docYour Pharmacy Benefits - Clark
download 
Report Transcription
Your Pharmacy Benefits - Clark
Your Pharmacy Benefits Retail Pharmacy Network A well-balanced pharmacy network offers you convenient access and competitive discounts for brand and generic medications. Our national retail pharmacy network includes more than 64,000 chain and independent retail pharmacies, so you’re sure to find one close to home or work. Using Your ID Card When you fill a prescription through a participating pharmacy, show the pharmacy your ID card so they can submit a claim for coverage by your pharmacy benefit plan. When you pick up your prescription, the pharmacy then collects your applicable member contribution as defined by your plan. If you do not present your ID card or you fill a prescription at a non-participating pharmacy, you pay the full retail price for your medication. If the prescription is eligible for coverage under your pharmacy benefit plan, you may submit a claim to request reimbursement (forms are available at www.optumrx.com or by calling customer service). When you submit a claim using the reimbursement form, OptumRx first determines if your plan covers the medication. If it is covered, the amount you receive is based on contracted pharmacy rates less your plan’s out-of-pocket member contribution. All prescription claims are subject to your pharmacy benefit plan’s rules and restrictions. Retail Pharmacy Network Finding a Network Pharmacy You can choose from three easy ways to find participating pharmacies near you: 1. Review the partial list included on the following pages. 2. Go to our website and use the LOCATE A PHARMACY tool. 3. Contact customer service using the number on the back of your benefit plan member ID card. A Brown & Cole Stores Dominicks A & P Pharmacy Bruno’s Drug Castle ABCO Desert Markets Buehler Foods Drug Emporium C AccessHealth Member Pharmacies Drug Town Acme Pharmacy Cash Wise Pharmacy Drug World Pharmacy Ahold USA Care Pharmacies Duane Reade AHS — St. John Pharmacy Carrs Pharmacy Albertsons Centex Pharmacies Eagle Food Centers Pharmacy Allina Community Pharmacy Chronimed Eagle Pharmacy Allscripts City Center Drug Eckerd Drugs Ambulatory Pharmaceutical Svcs City Market (Kroger) Econo Foods American Drug Stores CJM Em Dee Drug Anchor Pharmacy Cleveland Clinic Foundation Enloe Drugs Appalachian Regional Health Clinic Pharmacy Administration Epic Pharmacy Network Assoc Wholesalers Groc Ntwk Clinic Pharmacy of Marshfield Erlanger Pharmacy Astrup Drug Coborn’s Pharmacy Eureka Drug Stores Aurora Pharmacy Community Distributors B E F Community Pharmacy Fagen Pharmacy B & R Stores Continuing Care Rx Family Pharmacare Center Bakers Pharmacy Controlex Enterprises Fairview Pharmacy Services Balls Four B Costco Family Fare Bartell Drugs Covenant Regional Services Family Pharmacy Bashas’ United Drug Cub Pharmacy Familycare Network Bel Air Pharmacy CVS/Pharmacy Familymeds D Bell Pharmacy Farm Fresh Pharmacies Big A Drug Stores D & W Food Centers Felpausch Pharmacy Big Bear/Harts Stores Dahl’s Foods Fleming Companies Biggs Pharmacy Dean Pharmacy Administration Food Circus Super Markets Bi-Lo Food City Pharmacy Bi-Mart Department of Veterans Affairs Pharmacies BJ’s Pharmacy Dierbergs Family Markets Fred’s Brooks Pharmacy Dillon’s Pharmacy (Kroger) Fruth Brookshire Brothers Discount Drug Mart Frys Food And Drug (Kroger) Brookshire Grocery Discount Emporium Furrs Supermarkets Doc’s Drugs Ltd Fred Meyer (Kroger) Kessel Pharmacy Mr Discount Drugs G & A Medical Personnel Keystone - Medicine Chest Mr Z’s Pharmacy Gabler’s Drug King Kullen Pharmacy Gavin Herbert King Soopers Pharmacy (Kroger) Nash Finch Gentiva Health Svcs (Quantum) Kings Pharmacy Navarro Discount Pharmacy Genuardi’s (Safeway) Kinney Drugs NCS Healthcare Gerimed Pharmacy Klingensmith’s Drug Stores Neighborcare Pharmacy Giant Eagle Pharmacy Knight Drugs New Oakland Pharmacy Giant Food Stores Kohll’s Pharmacy & Homecare Nob Hill Pharmacy Giant Of Maryland Kopp Drug Nortex Drug Distributors Glass Gardens Kreisler Drug Northwest Health Ventures Golub Kroger Pharmacy Nova Factor Good Neighbor Pharmacy Provider Network K-VA-T Food Stores G N O L Greco Enterprises Oakwood Healthcare Gristedes Leader Drug Stores OK Health Care Authority-Tpl Group Health Associates Lewis Drug Omnicare Inc. Lewis Family Drug Oncology Pharmacy Services H E B Pharmacy Longs Drug Store OptionCare Haggen Food & Pharmacy Louis & Clark Drugstores Osco Drug Hannaford Bros Lowe’s Marketplace Pharmacy H M Happy Harry’s Discount Drug P P & C Food Markets Harmons Pharmacy M.K. Stores Pamida Harps Food Stores Major Value Member Pharmacies Park Nicollet Pharmacy Harris Teeter Pharmacy MAL Enterprises Pathmark Stores Hartig Drug Marc Glassman Patient’s Pharmacy Health Mart Market Basket Pavilions Pharmacy Healthpartners Pharmacy Marsh Drugs Payless Drugs Heartland Pharmacy Maxor Pharmacy Perlmart/Shoprite Henry Ford Med Ctr Pharmacy Maxi Drug Inc. Pediatric Services Of America HIP Pharmacy Service of NY Mays Drug Stores Penn Traffic Hi-School Pharmacy Mcauley Pharmacy Peoples Pharmacy Homeland Stores McKesson Pharma-Card Hy-Vee Food Stores Med-Fast Pharmacy Pharmacare Medic Drug Pharmacy Associates IHC Health Services Medicap Pharmacy Pharmacy Express Services Ingles Markets Medicine Center Pharmacy Plus Medicine Shoppe Pharmacy Providers Of OK Mediserv Pharmapoint Pharmacy Network Med-Rx Drug Pharmerica Drug Systems Med-X Drug Pinnacle Pharmacy Meijer Pharmacy Planned Parenthood Greater NNJ Metro Group #64 Price Chopper Pharmacy Minyard Food Stores Price Cutter Pharmacy Morton Drug Primemed Pharmacy Services I J Jewel-OSCO Jordan Drug K K Mart Pharmacy Kelsey Seybold Pharmacy Kerr Drug Stores Priority Health Care Pharmacy Shaws Supermarkets Procare Pharmacy Shelby Shore Drugs Ukrops Super Markets Professional Pharmacy Services Shelly’s Pharmacy UMC Dept Of Pharmacy Services Providence Pharmacy Shop n Save Pharmacy Union Prescription Center Publix Super Markets Shopko Pharmacy United Pharmacy Shoppers Pharmacy United Supermarkets QFC (Kroger) Shoprite Pharmacy Unity Retail Pharmacy Quick Chek Pharmacy Dept Smiths Food & Drug Centers (Kroger) Univ Of Utah Health Network Smittys Pharmacy University Of Wisconsin Snyder Drug Emporium USA/Super D Drug Q R Rainbow Food Group U Snyder’s Drug Store Raley’s Pharmacy V St Louis Connectcare Ralphs (Kroger) Standard Drug Randalls Vg’s Pharmacy Statscript Pharmacy Reasor’s Ridley’s Food And Drug Rinderer’s Drug Stores Village Supermarkets Steele’s Pharmacy Stop & Shop Pharmacy Strategic Health Alliance/Caremax Rite Aid Value Center Vollmer Pharmacy Von’s Pharmacy W Sun Factors Ritzman Pharmacy W P Malone Sun Fresh Pharmacy Rogers Pharmacy Ronci Family Discount Drugs Inc Ronetco Rosauers Supermarkets Rxd Pharmacy Walgreens Super D Super One Pharmacy Wayne Drug Super Rx Pharmacy Supermarket Inv/ Harvest Foods T Safeway (Genuardi’s) Target Pharmacy Sam’s Club Pharmacy Thriftway Pharmacy Associates Save Mart Pharmacy Thrifty-White Drug Sav-Mor Drug Stores Tidyman’s Pharmacy Sav-On Drugs Tiffany-Davis Drug Schnucks Markets Tom Thumb Scolari’s Food & Drug Scots Lo-Cost Pharmacy Seaway Food Town Weber & Judd Wegmans Food Market Supervalu Pharmacy S Wal-Mart Pharmacy Weis Pharmacy Welcome Pharmacy Wender & Roberts Westbury Pharmacy Wilkinson Pharmacy Winn-Dixie Stores Woods Pharmacy Y Tom’s Mad Pricer Discount TOPS Markets Yoke’s Pharmacy Z TriNet Pharmacy (Truecare) Sedano’s Pharmacy Twin Knolls Pharmacy Sedell’s Pharmacy Zallie Supermarkets www.optumrx.com 2300 Main Street, Irvine, CA 92614 OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at www.optum.com. All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. ORX0779_120720 ©2012 OptumRx, Inc. Your 2016 Prescription Drug List Effective January 1, 2016 Please read: This document contains information about the drugs covered under your pharmacy benefit plan. For a complete list of covered drugs or if you have questions: Call the toll-free member phone number on the back of your ID card. Visit optumrx.com • Locate a participating retail pharmacy by zip code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options. OptumRx | optumrx.com 1 Your Prescription Drug List This Prescription Drug List (PDL) outlines the most commonly prescribed medications from your plan’s complete pharmacy benefit coverage list, also known as a formulary. A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the PDL is giving you choices so you and your doctor can choose the best course of treatment for you. Go to optumrx.com for complete and up-to-date drug information Since the PDL may change, we encourage you to visit our website, optumrx.com. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons. John Smith John Smith JOHN SMITH 2 Table of Contents Drug tiers and cost . . . . . . . . . . . . . . . . . . . . 5 Programs and limits . . . . . . . . . . . . . . . . . . . 6 Drugs by category . . . . . . . . . . . . . . . . . . . . . 9 Gastrointestinal Acid Suppression . . . . . . . . . . . . . . . . . . . . . . 16 Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . . 16 Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Anti-Infectives Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Men’s Health Erectile Dysfunction . . . . . . . . . . . . . . . . . . . . 17 Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Testosterone Therapy . . . . . . . . . . . . . . . . . . . 17 Cardiovascular/Heart Disease Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . 9 High Blood Pressure . . . . . . . . . . . . . . . . . . . . 10 High Cholesterol . . . . . . . . . . . . . . . . . . . . . . . 10 Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Pulmonary Arterial Hypertension . . . . . . . . . . . 11 Central Nervous System Attention Deficit Disorder . . . . . . . . . . . . . . . . Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . 11 11 11 12 12 12 12 Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Inflammatory Conditions . . . . . . . . . . . . . . 17 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . 17 Musculoskeletal Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Overactive Bladder . . . . . . . . . . . . . . . . . . . 19 Respiratory Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . 19 Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . 19 Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . 19 Dermatology . . . . . . . . . . . . . . . . . . . . . . . . 13 Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Diabetes/Endocrine Blood Glucose Monitoring . . . . . . . . . . . . . . . 13 Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Vitamins/Electrolytes . . . . . . . . . . . . . . . . . . 19 Endocrine Growth Hormone . . . . . . . . . . . . . . . . . . . . . . 15 Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Thyroid Hormone Replacement . . . . . . . . . . . . 15 Eye Conditions Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 15 16 16 Women’s Health Birth Control . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Hormone Replacement . . . . . . . . . . . . . . . . . . 20 Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . . 20 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 3 At OptumRx, we want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Prescription Drug List. What is a Prescription Drug List (PDL)? This document is a list of commonly prescribed medications preferred by your plan sponsor for their safety, cost and effectiveness. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA). Please note: Where differences are noted between this PDL and your benefit plan documents, the benefit plan documents will rule. It is not intended to be a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or plan sponsor to see what medications are covered under your plan. You may also log on to optumrx.com or call the toll-free member phone number on the back of your ID card for more information. How do I use my Prescription Drug List? When choosing a medication, you and your doctor should consult the PDL. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically. If your medication is not listed in this document, please visit optumrx.com or call the toll-free member phone number on the back of your ID card. 4 What are tiers? Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or plan sponsor. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor. Drug names shown in orange are preferred for their cost and effectiveness. If there is a symbol in the Drug Tier column, check your benefit plan documents to find out your specific pharmacy plan costs. $ Drug Tier Includes Helpful Tips Tier 1 Lowest Cost Lower-cost, commonly used generic drugs. Some low-cost brands may be included. Use Tier 1 drugs for the lowest out-ofpocket costs. $$ $$$ $$ Tier 2 Mid-range Cost Many common brandname drugs, called preferred brands. Use Tier 2 drugs, instead of Tier 3, to help reduce your out-of-pocket costs. $$$ $$$ Tier 3 Highest Cost Mostly higher-cost brand drugs, also known as nonpreferred brands. Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you. $ $ $$ $ Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels will apply once you hit your deductible. Refer to your enrollment and plan materials on optumrx.com, or call the toll-free member phone number of the back of your ID card for more information about your benefit plan. When does the Prescription Drug List change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when its generic becomes available. • Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year. When a medication changes tiers, you may have to pay a different amount for that medication. For the most up-to-date list, call customer service at the toll-free member phone number on the back of your ID card. 5 Programs and Limits Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you. PA rior Authorization – Your doctor is required to provide additional P information to determine coverage. ST tep Therapy – Trial of lower cost medication(s) is required before S a higher-cost medication is covered. QL uantity Limits – Amount of medication covered per copayment Q or in a specific time period. AR Age Restrictions – Some restrictions may apply based on patient age. SP Specialty Medication – Medication is designated as a specialty pharmacy drug. GR Gender Restrictions – Some restrictions may apply based on patient gender. To learn more about a pharmacy program or to find out if it applies to you, please visit optumrx.com or call the toll-free member phone number on the back of your ID card. 6 Why are some medications excluded from coverage? Medications may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available. What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling the toll-free member phone number on the back of your ID card. Should I talk to my doctor about OTC medications? An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than your out-of-pocket expense for prescription medications. What is the difference between brand-name and generic medications? Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes the same company that makes a brand-name medication also makes the generic version. Is it a generic or brand-name drug? The drug list shows brand-name drugs in bold type (for example, Lamictal) and generic drugs in plain type (for example, lamotrigine). What if my doctor writes a brand-name prescription? The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit optumrx.com to make sure. 7 Are you taking a specialty medication? Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the PDL. OptumRx is the specialty pharmacy that can provide most of your specialty medications along with helpful programs and services. Call OptumRx® Specialty Pharmacy at 1-888-702-8423 and have your prescriptions delivered right to your home or office. How do I get updated information about my pharmacy benefit? Since the PDL may change during your plan year, we encourage you to visit optumrx.com or call the toll-free member phone number on the back of your ID card for more current information. When you register at optumrx.com and open an account, you can use the website’s helpful tools and features to: • Look up the price of drugs covered by your plan • Find lower-cost options • Refill and renew mail service prescriptions • View your order status and claims history • Sign up for text reminders to take and refill your medicine • View your benefits in real time • Order medical supplies • Shop for health and wellness products More information If you have additional questions please call customer service, 24 hours a day, 7 days a week using the toll-free member phone number on the back of your ID card. Or visit optumrx.com. 8 Drug Name Drug Tier Programs and Limits SulfamethoxazoleTrimethoprim DS Anti-Infectives: Antibiotics Amoxicillin Amoxicillin/Clavulanate Azithromycin Bethkis Cefadroxil Cap Cefdinir Cefuroxime Tab Cephalexin Ciprodex Otic Suspension Ciprofloxacin Tab Clarithromycin Clindamycin Cap Dificid Doxycycline Hyclate Cap Doxycycline Hyclate Tab (Immediate Release) Doxycycline Monohydrate Cap Doxycycline Monohydrate Oral Suspension, Tab Erythromycin Levofloxacin Tab Metronidazole Tab Minocycline Cap Moxifloxacin Neomycin/Polymyxin/ HC Otic Suspension, Solution Nitrofurantoin Macrocrystalline Nitrofurantoin Monohydrate Macrocrystalline Ofloxacin Otic Solution Oracea Penicillin VK Solodyn SulfamethoxazoleTrimethoprim 1 1 1 2 1 1 1 1 Programs and Limits 1 Anti-Infectives: Antifungals SP Fluconazole Nystatin Oral Powder Nystatin Suspension Terbinafine Tab 1 1 1 1 Anti-Infectives: Antivirals 3 1 1 1 3 1 Drug Tier Drug Name PA 1 1 Acyclovir Cap, Tab, Suspension Baraclude Entecavir Famciclovir Tab Harvoni Pegasys Sovaldi Tamiflu Valacyclovir 1 3 1 1 2 2 3 1 QL, SP QL, SP PA, QL, SP PA, SP PA, QL, ST, SP QL QL Cancer 1 Anastrozole Tab Capecitabine Gleevec Letrozole Revlimid Tamoxifen Tab Tasigna Temozolomide Zytiga 1 1 1 1 1 1 1 1 Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing SP PA, QL, SP PA PA, QL, SP PA, QL, SP PA, SP PA, SP Cardiovascular/Heart Disease: Anticoagulants 1 1 3 1 3 1 1 2 1 2 1 2 1 2 QL QL Brilinta Clopidogrel Effient Eliquis Enoxaparin Pradaxa Savaysa Warfarin Xarelto PAPrior Authorization STStep Therapy QLQuantity Limits 2 1 2 3 1 2 3 1 2 QL QL QL QL QL QL QL QL ARAge Restrictions SP Specialty Program GRGender Restrictions 9 Drug Programs Tier and Limits Cardiovascular/Heart Disease: High Blood Pressure Drug Name Amlodipine Amlodipine/Benazepril Amlodipine/Valsartan Amlodipine/Valsartan/ HCTZ Atenolol Atenolol/Chlorthalidone Azor Benazepril Benazepril/HCTZ Benicar Benicar HCT Bisoprolol Bisoprolol/HCTZ Bumetanide Bystolic Cartia XT Carvedilol Chlorthalidone Clonidine Patch Clonidine Tab Coreg CR Diltiazem Tab Diovan Doxazosin Dutoprol Edarbi Edarbyclor Enalapril Enalapril/HCTZ Felodipine Fosinopril Furosemide Guanfacine Tab (Immediate Release) Hydralazine Hydrochlorothiazide Irbesartan Irbesartan/HCTZ Labetalol Lisinopril Lisinopril/HCTZ 1 1 1 QL QL QL 1 QL 1 1 2 1 1 2 2 1 1 1 2 1 1 1 1 1 3 1 3 1 2 3 3 1 1 1 1 1 QL, ST QL, ST QL, ST QL QL QL QL, ST QL, ST QL QL, ST QL, ST QL 1 1 1 1 1 1 1 1 Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing QL QL Drug Name Losartan Losartan/HCTZ Metoprolol Succinate Metoprolol Tartrate Nadolol Nifedipine ER Propranolol Propranolol ER Quinapril Ramipril Spironolactone Tekturna Tekturna HCT Telmisartan Terazosin Torsemide Tab Triamterene/HCTZ Tribenzor Valsartan Valsartan/HCTZ Verapamil ER Drug Tier Programs and Limits 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 2 1 1 1 QL QL QL QL, ST QL, ST QL QL, ST QL QL Cardiovascular/Heart Disease: High Cholesterol Atorvastatin Cholestyramine Crestor Fenofibrate 43 mg, 48 mg, 50 mg, 54 mg, 67 mg, 130 mg, 134 mg, 145 mg, 150 mg, 160 mg, 200 mg Fenofibrate 120 mg Gemfibrozil Lipitor Livalo Lovastatin Lovaza Niacin ER Tab Omega-3 Acid Cap 1 gm Pravastatin Simcor PAPrior Authorization STStep Therapy QLQuantity Limits 1 1 2 QL QL 1 QL 3 1 3 3 1 3 1 QL, ST QL QL, ST QL, ST 1 QL 1 2 QL QL QL ARAge Restrictions SP Specialty Program GRGender Restrictions 10 Drug Name Simvastatin 5 mg, 10 mg, 20 mg, 40 mg Simvastatin 80 mg Vascepa Vytorin 10-10 mg, 10-20 mg, 10-40 mg Vytorin 10-80 mg Welchol Zetia Drug Tier Programs and Limits 1 QL 1 2 PA, QL QL 2 QL 2 2 3 PA, QL QL QL Cardiovascular/Heart Disease: Other Amiodarone Amlodipine/Atorvastatin Digoxin Flecainide Isosorbide Mononitrate Nitrostat Ranexa Sotalol 1 1 1 1 1 2 2 1 QL ST Cardiovascular/Heart Disease: Pulmonary Arterial Hypertension Adcirca Adempas Letairis Opsumit Orenitram Sildenafil Tab 20 mg Tracleer 3 2 2 2 3 1 2 PA, QL, SP PA, QL, SP PA, QL, SP PA, QL, SP PA, SP PA, QL, SP PA, QL, SP Central Nervous System: Attention Deficit Disorder Adderall XR Cap AmphetamineDextroamphetamine Tab AmphetamineDextroamphetamine SR 24Hr Cap Dexmethylphenidate ER Cap Focalin XR Guanfacine ER Tab Intuniv 3 QL, ST 1 QL Drug Name Methylphenidate ER Cap Methylphenidate ER Tab Methylphenidate SA Osmotic ER Tab Methylphenidate Tab Strattera Vyvanse Drug Tier Programs and Limits 1 QL 1 QL 1 QL 1 2 2 QL QL QL Central Nervous System: Depression Amitriptyline Bupropion Bupropion ER Bupropion SR Bupropion XL Citalopram Doxepin Duloxetine Cap 20 mg, 30 mg, 60 mg Escitalopram Tab Fluoxetine Cap (not PMDD) Fluvoxamine Tab Forfivo XL Mirtazapine Nortriptyline Paroxetine Tab Pristiq Sertraline Trazodone Venlafaxine Tab Venlafaxine ER Cap Venlafaxine ER Tab Viibryd 1 1 1 1 1 1 1 QL QL 1 QL 1 QL 1 1 2 1 1 1 2 1 1 1 1 1 3 QL QL QL QL QL, ST Central Nervous System: Migraine 1 QL 1 QL 3 1 3 QL, ST QL QL Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing ButalbitalAcetaminophenCaffeine Cap, Tab 50-325-40 mg Migranal Relpax Rizatriptan Tab, ODT PAPrior Authorization STStep Therapy QLQuantity Limits 1 QL 3 3 1 QL QL QL ARAge Restrictions SP Specialty Program GRGender Restrictions 11 Drug Name Sumatriptan Tab and Spray Sumavel Dose Zolmitriptan Tab Zomig Nasal Spray Drug Tier Programs and Limits 1 QL 3 1 2 QL QL QL Central Nervous System: Multiple Sclerosis Ampyra Avonex Kit Avonex Pen Kit Avonex Prefill Kit Betaseron Copaxone Gilenya* Plegridy Rebif Rebif Titrtn Tecfidera 2 3 2 PA, QL, SP PA, QL, SP PA, QL, SP PA, QL, SP PA, QL, ST, SP PA, QL, SP PA, QL, ST, SP PA, QL, SP PA, QL, ST, SP PA, QL, ST, SP PA, QL, SP Central Nervous System: Other Abilify Tab Alprazolam Tab Aripiprazole Benztropine Buspirone Carbidopa/Levodopa Tab (Immediate Release) Diazepam Tab Donepezil Tab Hydroxyzine HCL Hydroxyzine Pamoate Latuda Lithium Carbonate Lorazepam Tab Modafinil Namenda Tab Namenda XR Cap Nuvigil Olanzapine Tab 3 1 1 1 1 QL QL QL 1 1 1 1 1 3 1 1 1 3 2 3 1 QL QL, ST QL PA, QL QL QL PA, QL QL Drug Name Pramipexole Prochlorperazine Quetiapine Risperidone Tab Ropinirole (Immediate Release) Saphris Seroquel XR Zelapar Ziprasidone Cap Drug Tier Programs and Limits 1 1 1 1 QL QL 1 2 2 3 1 QL QL QL Central Nervous System: Sedatives/Hypnotics Eszopiclone Tab Silenor Temazepam Triazolam Tab Zolpidem Zolpidem ER 1 3 1 1 1 1 QL QL QL QL QL QL Central Nervous System: Seizure Disorders Carbamazepine Tab Clonazepam Divalproex DR Divalproex ER Gabapentin Lamictal Tab, Chew Lamictal ODT Lamictal XR Lamotrigine (Immediate Release) Lamotrigine ER Levetiracetam Levetiracetam ER Lyrica Cap Onfi Oxcarbazepine Phenytoin Primidone Topiramate Tab Zonisamide 1 1 1 1 1 2 3 3 QL QL 1 1 1 1 2 3 1 1 1 1 1 QL QL QL PA, SP * Tier 3 Preferred Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing PAPrior Authorization STStep Therapy QLQuantity Limits ARAge Restrictions SP Specialty Program GRGender Restrictions 12 Drug Name Drug Tier Programs and Limits Dermatology Acanya Gel Acyclovir Ointment 5% Aczone Gel Atralin Benzaclin Betamethasone Dipropionate Cream Ciclopirox Cream Clindamycin Gel, Lotion, Solution Clindamycin/ Benzoyl Peroxide Gel 1-5% Clindamycin/Benzoyl Peroxide Gel 1.2-5% Clobetasol Cream, Ointment, Solution Clobex Cloderm Clotrimazole/ Betamethasone Cream, Lotion Desonide Cream, Ointment Desoximetasone Cream, Gel, Ointment Differin Econazole Cream Elidel Epiduo Finacea Fluocinonide Cream, 0.1% Fluocinonide Cream, Gel, Ointment, Solution 0.05% Hydrocortisone Cream, Ointment 2.5% Lidocaine Topical Ointment, Solution 3 1 3 3 3 QL QL , AR QL 1 1 1 1 1 QL QL 1 3 3 1 1 1 3 1 2 3 2 1 1 1 QL, AR QL , ST, AR QL Drug Tier Drug Name Lidocaine/Prilocaine Cream Ketoconazole Cream/ Shampoo Metrogel Metronidazole Gel 0.75% Mometasone Mupirocin Ointment Nystatin Cream, Ointment, Powder Nystatin/Triamcinolone Cream, Ointment Oxsoralen-UL Permethrin Cream 5% Protopic Ointment Retin-A Micro Sulfacetamide/Sulfur Emulsion Taclonex Tretinoin Cream Tretinoin Microsphere Gel Triamcinolone Vectical Zovirax Cream Zovirax Ointment Zyclara Programs and Limits 1 1 3 1 1 1 1 1 2 1 3 3 PA QL, AR QL, AR 1 3 1 QL AR 1 QL, AR 1 3 2 3 3 QL Diabetes/Endocrine Blood: Glucose Monitoring Accu-Chek Active Glucose Control Liquid Accu-Chek Active Test Strips Accu-Chek Aviva Plus Control Liquid Accu-Chek Aviva Plus Kit Accu-Chek Aviva Plus Test Strips 2 2 QL 2 2 2 QL 1 Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing PAPrior Authorization STStep Therapy QLQuantity Limits ARAge Restrictions SP Specialty Program GRGender Restrictions 13 Drug Name Accu-Chek Comfort Curve Control Liquid Accu-Chek Comfort Curve Test Strips Accu-Chek Compact Plus Control Liquid Accu-Chek Compact Plus Test Strips Accu-Chek Compact Plus Kit Accu-Chek FastClix Kit Accu-Chek FastClix Lancets Accu-Chek Multiclix Kit Accu-Chek Multiclix Lancets Accu-Chek Nano Kit Accu-Chek SmartView Control Liquid Accu-Chek SmartView Test Strips Accu-Chek Soft Touch Lancets Accu-Chek Softclix Kit Accu-Chek Softclix Lancets Bayer Contour Test Strips Dexcom G4 Platinum Kit Dexcom G4 Platinum Sensor Kit Dexcom G4 Platinum Transmitter Kit Freestyle Test Strips Glucocard Test Strips Insulin Pen Needle Insulin Syringe/ Needle Novofine Pen Needle Drug Tier Programs and Limits 2 2 QL 2 2 QL 2 2 2 2 2 2 QL 2 2 2 3 PA, QL 3 3 3 3 3 2 2 2 Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing Novofine Autocover Pen Needle Novotwist Pen Needle Onetouch Kit Ultra Smart Onetouch Kit Ultra Onetouch Kit Ultra 2 Onetouch Kit Ultra Mini Onetouch Kit Verio IQ Onetouch Lancets Onetouch Test Strips Onetouch Ultra Blue Test Strips Onetouch Verio Test Strips Precision Test Strips Truetest Test Strips Truetrack Test Strips Programs and Limits 2 2 2 2 2 2 2 2 2 QL 2 QL 2 QL 3 3 3 PA, QL PA, QL PA, QL Diabetes/Endocrine: Insulin 2 2 Drug Tier Drug Name PA, QL PA, QL Humalog Vials Humalog Kwik Pen 100 unit/ml Humalog Mix 50/50 Kwik Pen Humalog Mix 50/50 Vials Humalog Mix 75/25 Kwik Pen Humalog Mix 75/25 Vials Humulin 70/30 Vials Humulin N Vials Humulin N Pen Humulin Pen 70/30 Humulin R U-500 Humulin R Vials Lantus Solostar Lantus Vials Levemir FlexTouch Levemir Vials Novolin 70/30 Vials PAPrior Authorization STStep Therapy QLQuantity Limits 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 ARAge Restrictions SP Specialty Program GRGender Restrictions 14 Drug Name Novolin N Vials Novolin R Vials Novolog Flexpen Novolog Mix Flexpen Novolog Mix 70/30 Vials Novolog Penfill Novolog Vials Drug Tier Programs and Limits 2 2 2 2 2 2 2 Diabetes/Endocrine: Non-Insulin Bydureon Byetta Glimepiride Glipizide Glipizide ER Glipizide XL Glumetza Glyburide Glyburide/Metformin Invokamet Invokana Janumet Janumet XR Januvia Jardiance Kombiglyze Metformin Metformin ER Onglyza Pioglitazone Victoza 2 2 1 1 1 1 3 1 1 2 2 2 2 2 2 2 1 1 2 1 2 QL, ST QL, ST PA QL, ST QL, ST QL, ST QL, ST QL, ST QL, ST QL, ST QL, ST QL QL, ST Endocrine: Growth Hormone Nutropin AQ Omnitrope Saizen Zomacton PA, SP PA, ST, SP PA, SP PA, ST, SP Endocrine: Other Calcitriol Cap Dexamethasone Tab Hydrocortisone Tab Lupron Depot 3.75 mg, 11.25 mg 1 1 1 Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing PA, SP Drug Name Lupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mg Methylprednisolone Tab Prednisone Prednisolone Solution 25 mg/5 ml Prednisolone Syrup, Solution 15 mg/5 ml Sensipar Drug Tier Programs and Limits PA, SP 1 1 1 1 3 SP Endocrine: Thyroid Hormone Replacement Armour Thyroid Levothyroxine Liothyronine Methimazole Synthroid Tirosint 3 1 1 1 3 3 Eye Conditions: Allergies Azelastine Ophthalmic Solution Pataday Patanol 1 2 2 QL Eye Conditions: Antibiotics Ciprofloxacin Ophthalmic Solution Erythromycin Ointment Gentamicin Moxeza Neomycin/Polymyxin B/Dexamethasone Ointment, Suspension Ofloxacin Ophthalmic Solution Polymyxin B/ Trimethoprim Solution Tobramycin Tobramycin/ Dexamethasone Vigamox PAPrior Authorization STStep Therapy QLQuantity Limits 1 QL 1 1 2 QL 1 1 QL 1 1 1 2 QL ARAge Restrictions SP Specialty Program GRGender Restrictions 15 Drug Name Drug Tier Programs and Limits Transderm-Scop Eye Conditions: Glaucoma Alphagan P Azopt Brimonidine Combigan Dorzolamide-Timolol Maleate Latanoprost Lumigan Timolol Timoptic Ocudose Travatan Z 2 2 1 2 QL QL QL 1 1 2 1 2 2 QL QL QL Eye Conditions: Other Durezol Ophthalmic Emulsion Lotemax Ophthalmic Gel Ketorolac Ophthalmic Solution Prednisolone Ophthalmic Suspension Restasis 3 3 1 QL 1 3 PA Gastrointestinal: Acid Suppression Carafate Suspension Dexilant Esomeprazole (Rx only) Famotidine Tab 20 mg and 40 mg (Rx only) Lansoprazole (Rx only) Nexium (Rx only) Omeprazole (Rx only) Pantoprazole Rabeprazole Ranitidine Tab, Cap, Syrup (Rx only) Sucralfate Tab 2 2 1 QL QL 1 1 2 1 1 1 QL QL QL QL QL 1 1 Gastrointestinal: Nausea/Vomiting Metoclopramide Ondansetron Tab 1 1 Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing Drug Tier Drug Name QL QL Programs and Limits 3 Gastrointestinal: Other Amitiza Apriso Asacol HD Canasa Creon Delzicol Dicyclomine Diphenoxylate/Atropine Gavilyte Solution Hyoscyamine Sublingual Tab Lactulose Lialda Linzess Movantik Moviprep Omeclamox Pak Pentasa Polyethylene Glycol 3350 Powder Protosol HC Prepopik Pylera Sulfasalazine Suprep Bowel Prep Uceris Zenpep 2 3 3 2 2 3 1 1 1 QL, ST, AR QL, ST QL, ST QL QL, ST QL 1 1 2 2 2 3 2 3 QL QL, ST, AR QL QL QL QL 1 1 3 2 1 3 3 2 QL QL HIV/AIDS Atripla Complera Epzicom Intelence Isentress Kaletra Nevirapine Norvir Prezista Reyataz Stribild PAPrior Authorization STStep Therapy QLQuantity Limits 2 2 2 2 2 2 1 2 2 2 2 SP SP SP SP SP SP SP SP SP SP SP ARAge Restrictions SP Specialty Program GRGender Restrictions 16 Drug Name Drug Tier Programs and Limits 2 2 2 2 2 SP SP SP SP SP 3 SP PA, SP PA, SP PA, SP SP Sustiva Tivicay Triumeq Truvada Viread Infertility Cetrotide Follistim AQ Gonal-f Gonal-f RFF Ovidrel Inflammatory Conditions Cimzia Kit Depen Humira Kit Humira Pen Kit Humira Pen Kit Crohns Humira Pen Kit Psoriasis Hydroxychloroquine Methotrexate Tab Orencia SC Rasuvo Simponi Stelara 2 PA, QL, SP PA, QL, SP PA, QL, SP 1 1 PA, QL, ST, SP PA, QL, ST, SP PA, QL, SP PA, QL, SP PA, QL, SP PA, QL, SP Men’s Health: Erectile Dysfunction Cialis Levitra Stendra Viagra 2 3 2 3 QL, AR, GR QL, AR, GR QL, AR, GR QL, AR, GR Men’s Health: Prostate Alfuzosin Avodart Doxazosin Finasteride 5 mg Jalyn Rapaflo Tamsulosin 1 2 1 1 2 2 1 Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing QL QL QL QL QL QL Drug Tier Drug Name Terazosin Programs and Limits 1 Men’s Health: Testosterone Therapy Androderm Androgel 1.62% Androgel 1% Testosterone Cypionate IM Injection 2 2 3 PA, QL, GR PA, QL, GR PA, QL, GR 1 PA Miscellaneous Allopurinol Antipyrine/Benzocaine Otic Solution 5.4 - 1.4% Aranesp Benzonatate Botox 100, 200 unit Injection (non-cosmetic) Bunavail Cerdelga Chantix Cheratussin Chlorhexidine Colcrys Cyproheptadine Desmopressin Epipen 2-Pak Euflexxa Fosrenol Guaifenesin/Codeine Syrup Homatropine/ Hydrocodone Syrup Hydrocodone/ Chlorpheniramine Liquid Hydrocortisone AC Suppository 25 mg Hydromet Lidocaine Viscous Solution 2% Makena PAPrior Authorization STStep Therapy QLQuantity Limits 1 1 1 PA, SP 3 PA, SP 3 3 3 1 1 2 1 1 2 3 PA, QL PA, QL, SP QL QL QL PA, SP 1 1 1 1 1 1 PA, SP ARAge Restrictions SP Specialty Program GRGender Restrictions 17 Drug Name Phenazopyridine (Rx only) Phentermine Tab Procrit Promethazine DM Syrup Promethazine/Codeine Syrup Pulmozyme Rectiv Renvela Tab Rezira Suboxone Film Synagis Synvisc Uloric Ursodiol Velphoro Zubsolv Zutripro Drug Tier Programs and Limits 1 1 1 PA PA, SP AR 1 AR 2 3 2 3 2 2 2 1 3 2 3 SP PA, QL PA, SP PA, SP QL, ST PA, QL Musculoskeletal: Osteoporosis Alendronate Tab Evista Forteo Ibandronate Tab Raloxifene 1 3 1 1 QL QL PA, QL, SP QL QL Musculoskeletal: Other Baclofen Tab Carisoprodol 350 mg Cyclobenzaprine Tab 5, 10 mg Metaxalone Methocarbamol Tizanidine Cap Tizanidine Tab 1 1 1 1 1 1 1 Musculoskeletal: Pain Relief Acetaminophen w/ Codeine Cambia Celebrex Celecoxib Diclofenac Tab 1 QL 3 3 1 1 QL QL QL QL Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing Drug Name Endocet Tab Etodolac Fentanyl Patch 25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr Fentanyl Patch 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr Gralise Hydrocodone w/ Ibuprofen Tab 7.5-200 mg Hydrocodone/APAP 5, 7.5, 10/325 mg Hydromorphone Tab Ibuprofen Tab 400, 600, 800 mg (Rx only) Indomethacin Cap Ketorolac Tab Lazanda Lidocaine Patch 5% Meloxicam Methadone Tab Morphine Sulfate Tab Nabumetone Naproxen (Rx only) Nucynta Nucynta ER Opana ER Oxycodone Tab 5, 10, 15, 30 mg (Immediate Release) Oxycodone w/ Acetaminophen Oxycontin Tramadol Tab 50 mg Tramadol w/ Acetaminophen Vicodin Vicodin ES PAPrior Authorization STStep Therapy QLQuantity Limits Drug Tier Programs and Limits 1 1 QL QL 1 QL 1 QL 3 QL, ST 1 QL 1 QL 1 1 QL 1 1 3 1 1 1 1 1 1 3 3 2 QL QL PA, QL QL QL QL QL QL QL PA, QL QL 1 1 QL 2 1 QL QL 1 QL 1 1 QL QL ARAge Restrictions SP Specialty Program GRGender Restrictions 18 Drug Name Drug Tier Programs and Limits Voltaren Gel 2 QL Overactive Bladder Enablex Gelnique Myrbetriq Oxybutynin Oxybutynin ER Tolterodine Toviaz Vesicare 3 2 3 1 1 1 3 2 QL QL QL, ST QL QL QL QL Respiratory: Asthma/COPD Advair Diskus Advair HFA Aerospan Albuterol Nebulizer Solution Breo Ellipta Budesonide Inhalation Suspension Combivent Respimat Dulera Flovent Diskus Flovent HFA Foradil Incruse Ellipta Ipratropium/Albuterol Levalbuterol Nebulizer Solution Montelukast Perforomist Proair HFA, RespiClick Proventil HFA Pulmicort Flexhaler Qvar Serevent Diskus Spiriva Handihaler Spiriva Respimat Symbicort Tudorza Pressair Ventolin HFA Xolair Xopenex HFA 2 2 3 QL QL QL 1 2 QL 1 2 3 2 2 2 2 1 QL QL, ST QL QL QL, ST QL 1 1 3 2 3 2 2 2 2 2 2 2 2 3 Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing QL QL QL QL, ST QL QL QL, ST QL QL QL QL QL PA, SP QL, ST Drug Tier Drug Name Programs and Limits Respiratory: Nasal Allergies Azelastine Spray Dymista Spray Ipratropium Spray Nasonex Omnaris QNasl Veramyst Zetonna 1 3 1 2 3 3 2 3 QL QL QL QL QL QL QL Respiratory: Oral Allergies Promethazine Tab Desloratadine Levocetirizine 1 1 1 AR QL QL Transplant Azathioprine Tab Cellcept Tab/ Suspension Cyclosporine Cap Mycophenolate Mofetil 250 mg Cap/ 500 mg Tab Mycophenolate Sodium 180 mg, 360 mg Tab Prograf Cap Rapamune Tacrolimus Cap 1 3 SP 1 SP 1 SP 1 SP 3 3 1 SP SP SP Vitamins/Electrolytes Cyanocobalamine Injection Folic Acid 1 mg (Rx only) Klor-Con 8 and 10 MEQ Klor-Con M10 and M20 Potassium Chloride ER Tab, Cap PAPrior Authorization STStep Therapy QLQuantity Limits 1 1 1 1 1 ARAge Restrictions SP Specialty Program GRGender Restrictions 19 Drug Name Potassium Chloride Micro ER Tab Potassium Citrate 540 mg, 1080 mg Tab Vitamin D 50,000 units (Rx only) Drug Tier Programs and Limits 1 1 1 Women’s Health: Birth Control Apri Aviane Azurette Beyaz Cryselle-28 Falmina Generess Fe Chewable Gianvi Gildess Fe Jolivette Junel Kariva Levora 28 Lo Loestrin Lomedia Fe Loryna Low-Ogestrel Lutera Medroxyprogesterone Acetate Injection Microgestin Microgestin Fe Minastrin 24 Fe Chewable Mono-Linyah Mononessa Natazia Necon Nora-Be Norgest/Ethi Estradio Nortrel Nuvaring Ocella Orsythia 1 1 1 3 1 1 GR GR GR GR GR GR 3 GR 1 1 1 1 1 1 3 1 1 1 1 GR GR GR GR GR GR GR GR GR GR GR 1 QL 1 1 GR GR 3 GR 1 1 2 1 1 1 1 2 1 1 GR GR GR GR GR GR GR Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing Drug Name Ortho Tri-Cyclen Lo Previfem Reclipsen Safyral Sprintec 28 Tri-Linyah Tri-Previfem Trinessa Tri-Sprintec Vestura Viorele Xulane Zarah Drug Tier Programs and Limits 3 1 1 3 1 1 1 1 1 1 1 1 1 GR GR GR GR GR GR GR GR GR GR GR GR GR Women’s Health: Hormone Replacement Climara Pro Divigel Duavee Estrace Vaginal Cream Estradiol Tab Estradiol/Norethindrone Tab Medroxyprogesterone Acetate Tab Minivelle Osphena Premarin Tab Premarin Vaginal Cream Premphase Prempro Progesterone Cap Vagifem Vivelle-Dot 2 3 2 3 1 QL, GR GR QL, GR 1 QL, GR QL, GR 1 3 3 2 QL, GR QL, GR 2 2 2 1 3 3 QL, GR QL, GR GR QL, GR Women’s Health: Vaginal Anti-Infectives Gynazole-1 Vaginal Cream Metronidazole Vaginal Gel Terconazole Vaginal Cream 3 1 1 QL GR GR PAPrior Authorization STStep Therapy QLQuantity Limits ARAge Restrictions SP Specialty Program GRGender Restrictions 20 Index of Covered Drugs A Abilify Tab . . . . . . . . . . 12 Acanya Gel . . . . . . . . . 13 Accu-Chek Active Glucose Control Liquid . . . . . . 13 Accu-Chek Active Test Strips . . . . . . . . 13 Accu-Chek Aviva Plus Control Liquid . . . . . . 13 Accu-Chek Aviva Plus Kit . . 13 Accu-Chek Aviva Plus Test Strips . . . . . . . . 13 Accu-Chek Comfort Curve Control Liquid . . . . . . 14 Accu-Chek Comfort Curve Test Strips . . . . . . . . 14 Accu-Chek Compact Plus Control Liquid . . . . . . 14 Accu-Chek Compact Plus Kit . . . . . . . . . 14 Accu-Chek Compact Plus Test Strips . . . . . . . . 14 Accu-Chek FastClix Kit . . . 14 Accu-Chek FastClix Lancets 14 Accu-Chek Multiclix Kit . . . 14 Accu-Chek Multiclix Lancets14 Accu-Chek Nano Kit . . . . 14 Accu-Chek SmartView Control Liquid . . . . . . 14 Accu-Chek SmartView Test Strips . . . . . . . . 14 Accu-Chek Softclix Kit . . . 14 Accu-Chek Softclix Lancets . 14 Accu-Chek Soft Touch Lancets . . . . . . 14 Acetaminophen w/ Codeine . 18 Acyclovir Cap, Tab, Suspension 9 Acyclovir Ointment 5% . . . . 13 Aczone Gel . . . . . . . . . 13 Adcirca . . . . . . . . . . . 11 Adderall XR Cap . . . . . . 11 Adempas . . . . . . . . . . 11 Advair Diskus . . . . . . . .19 Advair HFA . . . . . . . . . 19 Aerospan . . . . . . . . . . 19 Albuterol Nebulizer Solution . 19 Alendronate Tab . . . . . . . 18 Alfuzosin . . . . . . . . . . .17 Allopurinol . . . . . . . . . . 17 Bold type = Brand-name drug [Plain type = Generic drug] Alphagan P . . . . . . . . . 16 Alprazolam Tab . . . . . . . . 12 Amiodarone . . . . . . . . . 11 Amitiza . . . . . . . . . . . 16 Amitriptyline . . . . . . . . . 11 Amlodipine . . . . . . . . . . 10 Amlodipine/Atorvastatin . . . 11 Amlodipine/Benazepril . . . . 10 Amlodipine/Valsartan . . . . . 10 Amlodipine/Valsartan/HCTZ . . 10 Amoxicillin . . . . . . . . . . 9 Amoxicillin/Clavulanate . . . . 9 AmphetamineDextroamphetamine SR 24Hr Cap . . . . . . . . . 11 AmphetamineDextroamphetamine Tab . 11 Ampyra . . . . . . . . . . . 12 Anastrozole Tab . . . . . . . . 9 Androderm . . . . . . . . . 17 Androgel 1% . . . . . . . . 17 Androgel 1.62% . . . . . . 17 Antipyrine/Benzocaine Otic Solution 5.4 - 1.4% . . . 17 Apri . . . . . . . . . . . . . 20 Apriso . . . . . . . . . . . . 16 Aranesp . . . . . . . . . . . 17 Aripiprazole . . . . . . . . . 12 Armour Thyroid . . . . . . .15 Asacol HD . . . . . . . . . .16 Atenolol . . . . . . . . . . . 10 Atenolol/Chlorthalidone . . . 10 Atorvastatin . . . . . . . . . 10 Atralin . . . . . . . . . . . . 13 Atripla . . . . . . . . . . . . 16 Aviane . . . . . . . . . . . . 20 Avodart . . . . . . . . . . . 17 Avonex Kit . . . . . . . . . 12 Avonex Pen Kit . . . . . . . 12 Avonex Prefill Kit . . . . . . 12 Azathioprine Tab . . . . . . . 19 Azelastine Ophthalmic Solution . . . . . . . . . 15 Azelastine Spray . . . . . . . 19 Azithromycin . . . . . . . . . 9 Azopt . . . . . . . . . . . . 16 Azor . . . . . . . . . . . . . 10 Azurette . . . . . . . . . . . 20 B Baclofen Tab . . . . . . . . . 18 Baraclude . . . . . . . . . . 9 Bayer Contour Test Strips . 14 Benazepril . . . . . . . . . . 10 Benazepril/HCTZ . . . . . . . 10 Benicar . . . . . . . . . . . 10 Benicar HCT . . . . . . . . . 10 Benzaclin . . . . . . . . . . 13 Benzonatate . . . . . . . . . 17 Benztropine . . . . . . . . . 12 Betamethasone Dipropionate . 13 Betaseron . . . . . . . . . . 12 Bethkis . . . . . . . . . . . . 9 Beyaz . . . . . . . . . . . . 20 Bisoprolol . . . . . . . . . . . 10 Bisoprolol/HCTZ . . . . . . . 10 Botox 100, 200 unit Injection . . . . . . . . 17 Breo Ellipta . . . . . . . . . 19 Brilinta . . . . . . . . . . . . 9 Brimonidine . . . . . . . . . 16 Budesonide Inhalation Suspension . . . . . . . . 19 Bumetanide . . . . . . . . . 10 Bunavail . . . . . . . . . . . 17 Bupropion . . . . . . . . . . 11 Bupropion ER . . . . . . . . . 11 Bupropion SR . . . . . . . . . 11 Bupropion XL . . . . . . . . . 11 Buspirone . . . . . . . . . . 12 Butalbital-AcetaminophenCaffeine Cap, Tab . . . . . 11 Bydureon . . . . . . . . . . 15 Byetta . . . . . . . . . . . . 15 Bystolic . . . . . . . . . . . 10 C Calcitriol Cap . . . . . . . . . 15 Cambia . . . . . . . . . . . 18 Canasa . . . . . . . . . . . . 16 Capecitabine . . . . . . . . . 9 Carafate Suspension . . . . 16 Carbamazepine Tab . . . . . 12 Carbidopa/Levodopa Tab . . . 12 Carisoprodol . . . . . . . . . 18 Cartia XT . . . . . . . . . . . 10 Carvedilol . . . . . . . . . . 10 21 Index of Covered Drugs Cefadroxil Cap . . . . . . . . 9 Cefdinir . . . . . . . . . . . . 9 Cefuroxime Tab . . . . . . . . 9 Celebrex . . . . . . . . . . . 18 Celecoxib . . . . . . . . . . .18 Cellcept Tab/Suspension . . 19 Cephalexin . . . . . . . . . . 9 Cerdelga . . . . . . . . . . . 17 Cetrotide . . . . . . . . . . 17 Chantix . . . . . . . . . . . 17 Cheratussin . . . . . . . . . . 17 Chlorhexidine . . . . . . . . 17 Chlorthalidone . . . . . . . . 10 Cholestyramine . . . . . . . .10 Cialis . . . . . . . . . . . . . 17 Ciclopirox Cream . . . . . . .13 Cimzia Kit . . . . . . . . . . 17 Ciprodex Otic Suspension . 9 Ciprofloxacin Ophthalmic Solution . . . . . . . . . 15 Ciprofloxacin Tab . . . . . . . 9 Citalopram . . . . . . . . . . 11 Clarithromycin . . . . . . . . 9 Climara Pro . . . . . . . . . 20 Clindamycin/Benzoyl Peroxide 13 Clindamycin . . . . . . . . 9, 13 Clobetasol Cream, Ointment, Solution . . . . . . . . . 13 Clobex . . . . . . . . . . . . 13 Cloderm . . . . . . . . . . . 13 Clonazepam . . . . . . . . . 12 Clonidine Patch . . . . . . . .10 Clonidine Tab . . . . . . . . . 10 Clopidogrel . . . . . . . . . . 9 Clotrimazole/Betamethasone . 13 Colcrys . . . . . . . . . . . . 17 Combigan . . . . . . . . . . 16 Combivent Respimat . . . . 19 Complera . . . . . . . . . . 16 Copaxone . . . . . . . . . . 12 Coreg CR . . . . . . . . . . 10 Creon . . . . . . . . . . . . 16 Crestor . . . . . . . . . . . 10 Cryselle-28 . . . . . . . . . . 20 Cyanocobalamine Injection . . 19 Cyclobenzaprine Tab . . . . .18 Cyclosporine Cap . . . . . . .19 Cyproheptadine . . . . . . . 17 Bold type = Brand-name drug [Plain type = Generic drug] D Delzicol . . . . . . . . . . . 16 Depen . . . . . . . . . . . . 17 Desloratadine . . . . . . . . . 19 Desmopressin . . . . . . . . 17 Desonide . . . . . . . . . . . 13 Desoximetasone . . . . . 13, 15 Dexcom G4 Platinum Kit . . 14 Dexcom G4 Platinum Sensor Kit . . . . . . . . 14 Dexcom G4 Platinum Transmitter Kit . . . . . 14 Dexilant . . . . . . . . . . . 16 Dexmethylphenidate ER . . . 11 Diazepam Tab . . . . . . . . 12 Diclofenac Tab . . . . . . . . 18 Dicyclomine . . . . . . . . . 16 Differin . . . . . . . . . . . 13 Dificid . . . . . . . . . . . . 9 Digoxin . . . . . . . . . . . . 11 Diltiazem Tab . . . . . . . . .10 Diovan . . . . . . . . . . . . 10 Diphenoxylate/Atropine . . . 16 Divalproex DR . . . . . . . . 12 Divalproex ER . . . . . . . . . 12 Divigel . . . . . . . . . . . . 20 Donepezil Tab . . . . . . . . 12 Dorzolamide-Timolol Maleate 16 Doxazosin . . . . . . . . 10, 17 Doxepin . . . . . . . . . . . 11 Doxycycline Hyclate . . . . . . 9 Doxycycline Monohydrate . . . 9 Duavee . . . . . . . . . . . 20 Dulera . . . . . . . . . . . . 19 Duloxetine Cap . . . . . . . . 11 Durezol Ophthalmic Emulsion . . . . . . . . 16 Dutoprol . . . . . . . . . . 10 Dymista Spray . . . . . . . 19 E Econazole Cream . . . . . . . 13 Edarbi . . . . . . . . . . . . 10 Edarbyclor . . . . . . . . . . 10 Effient . . . . . . . . . . . . 9 Elidel . . . . . . . . . . . . 13 Eliquis . . . . . . . . . . . . 9 Enablex . . . . . . . . . . . 19 Enalapril . . . . . . . . . . . 10 Enalapril/HCTZ . . . . . . . . 10 Endocet Tab . . . . . . . . . 18 Enoxaparin . . . . . . . . . . 9 Entecavir . . . . . . . . . . . 9 Epiduo . . . . . . . . . . . . 13 Epipen 2-Pak . . . . . . . . 17 Epzicom . . . . . . . . . . . 16 Erythromycin . . . . . . . . . 9 Erythromycin Ointment . . . . 15 Escitalopram Tab . . . . . . . 11 Esomeprazole . . . . . . . . 16 Estrace Vaginal Cream . . . 20 Estradiol/Norethindrone Tab . 20 Estradiol Tab . . . . . . . . . 20 Eszopiclone Tab . . . . . . . . 12 Etodolac . . . . . . . . . . . 18 Euflexxa . . . . . . . . . . . 17 Evista . . . . . . . . . . . . 18 F Falmina . . . . . . . . . . . . 20 Famciclovir Tab . . . . . . . . 9 Famotidine Tab . . . . . . . . 16 Felodipine . . . . . . . . . . 10 Fenofibrate . . . . . . . . . 10 Fenofibrate . . . . . . . . . 10 Fentanyl Patch . . . . . . . .18 Finacea . . . . . . . . . . . 13 Finasteride . . . . . . . . . . 17 Flecainide . . . . . . . . . . .11 Flovent Diskus . . . . . . . 19 Flovent HFA . . . . . . . . . 19 Fluconazole . . . . . . . . . . 9 Fluocinonide . . . . . . . . . 13 Fluoxetine Cap . . . . . . . . 11 Fluvoxamine Tab . . . . . . . 11 Focalin XR . . . . . . . . . . 11 Folic Acid 1 mg . . . . . . . . 19 Follistim AQ . . . . . . . . . 17 Foradil . . . . . . . . . . . . 19 Forfivo XL . . . . . . . . . . 11 Forteo . . . . . . . . . . . . 18 Fosinopril . . . . . . . . . . .10 Fosrenol . . . . . . . . . . . 17 Freestyle Test Strips . . . . 14 Furosemide . . . . . . . . . . 10 22 Index of Covered Drugs G Gabapentin . . . . . . . . . . 12 Gavilyte Solution . . . . . . . 16 Gelnique . . . . . . . . . . 19 Gemfibrozil . . . . . . . . . . 10 Generess Fe Chewable . . . 20 Gentamicin . . . . . . . . . .15 Gianvi . . . . . . . . . . . . 20 Gildess Fe . . . . . . . . . . 20 Gilenya . . . . . . . . . . . 12 Gleevec . . . . . . . . . . . 9 Glimepiride . . . . . . . . . .15 Glipizide . . . . . . . . . . . 15 Glipizide ER . . . . . . . . . .15 Glipizide XL . . . . . . . . . . 15 Glucocard Test Strips . . . . 14 Glumetza . . . . . . . . . . 15 Glyburide . . . . . . . . . . .15 Glyburide/Metformin . . . . . 15 Gonal-f . . . . . . . . . . . 17 Gonal-f RFF . . . . . . . . . 17 Gralise . . . . . . . . . . . . 18 Guaifenesin/Codeine Syrup . . 17 Guanfacine ER Tab . . . . . . 11 Guanfacine Tab . . . . . . . . 10 Gynazole-1 Vaginal Cream . 20 H Harvoni . . . . . . . . . . . 9 Homatropine/Hydrocodone Syrup . . . . . . . . . . . 17 Humalog Kwik Pen 100 unit/ml . . . . . . . 14 Humalog Mix 50/50 Kwik Pen . . . . . 14 Humalog Mix 50/50 Vials . 14 Humalog Mix 75/25 Kwik Pen . . . . . 14 Humalog Mix 75/25 Vials . 14 Humalog Vials . . . . . . . 14 Humira Kit . . . . . . . . . 17 Humira Pen Kit . . . . . . . 17 Humira Pen Kit Crohns . . . 17 Humira Pen Kit Psoriasis . . 17 Humulin 70/30 Vials . . . . 14 Humulin N Pen . . . . . . . 14 Humulin N Vials . . . . . . 14 Bold type = Brand-name drug [Plain type = Generic drug] Humulin Pen 70/30 . . . . . 14 Humulin R U-500 . . . . . . 14 Humulin R Vials . . . . . . .14 Hydralazine . . . . . . . . . .10 Hydrochlorothiazide . . . . . 10 Hydrocodone/APAP . . . . . 18 Hydrocodone/Chlorpheniramine Liquid . . . . . . . . . . . 17 Hydrocodone w/ Ibuprofen . . 18 Hydrocortisone AC Suppository . . . . . . . . 17 Hydrocortisone Cream, Ointment 2.5% . . . . . . 13 Hydrocortisone Tab . . . . . . 15 Hydromet . . . . . . . . . . 17 Hydromorphone Tab . . . . . 18 Hydroxychloroquine . . . . . 17 Hydroxyzine HCL . . . . . . . 12 Hydroxyzine Pamoate . . . . .12 Hyoscyamine Sublingual Tab . 16 I Ibandronate Tab . . . . . . . 18 Ibuprofen Tab . . . . . . . . 18 Incruse Ellipta . . . . . . . .19 Indomethacin Cap . . . . . . 18 Insulin Pen Needle . . . . . 14 Insulin Syringe/Needle . . 14 Intelence . . . . . . . . . . 16 Intuniv . . . . . . . . . . . . 11 Invokamet . . . . . . . . . . 15 Invokana . . . . . . . . . . 15 Ipratropium/Albuterol . . . . 19 Ipratropium Spray . . . . . . 19 Irbesartan . . . . . . . . . . 10 Irbesartan/HCTZ . . . . . . . 10 Isentress . . . . . . . . . . . 16 Isosorbide Mononitrate . . . . 11 J Jalyn . . . . . . . . . . . . . 17 Janumet . . . . . . . . . . . 15 Janumet XR . . . . . . . . . 15 Januvia . . . . . . . . . . . 15 Jardiance . . . . . . . . . . 15 Jolivette . . . . . . . . . . . 20 Junel . . . . . . . . . . . . . 20 K Kaletra . . . . . . . . . . . 16 Kariva . . . . . . . . . . . . 20 Ketoconazole Cream/ Shampoo . . . . . . . . .13 Ketorolac Ophthalmic Solution . . . . . . . . . 16 Ketorolac Tab . . . . . . . . . 18 Klor-Con 8 and 10 MEQ . . . 19 Klor-Con M10 and M20 . . . 19 Kombiglyze . . . . . . . . . 15 L Labetalol . . . . . . . . . . . 10 Lactulose . . . . . . . . . . . 16 Lamictal ODT . . . . . . . . 12 Lamictal Tab, Chew . . . . . 12 Lamictal XR . . . . . . . . . 12 Lamotrigine ER . . . . . . . . 12 Lamotrigine . . . . . . . . . 12 Lansoprazole . . . . . . . . . 16 Lantus Solostar . . . . . . . 14 Lantus Vials . . . . . . . . .14 Latanoprost . . . . . . . . . 16 Latuda . . . . . . . . . . . . 12 Lazanda . . . . . . . . . . . 18 Letairis . . . . . . . . . . . 11 Letrozole . . . . . . . . . . . 9 Levalbuterol Nebulizer Solution . . . . 19 Levemir FlexTouch . . . . . 14 Levemir Vials . . . . . . . . 14 Levetiracetam . . . . . . . . 12 Levetiracetam ER . . . . . . . 12 Levitra . . . . . . . . . . . . 17 Levocetirizine . . . . . . . . . 19 Levofloxacin Tab . . . . . . . . 9 Levora 28 . . . . . . . . . . . 20 Levothyroxine . . . . . . . . 15 Lialda . . . . . . . . . . . . 16 Lidocaine Patch 5% . . . . . 18 Lidocaine/Prilocaine Cream . . 13 Lidocaine Topical Ointment, Solution . . . . . . . . . 13 Lidocaine Viscous Solution 2% . . . . . . . 17 Linzess . . . . . . . . . . . . 16 23 Index of Covered Drugs Liothyronine . . . . . . . . . 15 Lipitor . . . . . . . . . . . . 10 Lisinopril . . . . . . . . . . . 10 Lisinopril/HCTZ . . . . . . . . 10 Lithium Carbonate . . . . . . 12 Livalo . . . . . . . . . . . . 10 Lo Loestrin . . . . . . . . . 20 Lomedia Fe . . . . . . . . . . 20 Lorazepam Tab . . . . . . . . 12 Loryna . . . . . . . . . . . . 20 Losartan . . . . . . . . . . . 10 Losartan/HCTZ . . . . . . . . 10 Lotemax Ophthalmic Gel . . 16 Lovastatin . . . . . . . . . . 10 Lovaza . . . . . . . . . . . . 10 Low-Ogestrel . . . . . . . . . 20 Lumigan . . . . . . . . . . . 16 Lupron Depot . . . . . . . 15 Lutera . . . . . . . . . . . . 20 Lyrica Cap . . . . . . . . . . 12 Minastrin 24 Fe Chewable . 20 Minivelle . . . . . . . . . . 20 Minocycline Cap . . . . . . . 9 Mirtazapine . . . . . . . . . 11 Modafinil . . . . . . . . . . . 12 Mometasone . . . . . . . . . 13 Mono-Linyah . . . . . . . . . 20 Mononessa . . . . . . . . . . 20 Montelukast . . . . . . . . . 19 Morphine Sulfate Tab . . . . . 18 Movantik . . . . . . . . . . 16 Moviprep . . . . . . . . . . 16 Moxeza . . . . . . . . . . . 15 Moxifloxacin . . . . . . . . . 9 Mupirocin Ointment . . . . . 13 Mycophenolate Mofetil . . . . 19 Mycophenolate Sodium . . . 19 Myrbetriq . . . . . . . . . . 19 M Nabumetone . . . . . . . . . 18 Nadolol . . . . . . . . . . . . 10 Namenda Tab . . . . . . . . 12 Namenda XR Cap . . . . . . 12 Naproxen . . . . . . . . . . . 18 Nasonex . . . . . . . . . . . 19 Natazia . . . . . . . . . . . 20 Necon . . . . . . . . . . . . 20 Neomycin/Polymyxin B/ Dexamethasone Ointment, Suspension . . . . . . . . 15 Neomycin/Polymyxin/HC Otic Suspension, Solution . . . 9 Nevirapine . . . . . . . . . . 16 Nexium . . . . . . . . . . . 16 Niacin ER Tab . . . . . . . . . 10 Nifedipine ER . . . . . . . . . 10 Nitrofurantoin Macrocrystalline 9 Nitrofurantoin Monohydrate Macrocrystalline . . . . . . 9 Nitrostat . . . . . . . . . . . 11 Nora-Be . . . . . . . . . . . 20 Norgest/Ethi Estradio . . . . . 20 Nortrel . . . . . . . . . . . . 20 Nortriptyline . . . . . . . . . 11 Norvir . . . . . . . . . . . . 16 Makena . . . . . . . . . . . 17 Medroxyprogesterone Acetate20 Meloxicam . . . . . . . . . . 18 Metaxalone . . . . . . . . . . 18 Metformin . . . . . . . . . . 15 Metformin ER . . . . . . . . 15 Methadone Tab . . . . . . . . 18 Methimazole . . . . . . . . . 15 Methocarbamol . . . . . . . 18 Methotrexate Tab . . . . . . . 17 Methylphenidate ER . . . . . 11 Methylphenidate SA Osmotic ER Tab . . . . . . 11 Methylphenidate Tab . . . . . 11 Methylprednisolone Tab . . . 15 Metoclopramide . . . . . . . 16 Metoprolol Succinate . . . . . 10 Metoprolol Tartrate . . . . . . 10 Metrogel . . . . . . . . . . 13 Metronidazole Gel 0.75% . . 13 Metronidazole Tab . . . . . . 9 Metronidazole Vaginal Gel . . 20 Microgestin . . . . . . . . . . 20 Microgestin Fe . . . . . . . . 20 Migranal . . . . . . . . . . 11 Bold type = Brand-name drug [Plain type = Generic drug] N Novofine Autocover Pen Needle . . . . . . . 14 Novofine Pen Needle . . . . 14 Novolin 70/30 Vials . . . . .14 Novolin N Vials . . . . . . . 15 Novolin R Vials . . . . . . . 15 Novolog Flexpen . . . . . . 15 Novolog Mix 70/30 Vials . . 15 Novolog Mix Flexpen . . . . 15 Novolog Penfill . . . . . . . 15 Novolog Vials . . . . . . . .15 Novotwist Pen Needle . . . 14 Nucynta . . . . . . . . . . . 18 Nucynta ER . . . . . . . . . 18 Nutropin AQ . . . . . . . . 15 Nuvaring . . . . . . . . . . 20 Nuvigil . . . . . . . . . . . . 12 Nystatin Cream, Ointment, Powder . . . . . . . . . .13 Nystatin Oral Powder . . . . . 9 Nystatin Suspension . . . . . . 9 Nystatin/Triamcinolone Cream, Ointment . . . . . . . . . 13 O Ocella . . . . . . . . . . . . 20 Ofloxacin Ophthalmic Solution15 Ofloxacin Otic Solution . . . . 9 Olanzapine Tab . . . . . . . . 12 Omeclamox Pak . . . . . . . 16 Omega-3 Acid Cap . . . . . .10 Omeprazole . . . . . . . . . 16 Omnaris . . . . . . . . . . . 19 Omnitrope . . . . . . . . . 15 Ondansetron Tab . . . . . . . 16 Onetouch Kit Ultra . . . . . 14 Onetouch Kit Ultra 2 . . . . 14 Onetouch Kit Ultra Mini . . 14 Onetouch Kit Ultra Smart . 14 Onetouch Kit Verio IQ . . . 14 Onetouch Lancets . . . . . 14 Onetouch Test Strips . . . . 14 Onetouch Ultra Blue Test Strips . . . . . . . . 14 Onetouch Verio Test Strips . 14 Onfi . . . . . . . . . . . . . 12 Onglyza . . . . . . . . . . . 15 24 Index of Covered Drugs Opana ER . . . . . . . . . . 18 Opsumit . . . . . . . . . . . 11 Oracea . . . . . . . . . . . . 9 Orencia SC . . . . . . . . . 17 Orenitram . . . . . . . . . . 11 Orsythia . . . . . . . . . . . 20 Ortho Tri-Cyclen Lo . . . . .20 Osphena . . . . . . . . . . . 20 Ovidrel . . . . . . . . . . . 17 Oxcarbazepine . . . . . . . . 12 Oxsoralen-UL . . . . . . . . 13 Oxybutynin . . . . . . . . . 19 Oxybutynin ER . . . . . . . . 19 Oxycodone Tab . . . . . . . . 18 Oxycodone w/ Acetaminophen . . . . 18 Oxycontin . . . . . . . . . . 18 P Pantoprazole . . . . . . . . . 16 Paroxetine Tab . . . . . . . . 11 Pataday . . . . . . . . . . . 15 Patanol . . . . . . . . . . . 15 Pegasys . . . . . . . . . . . 9 Penicillin VK . . . . . . . . . . 9 Pentasa . . . . . . . . . . . 16 Perforomist . . . . . . . . . 19 Permethrin Cream 5% . . . . 13 Phenazopyridine . . . . . . . 18 Phentermine Tab . . . . . . . 18 Phenytoin . . . . . . . . . . 12 Pioglitazone . . . . . . . . . 15 Plegridy . . . . . . . . . . . 12 Polyethylene Glycol 3350 Powder . . . 16 Polymyxin B/Trimethoprim Solution . . . . . . . . . 15 Potassium Chloride ER . . . . 19 Potassium Chloride Micro ER . 20 Potassium Citrate . . . . . . .20 Pradaxa . . . . . . . . . . . 9 Pramipexole . . . . . . . . . 12 Pravastatin . . . . . . . . . . 10 Precision Test Strips . . . . 14 Prednisolone Ophthalmic Suspension . . . . . . . . 16 Prednisolone Solution . . . . 15 Bold type = Brand-name drug [Plain type = Generic drug] Prednisolone Syrup, Solution . 15 Prednisone . . . . . . . . . . 15 Premarin Tab . . . . . . . . 20 Premarin Vaginal Cream . . 20 Premphase . . . . . . . . . 20 Prempro . . . . . . . . . . . 20 Prepopik . . . . . . . . . . . 16 Previfem . . . . . . . . . . . 20 Prezista . . . . . . . . . . . 16 Primidone . . . . . . . . . . 12 Pristiq . . . . . . . . . . . . 11 Proair HFA, RespiClick . . . 19 Prochlorperazine . . . . . . . 12 Procrit . . . . . . . . . . . . 18 Progesterone Cap . . . . . . 20 Prograf Cap . . . . . . . . . 19 Promethazine/Codeine Syrup . 18 Promethazine DM Syrup . . . 18 Promethazine Tab . . . . . . 19 Propranolol . . . . . . . . . . 10 Propranolol ER . . . . . . . . 10 Protopic Ointment . . . . . 13 Protosol HC . . . . . . . . . 16 Proventil HFA . . . . . . . . 19 Pulmicort Flexhaler . . . . . 19 Pulmozyme . . . . . . . . . 18 Pylera . . . . . . . . . . . . 16 Q QNasl . . . . . . . . . . . . 19 Quetiapine . . . . . . . . . . 12 Quinapril . . . . . . . . . . . 10 Qvar . . . . . . . . . . . . . 19 R Rabeprazole . . . . . . . . . 16 Raloxifene . . . . . . . . . . 18 Ramipril . . . . . . . . . . . 10 Ranexa . . . . . . . . . . . 11 Ranitidine . . . . . . . . . . 16 Rapaflo . . . . . . . . . . . 17 Rapamune . . . . . . . . . . 19 Rasuvo . . . . . . . . . . . 17 Rebif . . . . . . . . . . . . . 12 Rebif Titrtn . . . . . . . . . 12 Reclipsen . . . . . . . . . . . 20 Rectiv . . . . . . . . . . . .18 Relpax . . . . . . . . . . . . 11 Renvela Tab . . . . . . . . . 18 Restasis . . . . . . . . . . . 16 Retin-A Micro . . . . . . . .13 Revlimid . . . . . . . . . . . 9 Reyataz . . . . . . . . . . . 16 Rezira . . . . . . . . . . . . 18 Risperidone Tab . . . . . . . . 12 Rizatriptan Tab, ODT . . . . . 11 Ropinirole . . . . . . . . . . 12 S Safyral . . . . . . . . . . . . 20 Saizen . . . . . . . . . . . . 15 Saphris . . . . . . . . . . . 12 Savaysa . . . . . . . . . . . 9 Sensipar . . . . . . . . . . . 15 Serevent Diskus . . . . . . . 19 Seroquel XR . . . . . . . . . 12 Sertraline . . . . . . . . . . . 11 Sildenafil Tab . . . . . . . . . 11 Silenor . . . . . . . . . . . . 12 Simcor . . . . . . . . . . . . 10 Simponi . . . . . . . . . . . 17 Simvastatin . . . . . . . . . .11 Solodyn . . . . . . . . . . . 9 Sotalol . . . . . . . . . . . . 11 Sovaldi . . . . . . . . . . . . 9 Spiriva Handihaler . . . . . 19 Spiriva Respimat . . . . . . 19 Spironolactone . . . . . . . . 10 Sprintec 28 . . . . . . . . . . 20 Stelara . . . . . . . . . . . . 17 Stendra . . . . . . . . . . . 17 Strattera . . . . . . . . . . . 11 Stribild . . . . . . . . . . . 16 Suboxone Film . . . . . . . 18 Sucralfate Tab . . . . . . . . 16 Sulfacetamide/Sulfur Emulsion13 Sulfamethoxazole-Trimethoprim9 SulfamethoxazoleTrimethoprim DS . . . . . 9 Sulfasalazine . . . . . . . . . 16 Sumatriptan Tab and Spray . . 12 Sumavel Dose . . . . . . . . 12 Suprep Bowel Prep . . . . . 16 25 Index of Covered Drugs Sustiva . . . . . . . . . . . 17 Symbicort . . . . . . . . . . 19 Synagis . . . . . . . . . . . 18 Synthroid . . . . . . . . . . 15 Synvisc . . . . . . . . . . . 18 T Taclonex . . . . . . . . . . . 13 Tacrolimus Cap . . . . . . . . 19 Tamiflu . . . . . . . . . . . . 9 Tamoxifen Tab . . . . . . . . . 9 Tamsulosin . . . . . . . . . . 17 Tasigna . . . . . . . . . . . . 9 Tecfidera . . . . . . . . . . 12 Tekturna . . . . . . . . . . . 10 Tekturna HCT . . . . . . . . 10 Telmisartan . . . . . . . . . . 10 Temazepam . . . . . . . . . 12 Temozolomide . . . . . . . . 9 Terazosin . . . . . . . . . . . 10 Terazosin . . . . . . . . . . . 17 Terbinafine Tab . . . . . . . . 9 Terconazole Vaginal Cream . . 20 Testosterone Cypionate IM Injection . . . . . . . . . 17 Timolol . . . . . . . . . . . .16 Timoptic Ocudose . . . . . 16 Tirosint . . . . . . . . . . . 15 Tivicay . . . . . . . . . . . . 17 Tizanidine . . . . . . . . . . 18 Tobramycin . . . . . . . . . . 15 Tobramycin/Dexamethasone . 15 Tolterodine . . . . . . . . . . 19 Topiramate Tab . . . . . . . . 12 Torsemide Tab . . . . . . . . 10 Toviaz . . . . . . . . . . . . 19 Tracleer . . . . . . . . . . . 11 Tramadol Tab . . . . . . . . . 18 Tramadol w/ Acetaminophen 18 Transderm-Scop . . . . . . .16 Travatan Z . . . . . . . . . . 16 Trazodone . . . . . . . . . . 11 Tretinoin Cream . . . . . . . 13 Tretinoin Microsphere Gel . . 13 Triamcinolone . . . . . . . . 13 Triamterene/HCTZ . . . . . . 10 Bold type = Brand-name drug [Plain type = Generic drug] Triazolam Tab . . . . . . . . . 12 Tribenzor . . . . . . . . . . 10 Tri-Linyah . . . . . . . . . . .20 Trinessa . . . . . . . . . . . . 20 Tri-Previfem . . . . . . . . . .20 Tri-Sprintec . . . . . . . . . .20 Triumeq . . . . . . . . . . . 17 Truetest Test Strips . . . . . 14 Truetrack Test Strips . . . . 14 Truvada . . . . . . . . . . . 17 Tudorza Pressair . . . . . . 19 W Warfarin . . . . . . . . . . . 9 Welchol . . . . . . . . . . . 11 X Xarelto . . . . . . . . . . . . 9 Xolair . . . . . . . . . . . . 19 Xopenex HFA . . . . . . . . 19 Xulane . . . . . . . . . . . . 20 U Z Uceris . . . . . . . . . . . . 16 Uloric . . . . . . . . . . . . 18 Ursodiol . . . . . . . . . . . 18 Zarah . . . . . . . . . . . . . 20 Zelapar . . . . . . . . . . . 12 Zenpep . . . . . . . . . . . 16 Zetia . . . . . . . . . . . . . 11 Zetonna . . . . . . . . . . . 19 Ziprasidone Cap . . . . . . . 12 Zolmitriptan Tab . . . . . . . 12 Zolpidem . . . . . . . . . . . 12 Zolpidem ER . . . . . . . . . 12 Zomacton . . . . . . . . . . 15 Zomig Nasal Spray . . . . . 12 Zonisamide . . . . . . . . . . 12 Zovirax . . . . . . . . . . . 13 Zubsolv . . . . . . . . . . . 18 Zutripro . . . . . . . . . . . 18 Zyclara . . . . . . . . . . . . 13 Zytiga . . . . . . . . . . . . 9 V Vagifem . . . . . . . . . . . 20 Valacyclovir . . . . . . . . . . 9 Valsartan . . . . . . . . . . . 10 Valsartan/HCTZ . . . . . . . . 10 Vascepa . . . . . . . . . . . 11 Vectical . . . . . . . . . . . 13 Velphoro . . . . . . . . . . 18 Venlafaxine ER . . . . . . . . 11 Venlafaxine Tab . . . . . . . . 11 Ventolin HFA . . . . . . . . 19 Veramyst . . . . . . . . . . 19 Verapamil ER . . . . . . . . . 10 Vesicare . . . . . . . . . . . 19 Vestura . . . . . . . . . . . . 20 Viagra . . . . . . . . . . . . 17 Vicodin . . . . . . . . . . . . 18 Vicodin ES . . . . . . . . . . 18 Victoza . . . . . . . . . . . 15 Vigamox . . . . . . . . . . 15 Viibryd . . . . . . . . . . . 11 Viorele . . . . . . . . . . . . 20 Viread . . . . . . . . . . . . 17 Vitamin D . . . . . . . . . . 20 Vivelle-Dot . . . . . . . . . 20 Voltaren Gel . . . . . . . . 19 Vytorin . . . . . . . . . . . 11 Vyvanse . . . . . . . . . . . 11 26 “My Medications” worksheet Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well. Name of Medicine and Strength Drug Tier I Take This Medicine For Directions Doctor Example: Lisinopril, 20 mg Tier 1 High blood pressure One tablet daily Dr. Johnson 27 Half Tab Rx – Tablet Splitting Through your plan’s Half Tab Rx Program, tablet splitting may be a safe, effective way for you to lower your prescription medication costs. To take advantage of the potential savings, your doctor writes a new prescription for double the strength and half the quantity of your current medication. Then, you simply split the tablets in half to safely and easily save up to 50 percent on your prescription costs. Half Tab Rx works because some medications cost about the same, regardless of dosage. For example, the 20-mg and 40-mg dosages of a popular medication used to treat high cholesterol both cost about $80.70 for a 30-day supply. When 15 40-mg tablets are split, a 30-day supply of 20-mg half tablets costs only $40.35. Splitting the 40-mg tablets effectively cuts the cost of your drug in half. See the following example: Without Half Tab Rx With Half Tab Rx Drug* and dosage 20 mg 40 mg Number of tablets 30 (whole tablets) 15 (split in half) 30 30 Days supplied Cost Annual savings Plan: $80.70 You: $20.00 Plan: $40.35 None You: $10.00 Plan: $484.20 You: $120.00 Actual savings vary based on your plan design, but with Half Tab Rx, the savings are real. Helping your plan save money contributes to the overall cost management of your pharmacy benefit plan. * Drug included in this savings example is a popular medication used to treat high cholesterol. To Split or Not to Split? You are not required to split tablets to save money, but if you choose to participate, talk with your doctor before splitting any of your medications. If you and your doctor agree that tablet splitting is a safe way for you to save money, you will need: 1. A new prescription from your doctor for the new dosage of your medication. The prescription must clearly instruct you to take one-half tablet daily. 2. A tablet splitting device. Tablet splitters allow you to cut tablets more accurately and safely. You can purchase one for just a few dollars at a local pharmacy. Safe Tablet Splitting Because not all drugs are safe to split, our independent review committee of practicing doctors and pharmacists has defined a list of drugs covered under the Half Tab Rx Program. Only those listed below are eligible for the program. s Atacand s Fosinopril (Monopril) s Avapro s Lisinopril (Prinivil, Zestril) s Cozaar s Metoprolol ER (Toprol XL) s Crestor s Paroxetine (Paxil) s Diovan s Pravastatin (Pravachol) s Lexapro s Quinapril (Accupril) s Lipitor s Sertraline (Zoloft) s Benazepril (Lotensin) s Simvastatin (Zocor) s Citalopram (Celexa) s Zolpidem (Ambien) s Doxazosin (Cardura) www.optumrx.com 2300 Main Street, Irvine, CA 92614 OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at www.optum.com. All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. ORX0623-INV_120714 ©2012 OptumRx, Inc. Welcome to OptumRx Specialty Pharmacy We’re Here to Help Specialty pharmaceuticals are some of the true “wonder drugs” in medicine today. Because treatment with these unique products can sometimes be an intense experience, OptumRxTM Specialty Pharmacy does more than fill your prescriptions. We also provide you — and your prescriber — with a team to support you throughout the course of your specialty medication therapy. Your pharmacy benefit plan has chosen OptumRx as its exclusive specialty pharmacy. This means you must fill all prescriptions for specialty drugs through OptumRx Specialty Pharmacy. Program Features Your Treatment Team: Patient Care Coordinators (PCCs) are your primary contacts at OptumRx Specialty Pharmacy. They will check in with you to schedule deliveries and help manage your inventory of medication and supplies. Our Registered Pharmacists will also actively participate as members of your treatment team, reviewing lab results, monitoring compliance and checking for side effects or drug interactions. If necessary, they will also recommend treatment adjustments to your prescriber. Copayments/Coinsurance: Before your specialty drug order can ship, you must pay the specialty copayment/coinsurance defined by your plan. Credit cards are preferred and may also be more convenient for you. We can securely file the number (with your permission) to charge future refills to the same credit card. Orders and Refills: When you’re on an intensive drug therapy, it’s critical to receive your refills in a timely manner. That’s why a PCC will contact you about a week before each shipment. In addition to scheduling your deliveries, the PCC will check to see if you need any additional supplies and answer any questions you may have. Deliveries: All specialty pharmaceuticals are shipped at no charge to you. Refrigerated specialty pharmaceuticals are shipped overnight, with scheduled deliveries Tuesday through Friday. Non-refrigerated items are shipped via ground delivery. Orders can be shipped either to your doctor’s office or your home, depending on who administers your medication. Clinical Management Programs (CMPs): CMPs provide an enhanced level of care for certain medical conditions treated with select specialty pharmaceuticals. If you are eligible to participate in a CMP, specially trained nurses and pharmacists will contact you regularly via telephone with additional care and support. If you fill a prescription for a specialty medication with an available CMP, you are automatically enrolled. For more information on available programs, please call 1-800-548-6150 (TTY 711). For more information about OptumRx Specialty Pharmacy, call 1-866-218-5445 (TTY 711). Our Telephonic Device for the Hearing Impaired (TDHI) number is 1-800-498-5428. We’re available to assist you 6 a.m.–5 p.m., PT, Monday– Friday. On-call pharmacists are available 24 hours a day, 7 days a week. You may also visit us online at www.optumrx.com. www.optumrx.com 2300 Main Street, Irvine, CA 92614 OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at www.optum.com. All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. ORX0121A_120629 ©2012 OptumRx, Inc. Quantity Limits on Medications Your pharmacy benefit plan’s quantity limits program protects you and can help you get the best results from your medication therapy. Along with supporting safe and appropriate dosing, quantity limits can also keep prescription drug costs lower for you and your benefit plan sponsor. Determining Quantity Limits Quantity limits are meant to minimize the risk of over-dosing and unwanted drug interactions. Quantity limit rules are based on: • Food and Drug Administration (FDA) approved indications • Manufacturer’s package labeling instructions • Well-accepted or published clinical recommendations Establishing Guidelines for Use Our review committee of independent doctors and pharmacists meets regularly to review medications and consider how they should be covered by pharmacy benefit plans. They also recommend quantity limit guidelines. Quantity Limits on Medications Common Medications with Quantity Limit THERAPY CLASS MEDICATION NAME LIMIT Aciphex Sprinkles Dexilant Esomeprazole 24.65 mg Esomeprazole 49.3 mg First-Omeprazole Helidac Lansoprazole Metozolv ODT Nexium Nexium Granules Omeprazole + SyrSpend Prevacid 2 tablets per day 1 capsule per day 2 capsules per day 1 tablet per day 2 tablets per day 40 mL per day 224 tablets per year 20 mL per day 12-week supply per six months 2 capsules per day 2 packs per day 40 mL per day 2 tablets per day Page title interior spread Acid Suppression Aciphex (rabeprazole) Prevacid 24H (lansoprazole) Prevpac (lansoprazole/amoxicillin) Prilosec Prilosec (omeprazole) Protonix Protonix (pantoprazole) Pylera Zegerid Zegerid OTC (omeprazole/sodium bicarbonate) Allergies, Cough and Cold Allegra Allergy (fexofenadine) suspension Allegra Allergy Childrens Allergy-D 12 Hour (wal-fex-D) Allergy-D 24 Hour (fexofen/pse, wal-fex-D) Astelin Nasal (azelastine) Astepro (azelastine) Beconase AQ Clarinex (deloratadine), Clarinex RDT (desloratadine) Clarinex Syrup Clarinex-D 5-240 mg Clarinex-D 2.5-120 mg Dymista 2 OptumRx | optumrx.com 2 capsules per day 112 capsules per year 2 packets per day 2 capsules per day 2 packets per day 2 tablets per day 1 bottle (120 capsules) per year 2 packets per day 2 capsules per day 10 mL per day 2 tablets per day 2 tablets per day 1 tablet per day 2 bottles (60 mL) per month 2 bottles (60 mL) per month 2 bottles (50 gms) per month 1 tablet per day 10 mL per day 1 tablet per day 2 tablets per day 1 bottle (23 g) per month THERAPY CLASS MEDICATION NAME Allergies, Cough and Cold Grastek Continued Nasonex Omnaris Patanase Qnasl Ragwitek Rhinocort (budesonide) Veramyst Alzheimer's Disease Antipsychotics Xyzal (levocetirizine) Xyzal (levocetirizine) Solution Zetonna Aricept (donepezil) Aricept ODT (donepezil odt) Exelon Exelon (rivastigmine) Namenda 10 mg Namenda 5 mg Namenda Titration Pak Namenda XR Razadyne (galantamine) Razadyne ER (galantamine er) Abilify Abilify Disc Abilify Injection Abilify Solution clozapine 200 mg clozapine 50 mg Clozaril (clozapine) 100 mg Clozaril (clozapine) 25 mg Fanapt Fanapt Pak Fazaclo Fazaclo (clozapine odt) 100 mg Fazaclo (clozapine odt) 12.5 mg, 25 mg Geodon Geodon (ziprasidone) Invega 1.5 mg, 3 mg, 9 mg Invega 6 mg Invega Sustenna LIMIT 1 tablet per day 2 bottles (34 g) per month 1 bottle (12.5 g) per month 1 bottle (30.5 g) per month 0.29 g per day 1 tablet per day 2 bottles (17.2 g) per month 1 bottle (10 g) per month 1 tablet per day 10 mL daily 1 inhaler (6.1 g) per month 1 tablet per day 1 tablet per day 1 patch per day 2 capsules per day 2 tablets per day 3 tablets per day 1 pack (49 tablets) per month 1 capsule per day 2 tablets per day 1 tablet per day 1 tablet per day 2 tablets per day 4 mL per day 25 mL per day 4 tablets per day 3 tablets per day 9 tablets per day 3 tablets per day 2 tablets per day 1 pak per prescription 3 tablets per day 9 tablets per day 3 tablets per day 2 vials per day 2 capsules per day 1 tablet per day 2 tablets per day 1 syringe per month 3 Quantity Limits on Medications THERAPY CLASS MEDICATION NAME LIMIT Antipsychotics Continued Risperdal M (risperidone odt) Risperdal (risperidone) Risperdal (risperidone) Solution Risperdal Injection risperidone odt Saphris Seroquel (quetiapine) 25 mg, 50 mg, 100 mg, 200 mg Seroquel (quetiapine) 300 mg, 400 mg Seroquel XR 200 mg Seroquel XR 50 mg, 150 mg, 300 mg, 400 mg Versacloz Zyprexa (olanzapine) Zyprexa (olanzapine) Injection Zyprexa Relprevv 210 mg, 300 mg Zyprexa Relprevv 405 mg Zyprexa Zydis (olanzapine odt) alprazolam alprazolam Ativan (lorazepam) 0.5 mg, 1 mg Ativan (lorazepam) 2 mg chlordiazepoxide 10 mg chlordiazepoxide 25 mg chlordiazepoxide 5 mg lorazepam intensol Niravam (alprazolam) 0.25 mg, 0.5 mg, 1 mg Niravam (alprazolam) 2 mg oxazepam Tranxene T (clorazepate dipotassium, gene-xene) 15 mg Tranxene T (clorazepate dipotassium, gene-xene) 3.75 mg Tranxene T (clorazepate dipotassium, gene-xene) 7.5 mg Xanax (alprazolam) 0.25 mg, 0.5 mg, 1 mg Xanax (alprazolam) 2 mg Xanax XR (alprazolam er) 0.5 mg, 1 mg 2 tablets per day 2 tablets per day 8 mL per day 2 vials per month 2 tablets per day 2 tablets per day 3 tablets per day Anxiety 4 OptumRx | optumrx.com 2 tablets per day 3 tablet per day 2 tablets per day 18 mL per day 1 tablet per day 3 vials per day 2 vials per month 1 vial per month 1 tablet per day 4 tablets per day 10 mL per day 3 tablets per day 5 tablets per day 30 capsules per day 12 capsules per day 4 capsules per day 5 mL per day 4 tablets per day 5 tablets per day 4 capsules per day 6 tablets per day 24 tablets per day 12 tablets per day 4 tablets per day 5 tablets per day 1 tablet per day THERAPY CLASS MEDICATION NAME LIMIT Anxiety Continued Xanax XR (alprazolam er) 2 mg Xanax XR (alprazolam er) 3 mg Accolate (zafirlukast) Advair Diskus Advair HFA Aerospan Alvesco Anoro Ellipta Arcapta Asmanex Breo Ellipta Combivent Dulera Flovent Diskus 250 mcg 5 tablets per day 3 tablets per day 2 tablets per day 1 inhaler (60 blisters) per month 1 inhaler (12 g) per month 2 inhalers (17.8 g) per month 2 inhalers per month 1 inhaler (60 blisters) per month 1 inhaler (30 blisters) per month 1 inhaler per month 1 inhaler (60 blisters) per month 2 inhalers (8 g) per month 1 inhaler (13 g) per month 4 inhalers (240 capsules) per month Flovent Diskus 50 mcg, 100 mcg Flovent HFA Foradil Perforomist Proair HFA Proventil Pulmicort Qvar 40 mcg Qvar 80 mcg Serevent Diskus Singulair (montelukast) Tabs, Chews, Granules Spiriva Striverdi Symbicort Tudorza Pressair Ventolin HFA Xopenex HFA Zyflo, Zyflo CR Adderall (amphetamine/ dextroamphetamine) Adderall XR (amphetamine/ dextroamphetamine er) 20 mg, 25 mg, 30 mg Adderall XR (amphetamine/ dextroamphetamine er) 5 mg, 10 mg, 15 mg 2 inhalers (120 blisters) per month 2 inhalers per month 1 inhaler (60 capsules) per month 2 vials (4 mL) per day 2 inhalers per month 2 inhalers per month 2 inhalers per month 2 inhalers per month 3 inhalers per month 1 device per month 1 tablet/chewable/packet per day Asthma/COPD Attention Deficit Disorder 1 inhaler (30 capsules) per month 1 inhaler per month 1 inhaler per month 1 inhaler per month 2 inhalers per month 2 inhalers per month 4 tablets per day 2 tablets per day 2 capsules per day 1 capsule per day 5 Quantity Limits on Medications THERAPY CLASS MEDICATION NAME LIMIT Attention Deficit Disorder Continued Concerta (methylphenidate er) 18 mg, 27 mg, 36 mg Concerta (methylphenidate er) 54 mg Daliresp Daytrana Desoxyn (methamphetamine) Dexedrine CR (dextroamphetamine er) 10 mg Dexedrine CR (dextroamphetamine er) 15 mg Dexedrine CR (dextroamphetamine er) 5 mg Focalin (dexmethylphenidate) 10 mg Focalin (dexmethylphenidate) 2.5 mg, 5 mg Focalin XR (dexmethylphenidate er) Focalin XR 20 mg Focalin XR 5 mg, 10 mg Intuniv Kapvay Dose Pack Kapvay (clonidine er) Metadate CD (methylphenidate cd) Metadate ER (methylphenidate sr) Methylin (methylphenidate) 10 mg/5 mL Solution Methylin (methylphenidate) 5 mg/5 mL Solution Methylin 10 mg Methylin 2.5 mg, 5 mg methylphenidate er Procentra (dextroamphetamine) Solution Quillivant Ritalin (methylphenidate) 10 mg Ritalin (methylphenidate) 5 mg, 20 mg Ritalin LA (methylphenidate er) 10 mg, 20 mg, 40 mg Ritalin LA (methylphenidate er) 30 mg Ritalin SR (methylphenidate er) Strattera 10 mg, 40 mg, 60 mg, 80 mg, 100 mg 2 tablets per day 6 OptumRx | optumrx.com 1 tablet per day 1 tablet per day 1 patch per day 5 tablets per day 5 capsules per day 4 capsules per day 2 capsules per day 2 tablets per day 3 tablets per day 1 capsule per day 2 capsules per day 1 capsule per day 1 tablet per day 2 tablets per day 4 tablets per day 1 capsule per day 3 tablets per day 30 mL per day 60 mL per day 6 tablets per day 3 tablets per day 5 tablets per day 60 mL per day 12 mL per day 5 tablets per day 3 tablets per day 1 capsule per day 2 capsules per day 3 tablets per day 1 capsule per day THERAPY CLASS Attention Deficit Disorder Continued MEDICATION NAME Strattera 18 mg, 25 mg Vyvanse Zenzedi (dexedrine, dextroamphetamine) 10 mg Zenzedi (dexedrine, dextroamphetamine) 5 mg Zenzedi 15 mg, 30 mg Zenzedi 2.5 mg, 20 mg Zenzedi 7.5 mg Birth Control Depo-Provera (medroxyprogesterone) Ella Plan B (My Way, Next Choice, levonorgestrel) Blood Glucose Monitoring Blood Glucose Test Strips Blood Thinners Aggrenox Brilinta Effient Eliquis Plavix (clopidogrel) 300 mg Plavix (clopidogrel) 75 mg Pradaxa ticlopidine Xarelto 10 mg, 20 mg Xarelto 15 mg Zontivity Cancer Bosulif 100 mg Bosulif 500 mg Caprelsa 100 mg Caprelsa 300 mg Cometriq 100 mg Cometriq 140 mg Cometriq 60 mg Erivedge Gilotrif Gleevec 100 mg Gleevec 400 mg Iclusig 15 mg Iclusig 45 mg Imbruvica Inlyta 1 mg Inlyta 5 mg LIMIT 2 capsules per day 1 capsule per day 6 tablets per day 2 tablets per day 2 tablets per day 3 tablets per day 8 tablets per day 1 vial per prescription 1 tablet per prescription 1 tablet per prescription 300 test strips per month 2 capsules per day 2 tablets per day 1 tablet per day 2 tablets per day 3 tablets per prescription 1 tablet per day 2 tablets per day 2 tablets per day 1 tablet per day 2 tablets per day 1 tablet per day 4 tablets per day 1 tablet per day 2 tablets per day 1 tablet per day 2 capsules per day 4 capsules per day 3 capsules per day 1 capsule per day 1 tablet per day 8 tablets per day 2 tablets per day 2 tablets per day 1 tablet per day 4 capsules per day 8 tablets per day 4 tablets per day 7 Quantity Limits on Medications THERAPY CLASS MEDICATION NAME LIMIT Cancer Continued Jakafi Mekinist 0.5 mg Mekinist 2 mg Nexavar 2 tablets per day 4 tablets per day 1 tablet per day 4 tablets per day Pomalyst Revlimid Sprycel 100 mg, 140 mg Sprycel 20 mg Sprycel 50 mg Sprycel 70 mg, 80 mg Stivarga Sutent 12.5 mg Sutent 25 mg Sutent 37.5 mg, 50 mg Tafinlar 50 mg Tafinlar 75 mg Tarceva 25 mg Tarceva 100 mg, 150 mg Torisel Tykerb Votrient Xalkori Xtandi Zelboraf Zolinza Zydelig Zykadia Kalydeco Aplenzin Brintellix Celexa (citalopram) citalopram solution Desvenlafaxine 50 mg Desvenlafaxine 100 mg Desvenlafaxine ER 50 mg Desvenlafaxine ER 100 mg Effexor XR (venlafaxine er) 150 mg Effexor XR (venlafaxine er) 37.5 mg, 75 mg Emsam 1 capsule per day 1 capsule per day 1 tablet per day 9 tablets per day 3 tablets per day 2 tablets per day 3 tablets per day 7 capsules per day 3 capsules per day 1 capsule per day 6 capsules per day 4 capsules per day 6 tablets per day 1 tablet per day 8 mL per month 6 tablets per day 4 tablets per day 2 capsules per day 4 capsules per day 8 tablets per day 4 capsules per day 2 tablets per day 5 capsules per day 2 tablets per day 1 tablet per day 1 tablet per day 1 tablet per day 20 mL per day 1 tablet per day 4 tablets per day 1 tablet per day 4 tablets per day 2 tablets per day 3 tablets per day Cystic Fibrosis Depression 8 OptumRx | optumrx.com 1 patch per day THERAPY CLASS MEDICATION NAME LIMIT Depression Continued Fetzima fluoxetine 10 mg fluoxetine 20 mg Forfivo XL Khedezla 100 mg Khedezla 50 mg Latuda Lexapro (escitalopram) Lexapro (escitalopram) Solution Luvox CR (fluvoxamine er) Oleptro Paxil CR (paroxetine er) Pexeva Pristiq 100 mg Pristiq 50 mg Prozac Weekly (fluoxetine dr) Sarafem 10 mg Sarafem 20 mg Symbyax (olanzapine/fluoxetine) 3-25 mg, 6-25 mg Symbyax (olanzapine/fluoxetine) 6-50 mg, 12-25 mg, 12-50 mg venlafaxine er 150 mg venlafaxine er 225 mg venlafaxine er 37.5 mg, 75 mg Viibryd Viibryd Kit Wellbutrin XL (bupropion xl) 150 mg Wellbutrin XL (bupropion xl) 300 mg Actoplus Met (pioglitazone/ metformin) Actoplus Met XR 15-1000 mg Actoplus Met XR 30-1000 mg Actos (pioglitazone) 15 mg Actos (pioglitazone) 30 mg, 45 mg Avandamet Avandaryl Avandia 2 mg Avandia 4 mg Avandia 8 mg 1 capsule per day 1 tablet per day 2 tablets per day 1 tablet per day 4 tablets per day 1 tablet per day 1 tablet per day 1 tablet per day 20 mL per day 2 capsules per day 1 tablet per day 2 tablets per day 1 tablet per day 4 tablets per day 1 tablet per day 1 tablet per week 1 tablet per day 2 tablets per day 3 capsules per day Diabetes 1 capsule per day 2 tablets per day 1 tablet per day 3 tablets per day 1 tablet per day 1 kit (30 tablets) per prescription 3 tablets per day 1 tablet per day 3 tablets per day 2 tablets per day 1 tablet per day 2 tablets per day 1 tablet per day 2 tablets per day 1 tablet per day 3 tablets per day 2 tablets per day 1 tablet per day 9 Quantity Limits on Medications THERAPY CLASS MEDICATION NAME LIMIT Diabetes Continued Bydureon Byetta 10 mcg Byetta 5 mcg Cycloset Duetact (pioglitazone/glimepiride) Farxiga Invokamet Invokana Janumet Janumet XR 100-1,000 mg Janumet XR 50-500 mg, 50-1,000 mg Januvia Jardiance Jentadueto Juvisync Kazano Kombiglyze 2.5-1,000 mg Kombiglyze 5-500 mg, 5-1,000 mg Nesina Onglyza Oseni Prandimet Prandin (repaglinide) 0.5 mg Prandin (repaglinide) 2 mg Starlix (nateglinide) Tanzeum Tradjenta Victoza Bunavail buprenorphine sublingual Suboxone 2-0.5 mg, 8-2 mg Suboxone 4-1 mg, 12-3 mg Zubsolv Northera 100 mg Northera 200 mg, 300 mg Cialis 10 mg, 20 mg Cialis 2.5 mg, 5 mg Levitra Staxyn 4 pens or vials per month 2 syringes (2.4 mL) per month 2 syringes (1.2 mL) per month 6 tablets per day 1 tablet per day 1 tablet per day 2 tablets per day 1 tablet per day 2 tablets per day 1 tablet per day 2 tablets per day 1 tablet per day 1 tablet per day 2 tablets per day 1 tablet per day 2 tablets per day 2 tablets per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 5 tablets per day 4 tablets per day 8 tablets per day 3 tablets per day 4 syringes per month 1 tablet per day 3 pens per month 2 films per day 3 tablets per day 3 tablets per day 2 tablets per day 3 tablets per day 3 capsules per day 6 capsules per day 6 tablets per month 1 tablet per day 6 tablets per month 6 tablets per month Drug Dependence Enzyme Replacement Therapy Erectile Dysfunction 10 OptumRx | optumrx.com THERAPY CLASS MEDICATION NAME LIMIT Erectile Dysfunction Continued Stendra Viagra Acular (ketorolac) Acular LS (ketorolac) Acuvail Alphagan P (brimonidine) Azopt Bepreve Besivance Bromday Bromfenac Ciloxan Ciloxan (ciprofoxacin) Combigan diclofenac solution Ilevro Lastacaft levofloxacin solution Lumigan Moxeza Nevanac Ocufen (flurbiprofen) Ocuflox (gatifloxacin) Patanol Prolensa Rescula Simbrinza Tobradex ST Travatan Z travoprost Vigamox Xalatan (latanaprost) Zioptan Zirgan Zymaxid (gatifloxacin) Savella Savella Titration Pak 6 tablets per month 6 tablets per month 15 mL per month 5 mL per month 65 units per 180 days 10 mL per month 15 mL per month 1 bottle (10 mL) per month 1 bottle (5 mL) per month 1 bottle per prescription 1 bottle (2.5 mL ) per prescription 7 g per month 10 mL per month 10 mL per month 2.5 mL per month 1 bottle (1.7 mL) per month 3 mL per month 10 mL per month 2.5 mL per month 3 mL per prescription 6 mL per month 2.5 mL per month 10 mL per month 1 bottle (5 mL) per month 2 bottles (3.2 mL) per six months 1 bottle (5 mL) per month 8 mL per month 20 mL per prescription 5 mL per month 5 mL per month 3 mL per month 1 bottle (2.5 mL) per month 30 containers (9 mL) per 30 days 1 tube (5 g) per prescription 2.5 mL per month 2 tablets per day 55 tablets (1 pack) per prescription Eye Conditions Fibromyalgia 11 Quantity Limits on Medications THERAPY CLASS MEDICATION NAME LIMIT Fungal Infections Oravig Terazol 3 (terconazole, zazole) Terazol 3 (terconazole, zazole) suppository Terazol 7 (terconazole, zazole) Vfend (voriconazole) Cerdelga Colcrys Krystexxa Uloric Serostim Zorbtive Altace (ramipril) Amturnide Atacand (candesartan) 16 mg Atacand (candesartan) 4 mg, 32 mg Atacand (candesartan) 8 mg Atacand HCT (candesartan/hctz) 16-12.5 mg Atacand HCT (candesartan/hctz) 32-12.5 mg, 32-25 mg Avalide (irbesartan/hctz) 150-12.5 mg Avalide (irbesartan/hctz) 300-12.5 mg Avapro (irbesartan) 150 mg Avapro (irbesartan) 300 mg Avapro (irbesartan) 75 mg Azor Bactroban (mupirocin) Benicar 40 mg Benicar 5 mg, 20 mg Benicar HCT Bidil Bystolic 2.5 mg Bystolic 20 mg Bystolic 5 mg, 10 mg Caduet (amlodipine/atorvastatin) Cardene SR Cardizem CD (cartia-xt, dilt-cd, dilt-XR, diltiazem) Cardizem LA (diltiazem er, matzim la) 180 mg 14 tablets per prescription 1 tube (20 g) per prescription 1 box (3 suppositories) per prescription 1 tube (45 g) per prescription 4 tablets per day 2 capsules per day 4 tablets per day 2 vials (4 mL) per month 1 tablet per day 1 vial per day 1 vial per day 2 capsules per day 1 tablet per day 2 tablets per day 1 tablet per day 3 tablets per day 2 tablets per day Gaucher Disease Gout Growth Hormones High Blood Pressure 12 OptumRx | optumrx.com 1 tablet per day 2 tablets per day 1 tablet per day 2 tablets per day 1 tablet per day 3 tablets per day 1 tablet per day 1 tube (15 g) per month 1 tablet per day 2 tablets per day 1 tablet per day 6 tablets per day 1 tablet per day 2 tablets per day 3 tablets per day 1 tablet per day 2 capsules per day 1 tablet per day 3 tablets per day THERAPY CLASS MEDICATION NAME LIMIT High Blood Pressure Continued Cardizem LA (diltiazem er, matzim la) 240 mg Cardizem LA (diltiazem er, matzim la) 300 mg, 360 mg, 420 mg Cardizem LA 120 mg Catapres-TTS (clonidine) 0.1 mg Catapres-TTS (clonidine) 0.2 mg, 0.3 mg Coreg CR 10 mg, 20 mg, 40 mg Coreg CR 80 mg Cozaar (losartan) 100 mg Cozaar (losartan) 25 mg, 50 mg Diovan (valsartan) 320 mg Diovan (valsartan) 40 mg, 80 mg, 160 mg Diovan HCT (valsartan/hctz) 320-12.5 mg, 320-25 mg Diovan HCT (valsartan/hctz) 80-12.5 mg, 160-12.5 mg, 160-25 mg Edarbi Edarbyclor Epaned Exforge 5-160 mg Exforge 5-320 mg, 10-160 mg, 10-320 mg Exforge HCT felodipine Hyzaar (losartan/hctz) 100-12.5 mg, 100-25 mg Hyzaar (losartan/hctz) 50-12.5 mg Lotrel (amlodipine/benazepril) Micardis (telmisartan) Micardis HCT (telmisartan/hctz) nisoldipine 20 mg, 25.5 mg nisoldipine 30 mg Norvasc (amlodipine) Sular (nisoldipine) Tekamlo Tekturna, Tekturna HCT Teveten Teveten (eprosartan) 600 mg, Teveten HCT 2 tablets per day 1 tablet per day 4 tablets per day 4 patches per month 8 patches per month 2 tablets per day 1 tablet per day 1 tablet per day 2 tablets per day 1 tablet per day 2 tablets per day 1 tablet per day 2 tablets per day 1 tablet per day 1 tablet per day 40 mg (40 mL) per day 2 tablets per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 2 tablets per day 1 tablet per day 1 tablet per day 2 tablets per day 1 tablet per day 2 tablets per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 2 tablets per day 1 tablet per day 13 Quantity Limits on Medications THERAPY CLASS MEDICATION NAME LIMIT High Blood Pressure Continued Tribenzor Twynsta (telmisartan/amlodipine) Advicor 1000-40 mg Advicor 500-20 mg, 750-20 mg, 1000-20 mg Altoprev Antara (fenofibrate) 134 mg, 200 mg Antara (fenofibrate) 43 mg Antara (fenofibrate) 67 mg, 130 mg Antara 30 mg Antara 90mg Crestor Fenoglide 120 mg Fenoglide 40 mg Fibricor (fenofibric) 105 mg Fibricor (fenofibric) 35 mg Juxtapid 20 mg Juxtapid 5 mg, 10 mg Lescol (fluvastatin) 20 mg Lescol (fluvastatin) 40 mg Lescol XL Lipitor (atorvastatin) Lipofen (fenofibrate) 150 mg Lipofen (fenofibrate) 50 mg Liptruzet Livalo Lofibra (fenofibrate) Lofibra (fenofibrate) 54 mg Lopid (gemfibrozil) Lovaza (omega-3-acid) Niaspan (niacin er) 500 mg Niaspan (niacin er) 750 mg, 1,000 mg Simcor 500-20 mg, 750-20 mg, 1000-20 mg Simcor 500-40 mg, 1000-40 mg Tricor (fenofibrate) 145 mg Tricor (fenofibrate) 48 mg Triglide Triglide 160 mg Trilipix (fenofibric) 135 mg Trilipix (fenofibric) 45 mg 1 tablet per day 1 tablet per day 1 tablet per day 2 tablets per day High Cholesterol 14 OptumRx | optumrx.com 1 tablet per day 1 capsule per day 2 capsules per day 1 capsule per day 2 capsules per day 1 capsule per day 1 tablet per day 1 tablet per day 2 tablets per day 1 tablet per day 2 tablets per day 3 capsules per day 2 capsules per day 1 tablet per day 2 tablets per day 1 tablet per day 1 tablet per day 1 capsule per day 2 capsule per day 1 tablet per day 1 tablet per day 1 tablet per day 2 tablets per day 2 tablets per day 4 capsules per day 3 tablets per day 2 tablets per day 2 tablets per day 1 tablet per day 1 tablet per day 2 tablets per day 2 tablets per day 1 tablet per day 1 tablet per day 2 tablets per day THERAPY CLASS MEDICATION NAME LIMIT High Cholesterol Continued Vascepa Vytorin Welchol Welchol Pak Zetia Zocor (simvastatin) 10 mg, 20 mg, 40 mg Zocor (simvastatin) 5 mg, 80 mg Egrifta 1 mg Egrifta 2 mg Fuzeon Acticlate 150 mg Acticlate 75 mg Adoxa (doxycycline) 100 mg Adoxa (doxycycline) 50 mg, 75 mg Adoxa Pak 1/100 Adoxa Pak 1/150 (doxycycline) Adoxa Pak 2/100 Doryx Doryx (doxycyline) minocycline Monodox (doxycycline) 100 mg Monodox (doxycycline) 75 mg Morgidox Ocudox Priftin Solodyn Tindamax (tinidazole) Uribel Cimzia Kit/ Prefill Cimzia Starter Kit Enbrel 25 mg Enbrel 50 mg Humira Humira Pen Humira Pen CR Humira Pen PS Ilaris Orencia Otezla 10/20/30 mg Otezla 30 mg 4 capsules per day 1 tablet per day 7 tablets per day 1 packet per day 1 tablet per day 1.5 tablets per day HIV/AIDS Infections Inflammatory Conditions 1 tablet per day 2 vials per day 1 vial per day 2 vials per day 30 capsules per prescription 20 capsules per prescription 30 tablets per prescription 20 tablets per prescription 1 tablet per day 1 pack per day 2 tablets per day 7 tablets per prescription 1 tablet per day 1 tablet per day 30 capsules per prescription 20 capsules per prescription 1 kit per month 1 kit per prescription 32 tablets per month 1 tablet per day 40 tablets per prescription 4 capsules per day 1 kit (2 syringes or vials) per month 1 kit (3 syringes) per year 8 syringes or vials per month 4 syringes per month 1 kit (2 syringes) per month 1 kit (2 syringes) per month 1 kit (6 syringes) per year 1 kit (4 syringes) per year 2 vials per two months 4 vials/syringes per month 27 tablets per 365 days 2 tablets per day 15 Quantity Limits on Medications THERAPY CLASS MEDICATION NAME LIMIT Inflammatory Conditions Continued Pentasa CR 250 mg Pentasa CR 500 mg Rasuvo Simponi 50 mg/0.5 mL 4 capsules per day 8 capsules per day 1 injection per week 1 syringe/autoinjector (0.5 mL) per month 1 syringe (1 mL) per month 1 patch per day 1 packet (2.5 units) per day 300 g per month 2 bottles (150 g) per month 1 pack (1.25 g) per day 2 packs (5 g) per day 2 pump bottles (150 g) per month 2 bottles (180 g) per month 2 bottles (120 g) per month 1 box (60 tablets) per month 300 g per month 300 g per month 2 bottles (120 g) per month 300 g per month 1 capsule per day Men’s Health: Hormone Therapy Men’s Health: Prostate Migraines Simponi 100 mg/mL Androderm Androgel 1% (25 mg) Androgel 1% (50 mg/5 g) Androgel 1.62% (20.25 mg) Androgel 1.62% (20.25 mg/1.25 g) Androgel 1.62% (40.5 mg/2.5 g) Androgel Pump Axiron Fortesta Striant Testim testosterone gel 1% Testosterone Gel 10 mg/actuation Vogelxo Avodart Cardura XL Flomax (tamsulosin) Jalyn Proscar (finasteride) Rapaflo Uroxatral (afluzosin) Alsuma (sumatriptan succinate) Amerge (naratriptan hcl) Axert Cambia Frova Imitrex (sumatriptan succinate) Injection Imitrex (sumatriptan) 50 mg, 100 mg Imitrex (sumatriptan) 20 mg/ actuation Imitrex (sumatriptan) 25 mg Imitrex (sumatriptan) 5 mg/ actuation Maxalt (rizatriptan) 16 OptumRx | optumrx.com 1 tablet per day 2 capsules per day 1 tablet per day 1 tablet per day 1 capsule per day 1 tablet per day 4 kits (4 mL) per month 18 tablets per month 12 tablets per month 9 packets per month 18 tablets per month 4 kits (4 mL) per month 18 tablets per month 2 packages (12 devices ) per month 18 tablets per month 2 packages (12 devices ) per month 18 tablets per month THERAPY CLASS MEDICATION NAME LIMIT Migraines Continued Maxalt-MLT (rizatriptan benzoate odt) Migranal (dihydroergot mesylate) Relpax Sumavel Dosepro Treximet Zomig (zolmitriptan) 2.5 mg Zomig (zolmitriptan) 5 mg Zomig Nasal 18 tablets per month 1 kit (8 units) per month 12 tablets per month 8 units (4 mL) per month 9 tablets per month 12 tablets per month 9 tablets per month 2 packages (12 devices) per month 6 pkgs (36 devices) at mail only 12 tablets per month 9 tablets per month 1 tablet per day 2 tablets per day 2 tablets per day 1 tablet per day 1 box per month 15 vials per month 1 kit (30 syringes) per month 1 kit (12 syringes) per month 15 vials per month 1 capsule per day 12 syringes (6 mL) per month 12 syringes (6 mL) per month 1 box (4.2 mL) per year 1 box (4.2 mL) per year 2 capsules per day 1 kit (60 capsules) per year 3 tablets per prescription or up to a maximum of 3-day supply, whichever is less 6 tablets per prescription or up to a maximum of 3-day supply, whichever is less 20 tablets per prescription or up to a maximum of 3-day supply, whichever is less 4 tablets per day 1 capsule per prescription 2 capsules per prescription 1 pack (3 capsules) per prescription 2 vials per prescription Miscellaneous Multiple Sclerosis Nausea and Vomiting Zomig ZMT (zolmitriptan odt) 2.5 mg Zomig ZMT (zolmitriptan odt) 5 mg Samsca 15 mg Samsca 30 mg Ampyra Aubagio Avonex, Avonex Pen, Avonex Prefilled Betaseron Copaxone 20 mg/mL Copaxone 40 mg/mL Extavia Gilenya Rebif Rebif Rebidose Rebif Rebidose Titration Pack Rebif Titration Pack Tecfidera 120 mg, 240 mg Tecfidera Starter Kit Anzemet 100 mg Anzemet 50 mg Cesamet Diclegis Emend 40 mg, 125 mg Emend 80 mg Emend Pak Emend Solution 17 Quantity Limits on Medications THERAPY CLASS MEDICATION NAME LIMIT Nausea and Vomiting Continued granisetron 6 tablets per prescription or up to a maximum of 3-day supply, whichever is less 1 bottle (30 mL) per prescription or up to a maximum of 3-day supply, whichever is less 3 tablets per prescription or up to a maximum of 3-day supply, whichever is less 12-week supply per 6 months 1 patch per prescription 18 tablets per month 60 tablets per month 18 films per month 60 films per month 2 tablets per day 1 capsule per day 1 tablet per month 4 tablets per month 1 tablet per day 5 bottles (375 mL) per month 4 tablets per month 5 tablets per month 1 tablet per month 1 tablet per day 1 bottle (3.8 mL) per month 5 tablets per month 1 bottle (3.8 mL) per month 1 vial per 135 days 1 vial (1.7 mL) per month 2 tablets per day 1 capsule per day 2 tablets per day Granisol ondansetron Obesity/Weight Loss Osteoporosis Overactive Bladder 18 OptumRx | optumrx.com Reglan (metoclopramide) Sancuso Zofran (ondansetron) 4 mg Zofran (ondansetron) 8 mg Zuplenz 4 mg Zuplenz 8 mg Belviq Qsymia Actonel (risedronate) 150 mg Actonel 35 mg Actonel 5 mg, 30 mg alendronate solution Atelvia Binosto Boniva (ibandronate) Evista (raloxifene) Fortical Fosamax + D Miacalcin (calcitonin) Prolia Xgeva Detrol (tolterodine) Detrol LA (tolterodine er) Ditropan XL (oxybutynin er) 10 mg, 15 mg Ditropan XL (oxybutynin er) 5 mg Enablex Gelnique 10% Gelnique 3% Myrbetriq Oxytrol, Oxytrol Women Sanctura (trospium) 20 mg 1 tablet per day 1 tablet or capsule per day 1 sachet per day 1 bottle (92 g) per month 1 tablet per day 10 patches per month 2 tablets per day THERAPY CLASS MEDICATION NAME LIMIT Overactive Bladder Continued Sanctura XR (trospium er) Toviaz Vesicare Abstral Actiq (fentanyl ot) Alagesic LQ Anaprox (naproxen sodium) 275 mg Anaprox DS (naproxen sodium) 550 mg apap/caffeine/dihydrocodeine apap/codeine apap/codeine solution Avinza (morphine sulfate er) 120 mg Avinza (morphine sulfate er) 30 mg, 45 mg, 60 mg, 75 mg, 90 mg Bupap butalbital/acetaminophen butalbital/apap/caffeine butalbital/aspirin/caffeine butorphanol Butrans Caldolor 400 mg/4 mL Caldolor 800 mg/8 mL Capital/Codeine Cataflam (diclofenac postassium) Celebrex 100 mg Celebrex 400 mg Celebrex 50 mg, 200 mg choline magnesium trisalicylate choline magnesium trisalicylate Conzip Daypro (oxaprozin) diclofenac 25 mg diclofenac 50 mg diclofenac 75 mg diflunisal Dolgic Plus Duexis Duragesic (fentanyl) 12 mcg/hr, 25 mcg/hr, 50 mcg/hr 1 capsule per day 1 tablet per day 1 tablet per day 4 tablets per day 4 lollipops (units) per day 90 mL per day 6 tablets per day 3 tablets per day Pain Relief 5 tablets per day 13 tablets per day 150 mL per day 2 capsules per day 1 capsule per day 6 tablets per day 6 tablets per day 6 tablets per day 6 tablets per day 3 bottles (9 mL) per month 4 patches per month 24 mL per day 32 mL per day 150 mL per day 4 tablets per day 3 capsules per day 1 capsule per day 2 capsules per day 3 tablets per day 30 mL per day 1 capsule per day 3 tablets per day 8 tablets per day 4 tablets per day 2 tablets per day 3 tablets per day 5 tablets per day 3 tablets per day 15 patches per month 19 Quantity Limits on Medications THERAPY CLASS MEDICATION NAME LIMIT Pain Relief Continued Duragesic (fentanyl) 75 mcg/hr, 100 mcg/hr EC-Naprosyn (naproxen dr) 375 mg EC-Naprosyn (naproxen dr) 500 mg Esgic (butalbital/apap/caffeine, capacet, margesic, zebutal) Esgic, Esgic-Plus, Fioricet (butalbital/ apap/caffeine) etodolac 200 mg etodolac 300 mg etodolac 400 mg etodolac 500 mg etodolac er 400 mg etodolac er 500 mg, 600 mg Exalgo (hydromorphone er) Feldene (piroxicam) 10 mg Feldene (piroxicam) 20 mg fenoprofen Fentora Fioricet (butalbital/acetaminophen/ caffeine/codeine) Fioricet, Orbivan (butalbital/apap/ caffeine) Fiorinal (butalbital/asa/caffeine) Flector flurbiprofen 100 mg flurbiprofen 50 mg Gralise 300 mg Gralise 600 mg Gralise Starter 30 patches per month Horizant 300 mg, 600 mg Hycet (hydrocodone/acetaminophen) hydrocodone/apap 10-300 mg hydrocodone/apap 10-660 mg hydrocodone/apap 2.5-325 mg hydrocodone/apap 2.5-500 mg hydrocodone/apap 7.5-750 mg hydrogesic Ibudone (hydrocodone/ibuprofen) 20 OptumRx | optumrx.com 4 tablets per day 3 tablets per day 6 capsules per day 6 tablets per day 6 capsules per day 4 capsules per day 3 tablets per day 2 tablets per day 3 tablets per day 2 tablets per day 6 tablets per day 2 capsules per day 1 capsule per day 5 tablets per day 4 tablets per day 6 capsules per day 6 capsules per day 6 capules per day 2 patches per day 3 tablets per day 6 tablets per day 1 tablet per day 3 tablets per day 1 packet (78 tablets) per prescription 2 tablets per day 185 mL per day 13 tablets per day 6 tablets per day 12 tablets per day 8 tablets per day 5 tablets per day 8 capsules per day 5 tablets per day THERAPY CLASS MEDICATION NAME LIMIT Pain Relief Continued Ibudone (hydrocodone/ibuprofen, xylon) ibuprofen 400 mg Ibuprofen 600 mg Ibuprofen 800 mg Ibuprofen suspension Indocin 25 mg/5 mL Indocin 50 mg indomethacin 25 mg indomethacin 50 mg indomethacin 75 mg Kadian (morphine sulfate er) 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg Kadian 40 mg, 200 mg Ketoprofen 50 mg Ketoprofen 75 mg Ketoprofen 200 mg Ketorolac Ketorolac 15 mg/mL Ketorolac 30 mg/mL Lazanda Lidoderm (lidocaine) Patch Lidodextrapine Patch Liquicet Lorcet (hydrocodone/acetaminophen) Lorcet Plus (hydrocodone/ acetaminophen) 7.5-650 mg Lorcet Plus (hydrocodone/ acetaminophen) 7.5-325 mg Lortab (hydrocodone/acetaminophen) 10-300 mg Lortab (hydrocodone/acetaminophen) 5-325 mg Lortab (hydrocodone/acetaminophen) Solution Lortab (hydrocodone/acetaminophen, co-gesic) 5-500 mg, 7.5-500 mg, 10-500 mg Lorzone 375 mg Lorzone 750 mg Magnacet 5 tablets per day 8 tablets per day 5 tablets per day 4 tablets per day 160 mL per day 40 mL per day 4 suppositories per day 8 capsules per day 4 capsules per day 2 capsules per day 2 capsules per day 2 capsules per day 6 capsules per day 4 capsules per day 1 capsule per day 20 tablets per month at retail only 40 mL per month 20 mL per month 1 nasal spray bottle per day 3 patches per day 4 patches per day 120 mL per day 12 tablets per day 6 tablets per day 12 tablets per day 200 mL per day 12 tablets per day 120 mL per day 8 tablets per day 8 tablets per day 4 tablets per day 10 tablets per day 21 Quantity Limits on Medications THERAPY CLASS MEDICATION NAME LIMIT Pain Relief Continued marten-tab Maxidone (hydrocodone bitartrate/ acetaminophen) meclofenamate 100 mg meclofenamate 50 mg Mobic (meloxicam) 15 mg Mobic (meloxicam) 7.5/5 mL Mobic (meloxicam) 7.5 mg MS Contin (morphine sulfate er) 15 mg, 30 mg, 60 mg, 100 mg MS Contin (morphine sulfate er) 200 mg nabumetone 500 mg nabumetone 750 mg Nalfon (fenoprofen) Naprelan 375 mg Naprelan 500 mg Naprelan 750 mg Naprosyn (naproxen) 250 mg Naprosyn (naproxen) 375 mg Naprosyn (naproxen) 500 mg Naproxen (naproxen) 125/5 mL Norco (hydrocodone/acetaminophen) Norco (lorcet hd), Norco (lortab) Nucynta 100 mg Nucynta 50 mg, 75 mg Nucynta ER Opana (oxymorphone) Opana ER (oxymorphone er) Orbivan CF oxycodone/apap oxycodone/Ibuprofen Oxycontin (oxycodone) oxymorphone er pentazocine/apap pentazocine/naloxone Percocet (endocet, oxycodone/ acetaminophen) 7.5-500 mg Percocet (endocet, oxycodone/ acetaminophen, roxicet) 2.5-325 mg, 5-325 mg, 7.5-325 mg 6 tablets per day 5 tablets per day 22 OptumRx | optumrx.com 4 capsules per day 8 capsules per day 1 tablet per day 10 mL per day 2 tablets per day 4 tablets per day 3 tablets per day 4 tablets per day 2 tablets per day 8 capsules per day 4 tablets per day 3 tablets per day 2 tablets per day 6 tablets per day 4 tablets per day 3 tablets per day 60 mL per day 12 tablets per day 12 tablets per day 7 tablets per day 6 tablets per day 2 tablets per day 12 tablets per day 4 tablets per day 6 tablets per day 8 capsules per day 4 tablets per day 4 tablets per day 4 tablets per day 6 tablets per day 12 tablets per day 8 tablets per day 12 tablets per day THERAPY CLASS MEDICATION NAME LIMIT Pain Relief Continued Percocet (oxycodone/aceteminophen) 10-325 mg Percocet (oxycodone/aceteminophen) 10-650 mg Phrenilin Ponstel (mefenam acid) Primlev Reciphexamine Patch Reprexain (hydrocodone/ibuprofen) Reprexain (hydrocodone/ibuprofen, xylon) Roxicet Rybix ODT Sprix stagesic Subsys Spray sulindac tencon tolmetin 400 mg tolmetin 600 mg tolmetin sodium tramadol er 100 mg, 200 mg, 300 mg tramadol er 150 mg Trezix Tylenol/Cod #3 (acetaminophen/ codeine #3) Tylenol/Cod #4 (acetaminophen/ codeine ) Ultracet (tramadol hydrochloride/ acetaminophen) Ultram (tramadol) Ultram ER (tramadol er) verdrocet Vicoprofen (hydrocodone/ibuprofen) Vimovo Voltaren Voltaren-XR (diclofenac xr) Xartemis XR Xodol (vicodin es, vicodin hp, hydrocodone) Xolox 12 tablets per day 6 tablets per day 6 capsules per day 5 capsules per day 13 tablets per day 4 patches per day 5 tablets per day 5 tablets per day 62 mL per day 8 tablets per day 5 spray bottles per month 8 capsules per day 12 unit doses per day 2 tablets per day 6 tablets per day 4 capsules per day 3 tablets per day 8 tablets per day 1 tablet per day 2 capsules per day 11 capsules per day 12 tablets per day 6 tablets per day 8 tablets per day 8 tablets per day 1 tablet per day 12 tablets per day 5 tablets per day 2 capsules per day 10 tubes (1,000 g) per month 2 tablets per day 12 tablets per day 13 tablets per day 8 tablets per day 23 Quantity Limits on Medications THERAPY CLASS MEDICATION NAME LIMIT Pain Relief Continued Zamicet (hydrocodone/acetaminophen) Solution Zipsor Zohydro ER Zolvit Zorvolex Zydone Mirapex ER Requip XL (ropinirole er) Adcirca Adempas Letairis Opsumit Revatio (sildenafil) Tracleer Tyvaso Ventavis Clonazepam ODT 0.125 mg, 0.25 mg, 0.5 mg, 1 mg Clonazepam ODT 2 mg Diastat ACDL (diazepam) Diastat Pediatric (diazaepam) Fycompa 2 mg, 4 mg, 8 mg, 10 mg, 12 mg Fycompa 6 mg Keppra XR (levetiracetam er) 500 mg Keppra XR (levetiracetam er) 750 mg Klonopin (clonazepam) 0.5mg, 1mg Klonopin (clonazepam) 2 mg Lamictal Starter Kit, ODT Kit, XR kit Lamictal XR (lamotrigine er) 100 mg, 200 mg Lamictal XR (lamotrigine er) 25 mg Lamictal XR (lamotrigine er) 250 mg, 300 mg Lamictal XR (lamotrigine er) 50 mg Lyrica 20 mg/mL Lyrica 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg, 225 mg Lyrica 300 mg Potiga 200 mg, 300 mg, 400 mg 185 mL per day Parkinson's Disease Pulmonary Arterial Hypertension Seizure Disorders 24 OptumRx | optumrx.com 4 capsules per day 2 capsules per day 67.5 mL per day 3 capsules per day 10 tablets per day 1 tablet per day 1 tablet per day 2 tablets per day 3 tablets per day 1 tablet per day 1 tablet per day 3 tablets per day 2 tablets per day 1 vial (2.9 mL) per day 9 mL per day 3 tablets per day 10 tablets per day 2 boxes per prescription 2 boxes per prescription 1 tablet per day 2 tablets per day 6 tablets per day 4 tablets per day 3 tablets per day 10 tablets per day 1 box per prescription 3 tablets per day 1 tablet per day 2 tablets per day 1 tablet per day 30 mL per day 3 capsules per day 2 capsules per day 3 tablets per day THERAPY CLASS MEDICATION NAME LIMIT Seizure Disorders Continued Potiga 50 mg Sabril Sabril Adrenaclick Auvi-Q Epinephrine Epi-Pen Epipen-Jr Acanya Aldara (imiquimod) Crème Atralin Benzaclin (clindamycin/benzoyl peroxide) bp cleansing, claris wash BPO Creamy Kit (benzoyl peroxide) Ciclodan Cream Kit Ciclodan Kit (ciclopirox) 9 tablets per day 6 tablets per day 6 packets per day 2 syringes per prescription 2 syringes per prescription 2 syringes per prescription 2 syringes per prescription 2 syringes per prescription 1 jar (50 g) per month 48 packets per 16 weeks 1 tube (45 g) per month 50 g per month CNL8 Nail Cordran Cordran Crème Cordran Lotion Differin (adapalene) Differin Lotion Duac (clindamycin/benzoyl peroxide, neuac) Dutoprol Elenzapatch Elidel Epiduo Evoclin (clindamycin) Foam Fabior Jublia Luzu Mirvaso Oracea Pedipirox-4 Penlac (ciclopirox, ciclodan) Protopic Regranex Retin-A Mico (tretinoin) 1 kit per prescription 1 unit per month 60 g per month 120 mL per month 1 tube (45 g) per month 1 bottle (59 mL) per month 1 tube (45 g) per month Severe Allergic Reaction Skin Conditions 1 bottle (473 mL) per month 1 kit per month 1 box (544 g) per prescription 1 kit (34.6 mL) per prescription 2 tablets per day 4 patches per day 100 g per month 1 tube (45 g) per month 100 g per month 100 g per month 1 bottle per month 60 g per month 30 g per month 1 capsule per day 1 kit per prescription 1 bottle (6.6 mL) per prescription 100 g per month 2 tubes (30 g) per month 50 g per month 25 Quantity Limits on Medications THERAPY CLASS MEDICATION NAME LIMIT Skin Conditions Continued se bpo cloths, bpo cloths sodium sulfacetamide/sulfur cleanser sodium sulfacetamide/sulur in urea gel 10-5% Solaraze (diclofenac) Gel Soriatane 10 mg (acitretin) Soriatane 17.5 mg, 25 mg (acitretin) Taclonex Taclonex (calcipotriene/betamethasone diproprionate) Ointment Tazorac Thalomid 150 mg, 200 mg Thalomid 50 mg, 100 mg Veltin Ziana Zyclara Crème Zyclara Pump Ambien (zolpidem), Ambien CR (zolpidem er) Doral (quazepam) Edluar estazolam flurazepam Halcion (triazolam) Hetlioz Intermezzo Lunesta (eszopiclone) Nuvigil 150 mg, 200 mg, 250 mg Nuvigil 50 mg Provigil (modafinil) Restoril (temazepam) Rozerem Silenor Sonata (zaleplon) 10 mg Sonata (zaleplon) 5 mg triazolam Xyrem Zolpimist 1 box (60 units) per month 1 bottle (355 mL) per month 1 tube (45 mL) per month Sleep Disorders 26 OptumRx | optumrx.com 1 tube (100 g) per month 4 capsules per day 2 capsules per day 60 g per month 60 g per month 30 g per month 8 capsules per day 4 capsules per day 1 tube (60 g) per month 1 tube (60 g) per month 56 packets (2 boxes) per 2 months 2 tubes (15 g) per 2 months 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 capsule per day 2 tablets per day 1 capsule per day 1 tablet per day 1 tablet per day 1 tablet per day 2 tablets per day 1 tablet per day 1 capsule per day 1 tablet per day 1 tablet per day 2 tablets per day 1 tablet per day 1 tablet per day 3 bottles (540 mL) per month 1 bottle (7.7 mL) per month THERAPY CLASS MEDICATION NAME LIMIT Smoking Cessation Chantix .5 mg Chantix 1 mg Chantix 1 mg Pak Chantix Pak Alinia Alinia Suspension Amitiza Apriso Asacol HD Canasa Delzicol Giazo Golytely Golytely (gavilyte-g, peg-3350) Halflytely 2 tablets per day 1 tablet per day 1 pack (30 tablets) per month 1 pak (53 tablets) per prescription 6 tablets per prescription 3 bottles (180 mL) per month 2 tablets per day 4 capsules per day 6 tablets per day 1 suppository per day 6 capsules per day 6 capsules per day 1 packet per prescription 1 jug (4,000 mL) per prescription 1 package (or 1 kit) per prescription 1 capsule per day 2 tablets per day 1 box per prescription 4,000 mL per prescription Stomach Conditions Viral Infections Women's Health: Hormone Therapy Linzess Lotronex Moviprep Nultyely (gavilyte-n, peg-3350 kcl), Trilyte Rowasa (mesalamine) Suclear Suprep Bowel Baraclude Baraclude (entecavir) Incivek Olysio Relenza Sovaldi Tamiflu 30 mg Tamiflu 45 mg, 75 mg Tamiflu 6 mg/ mL Valcyte Victrelis Activella (estradiol/norethindrone), mimvey, mimvey lo Alora Angeliq Brisdelle Cenestin 1 bottle/box (4 g) per day 1 kit (2,480 mL) per prescription 2 bottles (354 mL ) per prescription 20 mL per day 1 tablet per day 6 tablets per day 1 capsule per day 1 inhaler (20 blisters) per month 1 tablet per day 20 capsules per month 10 capsules per month 180 mL per month 4 tablets per day 12 capsules per day 1 tablet per day 8 patches per month 1 tablet per day 1 capsule per day 1 tablet per day 27 THERAPY CLASS MEDICATION NAME LIMIT Women’s Health: Hormone Therapy Continued Climara (estradiol), Climara Pro Combipatch Duavee Enjuvia Estrace (estradiol) Estrasorb Estring Estrogel estropipate Evamist Femhrt Femring jinteli Lysteda (tranexamic acid) Menest Menostar Minivelle ortho-est Prefest Premarin Premphase Prempro Vivelle-Dot 4 patches per month 8 patches per month 1 tablet per day 1 tablet per day 1 tablet per day 2 pouches per day 1 vaginal ring (unit) per 90 days 1 bottle (50 g) per month 1 tablet per day 1 bottle (8.1 mL) per month 1 tablet per day 1 ring per three months 1 tablet per day 30 tablets per month 1 tablet per day 4 patches per month 8 patches per month 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 1 tablet per day 8 patches per month Quantity Limits effective as of January 1, 2015. optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at optum.com. All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. ©2015 OptumRx, Inc. ORX0801_150101 Free Meter Program Diabetes can harm your eyes, kidneys, nerves, heart and blood vessels. The impact can be long-term. Regular blood sugar testing can help you manage your diabetes and may lead to better glucose control. Take advantage of this great offer To help you monitor blood sugar levels, your pharmacy benefit plan may have the Free Meter Program. With this program, you may be able to get a blood sugar meter at no charge to you. You and your doctor can choose from nine different meters. Information about each meter is inside. For more details, call OptumRx customer service using the toll-free member phone number on the back of your ID card. Or call the meter manufacturers. Their numbers are inside. How to get your free meter The first step in every diabetes care plan is talking with your health care team. If you would like a new blood sugar meter, tell your doctor or diabetes educator. They will help you select the no-charge meter that’s right for you. Once you decide, it’s easy to place your order. Just call the manufacturer’s Service Center any time. Your free meter choices are inside Free Meter Program Choose from these brand-name meters To order one of these OneTouch® meters call their Service Center at 1-866-355-9962 Order Code: 594PRX100 www.OneTouch.orderpoints.com OneTouch® Ultra 2 • L arge backlit screen — read results day or night • Add meal flags — lets you link the effects of food to your blood glucose results •R esult averages — Get 7-, 14- and 30-day averages to see your trends • Large memory and download port — more ways to review results OneTouch® UltraMini • S mall enough to fit in a purse or pocket • Comes in 6 attractive colors •2 -way scrolling buttons — for simple navigation • 500-test memory — to view recent results OneTouch® Verio IQ • The first meter ever with PatternAlert™ Technology • A 750-test memory, color-coded alerts and intuitive navigation • Spanish language available • A bright color display OneTouch® Verio® Sync • Stores up to 500 results • Easy-to-read screen and test strip port light for testing in the dark OptumRx | optumrx.com • Sends your blood sugar results wirelessly to your iPhone®, iPod Touch® or iPad® using the OneTouch® Reveal™ mobile app To order one of these GLUCOCARD® meters call their Service Center at 1-855-646-3232 No order code required www.glucocardusa.com/optumrx GLUCOCARD® 01 Meter • Auto-code technology •C linical data confirms high accuracy • Shares strips with the GLUCOCARD 01Mini, so you always have the right strips • F ewer open test strip bottles for less waste and greater savings GLUCOCARD® 01-Mini • Fast, accurate test results with only a tiny sample size •2 0 free interchangeable face plates GLUCOCARD® Vital Meter • Fast, accurate and easy to use • Auto-coded meter has a 250-test memory to help track of your results • S mall 0.5 µL sample size in the GO-based test strip platform gives accurate results in 7 seconds To order one of these ACCU-CHEK® meters call their Service Center at 1-877-411-9833 Order Code: RXAC10 http://meters.accu-chek.com ACCU-CHEK® Aviva Plus • Quick, 5-second results • Small 0.6 microliter sample size • Contoured, ergonomic design with easy-to-hold rubber grips • 4 customizable test reminders • Made in the U.S.A.1 ACCU-CHEK® Nano SmartView • Advanced accuracy with ACCU-CHEK® SmartView test strips — 23% tighter specification2 • Small, sleek design fits in the palm of your hand • No coding — fewer steps in testing 1 2 Using U.S. and imported materials Specifications based on current ISO 15197: 2003 • Brilliant backlit display makes reading numbers easy Free Meter Program Don’t delay. Talk with your doctor about choosing the best brand-name meter for you. Then order your meter by calling the manufacturer’s Service Center. optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at optum.com. All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. © 2014 Optum, Inc. All rights reserved. A07926 ORX0580_140609 3 Tier Benefit Design What is a 3 tier benefit design? Your prescription drug plan is organized by a 3 tier benefit design. As the name implies, prescription drugs are grouped into three tier levels, and each level is associated with a different copayment. A copayment is the portion of the drug cost you pay out-of-pocket. U The lowest tier or the lowest copayment level contains generic drugs. A generic drug contains the same active ingredient, has the same strength, dosage form, and route of administration, and works the same way in the body as the brand-name product. In the United States, generic drugs account for more than half of all the medications used.1 Generic drugs are safe and effective, and many are manufactured by major drug companies.2 Generic drugs must be approved by the FDA and are held to FDA’s established standards of quality but may cost 50% to 70% less.3 U The middle tier contains formulary brand name drugs. Formulary brand name drugs result in a slightly higher copayment because they cost more than generic drugs. A formulary is a list of drugs that is covered by your health plan and available to your health care provider to select the most appropriate drug for the care of your health. After careful review by a group of practicing health care providers and pharmacists, drugs that offer the most value without sacrificing efficacy, quality, and safety are placed on the formulary. U The highest tier contains non-formulary drugs and results in the highest copayment. Non-formulary drugs may not offer any additional value compared to lower tiered drugs. Usually, a similar drug that is on the formulary is available as a generic or a brand name drug at the lower tiers. Therefore, we are able to pass on the savings to you with a lower copayment. Often times, a higher copayment does not mean more value. How does this benefit design work? If your doctor prescribes a generic drug, you generally pay the lowest copayment. If your doctor prescribes a brand name drug on the formulary, you pay the middle copayment. If your doctor prescribes a drug not on the formulary (i.e., a non-formulary drug), you pay the highest copayment. Why a 3 tier benefit design? Prescription drugs can be a costly part of your medical expense. The American public spends $51 billion out-of-pocket every year on prescription drugs.1 In order to control costs, clients have turned to using a 3 tier benefit design that offers formularies with generics and brand name drugs that provide their members with the most value. Using generics and brand name drugs on the formulary may extend your drug benefit and lower your out-of-pocket expenses or copayments. References: 1. Statistical Abstract of the United States: 2008. US Census Bureau website. http://www.census.gov/prod/2007 pubs/08statab/health.pdf. Accessed May 1, 2009. 2. Generic Drugs: Questions and Answers. Available at: www.fda.gov/cder/ consumerinfo/generics_q&a.htm#cost. Accessed May 1, 2009. 3. McClellan, Mark B. Testimony on generic drug utilization in the Medicare prescription drug benefit before senate special committee on aging. US Department of Health & Human Services. Available at: www.dhhs.gov/asl/ testify/t060921.html. Accessed May 1, 2009. To find out which drugs are on the formulary visit www.optumrx.com or call us at 1-800-797-9791. www.optumrx.com 2300 Main Street, Irvine, CA 92614 OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum company — a leading provider of integrated health services. Learn more at www.optum.com. All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. ORX0387_120510 ©2012 OptumRx, Inc. Customer Service OptumRx administers your pharmacy benefit plan on behalf of your plan sponsor, and we’re here to help you. In addition to answering questions about your plan, we may also be able to help you save money on your prescription medications. We’re committed to you, and your well-being is important to us, so we offer two convenient ways for you to get information that can help you and your doctor make informed decisions about medication therapies. Dedicated Customer Service When you call OptumRx at 1-877-559-2955, you get real-time answers and information from our friendly and knowledgeable Customer Service Advocates. We encourage our staff to earn nationally recognized professional certification as certified pharmacy technicians (CPhT) to ensure you receive the best, most comprehensive service from our dedicated team. Customer Service Advocates are available to help you 24 hours a day, 7 days a week. Easy-to-Use Website Our website, www.optumrx.com, is easy to use and offers a fast, safe and secure way to refill prescriptions, manage your account, get medication pricing, find medication information and more. Registration is free and there are no extra fees to order online. Website content and services include: s Locate a pharmacy: a handy tool to quickly find participating pharmacies near you s My account dashboard: lets you manage your online account and get pharmacy benefit plan information s Consumer health education: find up-to-date wellness information and learn more about your personal health We welcome questions, comments and suggestions to help us provide you with a truly exceptional customer service experience! FAQ: Using Your Pharmacy Benefits Your pharmacy benefits help you get the right medication at a reasonable price. Take a few minutes to better understand the features and programs in your pharmacy plan. It can help you to get the most from your benefits when making medication decisions with your doctor. Who is OptumRx? OptumRx is your plan’s pharmacy benefit manager (PBM). Your plan sponsor chose us to manage and process your pharmacy claims. We will also answer your pharmacy benefit questions and tell you about programs offered in your plan. How do I find a participating retail pharmacy? Your plan’s pharmacy network includes tens of thousands of chain and independent pharmacies nationwide. To find one near you, visit our website, www.optumrx.com. Then use the Locate a Pharmacy tool. Or call the customer service number on the back of your member ID card. FAQ: Using Your Pharmacy Benefits FAQ: Using Your Pharmacy Benefits How do I fill a prescription at a pharmacy? There are several ways to fill/refill prescriptions at your pharmacy: • Option 1: Your doctor can call or fax your new prescription or refill request to the pharmacy. • Option 2: Your pharmacist can call your doctor to ask for a new prescription. • Option 3: Visit your retail pharmacy to request a refill or give them a new prescription written by your doctor. Why should I show my member ID card when I fill a prescription? Your pharmacy uses information on your ID card to send your prescription claim to OptumRx to process. Showing your ID card also ensures that you pay the lowest possible cost. Even when using a low-cost generics program, such as those at Walmart, Costco and Target, you should show your ID card. If the generic drug costs less than your copayment or coinsurance, you pay the smaller amount. If your plan has a deductible, showing your ID card allows your cost to go toward meeting the deductible. OptumRx | www.optumrx.com Can I order medications through the Mail Service Pharmacy? If your plan includes mail service, you can get up to a 90-day supply of your maintenance medication(s) from OptumRx™ Mail Service Pharmacy. One easy phone call gets you started: • Option 1: Call Customer Service — They’ll help you start using the Mail Service Pharmacy. Call the customer service number on the back of your member ID card, 24 hours a day, 7 days a week. • Option 2: Talk to your doctor — Tell your doctor you want to use OptumRx for home delivery of your maintenance medications. Be sure to ask for a new prescription for up to a 90-day supply with three refills. Then mail OptumRx your written prescription with a completed order form. Or ask your doctor to call 1-800-791-7658 with your prescription, or fax it to 1-800-491-7997. How long does it take to get my order from the Mail Service Pharmacy? Refills should arrive in about seven business days after OptumRx receives your order. New orders should arrive in about 10 business days. There is no cost to you for standard delivery. Overnight delivery is available for an additional charge. How do I order refills from the Mail Service Pharmacy? When can I refill my prescriptions? You have four ways to order refills from OptumRx Mail Service Pharmacy: You can usually refill prescriptions after you use about two-thirds of the medication. For example, when taken as prescribed: • Order online at www.optumrx.com • 30-day prescriptions may be refilled after 21 days • Call our automated phone system • 90-day prescriptions may be refilled after 63 days • Call customer service at the number on the back of your member ID card • Complete the reorder form inside each medication shipment and send it to us for processing Remember, by registering at our website, you’ll receive email reminders when it is time to refill your prescriptions. Are generic drugs as good and safe as brand-name drugs? Yes. Every generic drug is equivalent to the brand-name drug. They both have the same strength, purity and quality. Both brand-name and generic drugs meet U.S. Food and Drug Administration (FDA) standards for safety and effectiveness. Can I get permission to refill my medication early, such as before I go on vacation? If your plan allows early refills in special cases, call customer service at the number on your member ID card. Ask for an early refill authorization. How do I request a prior authorization? Certain medications may require special approval from your plan to be covered. This is called prior authorization. If your doctor prescribes one of these medications, you, your pharmacist or doctor can begin the review process by calling customer service. A customer service advocate will work with your doctor’s office to get the information for a prior authorization review. For members Preventive Care Medications $0 Cost-Share Medications & Products 1, 2, 3 Under the health reform law (Affordable Care Act), pharmacy benefit plans must cover certain Preventive Care Medications at 100 percent - without charging a copay, co-insurance or deductible. These products include: • U.S. Preventive Services Task Force A & B Recommendation medications • F ood and Drug Administration (FDA)-approved prescription and Over-The-Counter (OTC) birth control (contraceptives) for women To comply with this law, OptumRx is offering this updated list of no-cost Preventive Care Medications. You can use your OptumRx member ID card to get the products on this list for no cost if they are: • P rescribed by a health care professional • Age- and condition-appropriate • Filled at a network pharmacy These products are available at no cost to you on both standard and high-deductible or consumer-driven health plans. To find a network pharmacy, login to OptumRx.com, choose “Locate a Pharmacy” and enter your zip code - or call the number on your OptumRx member ID card. If you get these drugs or products from an out-of-network pharmacy, you will have to pay the full cost for them. Male forms of birth control are not currently considered Preventive Care Medications under the Affordable Care Act. U.S. Preventive Services Task Force A & B Recommendation Medications and Supplements A prescription is required to get these medications and supplements at no cost - even though most are available over-the-counter (OTC). OTC Rx Medication/Supplement Population Reason Aspirin - 81 mg Women who are at risk for preeclampsia during pregnancy Prevent preeclampsia during pregnancy Aspirin - 81 & 325 mg Men age 45-79 Women age 55-79 Prevent cardiovascular disease Folic acid 400 & 800 mcg Women who are or may become pregnant Prevent birth defects Iron liquid supplement Children age 0-1 year Prevent anemia due to iron deficiency Vitamin D - 400 & 1,000 units Age 65 and over Fall risk prevention Medication/Supplement Population Reason Fluoride tablets, solution (not toothpaste, rinses) Children age 0-5 years Prevent dental cavities if water source is deficient in fluoride Continued Æ Birth Control Products Birth Control Caps & Diaphragms (cervical) Generic Demulen 1/50 sold as: Zovia 1/50E Femcap Generic Alesse & Levlite sold as: Aubra Aviane Delyla Falmina Lessina-28 Levonor/Ethi 0.1-0.02 Lutera Orsythia Sronyx Wide Seal Birth Control Pills Generic Ortho Micronor & Nor-QD sold as: Camila 0.35mg Deblitane Errin 0.35mg Heather 0.35mg Jencycla 0.35mg Jolivette 0.35mg Lyza 0.35mg Nora-Be 0.35mg Norethindron 0.35mg Norlyroc Sharobel Generic Desogen-28 & Ortho-Cept sold as: Apri Cyred Deso/ethinyl estradiol Emoquette Enskyce Reclipsen Solia Generic Yaz 3-0.02mg sold as: Drospirenone/ethy est Gianvi Loryna Nikki Vestura Generic Yasmin 28 3-0.03mg sold as: Drospir/Ethi 3-0.03mg Ocella 3-0.03mg Syeda 3-0.03mg Zarah Generic Demulen 1/35 sold as: Kelnor 1/35 Zovia 1/35E Generic Generess FE CHW sold as: Layolis FE CHW Noreth/Ethin FE CHW Generic Nordette-28 sold as: Altavera Chateal Kurvelo Levonor/ethinyl estradiol Levora-28 Marlissa Portia-28 Generic Ovcon-35 sold as: Balziva Briellyn Gildagia Philith Vyfemla Zenchent Generic Brevicon 0.5/35 & Modicon 0.5/35 sold as: Necon 0.5/35 Nortrel 0.5/35 Wera 0.5/35 Generic Ortho-Novum 1/35-28 & Norinyl 1/35 sold as: Alyacen 1/35 Cyclafem 1/35 Dasetta 1/35 Necon 1/35 Nortrel 1/35 Pirmella 1/35 Generic Loestrin 24 FE sold as: Gildess 24 FE Junel 24 FE Larin 24 FE Lomedia 24 FE You can get a 3-month supply of your medication mailed to you with no cost for standard shipping. Just call the phone number on your OptumRx ID card, and ask for mail service. Generic Loestrin 1/20 sold as: Gildess 1/20 Junel 1/20 Larin 1/20 Microgestin 1/20 Noreth/Ethin 1/20 Generic Loestrin 1.5/30 sold as: Gildess 1.5/30 Junel 1.5/30 Larin 1.5/30 Microgestin 1.5/30 Generic Loestrin FE 1/20 sold as: Gildess FE 1/20 Junel FE 1/20 Larin FE 1/20 Microgestin FE 1/20 Noreth/Ethin FE 1/20 Tarina FE 1/20 Generic Loestrin FE 1.5/30 sold as: Gildess FE 1.5/30 Junel FE 1.5/30 Larin FE 1.5/30 Microgestin FE 1.5/30 Generic Norinyl 1+50-28 sold as: Necon 1/50-28 Generic Lo/Ovral-28 sold as: Cryselle-28 Elinest Low-Ogestrel Generic Ovral sold as: Ogestrel Generic Ortho-Cyclen 0.25/35 sold as: Estarylla Mono-Linyah Mononessa Norgestimate & Ethinyl EstradioI 0.25mg-35mcg Previfem Sprintec 28 Generic Femcon FE chewable sold as: Wymzya FE chewable Zenchent FE chewable Generic Mircette 28 Day sold as: Azurette Deso/Ethinyl estradiol Kariva Kimidess Pimtrea Viorele Continued Æ Birth Control Products continued… Generic Ortho-Novum 10/11 sold as: Necon 10/11-28 Generic Estrostep FE sold as: Tilia FE Tri-Legest FE Generic Cyclessa Pak sold as: Caziant Pak Cesia Pak Velivet Pak Generic Loseasonique sold as: Amethia Lo Camrese Lo Levonorgestrel and Ethinyl Estradiol Generic Triphasil sold as: Enpresse-28 Levonest Myzilra Trivora-28 Generic Ortho-Novum 7/7/7-28 sold as: Alyacen 7/7/7 Cyclafem 7/7/7 Dasetta 7/7/7 Necon 7/7/7 Nortrel 7/7/7 Pirmella 7/7/7 medroxyprogesterone 150mg IM (generic Depo-Provera contraceptive) Emergency Birth Control ella Levonorgestrel 0.75mg, (generic Plan B) Generic Seasonique sold as: Amethia Ashlyna Camrese Daysee Levonor/ethi estradio Over-The-Counter (OTC) Birth Control (must have a prescription and get them from a network pharmacy for OptumRx to cover the costs) Birth Control Rings (vaginal) Generic Ortho Tri-Cyclen sold as: Norgestimate/Ethinyl Estradiol Tri-Estaryll Tri-Linyah Tri-Previfem Tri-Sprintec Trinessa Depo-SQ Provera 104 Generic Seasonale sold as: Introvale Jolessa Levonor/ethinyl estradiol Quasense Generic Lybrel 90-20mcg sold as: Amethyst 90-20mcg Levo-Eth Est 90-20mcg Generic Tri-Norinyl 28 sold as: Aranelle Leena Birth Control Shots (injection) Nuva-Ring Birth Control Patches (transdermal) Generic Ortho Evra sold as: Xulane Levonorgestrel 1.5mg, (generic Plan B One-Step) Contraceptive films (e.g. VCF Vaginal) Contraceptive foams (e.g. VCF Vaginal Aer) Contraceptive gels (e.g. Conceptrol, Gynol II, Shur-Seal) FC Female (female condom) Generic emergency birth control (e.g. Aftera, EContra EZ, Opcicon, Fallback, My Way, Next Choice, Take Action) Today sponge Tobacco Cessation Medications If you need help to quit smoking or using tobacco products, these preventive medications will be available at $0 cost-share starting on your health plan’s next renewal date on or after January 1, 2016. To qualify, you need to: • Be age 18 or older Over-the-Counter Medications (generic or store-brand only) • Get a prescription for these products from your doctor, even if the products are sold over-thecounter (OTC) • Fill the prescription at a network pharmacy Up to 180 days of treatment are covered at no cost each year. Maximum daily dose quantity limits apply. • Nicotine Replacement Gum • Nicotine Replacement Lozenge • Nicotine Replacement Patch • Bupropion sustained-release (generic Zyban) Tablet Prescriptions • Chantix Tablet •N icotrol Inhaler • Nicotrol Nasal Spray These three prescription medications are covered with Prior Authorization after members have tried: 1) One over-the-counter nicotine product and 2) B upropion sustained-release (generic Zyban) separately Continued Æ Breast Cancer Preventive Medications For members who are at increased risk for breast cancer but have not had breast cancer, these preventive medications are available at $0 cost-share. To qualify, a member must: • Be age 35 or older • Be at increased risk for the first occurrence of breast cancer – after risk assessment and counseling • Obtain Prior Authorization Most plans cover these medications at normal costshare for the treatment of breast cancer, to prevent breast cancer recurrence and for other indications. They are available at $0 cost-share to prevent the first occurrence of breast cancer if a Prior Authorization is obtained. If a member qualifies, they can receive these drugs at $0 cost-share for up to five years, minus any time they have been taking them for prevention. raloxifene tamoxifen Frequently Asked Questions Pharmacy Benefit Preventive Care Medications Coverage When will no cost Preventive Care Medications be available? Preventive Care Medications are available now.4 What Preventive Care Medications are available at no cost? A list of Preventive Care Medications can be found on pages 1-3 of this document so you can discuss them with your doctor. You can also login to OptumRx.com or call the number on your OptumRx ID card to confirm the most current list of Preventive Care Medications for your plan. Are all birth control products available at no cost to me? No, only the products on the list applicable to your plan will be no cost under the pharmacy benefit.5 The health reform law allows plans to use reasonable medical management to decide which birth control products will be provided at no cost. If you choose a product from this list, your cost at the pharmacy will be $0. If you choose a covered birth control product that is not on the list, a copay or co-insurance may be required. And this cost will apply to your deductible if you have one. What if my doctor says I need birth control that is not on this Preventive Care Medication List? Our Preventive Care Medications List includes at least one form of birth control from each of the 13 FDA-approved methods typically available through your pharmacy benefit. If your doctor recommends pharmacy-dispensed birth control not on our list for medical reasons, OptumRx will cover that recommended drug or product at no cost to you through our exceptions process. Just call the number on your OptumRx ID card, and ask how to obtain coverage. Medical reasons may include side effects, whether the birth control is permanent or can be reversed, and whether you can use the product as required. Other methods of birth control may be available through your medical benefit such as IUDs and implants. If I’m at risk for preeclampsia during pregnancy, how can I get low-dose aspirin for no cost? Low-dose or baby aspirin (81 mg) is available at no cost to pregnant women at risk for preeclampsia. If you are pregnant and at risk for preeclampsia, talk to your doctor about whether lowdose aspirin can help. If so, your doctor can give you a prescription for low-dose aspirin which can be filled at no cost to you at a network retail pharmacy. How can I get preventive medications to help me stop using tobacco for no cost? If you are age 18 or older and want to quit using tobacco products, talk to your doctor about medications that can help. If your doctor decides this therapy is right for you, they may prescribe a generic Over-the-Counter or prescription medication. The tobacco cessation products on this list will be no cost to you starting on your health plan’s next renewal date on or after January 1, 2016. The products must be: • Prescribed by your doctor • Filled at a network pharmacy • Meet use and quantity guidelines If I’m at risk for breast cancer but have not had it, how can I get preventive drugs for $0 cost-share? If you are a member age 35 or older, talk to your doctor about your risk of getting breast cancer if you have not had it. If your doctor decides this treatment is appropriate for you, your doctor may offer to prescribe risk-reducing medications, such as raloxifene or tamoxifen.6 You doctor can submit a Prior Authorization request to get these approved for you at $0 cost-share if you meet coverage criteria. Continued Æ Frequently Asked Questions continued… How many Preventive Care Medications can I get? Some products have quantity limits based on FDA approved dosing or product packaging. Coverage is limited to up to a 30 day supply at retail pharmacies or up to a 90 day supply at mail service. Will this drug list change? Drug lists can and do change, so it’s always good to check. You can learn the cost of all products and no cost options by: • Logging in to OptumRx.com, or • Calling the number on the back of your OptumRx ID card. What if I have a high-deductible or consumer-driven health (CDH) plan? The same no cost options on the list applicable to your plan will be available to you. If you fill a prescription for covered birth control products that are not on your plan’s no cost drug list, you will need to pay the full cost, until your deductible is reached. Are the no cost Preventive Care Medications available at both retail and mail pharmacies? Preventive Care Medications are available at network retail pharmacies. Most are also available at the OptumRx® Mail Service Pharmacy for plans with a mail order benefit. What if the health care reform law requirements for Preventive Care Medication coverage change? If the law requiring plans to provide Preventive Care Medications at no cost changes, information on how your costs may be impacted will be available to you by: • Logging in to OptumRx.com, or • Calling the number on your OptumRx ID card. Is my plan required to cover contraceptives? Some plans may not have coverage for contraceptives if your employer qualifies for a religious exemption. Also, some organizations (Eligible Organizations) can choose not to cover contraceptives for religious reasons; OptumRx may provide or arrange for contraceptive coverage for members of Eligible Organizations as required by the health reform law. In either event, you will still have coverage without cost-share of the U.S. Preventive Services Task Force A & B Recommendation medications listed on the Preventive Care Medications list (such as aspirin and Vitamin D). The OptumRx Mail Service Pharmacy can mail a 3-month supply of your medication right to you with no cost for standard shipping. That means you can order four times a year instead of making 12 trips to pick up your medication. To start using mail service, just call the number on your OptumRx ID card. 1. Please note this list is subject to change. 2. Always refer to your benefit plan materials to determine your coverage for medications and cost-share. Some medications may not be covered under your specific benefit. Where differences are noted, the benefit plan documents will govern. 3. All branded medications are trademarks or registered trademarks of their respective owners. 4. The cost for U.S. Preventive Services Task Force A & B Recommendation medications and OTC contraceptives on this list could be reimbursed back to Feb. 20, 2013 when the U.S. Dept. of Labor FAQ guidance was issued. However, they became available at network retail pharmacies at $0 cost-share on November 1, 2013. 5. When informed, an issuer must accommodate any member when one of the zero cost contraceptives may be medically inappropriate as determined by the member’s health care provider and waive the otherwise applicable cost-sharing for a contraceptive not currently covered at zero cost. 6. If your pharmacy benefit plan is grandfathered under the ACA, these drugs may be covered at the normal cost-share. www.optumrx.com 2300 Main Street, Irvine, CA 92614 All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. M53772 9/15 ©2015 OptumRx, Inc. ORX6258 OptumRx quick reference guide Our website, optumrx.com is a fast, safe and secure way to manage your prescription benefits online. This quick reference guide illustrates how to use the tools and features that will help you manage your OptumRx account and prescriptions: • Search for drug pricing and lower-cost alternatives • Refill and renew mail service pharmacy prescriptions • Transfer your retail prescriptions to our mail service pharmacy • View your mail service order status and claim history • Sign up for medication reminders via text message • View your OptumRx benefits in real time Quick reference guide UMR home page As a UMR member, you can access your prescription information from the UMR website. Follow these steps to register: 1. Visit umr.com. 2. In the left margin menu, select Members. 3. Login by entering your username and password in the top right login section. If you have not yet registered for a member account, select New user? Register here shown underneath username field. 4. Once successfully registered and/or logged in, select Pharmacy from the menu on the left. The website will redirect you to your online services home page. Once on the pharmacy home page, you click on OptumRx or the Visit the pharmacy button to enter optumrx.com and begin to take advantage of the many tools and features that will help you manage your pharmacy benefit. On your first visit, you will also need to register at optumrx.com — just follow the simple instructions. 2 OptumRx | optumrx.com OptumRx.com features and tools My prescriptions dashboard After you register or log in you’ll see your OptumRx My Prescriptions Dashboard. The dashboard makes it easy to access the tools and features designed to help you manage your medications and health. Transfer prescriptions Select the Transfer Prescriptions tab to transfer eligible prescriptions from your retail pharmacy to our mail order pharmacy service. Quick links On most web pages, the Quick Links box provides fast access to the most frequently used areas of our website. Refill prescriptions You can refill mail service prescriptions from your dashboard. Or select the My Medicine Cabinet tab and order refills from that page. Note: Some sections are only available if you are logged in to your account. Not all sections of the website are available to all members — access to features and tools are determined by your benefits plan. 3 Quick reference guide My prescriptions dashboard — continued Quick view calendar The Quick View calendar alerts you to upcoming prescription refills or renewals. You can also transfer these reminders to your MS outlook calendar. Renew prescriptions You can begin a request to renew a prescription from your dashboard or from the Renew Prescriptions tab. Order status Check the status of your mail service orders. Note: Some sections are only available if you are logged in to your account. Not all sections of the website are available to all members — access to features and tools are determined by your benefits plan. 4 OptumRx | optumrx.com Quick links The quick links box provides access to a variety of benefits and tools such as: Drug pricing Search prices for medications and find their lower-cost alternatives. Drug lookup Find for detailed information about thousands of prescription drugs. Formulary (provider drug list) Learn which medications are covered by your benefit plan. Real time benefits See how much you’ve spent on medications, view your claims history and more. Locate a pharmacy Enter your zip code and select GO to find a retail pharmacy near you. Prior authorization Certain medications may require prior authorization by your health plan or pharmacy benefits manager (PBM) in order to be covered. Prior authorization is a formal process that requires your doctor to give a medical reason for prescribing that medicine instead of a less expensive one. Prior authorization Begin a prior authorization or check the status of an existing one. 5 Quick reference guide My medicine cabinet The My Medicine Cabinet tab displays all your medications, both mail service and retail, with pictures of your medications, refill status and other information. My medicine cabinet Go to My Medicine Cabinet from the tab on the navigation bar. My medication reminders Select the link or phone icon next to each refillable prescription to begin setting up your medication reminders. My additional medications and supplements Enter a medication or supplement name in the search box. Select ADD DRUG. My archive Save your past medications in the archive. 6 OptumRx | optumrx.com My medication reminders Sign up to receive medication reminders via text message and never forget to take or fill your medications again. My medication reminders Enter your mobile phone number to set up text message reminders for: • Refills • Renewals • Transfers • Order shipments • Daily text reminders to take medications Medication dosage reminders Customize your dosage reminders for daily, weekly or monthly alerts. Update medication reminders Select UPDATE MEDICATION REMINDERS when you’re done. 7 Quick reference guide Household/caregiver access Household/caregiver access allows you to become an account manager or let another person manage your account. Household/caregiver access Learn how you can: • Become an account manager for your family’s benefits (spouse and children) • Become a caregiver for another person • Assign a caregiver to manage your accounts on your behalf My household accounts Manage the benefits of your minor dependents’ and spouse (if you have your spouse’s permission). The family tree shows your spouse and minor dependents. Accept caregiver invitation Become a caregiver for another person. If someone wants you to manage their account on your behalf, they can send you a caregiver invitation by email. To accept the invitation, enter the access code that was included in the email invitation. Enter your date of birth and ZIP code. Select ACCEPT CAREGIVER INVITATION. 8 OptumRx | optumrx.com Website help No matter where you are on our website, help is just a few clicks away. Log in help From the optumrx.com home page, it’s easy to find Log In Help. Log in help On the home page of optumrx.com, select Log In Help. Customer service Find Login Assistance, Help Topics and other information. Or call 1-877-559-2955. Talk to a representative Select talk now to set up a time for a representative to call you. 9 Quick reference guide Help topics You will find a variety of additional Help Topics on the Customer Service page. Choose a topic Find the answers to many of our most common topics and frequently asked questions. 10 OptumRx | optumrx.com Contact us You can contact us electronically, by phone or mail. Contact us Use the feedback form or send us an email. Contact us by phone Contact us by phone for: • Customer service • Mail service pharmacy help • Medical supplies • Medicare drug plan help Prior authorization Your doctor can contact us to request prior authorization. OptumRx pharmacists Pharmacists are available 24 hours a day, 7 days a week to answer questions from mail service customers. 11 Quick reference guide Mobile website Use your smartphone to access the mobile website, m.optumrx.com. The mobile website lets you manage your prescription benefits from your smartphone. You can order refills, check your order status, set up medication reminders and more — anytime, anywhere. It’s perfect for people on the go. Mobile website Use your smartphone to access our mobile website where you can: • Request prescription refills • Check order status • Locate a retail pharmacy • Search your plan’s formulary • Register via our mobile website optumrx.com 2300 Main Street, Irvine, CA 92614 OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at optum.com. All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. © 2014 Optum, Inc. All rights reserved. ORX1558 ORX4929-UMR_140829 Your Pharmacy Benefits www.optumrx.com 2300 Main Street, Irvine, CA 92614 The information in this educational tool does not substitute for the medical advice, diagnosis or treatment of your physician. Always seek the help of your physician or qualified health provider for any questions you may have regarding your medical condition. OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at www.optum.com. All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. ORX2333_120629 ©2012 OptumRx, Inc.
