 days buprenorphine/naloxone tablets PA 60 tablets per 30 days citalopram 10 mg and 20 mg: 45 tablets per 30 days 40 mg: 30 tablets per 30 days escitalopram 10 mg: 1.5 tablets per day 5 mg, 20 mg: 1 tablet per day Solution: 20 mL per day Evzio PA 1 pack per 6 months Fanapt PA 2 tablets per day Titration pack: 1 pack per year clozapine ODT ST 12.5 mg: 1 tablet per day 25 mg: 3 tablets per day 100 mg: 9 tablets per day 150 mg: 6 tablets per day 200 mg: 4 tablets per day Invega Sustenna PA 1 syringe/kit per 28 days olanzapine 15 mg, 20 mg: 2 tablets per day 2.5 mg, 5 mg, 7.5 mg, 10 mg: 1 tablet per day olanzapine-fluoxetine ST 1 capsule per day paroxetine CR 1 tablet per day quetiapine PA 3 tablets per day Risperdal Consta PA 2 kits per 28 days risperidone 60 tablets per 30 days Oral solution: 240 mL per 30 days Suboxone film PA 2/0.5 mg: 60 film strips per 30 days 8/2 mg: 60 film strips per 30 days 4 mg/1 mg: 60 film strips per 30 days 12 mg/3 mg: 30 film strips per 30 days venlafaxine XR 150 mg: 2 capsules per day 37.5 mg: 1 capsule per day 75 mg: 3 capsules per day PA = Prior Authorization Required ST = Step Therapy Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 14 Medication Class Quantity Limits ziprasidone 2 capsules per day Zubsolv PA 1.4 mg/0.36 mg: 60 tablets per 30 days 5.7 mg/1.4 mg: 60 tablets per 30 days Seizure Medications Aptiom PA 200 mg, 400 mg, 800 mg: 30 tablets per 30 days 600 mg: 60 tablets per 30 days Fycompa PA 30 tablets per 30 days Levetiracetam ER 500 mg: 180 tablets per 30 days 750 mg: 120 tablets per 30 days Lyrica PA 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg: 90 capsules per month 225 mg, 300 mg: 60 capsules per month Onfi PA 60 tablets per 30 days 480 mL per 30 days Potiga PA 50 mg: 270 tablets per 30 days 200 mg, 300 mg: 90 tablets per 30 days 400 mg: 60 tablets per 30 days topiramate 180 capsules per 30 days Stop Smoking Aids buproban 12 weeks nicotine gum 12 weeks nicotine lozenges 12 weeks nicotine patches 12 weeks Nicotrol inhaler 24 weeks Nicotrol nasal spray 12 weeks Smoking cessation products will be limited to 2 quit attempts per 365 day period PA = Prior Authorization Required ST = Step Therapy Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. Pharmacies for Prescriptions Complaints, Grievances, and Fair Hearings UPMC for You has many participating pharmacies that can fill your prescription. You have pharmacy benefits coverage if the Department of Human Services has determined that you are eligible for this coverage. You can call UPMC for You Member Services to find a participating pharmacy close to you. You can also go online at www.upmchealthplan.com to look up the addresses of the participating pharmacies closest to you. You have the right to appeal any denial made by UPMC for You and the right to file a complaint about the administration of the drug formulary, by using the complaints and grievances process described in the UPMC for You member handbook. To request this handbook, or for information on the complaint and grievance Process, call Member Services. You can also go online to www.upmchealthplan.com to see a copy of this handbook. Pharmacy Benefit Questions If you have a question about your pharmacy benefit, please call UPMC for You Member Services. 15 UPMC for You Prescription Drug Formulary DRUG NAME 8-MOP CODE DRUG NAME ALOMIDE PA CODE abacavir alprazolam QL (fills/month) abacavir/lamivudine/ zidovudine alprazolam ODT ST, QL (fills/month) ABILIFY altavera PA (2 mg, 5 mg), ST (<12 years of age), QL amantadine ABILIFY MAINTENA PA, QL amethia ABSTRAL PA, QL, QL (fills/ month) amethia lo amcinonide amethyst acarbose amiloride acebutolol acetazolamide amiloride/ hydrochlorothiazide acetic acid/aluminum acetate amino acids 15% solution acetylcysteine amiodarone acitretin ST amitriptyline ACTEMRA PA, QL amlodipine ACTHAR GEL PA, QL amlodipine/benazepril ACTIMMUNE PA amnesteem acyclovir amoxicillin ADAGEN PA amoxicillin/clavulanate ADCIRCA PA, QL amphetamine salts ADDERALL XR PA (<4 or >18 years of age), QL ampicillin adefovir PA AMPYRA ADEMPAS PA, QL anagrelide ADVAIR AFINITOR PA, QL PA ANDROGEL PA APOKYN PA, QL apri alendronate ALFERON N PA, QL anastrozole albuterol ALDURAZYME PA (<4 or >18 years of age), QL APRISO PA APTIOM alfuzosin APTIVUS ALIMTA ARALAST NP ALKERAN aranelle allopurinol ARANESP KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 16 PA, QL PA PA UPMC for You Prescription Drug Formulary (continued) DRUG NAME ARCALYST CODE DRUG NAME betamethasone PA, QL CODE ASACOL betaxolol ASACOL HD BETHKIS ASMANEX BETOPTIC S aspirin bicalutamide atenolol bisoprolol atenolol/chlorthalidone atorvastatin bisoprolol/ hydrochlorothiazide ATRAPRO HYDROGEL BIVIGAM PA ATRIPLA BOSULIF PA, QL atropine sulfate BOTOX PA, QL AUBAGIO BREO ELLIPTA PA, QL AUVI-Q bromocriptine AVANDAMET brompheniramine/ pseudoephedrine AVANDARYL AVANDIA budeprion XL ST budesonide EC aviane budesonide RESPULES AVODART AVONEX bumetanide QL azathioprine azelastine azithromycin QL bacitracin baclofen buprenorphine PA, QL buprenorphine/naloxone tablets PA, QL buproban QL bupropion XL benazepril/ hydrochlorothiazide PA benzocaine/antipyrine butalbital/acetaminophen QL butalbital/acetaminophen/ caffeine QL butalbital/aspirin/caffeine QL calcipotriene benzonatate calcitriol benzoyl peroxide (Gel, cleanser, and lotion ONLY) calcium acetate camila benztropine BERINERT PA bupropion SR PA benazepril BENLYSTA BUPHENYL bupropion balsalazide BANZEL QL camrese PA KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 17 UPMC for You Prescription Drug Formulary (continued) DRUG NAME CANASA CODE DRUG NAME cimetidine CODE capecitabine PA CIMZIA PA, QL CAPRELSA PA, QL CINRYZE PA, QL captopril ciprofloxacin captopril/hydrochlorothiazide ciprofloxacin ER QL citalopram QL CARBAGLU PA carbamazepine claravis carbamazepine ER clarithromycin carbamide peroxide clindamycin carbidopa/levodopa clobetasol carbidopa/levodopa/ entacapone clomipramine carisoprodol QL clonazepam QL (fills/month) clonazepam ODT ST, QL (fills/month) carteolol clonidine carvedilol clopidogrel CAYSTON QL clotrimazole cefaclor clotrimazole/betamethasone cefadroxil clozapine ST (<12 years of age) cefdinir clozapine ODT ST, ST (<12 years of age), QL codeine QL (fills/month) codeine/acetaminophen QL, QL (fills/month) cefpodoxime CELEBREX ST, QL cephalexin CEREZYME COLCRYS PA cetirizine OTC colestipol cevimeline COMBIVENT chateal COMBIVENT RESPIMAT chlorhexidine COMBIVIR chloroquine COMETRIQ chlorpheniramine/ pseudoephedrine COMPLERA chlorpromazine COPAXONE ST (<12 years of age) PA, QL QL cortisone acetate chlorthalidone CREON cholestyramine CRIXIVAN choline magnesium trisalicylate cromolyn cilostazol cyanocobalamin CUPRIMINE KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 18 PA UPMC for You Prescription Drug Formulary (continued) DRUG NAME cyclobenzaprine CODE DRUG NAME diflorasone cyclopentolate digoxin cyclophosphamide dihydroergotamine cyclosporine diltiazem CYKLOKAPRON diphenhydramine CYSTADANE PA diphenoxylate/atropine CYSTAGON PA dipyridamole CYSTARAN PA, QL disopyramide DALIRESP PA disulfiram danazol PA DIURIL dantrolene divalproex DAPSONE divalproex DR dasetta divalproex ER daysee donepezil DELZICOL dorzolamide DEMSER PA PA dorzolamide/timolol DENAVIR DEPEN CODE doxazosin PA doxycycline desipramine DULERA desmopressin dyphylline-gg desonide DYSPORT desoximetasone econazole dexamethasone EDURANT PA, QL dexmethylphenidate PA (<4 or >18 years of age), QL EFFIENT QL EGRIFTA PA, QL dextroamphetamine PA (<4 or >18 years of age), QL ELAPRASE PA dextroamphetamine SA PA (<4 or >18 years of age), QL ELELYSO PA ELIDEL PA diazepam QL (fills/month) ELIGARD PA, QL elinest diazepam rectal DIBENZYLINE ELIQUIS PA EMCYT diclofenac EMEND dicloxacillin emoquette dicyclomine DIFICID QL EMTRIVA ST, QL KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 19 QL UPMC for You Prescription Drug Formulary (continued) DRUG NAME enalapril CODE DRUG NAME famciclovir enalapril/hydrochlorothiazide CODE QL famotidine ENBREL PA, QL FANAPT PA, QL enoxaparin QL FARESTON PA enpresse felbamate enskyce fenofibrate entacapone fenoprofen entecavir PA fentanyl citrate lozenge PA, QL, QL (fills/ month) ENTYVIO PA epinastine fentanyl patch QL, QL (fills/month) epinephrine FENTORA PA, QL, QL (fills/ month) PA eplerenone EPOGEN PA epoprostenol PA FERRIPROX fexofenadine OTC finasteride EPZICOM ergocalciferol ergotamine ERIVEDGE PA, QL FLOLAN PA QL fludrocortisone flunisolide QL fluocinolone estradiol/norethindrone fluocinonide estropipate fluorometholone ethosuximide fluorouracil etodolac fluoxetine etoposide PA, QL EURAX EVZIO PA, QL flucytosine estradiol EUFLEXXA FIRMAGON fluconazole QL estarylla estradiol transdermal PA, QL FLOVENT erythromycin escitalopram FIRAZYR EYLEA PA FABRAZYME PA flurazepam QL (fills/month) fluticasone exemestane PA ST (<12 years of age) flutamide PA,QL EXJADE fluphenazine fluvoxamine folic acid fondaparinux falmina KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 20 QL UPMC for You Prescription Drug Formulary (continued) DRUG NAME FORTEO CODE DRUG NAME GRASTEK PA, QL fosinopril guaifenisin/codeine QL (fills/month) fosinopril/ hydrochlorothiazide guaifensin/dextromethorphan PA, QL CODE guanabenz FRAGMIN QL guanfacine FULYZAQ PA, QL haloperidol ST (<12 years of age) furosemide HARVONI PA,QL FUZEON heather FYCOMPA PA, QL HETLIOZ PA, QL gabapentin HORIZANT PA, QL GABITRIL HUMALOG QL GABLOFEN HUMIRA PA, QL galantamine PA HUMULIN QL galantamine er PA HYCAMTIN PA GALZIN PA hydralazine GAMMAGARD PA hydrochlorothiazide GAMMAKED PA hydrocodone/acetaminophen QL, QL (fills/month) GAMUNEX PA hydrocodone/homatropine QL (fills/month) GATTEX PA,QL hydrocodone/ibuprofen QL, QL (fills/month) gemfibrozil hydrocortisone gentamicin hydroxychloroquine gianvi hydroxyurea gidagia hydroxyzine gildess hylira gildess fe HYPER-SAL GILENYA PA, QL ibandronate GILOTRIF PA, QL ibuprofen GLASSIA PA ICLUSIG PA, QL GLEEVEC PA, QL ILARIS PA, QL glipizide ER IMBRUVICA PA, QL GLUCAGON imipenem-cilastatin glyburide imipramine glycopyrrolate INCRELEX GRALISE ER PA indapamide granisetron ST, QL indomethacin GRANIX PA INFERGEN KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 21 PA PA, QL UPMC for You Prescription Drug Formulary (continued) DRUG NAME INLYTA CODE DRUG NAME PA, QL kariva INTELENCE INTRON-A ketoconazole PA ketoprofen introvale INVEGA SUSTENNA CODE ketorolac PA, QL QL ketorolac tromethamine INVIRASE ketotifen ipratropium KINERET PA, QL PA, QL irbesartan ST KORLYM irbesartan/HCTZ ST K-PHOS IRESSA PA, QL KRYSTEXXA PA, QL ISENTRESS KUVAN PA ISENTRESS KYNAMRO PA, QL isoniazid labetalol ISOPTO HYOSCINE lactulose isosorbide dinitrate lamivudine isosorbide mononitrate lamivudine isradipine lamivudine-zidovudine PA itraconazole PA, QL lamotrigine IVIG (intravenous immune globulin) PA lansoprazole QL JAKAFI PA, QL LANTUS QL latanoprost JANUMET LAZANDA JANUMET XR JANUVIA leena ST leflunomide jencycla lessina JENTADUETO JETREA LETAIRIS PA, QL PA, QL letrozole JEVANTIQUE LEUKERAN jolessa levalbuterol jolivette ST levetiracetam junel levetiracetam ER junel FE JUXTAPID PA, QL KALBITOR PA levobunolol levocetirizine levofloxacin KALETRA KALYDECO PA, QL levonest PA, QL levora KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 22 QL UPMC for You Prescription Drug Formulary (continued) DRUG NAME levothyroxine CODE DRUG NAME marlissa LEXIVA MATULANE lidocaine meclizine lidocaine patch PA, QL medroxyprogesterone lidocaine/prilocaine medroxyprogesterone injection LIFESCAN BLOOD GLUCOSE QL on test strips and PRODUCTS (One Touch) lancets megestrol acetate lisinopril MEKINIST lisinopril/hydrochlorothiazide meloxicam lithium carbonate meperidine lomustine MEPHYTON LOMUSTINE MEPRON loperamide mercaptopurine loratadine OTC mesalamine loratadine/pseudoephedrine OTC metformin QL (fills/month) methadone methazolamide losartan methenamine losartan-hydrochlorothiazide methimazole PA methocarbamol lovastatin methotrexate low-ogestrel methoxsalen loxapine ST (<12 years of age) methyldopa LUCENTIS PA methylergonovine LUMIZYME PA methylphenidate LUPANETA PACK PA, QL LUPRON PA, QL LUPRON DEPOT PA, QL LUPRON DEPOT-PED PA, QL LYRICA PA, QL methylphenidate ER methylphenidate SR methylprednisolone LYSODREN metoclopramide lyza MAKENA PA, QL metformin ER QL (fills/month) loryna LOTRONEX QL mefloquine liothyronine lorazepam CODE metolazone PA metoprolol malathion KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 23 PA PA (<4 or >18 years of age), QL PA (<4 or >18 years of age), QL PA (<4 or >18 years of age), QL UPMC for You Prescription Drug Formulary (continued) DRUG NAME metronidazole CODE DRUG NAME neomycin/polymixin b/ bacitracin mexiletine CODE neomycin/polymixin B/ hydrocortisone miconazole midodrine minocycline NEULASTA PA minoxidil NEUPOGEN PA mirtazapine nevirapine misoprostol nevirapine ER modafinil NEXAVAR PA, QL PA, QL mometasone niacin mononessa nicotine gum, lozenges, patches QL NICOTROL inhaler QL QL montelukast QL morphine sulfate QL (fills/month) morphine sulfate sustained release QL, QL (fills/month) NICOTROL nasal spray MOZOBIL PA, QL nimodipine nifedipine MULTAQ nisoldipine multivitamin/fluoride/iron nitrofurantoin macrocrystals mupirocin nitroglycerin MYALEPT nizatidine PA,QL NIZORAL A-D mycophenolate MYOBLOC PA, QL nora-BE MYOZYME PA NORDITROPIN norethindrone nadolol NAGLAZYME NORTHERA PA PA, QL nortriptyline naltrexone NAMENDA PA NORVIR PA NOXAFIL PA, QL NPLATE PA NASACORT OTC NUEDEXTA PA, QL nateglinide NULOJIX PA NEBUSAL NUVARING QL necon NUVIGIL PA, QL nefazodone nystatin neomycin sulfate nystatin/triamcinolone naproxen naratriptan QL KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 24 UPMC for You Prescription Drug Formulary (continued) ocella DRUG NAME paroxetine CR ofloxacin peg 3350/electrolytes DRUG NAME CODE OFORTA PA olanzapine ST (< 12 years of age), QL peg 3350/sodium bicarbonate/sodium chloride/potassium chloride olanzapine-fluoxetine ST, QL PEG-INTRON OLSYIO PA, QL omeprazole OTC QL OMONTYS PA ondansetron QL ONFI PA, QL ONMEL PA, QL phenobarbital ONSOLIS PA, QL, QL (fills/ month) phenylephrine phenytoin OPSUMIT PA, QL philith ORAP ST (<12 years of age) pilocarpine ORENCIA PA, QL pindolol ORENITRAM PA pioglitazone ORFADIN PA pioglitazone/glimepiride OTEZLA PA,QL pioglitazone/metformin OTREXUP PA,QL piroxicam oxazepam QL (fills/month) podofilox OXSORALEN PA polymixin B/bacitracin CODE QL PA, QL penicillin VK pentoxifylline permethrin perphenazine ST (<12 years of age) phenazopyridine oxybutynin POMALYST oxybutynin ER portia PA, QL potassium bicarbonate/ citrate oxycodone QL (fills/month) oxycodone/acetaminophen QL, QL (fills/month) oxycodone/aspirin QL, QL (fills/month) oxycodone/ibuprofen QL, QL (fills/month) potassium citrate POTIGA PA, QL oxymorphone QL (fills/month) PRADAXA QL oxymorphone ER QL, QL (fills/month) PANRETIN PA pantoprazole QL potassium chloride oxymetazoline pramipexole pramox pravastatin prazosin paromomycin prednisolone paroxetine KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 25 UPMC for You Prescription Drug Formulary (continued) DRUG NAME prednisone CODE DRUG NAME quinapril/hydrochlorothiazide PREMARIN quinidine PREMARIN CREAM QUTENZA PREMPHASE QVAR PREMPRO RAGWITEK PREZISTA raloxifene primaquine ramipril primidone RANEXA PROAIR HFA QL CODE PA, QL PA, QL ranitidine probenecid RAPAMUNE PA procainamide RASUVO PA, QL prochlorperazine RAVICTI PA, QL PROCRIT PA REBETOL QL PROCYSBI PA, QL RECLAST PA, QL REGRANEX QL progesterone PROLASTIN PA RELENZA QL PROLASTIN-C PA RELISTOR PA PROLIA PA, QL REMICADE PA PROMACTA PA, QL REMODULIN PA promethazine promethazine/codeine RENAGEL QL (fills/month) RENVELA propafenone repaglinide propranolol RESCRIPTOR propranolol/ hydrochlorothiazide REVLIMID REYATAZ propylthiouracil PROTOPIC PA PROVENGE PA, QL PULMOZYME PA, QL RIBASPHERE QL ribavirin QL RIDAURA rifampin pyrazinamide riluzole pyrethrins/piperonyl butoxide PA, QL rimantadine pyridostigmine quasense quetiapine PA, QL PA, ST (<12 years of age), QL RISPERDAL CONSTA PA, QL risperidone ST (<12 years of age), QL PA, QL RITUXAN quinapril KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 26 UPMC for You Prescription Drug Formulary (continued) DRUG NAME rivastigmine CODE PA rizatriptan QL DRUG NAME spironolactone/ hydrochlorothiazide rizatriptan ODT QL sprintec ropinirole SABRIL PA CODE SPRYCEL PA, QL SQIG PA stavudine salsalate SAMSCA PA, QL STELARA PA, QL SANDOSTATIN LAR DEPOT PA, QL STIVARGA PA, QL STRATTERA QL SANTYL SAVELLA STRIBILD PA, QL selegiline SUBOXONE FILM PA, QL selenium sulfide SUCRAID PA SELZENTRY sucralfate SEREVENT DISKUS sulfacetamide PA sulfacetamide-sulfur 10-5% lotion SIGNIFOR PA, QL sildenafil PA, QL sulfamethoxazole/ trimethoprim PA, QL sulfisoxazole SIRTURO PA sumatriptan QL SIVEXTRO QL SUPPRELIN LA PA, QL SEROSTIM sertraline sulfasalazine silver sulfadiazine SIMPONI sulindac simvastatin SUSTIVA sodium fluoride sodium polystyrene sulfonate SUTENT PA, QL sodium sulfacetamide sulfur 10-5% SYLATRON PA PA syeda SOLIRIS PA SYLVANT SOMATULINE DEPOT PA, QL SYMBICORT SOMAVERT PA, QL SYMLIN ST, QL SYNAGIS PA, QL SYNAREL PA, QL SPIRIVA SYNVISC PA, QL spironolactone SYPRINE PA sotalol SOVALDI PA,QL tacrolimus TAFINLAR KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 27 PA, QL UPMC for You Prescription Drug Formulary (continued) DRUG NAME TAMIFLU CODE DRUG NAME torsemide QL CODE tamoxifen TRACLEER PA, QL tamsulosin TRADJENTA ST TARCEVA PA, QL tramadol QL TARGRETIN PA tramadol/acetaminophen QL TASIGNA PA, QL trandolapril TECFIDERA PA, QL tranexamic acid temazepam QL (fills/month) trazodone temozolomide PA TRELSTAR PA, QL tretinoin PA (age 35 and older) terazosin terbinafine QL PA, QL trezix terbutaline triamcinolone terconazole PA triamterene/ hydrochlorothiazide triazolam QL (fills/month) PA, QL trifluoperazine ST (<12 years of age) testosterone injection tetracycline THALOMID trifluridine theophylline trihexyphenidyl thioguanine thioridazine ST (<12 years of age) thiothixene ST (<12 years of age) trimethoprim trimipramine maleate trinessa thyroid tri-previfem THYROLAR tri-sprintec tiagabine TRIUMEQ ticlopidine trivora timolol trospium tinidazole trospium ER TIVICAY TRUVADA tizanidine TOBI QL TOBI podhaler QL trypsin/balsalm/castor oil TUDORZA TYBOST tobramycin tolnaftate tolterodine tolterodine ER topiramate QL TYKERB PA, QL TYSABRI PA, QL TYVASO PA TYZEKA PA UROXATRAL KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 28 UPMC for You Prescription Drug Formulary (continued) DRUG NAME ursodiol CODE DRUG NAME XALKORI PA, QL XARELTO QL VALCYTE XELJANZ PA, QL valproic acid XENAZINE PA, QL valacyclovir QL CODE valsartan ST XEOMIN PA, QL valsartan/ hydrochlorothiazide ST XGEVA PA, QL XIFAXAN PA, QL XOFIGO PA, QL vancomycin VANTAS PA, QL XOLAIR PA, QL VELETRI PA XTANDI PA, QL velivet XYREM PA, QL venlafaxine zaleplon venlafaxine ER capsule QL zarah VENTAVIS PA ZAVESCA PA VENTOLIN HFA QL ZELBORAF PA, QL verapamil ZEMAIRA PA vestura ZETIA VIADUR PA zidovudine VICTOZA QL ziprasidone ST (<12 years of age), QL PA,QL ZOLADEX PA, QL VIRACEPT zoledronic acid PA, QL VIREAD ZOLINZA PA, QL vitamin A,D,C/fluoride/iron zolpidem vitamin B complex,C/folic acid VIVITROL zonisamide PA voriconazole QL VOTRIENT PA, QL VPRIV PA VYVANSE PA (<4 or >18 years of age), QL VIDEX VIMIZIM ZONTIVITY PA ZORBTIVE PA ZORTRESS PA zovia warfarin wera ZUBSOLV PA, QL ZYDELIG PA, QL ZYKADIA PA,QL ZYTIGA PA, QL ZYVOX QL KEY PA = Prior Authorization Required QL = Quantity Limits ST = Step Therapy Required Uppercase = brand name Lowercase = generic 29 UPMC for You Over-the-Counter Formulary The following is a list of some of the most commonly used over-the-counter (OTC) medications that are available in various dosage forms (e.g., tablets, liquids, ointments, creams, lotions) and strengths (e.g., adult, pediatric). Generic OTC medications are covered by UPMC for You with a prescription from your doctor. If a generic is not available, an OTC brand-name drug will be covered by UPMC for You. The brand names listed are for reference only. Category Generic benzoyl peroxide Panoxyl Analgesics acetaminophen and combinations aspirin and combinations ibuprofen and combinations naproxen Tylenol, Feverall, Q-Pap, Little Fevers Bayer, Ecotrin Advil, Motrin Aleve Anesthetics benzocaine dibucaine Orajel, Anbesol Nupercainal Antacids aluminum hydroxide aluminum/magnesium calcium carbonate calcium carbonate/magnesium hydroxide cimetidine famotidine ranitidine nizatidine omeprazole OTC lansoprazole Alternagel, Alu-cap, Alu-tab Mylanta, Maalox Advanced, Gaviscon Tums, Maalox Mylanta Supreme, Rolaids Tagamet Pepcid Zantac Axid Prilosec OTC Prevacid 24 hour Antibacterials bacitracin triple antibiotic providone-iodine Neosporin Betadine Antidiarrheals bismuth subsalicylate loperamide Kaopectate, Pepto-Bismol Imodium A-D Antiflatulents simethicone Gas-X, Phazyme, Mylicon Antihistamines chlorpheniramine diphenhydramine loratadine cetirizine fexofenadine ketotifen Chlor-trimeton, Aller-chlor Benadryl Claritin, Alavert Zyrtec Allegra Zaditor Acne Brand Name Example 30 UPMC for You Over-the-Counter Formulary Category Generic (continued) Brand Name Example Anti-inflammatory hydrocortisone Cortaid, Cortizone-10 Antinauseants bismuth subsalicylate dimenhydrinate meclizine sugar/orthophosphoric acid Kaopectate, Pepto-Bismol Dramamine, Driminate Dramamine Less Drowsy, Bonine Emetrol Cholesterol Agents niacin Slo-Niacin Cough/Cold Preparations guaifenesin Mucinex guaifenesin/dextromethorphan Robitussin DM, Mucinex-D Decongestants pseudoephedrine phenylephrine Sudafed Sudafed-PE Decongestant/ Antihistamine Combinations loratadine/pseudoephedrine Claritin-D, Alavert-D cetirizine/pseuodephedrine Zyrtec-D Dermatologic Baths colloidal oatmeal Aveeno Diabetes blood glucose monitors Lifescan monitors: One Touch Ultra Mini Meter, One Touch Ultra2 Meter, OneTouch Verio Sync Meter Lifescan test strips: One Touch Test Strips, One Touch Ultra Test Strips, One Touch Verio Test Strips One Touch Ultrasoft Lancets, One Touch Delica Lancets test strips lancets Fungicides glucose tablets insulin insulin syringes alcohol swabs Humulin R, Humulin N, Humulin 70/30 BD Syringes BD Alcohol Swabs clotrimazole miconazole tolnaftate terbinafine salicylic acid Lotrimin AF Micatin, Zeasorb-AF Tinactin, Ting Lamisil-AT Duofilm, Compound W 31 UPMC for You Over-the-Counter Formulary Category Laxatives/Stool Softeners Generic (continued) Brand Name Example magnesium hydroxide Milk of Magnesia bisacodyl docusate and combinations laxative enemas psyllium polyethylene glycol senna Dulcolax Colace, DocuSoft, Peri-colace Fleets Metamucil, Fiberall Miralax, Dulcolax Balance Senokot, Ex-lax Nasal Preparations oxymetazoline saline phenylephrine triamcinolone Afrin, Neo-Synephrine 12 hour Ocean Nasal Spray, Ayr, Simply Saline Neo-Synephrine, Vick's Sinex Nasacort Obstetrics/ Gynecology clotrimazole Gyne-Lotrimin-3, Gyne Lotrimin-7 miconazole tioconazole condoms, male condoms, female contraceptive devices Monistat Vagistat-1 Trojan, Durex FC Today Sponge, Cervical Caps cellulose derivatives Refresh, GenTeal, Systane polyvinyl alcohol sodium chloride Hypotears Muro-128 Rectal Preparations hydrocortisone zinc oxide Preparation H, Anusol Desitin, Balmex Scabicides/ Pediculicides permethrin Nix, Rid Spray piperonyl butoxide Pronto, Rid Shampoo nicotine gum Nicorette nicotine lozenge nicotine patch Commit Nicoderm CQ Opthalmic Preparations Smoking Cessation Aids 32 UPMC for You Over-the-Counter Formulary Category Vitamins/Minerals Wet Dressing Generic (continued) Brand Name Example vitamins (e.g., B-complex, cyanocobalamin, thiamine) calcium and combinations folic acid iron supplements multivitamins prenatal vitamins electrolyte solution Oscal, Oscal-D, Caltrate, Citracal Fer-in-sol, Feosol, Slow FE Centrum, One-A-Day, Poly-Vi-Sol Prenavite, Stuartnatal Pedialyte aluminum/calcium acetate Domeboro Brand/Generic Reference Guide Below is a list of the most commonly prescribed medications for members. This list can be used to determine the generic name for common brands. Brand Accolate Accupril Accuretic Accutane Actiq Actonel Actos Adderall/Adderall XR Aldactone Allegra Altace Amaryl Ambien Amerge Amoxil Antara Antivert Arava Aricept Arixtra Generic zafirlukast quinapril quinapril/HCTZ claravis, amnesteem fentanyl citrate risedronate pioglitazone amphetamine salt combo spironolactone fexofenadine ramipril glimepiride zolpidem tartrate naratriptan amoxicillin fenofibrate meclizine leflunomide donepezil fondaparinux Brand Generic Aromasin Astelin Atacand Atarax Ativan Augmentin Aurax Bactrim exemestane azelastine candesartan hydroxyzine lorazepam amoxicillin/clavulanate antipyrine-benzocaine otic sulfamethoxazole/ trimethoprim mupirocin diphenhydramine dicyclomine sotalol clarithromycin ibandronate soduim phenylbutyrate verapamil acamprosate calcium captopril sucralfate Bactroban Benadryl Bentyl Betapace Biaxin Boniva Buphenyl Calan Campral Capoten Carafate 33 Brand/Generic Reference Guide (continued) Brand Generic Brand Generic Cardizem Cardura Casodex Catapres Ceftin Celexa Cellcept Cipro Claritin OTC Claritin-D Cleocin Clinoril Clozaril Colestid Compazine Concerta Cordarone Coreg Cosopt Coumadin Cozaar Cymbalta Deltasone Depakote DR/ Depakote ER Desyrel Detrol Detrol LA Dexedrine Diabeta Diflucan Diovan Diovan HCT Diprolene Ditropan Ditropan XL Duetact Duragesic Duricef Effexor Effexor XR diltiazem doxazosin bicalutamide clonidine cefuroxime citalopram mycophenolate mofetil ciprofloxacin loratadine loratadine/pseudoephedrine clindamycin sulindac clozapine colestipol prochlorperazine methylphenidate ER amiodarone carvedilol dorzolamide/timolol warfarin losartan duloxetine prednisone divalproex sodium Elavil Elocon Epivir Epivir HBV Ery-tab Eskalith Evista Felbatol Feldene Femara Flagyl Flexeril Flomax Flonase Focalin Focalin XR Fortamet Fosamax Fosamax Solution Geodon Glucophage Glucotrol Halcion Haldol Hytone Hytrin Hyzaar Imdur Imitrex Imuran Inderal Indocin Kadian ER Keflex Kenalog Keppra Klonopin Lamictal Lamictal XR Lamisil Lanoxin amitriptyline mometasone furoate lamivudine lamivudine HBV erythromycin lithium carbonate raloxifene felbamate piroxicam letrozole metronidazole cyclobenzaprine tamsulosin fluticasone propionate dexmethylphenidate dexmethylphenidate ER metformin alendronate alendronate solution ziprasidone metformin glipizide triazolam haloperidol hydrocortisone terazosin losartan/HCTZ isosorbide mononitrate sumatriptan azathioprine propranolol indomethacin morphine sulfate ER cephalexin triamcinolone acetonide levetiracetam clonazepam lamotrigine lamotrigine estended release terbinafine digoxin trazodone tolterodine tolterodine ER dextroamphetamine sulfate glyburide fluconazole valsartan valsartan/HCTZ betamethasone dipropionate oxybutynin oxybutynin ER glimepiride/pioglitazone fentanyl patch cefadroxil venlafaxine venlafaxine ER 34 Brand/Generic Reference Guide (continued) Brand Generic Brand Generic Lasix Levaquin Levsin Lexapro Lidoderm Lipitor Lodine Lofibra Lomotil Lopid Loseasonique Lotensin Lotensin HCT Lotrel Lovenox Luvox Luxiq Lysteda Macrodantin Maxalt Maxalt MLT Metadate CD Metrogel Mevacor Minipress Minocin Mirapex Mobic Motrin MS Contin Naprosyn Neurontin Nicoderm Nicorette Nizoral Nolvadex Norvasc Omnicef Opana Opana ER furosemide levofloxacin hyoscyamine escitalopram lidocaine patch atorvastatin etodolac fenofibrate diphenoxylate/atropine gemfibrozil amethia lo, camrese lo benazepril benazepril/HCTZ amlodipine/benazepril enoxaparin fluvoxamine betamethasone valerate tranexamic acid nitrofurantoin macrocrystals rizatriptan rizatriptan ODT methylphenidate ER metronidazole topical lovastatin prazosin minocycline pramipexole meloxicam ibuprofen morphine sulfate ER naproxen gabapentin nicotine patch nicotine gum ketoconazole tamoxifen amlodipine besylate cefdinir oxymorphone oxymorphone ER Ortho Tri-Cyclen Ortho-Cept Ortho-Cyclen Oxy IR Pamelor Paxil Pepcid Percocet Peridex Plaquenil Plavix Prandin Pravachol Precose Prevacid Prilosec OTC Principen Prinivil Prinzide Procardia Prograf Prometrium Proscar Protonix Provigil Prozac Pulmicort Respules Questran/Questran Light Reclast Reglan Remeron Requip Restoril Retin-A Retin-A Micro Risperdal Ritalin Ritutek Seasonale tri-sprintec, trinessa apri, emoquette sprintec, mononessa oxycodone nortriptyline paroxetine famotidine oxycodone/acetaminophen chlorhexidine gluconate hydroxychloroquine clopidogrel repaglinide pravastatin acarbose lansoprazole omeprazole OTC ampicillin lisinopril lisinopril/HCTZ nifedipine tacrolimus progesterone finasteride pantoprazole modafinil fluoxetine budesonide respules cholestyramine 35 zoledronic acid metoclopramide mirtazapine ropinirole temazepam tretinoin tretinoin risperidone methylphenidate riluzole jolessa Brand/Generic Reference Guide (continued) Brand Generic Brand Generic Seroquel Sinemet Singulair Soma Sonata Sporanox Stalevo quetiapine carbidopa/levodopa montelukast carisoprodol zaleplon itraconazole carbidopa/levodopa/ entacapone mafenide acetate tetracycline trimipramine maleate olanzapine-fluoxetine levothyroxine cimetidine carbamazepine temozolomide guanfacine atenolol/chlorthalidone atenolol tobramycin topiramate methotrexate dorzolamide acetaminophen/codeine tramadol diazepam Valtrex Vancocin Vaseretic Vasotec Veetids Vfend Vibramycin Vicodin Viramune Voltaren Wellbutrin Xalatan Xanax Xeloda Zantac Zithromax Zocor Zofran Zoloft Zometa Zomig Zovirax Zyloprim Zyprexa valacyclovir vancomycin enalapril/HCTZ enalapril penicillin V potassium voriconazole doxycycline hydrocodone/acetaminophen nevirapine diclofenac bupropion latanoprost alprazolam capecitabine ranitidine azithromyicin simvastatin ondansetron sertraline zoledronic acid zolmitriptan acyclovir allopurinol olanzapine Sulfamylon Sumycin Surmontil Symbyax Synthroid Tagamet Tegretol Temodar Tenex Tenoretic Tenormin TOBI Topamax Trexall Trusopt Tylenol #3 Ultram Valium 36 This managed care plan may not cover all your health care expenses. If you have questions, please call a UPMC for You Member Services representative at 1-800-286-4242. TTY users should call toll-free 1-800-361-2629 CMN15-0101-96 U.S. Steel Tower, 600 Grant Street Pittsburgh, PA 15219 www.upmchealthplan.com/foryou Copyright 2015 UPMC Health Plan Inc. All rights reserved. MA ALL ZONES PHARM BK 15MA0029 (MCG) 10/19/15
