2015 FORMULARY GUIDE

Transcription

2015 FORMULARY GUIDE
Pharmacy Benefits Management
Table of Contents
Overview .................................................................................................................................................................... 3
Important Phone Numbers........................................................................................................................................ 3
Understanding Coverage and Cost‐Sharing .......................................................................................................... 3
Formulary .............................................................................................................................................................. 3
Understanding Our Symbols .................................................................................................................................... 4
Prior Authorization .............................................................................................................................................. 4
Step Therapy ......................................................................................................................................................... 4
Quantity Limits ..................................................................................................................................................... 4
About Generic Drugs ................................................................................................................................................ 5
How to Fill Your Prescription Medications ........................................................................................................... 5
Medication Supplies Not Covered by IU Health Plans .................................................................................... 6
Formulary Listing ...................................................................................................................................................... 7
2
iuhealthplans.org
Overview
This guide provides an overview of your pharmacy benefit. It explains the tiers for drug coverage, the process
for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more.
Important Phone Numbers
Pharmacy Services ‐ 866.822.6504.
Understanding Coverage and Cost‐Sharing
Formulary
The Formulary, also known as your Preferred Drug List, is a list of prescription drugs that are covered under
your plan. The inclusion of specific medications on the IU Health Plans formulary is based on the
medication's effectiveness, safety, and value.
The formulary offers a wide selection of generic and brand name prescription drugs suggested by the
Pharmacy and Therapeutics (P&T) Committee, a group of physicians and pharmacists who researches and
evaluates medications. The formulary is periodically reviewed and updated throughout the year in order to
ensure that our benefits package consistently and adequately meets your needs.
When you need a prescription medication, you and your doctor can choose from five different levels of the
formulary. These are Generics – Tier 1, Preferred Brands – Tier 2, Non‐Preferred Brands – Tier 3 and
Specialty – Tier 4. Each level has a different copayment. This gives you and your doctor the freedom to
choose the medication that is right for you. At the same time, this will help you to better budget your health
care dollars.
Preferred Generic Medications – Tier 1 have the lowest copayment/co‐insurance. Generic drugs
offer the same level of safety and quality as their brand‐name equivalents. They have the same amount
of active ingredients as brand‐name medications. You are required to use a generic version of the
drug if one is available.
Preferred‐Brand medications – Tier 2 have the middle level copayment/co‐insurance. These drugs are
brand medications and “preferred” because of their value and effectiveness.
Non‐Preferred Brand medications – Tier 3 have a higher copayment/co‐insurance level. These
medications are brand drugs that are more expensive and have similar effectiveness as tier 2 medications.
Specialty medications – Tier 4 have the highest copayment/co‐insurance level. These also include
Specialty medications which usually treat complex and rare conditions. These drugs can be high‐cost
medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or
inhalant).
3
iuhealthplans.org
Non‐Formulary medications may be covered if the formulary medications do not work for you. If you
require a Non‐Formulary medication, your doctor may request coverage for the Tier 3 copayment by making
a request for an exception.
Understanding Our Symbols
Prior Authorization
You will see the symbol “PA” next to certain drugs on our formulary tables. This is called prior
authorization. Prior authorization helps ensure that you’re using the best drugs in the safest way.
If you are currently taking or recently prescribed one of these drugs, please discuss possible alternatives or
have your doctor request authorization by calling 866.822.6504.
Drugs that require prior authorization are often:
• Newer drugs for which the Health Plan wants to track usage.
• Non‐formulary drugs which require the use of formulary drugs prior to coverage. These drugs are
not used as a standard first option in treating a medical condition.
• Drugs with potential side effects that the Health Plan wants to monitor for patient safety.
• Drugs categorized as specialty medications.
Step Therapy
You will see the symbol “ST” (Step Therapy) next to certain drugs on the formulary tables in this
booklet. Step therapy ensures you are taking the most effective medication at the best cost. This means
trying the least expensive medications usually generic medications or drugs that are considered as the
standard first‐line treatment.
How step therapy works
Step 1: When your prescribed drug is impacted by step therapy, first you will be asked to try generic or
first‐line treatment drugs. The drug recommended will be approved by the Food and Drug Administration
(FDA) as providing the same health benefit at a much lower cost.
Step 2: If the generic drug in step 1 does not work for you, then you will have coverage for a brand‐name
drug. For more information on step therapy call 866.822.6504.
Quantity Limits
The symbol “QL” next to the drugs in this formulary booklet stands for Quantity Limits. To ensure you are
getting the most cost‐effective dose for your medication, a quantity limit or dose duration may be placed on
certain drugs. These limits are based on FDA guidelines, clinical literature, and manufacturer’s instructions.
Quantity limits promote appropriate use of the drug, prevent waste, and help control costs.
For some drugs, the dosing guidelines may recommend that patients take the drug one time a day in a
larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and
cover one larger dose per day.
Prescriptions for controlled substances and specialty medications are limited to a 30‐day supply.
For more information on quantity limits or dose durations call 866.822.6504.
4
iuhealthplans.org
About Generic Drugs
Generic drugs have the same active ingredients as their brand‐name equivalents, but cost significantly less. Not
all drugs have a generic equivalent. Generally, new drugs receive patent protection for 20 years. Once the
patent expires, other pharmaceutical companies can produce the same drug in a generic formulation.
Companies that make generic drugs do not have to invest large amounts of money in research, since the
company making the brand‐name equivalent has already done this. Also, generic companies do not need to
advertise their drugs. As a result, generic drug makers can pass these savings on to you.
Generic drugs have the same active ingredients as brand‐name drugs, but their inactive ingredients can vary.
This is why the generic drug might look different from the brand‐name drug. Inactive ingredients can be dyes
used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic
drug works.
The FDA regulates generic drug manufacturers just as it regulates the makers of brand‐name medications. The
generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active
ingredient in the same time frame as its brand‐name counterpart. The manufacturer of the generic drug must
prove that it produces its product under the same strict guidelines as the brand‐name drug.
How to Fill Your Prescription Medications
Short‐term medications
These are drugs you need immediately. This includes medications used to treat short term infections, or to
relieve pain temporarily. You can fill these prescriptions:
• At a retail network pharmacy
• Your pharmacy benefits can also be filled at pharmacies accepting Express Scripts prescriptions.
Locate the nearest retail network pharmacy by calling 866.822.6504. To fill your prescription, present your
member ID card and written prescription and pay your copayment/co‐insurance as described above.
Long‐term medications
These are drugs you take on a regular basis. These could be drugs to treat asthma, high blood pressure,
diabetes, etc. These medications can be mailed to your home for up to a 90‐ day supply.
Specialty medications
Specialty medications treat specific medical conditions such as cancer, hemophilia, hepatitis, multiple sclerosis,
psoriasis, pulmonary arterial hypertension, respiratory syncytial virus, rheumatoid arthritis, and more. You can
fill these prescriptions:
• At IU Health and Kroger Retail Pharmacies
o Locate the nearest retail network pharmacy by calling 866.822.6504.
•
Through Accredo (the Express Scripts Specialty Pharmacy)
o Accredo, the Express Scripts specialty pharmacy, is a specialty pharmacy that
provides specialty medications. Please call 888.615.3244 to learn more about filling
your specialty medications.
5
iuhealthplans.org
Filling Your Prescription When Traveling
When you travel outside of your local area, thousands of pharmacies across the country will honor your IU
Health Plans member ID card.
To locate a participating pharmacy, contact your member services team at the phone number listed on the
back of your member ID card or on 1 page of this booklet.
To fill a prescription at a participating out‐of‐area pharmacy, present your IU Health Plans
member ID card. Some pharmacies may ask you to pay the full price of the medication. If that happens:
• Submit a Direct Reimbursement Claim form to IU Health Plans at:
IU Health Plans
950 N. Meridian St.
Suite 600
Indianapolis, IN 46204
• Or you may call your member services team for assistance
• If your claim is approved, you will be reimbursed the amount that you paid for the medication, less
the appropriate copayment.
If you will be away from home for an extended period of time, or if you will be traveling outside of the
country, you may want to use our mail‐order service so that you receive a 90‐day supply before you
leave home.
Medication Supplies Not Covered by IU Health Plans
No authorizations will be provided for medications that are reported by the member, provider, or
pharmacy to be lost, misplaced, stolen, destroyed, or damaged.
Medications received at no charge to the member (workers’ compensation, medications purchased with a
manufacturer’s coupon, etc.) will not be covered.
Prescriptions that are written more than a year ago will not be covered. Your doctor will need to write a
new prescription.
6
iuhealthplans.org
Formulary Listing
The following pages list the formulary and the associated tier level (cost share) of the medications. Please
reference this list when you discuss your medications with your doctor. The table below indicates the
definition of the symbols through the formulary listing.
Preferred Generics– Tier 1
Preferred Brands – Tier 2
Non‐Preferred Brands – Tier 3
Specialty – Tier 4
PA ‐ Prior Authorization
QL ‐ Quantity Limit
ST‐ Step Therapy
8-MOP PA
abacavir
abacavir / lamivudine /
zidovudine
Abilify Maintena PA, QL
(ST <12 years of age)
Abilify PA, QL (ST <12
years of age)
Abstral PA, QL
acamprosate
acarbose
acebutolol
acetaminophen / caffeine /
dihydrocodone QL
acetaminophen / codeine
QL
acetazolamide ER capsule
acetic acid
acetic acid /
hydrocortisone
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
2015 Drug Formulary (Effective January 1, 2015)
Suggested Alternative(s)
4
Specialty medication
4
1
1
2
3
fentanyl citrate (PA)
1
1
1
1
1
1
1
1
7
iuhealthplans.org
acitretin
Actemra PA, QL
Acthar gel PA, QL
Actimmune PA
Actonel QL
Actonel Weekly QL
Acuvail QL
acyclovir
acyclovir ointment
Aczone
Adagen PA
adapalene (PA >35 years
of age)
Adcirca PA, QL
adefovir PA
Adempas PA, QL
Adrenaclick
Advair
Advicor
Aerospan ST
Afinitor PA, QL
Aggrenox
alagesic
albuterol QL
alclometasone
dipropionate
Aldurazyme PA
alendronate
Alferon N PA
alfuzosin er
Alkeran
allopurinol
Alocril
Alomide
Alora QL
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
4
4
4
4
2
2
alendronate, ibandronate, risedronate
ketorolac, diclofenac, bromfenac
3
3
3
1
1
3
4
tretinoin, benzoyl peroxide, clindamycin, adapalene (PA)
4
4
4
4
EpiPen, Auvi-Q
1
3
2
3
atorvastatin, fluvastatin, lovastatin, pravastatin,
simvastatin, niacin ER
Flovent HFA, QVAR, Asmanex
clopidogrel, ticlopidine, dipyridamole, Effient
3
4
3
1
1
1
4
4
1
1
2
1
3
3
3
azelastine, epinastine, Pataday, Patanol
estradiol patch, Premarin
8
iuhealthplans.org
Aloxi ST, QL
Alphagan P 0.1%
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
3
alprazolam
alprazolam ODT ST
Alrex
Altavera
Alvesco ST
amantadine
amcinonide
Amethia
Amethia Lo
Amethyst
Amevive PA, QL
amiodarone
Amitiza QL
amitriptyline
amlodipine / atorvastatin
amlodipine besylate
amlodipine besylate /
benazepril
ammonium lactate
Amnesteem
amoxicillin
amoxicillin / clavulanate
amoxicillin / clavulanate
ER
amphetamine /
dextroamphetamine ER QL
(PA < 4 and >18 years of
age)
1
1
amphetamine salts QL (PA
< 4 and >18 years of age)
Ampyra PA, QL
Amturnide ST
1
ondansetron
betaxolol, brimonidine, carteolol, dorzolamide,
latanoprost, levobunolol, timolol, Azopt, Betoptic S,
Combigan
3
alprazolam
fluorometholone, prednisolone
3
Flovent HFA, QVAR, Asmanex
1
1
1
1
1
1
4
4
1
2
1
1
1
1
1
1
1
1
1
1
2
9
iuhealthplans.org
Analpram HC cream
Analpram HC lotion
anastrozole
Androderm PA, ST
Androgel 1% PA, ST
Androgel 1.62% PA
Android PA, ST
androxy PA, ST
Angeliq
Anoro Ellipta
antibiotics (generic oral)
Anzemet ST, QL
Apidra QL ST
Apokyn PA, QL
apraclonidine
Apri
Apriso ER
Aptiom PA, QL
Aptivus
Aquoral
Aralast NP PA
Aranelle
Aranesp PA
arbinoxa
Arcalyst PA, QL
Arcapta ST
Armour Thyroid
Asacol HD
Ascensia Blood Glucose
Meters
Asmanex
Atelvia QL
atenolol
atenolol / chlorthalidone
atorvastatin
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
3
hydrocortisone/pramoxine
3
testosterone injection (PA), Androgel 1.62% (PA)
Androgel 1.62% (PA)
3
Premarin, estradiol, estropipate
1
2
2
1
3
2
1
3
3
4
ondansetron
Humalog, Novolog
1
1
2
3
carbamazepine, oxcarbazepine, lamotrigine, valproic
acid, levetiracetam, phenytoin, zonisamide
2
3
4
Caphosol
4
4
3
3
Serevent, Foradil
levothyroxine, liothyronine
3
1
1
2
2
2
2
1
1
1
10
iuhealthplans.org
atovaquone suspension
Atripla
Atrovent HFA
Aubagio PA, QL
Aubra
aurodex
auroguard
Auvi-Q
Aveed PA, ST
Aviane
Avodart
Avonex QL
Axert ST, QL
Axiron PA, ST
Azasite
azathioprine
azelastine
Azelex ST
Azilect
azithromycin QL
Azopt
baclofen
Bactroban nasal ointment
balsalazide disodium
Banzel PA
Baraclude PA
Bayer Blood Glucose
Meters
Bayer Blood Glucose Test
Strips (QL > 18 years of
age)
Bayer Lancets (QL > 18
years of age)
Beconase AQ ST
beflex
benazepril
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
2
2
4
1
1
1
2
3
1
2
4
3
3
3
naratriptan, rizatriptan, sumatriptan, zolmitriptan
erythromycin
3
Generic topical acne agents
1
1
2
1
2
1
2
1
3
4
felbamate, lamotrigine, topiramate, valproate
2
2
2
3
fluticasone, flunisolide, Veramyst
1
1
11
iuhealthplans.org
benazepril / HCTZ
Benlysta PA
benprox
benzoyl peroxide
benztropine
Bepreve
Berinert PA
Besivance
1
betamethasone
Betaseron ST, QL
betaxolol
Bethkis QL
Betimol
Betoptic S
Beyaz
Biafine
bicalutamide
bisoprolol
bisoprolol / HCTZ
Bivigam PA
Blephamide
Bosulif PA, QL
Botox PA, QL
bp 10-1 wash
BPO gel
Breeze Blood Glucose
Meters
Breo Ellipta
Briellyn
Brilinta QL
brimonidine tartrate
Brintellix PA, QL
1
bromfenac ophthalmic
solution
1
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
4
1
1
1
3
4
3
ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Zymar,
Moxeza, Vigamox
4
4
3
timolol, Betoptic S
3
ammonium lactate, zenieva
1
2
2
1
1
1
4
4
4
2
1
1
2
2
1
3
clopidogrel, Effient
3
paroxetine, sertraline, citalopram, venlafaxine ER
capsules, duloxetine (ST)
1
12
iuhealthplans.org
Brovana
budeprion XL
budesonide EC
budesonide nasal spray
ST
budesonide respules
Buphenyl tablet PA
buprenorphine PA, QL
buprenorphine/naloxone
tablet PA, QL
bupropion
bupropion SA
buspirone
butorphanol nasal spray
QL
Bydureon QL
Byetta QL ST
Bystolic ST
calcipotriene
calcitriol
calcium acetate
Camila
Camrese
Camrese Lo
Canasa
candesartan
candesartan / HCTZ
capecitabine PA
Caphosol
Caprelsa PA, QL
captopril
captopril / HCTZ
Carbaglu PA
carbamazepine ER
carbidopa
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
Serevent, Foradil
1
1
1
1
4
1
3
Suboxone film (PA), Zubsolv (PA)
3
3
3
Bydureon, Victoza
atenolol, metoprolol, propranolol
1
1
1
1
2
2
1
1
1
1
1
1
3
mesalamine, balsalazide disodium, sulfasalazine,
sulfasalazine EC, Apriso, Asacol HD, Delzicol
1
1
4
4
4
2
1
1
1
1
13
iuhealthplans.org
carbidopa / levodopa
carbidopa / levodopa /
entacapone
Cardene SR
Cardura XL ST, QL
Carimune NF PA
carisoprodol
carteolol
cartia XT
carvedilol
Cayston QL
Ceenu
cefaclor
cefadroxil
cefdinir
cefpodoxime
cefprozil
ceftazidime
ceftibuten
cefuroxime
Celebrex ST, QL
Cenestin
cephalexin
Cerezyme PA
cevimeline
Chantix ST, QL
Chateal
Chemet PA
chlordiazepoxide
chlorpromazine (ST <12
years of age)
chlorpropamide
chlorthalidone
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
1
3
4
diltiazem, cartia XT, nifedipine, nifedipine ER, taztia XT,
verapamil, verapamil SR, Nifediac CC, amlodipine
besylate
doxazosin, tamsulosin, terazosin, prazosin, alfuzosin er
4
3
1
1
1
1
2
1
1
1
1
1
1
1
1
3
Generic NSAIDS (diclofenac, etodolac, ibuprofen,
meloxicam, naproxen)
3
1
4
1
2
1
3
1
1
1
1
14
iuhealthplans.org
chlorzoxazone
cholestyramine
ciclopirox
cilostazol
Ciloxan
1
1
1
1
cimetidine
Cimzia PA, QL
Cinryze PA, QL
Cipro HC
Ciprodex
ciprofloxacin
ciprofloxacin 0.2% ear
drops
ciprofloxacin ER QL
citalopram QL
Claravis
clarithromycin
clarithromycin ER
Climara-PRO QL
Clinac BPO
clindamycin
clobetasol
clonazepam
clonazepam ODT ST
clonidine
clonidine ER ST, QL
clopidogrel
clorazepate
clotrimazole
clozapine (ST <12 years of
age)
clozapine ODT QL (ST <12
years of age)
Coartem
codeine sulfate
1
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
Moxeza, Vigamox
4
4
2
2
1
1
1
1
1
1
1
3
3
1
1
1
1
1
1
1
1
1
1
estradiol
benzoyl peroxide
clonazepam
1
2
1
15
iuhealthplans.org
Colcrys
Colestid granules
colestipol
Combigan
Combipatch QL
Combivent Respimat
Cometriq PA, QL
Complera
Contour Blood Glucose
Meters
Copaxone QL
Copegus QL
Coreg CR
cortamox
Cortef
Cortifoam
Cosopt PF
Specialty
2
3
colestipol
3
estradiol-norethindrone, Jinteli, Prempro, Premphase
1
2
2
4
4
4
carvedilol
2
2
3
1
3
3
3
Covera- HS
Creon
Crestor PA, ST
Crinone 4% gel
Crixivan
cromolyn
Cryselle
Cuprimine PA
Cuvposa (PA > 16 years of
age)
Cyclafem
cyclobenzaprine
cyclopentolate drops
Cycloset
cyclosporine
cyclosporine modified
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
hydrocortisone tablet
hydrocortisone suppositories, proctozone
Azopt, betaxolol, Betoptic S, carteolol, dorzolamide,
dorzolamide-timolol, timolol maleate
besylate
2
3
simvastatin, atorvastatin, pravastatin
3
glycopyrrolate tablet
3
bromocriptine
2
2
1
1
2
1
1
1
1
1
16
iuhealthplans.org
Cystadane powder PA
Cystagon PA
Cystaran PA, QL
Daliresp PA
Specialty
Non-Preferred Brand
4
4
3
Advair, Dulera, Foradil, Serevent, Spiriva, Symbicort,
Tudorza
3
2
danazol PA
dantrolene
Dapsone
Dasetta
Daysee
Delatestryl PA, ST
Delyla
Delzicol
Demser PA
Denavir
Depen PA
Depo-Testosterone PA, ST
Dermatop
desogestrel / ethinyl
estradiol
desonide
desoximetasone
Desvenlafaxine ER ST, QL
1
1
dexamethasone
dexmethylphenidate ER
QL (PA < 4 and ≥18 years
of age)
1
1
dexmethylphenidate QL
(PA < 4 and ≥18 years of
age)
1
dextroamphetamine QL
age)
1
Diastat
Diastat Acudial
Preferred Brand
Drug Name
Generic
2
1
1
1
2
4
3
2
4
3
3
For cold sore treatment use over-the-counter agents
Generic topical steroids
1
1
1
3
citalopram, fluoxetine, paroxetine, sertraline, venlafaxine,
venlafaxine ER capsules, duloxetine (ST)
3
diazepam
2
17
iuhealthplans.org
diazepam
Dibenzyline PA
diclofenac
diclofenac ophthalmic
solution
diclofenac-misoprostol
dicloxacillin
didanosine
Dificid ST, QL
diflorasone
digoxin
dihydroergotamine
diltiazem
diltiazem ER
Dipentum ST
dipyridamole
disulfuram
divalproex sodium
divalproex sodium ER
Divigel
donepezil PA
dorzolamide
dorzolamide / timolol
doxazosin
doxercalciferol
doxycycline
drithocreme
Dritho-Scalp
dronabinol
Duavee
Dulera
duloxetine ST, QL
Durasal
Durezol
Dymista ST
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
4
4
1
1
1
1
1
1
1
1
1
1
3
balsalazide disodium, Apriso, Asacol HD, Delzicol
3
estradiol
3
3
3
3
salicyclic acid
1
1
1
1
1
1
1
1
1
1
1
2
1
2
1
18
iuhealthplans.org
Dynacirc CR
dyphylline gg
Dyrenium
Dysport PA, QL
Edarbi ST
Specialty
3
besylate
1
3
4
3
Edarbyclor ST
Edurant
Effient QL
Elaprase PA
Elelyso PA
Elidel PA
Eligard PA, QL
Elinest
eliphos
Eliquis QL
Ella
Elmiron
Emadine
Emcyt PA
Emend capsule QL
Emend vial QL
Emoquette
Emtriva
enalapril
Enbrel PA, QL
Endocet QL
Enjuvia
enoxaparin QL
Enpresse
Enskyce
entacapone
Entyvio PA, QL
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
triamterene-HCTZ
losartan, eprosartan, irbesartan, candesartan,
telmisartan, valsartan
candesartan-HCTZ, irbesartan-HCTZ, losartan-HCTZ,
telmisartan-HCTZ, valsartan-HCTZ
2
2
4
4
3
4
1
1
2
3
levonorgestrel, Next Choice
2
3
4
4
2
3
1
2
1
1
3
estradiol, estropipate, Premarin
1
1
1
1
4
19
iuhealthplans.org
epinastine ophthalmic
solution
epinephrine
EpiPen
eplerenone
Epogen PA
epoprostenol PA
eprosartan
Epzicom
ergotamine / caffeine
Erivedge PA, QL
Errin
EryPed
Ery-tab EC
Ery-tab EC 500mg
erythromycin
erythromycin / benzoyl
peroxide gel
escitalopram ST, QL
Estarylla
Estrace cream
Estraderm QL
estradiol
estradiol / norethindrone
estradiol patch QL
Estring
Estrogel
estropipate
eszopiclone ST, QL
etidronate
etodolac
etoposide PA
Euflexxa PA, QL
Evamist
Evzio PA, QL
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
1
2
1
4
4
4
1
2
1
1
3
erythromycin
3
3
estradiol
3
3
Premarin
1
2
1
1
1
1
1
1
1
1
1
1
1
4
4
3
4
estradiol
20
iuhealthplans.org
Exelon patch PA
exemestane
Exjade PA
Eylea PA
Fabior (PA >35 years of
age)
Fabrazyme PA
Factive QL
Falmina
famciclovir QL
famotidine
Fanapt PA, QL (ST <12
years of age)
Fareston PA
felbamate
felodipine
FemHRT
Femring
Femtrace
fenofibrate
fenofibric acid ST
fenoprofen
fentanyl citrate PA, QL
fentanyl transdermal QL
Fentora PA, ST, QL
Ferriprox PA
Fetzima PA, QL
Finacea
finasteride
Firazyr PA, QL
Firmagon PA, QL
First Testosterone 2%
cream PA, ST
First Testosterone 2%
ointment PA, ST
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
rivastigmine tartrate capsules (PA), donepezil (PA),
Namenda (PA)
1
4
4
4
ciprofloxacin, levofloxacin
3
3
1
1
1
3
4
risperidone (ST), olanzapine (ST), quetiapine (PA, ST),
Abilify (PA, ST), ziprasidone (ST)
1
1
3
3
3
3
fentanyl citrate (PA), Abstral (PA)
venlafaxine ER, duloxetine (ST)
1
1
1
1
1
4
3
3
1
4
4
3
3
21
iuhealthplans.org
First-BXN Mouthwash
Flarex
Flebogamma PA
flecainide
Flovent HFA
fluconazole QL
flunisolide
fluocinolone
fluocinonide
Fluor-A-Day chew
Fluor-A-Day drops
fluorometholone
fluoxetine
fluoxetine DR QL
fluphenazine (ST <12 years
of age)
flurbiprofen
fluticasone
fluvastatin
fluvoxamine
FML Forte
FML S.O.P.
fondaparinux QL
Foradil
Forteo ST, QL
Fortesta PA, ST
fosinopril
fosinopril / HCTZ
Fosrenol
Fragmin QL
Frova ST, QL
Fulyzaq PA, QL
furosemide
Fuzeon
Fycompa PA, QL
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
3
4
diphenhydramine, lidocaine, nystatin
1
2
1
1
1
1
1
2
1
1
1
1
1
1
1
1
3
2
1
2
4
3
1
1
3
4
3
4
calcium acetate, sevelamer carbonate, Renvela powder
packet
1
4
3
22
iuhealthplans.org
gabapentin
Gablofen
galantamine ER PA
galantamine PA
Galzin PA
Gammagard PA
Gammaked PA
Gammaplex PA
Gamunex PA
Gamunex-C PA
ganciclovir
gatifloxacin
Gattex PA, QL
gavilyte-g
gemfibrozil
Generess FE
1
Gianvi
Gildagia
Gildess
Gilenya PA, ST, QL
Gilotrif PA, QL
Glassia PA
Gleevec PA, QL
glimepiride
glipizide
glipizide / metformin
glipizide ER
Glucagon
glyburide
glyburide / metformin
Glyset
Gralise PA, QL
granisetron ST, QL
granisol ST, QL
Granix PA
1
1
1
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
1
1
2
4
4
4
4
4
4
1
1
1
1
3
Generic oral contraceptives, Beyaz, Natazia, Nuvaring,
Ortho Tri-Cyclen LO, Safyral
4
4
4
4
4
acarbose
gabapentin
ondansetron
ondansetron
1
1
1
1
2
1
1
3
3
1
1
23
iuhealthplans.org
griseofulvin
guanfacine
Halflytely
halobetasol
Halog
haloperidol (ST <12 years
of age)
HCTZ
Heather
Helidac
Hetlioz PA, QL
Hexalen
Hizentra PA
Horizant PA, QL
Humalog 50/50 QL
Humalog 75/25 QL
Humalog QL
Humira PA, QL
Humulin 50/50 QL
Humulin 70/30 QL
Humulin N QL
Humulin R QL
Hycamtin PA
hydralazine
hydrocodone / ibuprofen
hydrocodone/
acetaminophen QL
hydrocort / pramoxine
cream
hydrocortisone
hydromorphone
hydroxychloroquine
hydroxyurea
hydroxyzine
hyoscyamine
ibandronate IV ST, QL
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
1
3
peg-3350, Suprep, Moviprep
3
3
4
4
4
bismuth subsalicylate (OTC), metronidazole, tetracycline
gabapentin, pramipexole, ropinirole
4
4
1
1
1
1
3
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
3
24
iuhealthplans.org
ibandronate tablet QL
ibuprofen
Iclusig PA, QL
Ilaris PA, QL
Ilevro
Imbruvica PA, QL
imiquimod
Increlex PA
Incruse Ellipta
indomethacin
Infergen PA, QL
Inlyta PA, QL
Innopran XL ST
Intelence PA
Intron A PA
Introvale
Intuniv ST, QL
Invega PA, QL (ST <12
years of age)
Invega Sustenna PA, QL
Invirase
Invokana QL
ipratropium
ipratropium / albuterol
solution
irbesartan
irbesartan / HCTZ
Iressa PA, QL
Isentress
Isopto Carbachol
Specialty
Non-Preferred Brand
1
1
4
4
3
4
1
4
Spiriva, Tudorza
4
4
4
4
guanfacine
3
1
3
2
1
3
3
2
3
metformin, glyburide, glipizide, Januvia, Tradjenta
1
1
1
1
4
2
Isopto Homatropine
isosorbide
Preferred Brand
Drug Name
Generic
3
betaxolol, brimonidine, carteolol, dorzolamide,
latanoprost, levobunolol, timolol, Combigan, Azopt,
Betoptic S
3
homatropine, atropine, cyclopentolate, mydral,
tropicamide
1
25
iuhealthplans.org
isradipine
Istalol
itraconazole capsule PA,
QL
Jakafi PA, QL
Jalyn
Janumet
Janumet XR
Januvia
Jencycla
Jentadueto
Jetrea PA, QL
Jinteli
Jolessa
Jolivette
Junel
Junel FE
Juxtapid PA, QL
Kalbitor PA
Kaletra
Kalydeco PA, QL
Kariva
Kazano ST
Ketek QL
ketoconazole
ketoprofen
ketorolac ophthalmic
solution
ketorolac QL
Khedezla ER ST, QL
Kineret PA, QL
Kombiglyze XR ST
Korlym PA, QL
Krystexxa PA, QL
Kurvelo
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
3
timolol
1
4
4
4
4
4
2
2
2
2
1
2
1
1
1
1
1
2
1
3
3
Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta
azithromycin, clarithromycin ER, erythromycin
3
1
1
1
1
4
3
4
4
1
26
iuhealthplans.org
Kuvan PA
Kynamro PA, QL
labetalol
lactulose
lamivudine
lamivudine / zidovudine
lamivudine HBV PA
lamotrigine
lansoprazole / amoxicillin /
clarithromycin pack
lansoprazole QL
Lantus QL
Larin
Larin Fe
Lastacaft
latanoprost
Latuda ST, QL (ST <12
years of age)
Lazanda PA, ST, QL
Leena
leflunomide
Lessina
Letairis PA, QL
letrozole
Leukeran
Leukine PA
leuprolide PA
levalbuterol ST
Levatol ST
Levemir QL
levetiracetam
levetiracetam ER QL
levobunolol
levocetirizine
levofloxacin
levofloxacin ophthalmic
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
4
4
1
1
1
1
1
1
1
1
2
1
1
3
3
1
3
1
1
1
4
4
4
1
2
1
3
2
1
1
1
1
1
1
27
iuhealthplans.org
Levonest
levonorgestrel
Levora
levothyroxine
Lexiva
Lialda ST
lidocaine patch ST, QL
lidocaine-hc gel
LidoVir ointment
compounding kit
Lifescan Blood Glucose
Meters
Lifescan Blood Glucose
Test Strips (QL > 18 years
of age)
Lifescan Lancets (QL > 18
years of age)
Linzess QL
liothyronine
Lipofen
Liptruzet ST
1
1
1
1
lisinopril
lisinopril / HCTZ
Lo Loestrin FE
1
1
2
3
balsalazide disodium, Apriso, Asacol HD, Delzicol
3
For cold sore treatment use over-the-counter agents
3
Amitiza
3
3
fenofibrate
simvastatin, Zetia
3
1
1
2
2
2
1
Loestrin 24 FE
3
Lomedia 24 FE
3
Lo Minastrin FE
3
Lomustine
loratadine OTC
lorazepam
Lorcet HD QL
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
2
1
1
1
28
iuhealthplans.org
Lorcet plus QL
Lortab QL
Loryna
losartan
losartan / HCTZ
Lotemax
Lotronex PA
lovastatin
Low-ogestrel
loxapine (ST <12 years of
age)
Lucentis PA
Lumigan
Lumizyme PA
Lupaneta PA, QL
Lupron PA, QL
Lyrica PA, QL
Lysodren PA
Lyza
Makena PA
malathion
Matulane
matzim LA
Maxair ST, QL
Maxaquin
Maxidex
meclizine
medroxyprogesterone
acetate injection QL
mefenamic acid
Mekinist PA, QL
meloxicam
Menest
Menostar QL
meperidine tablet
mercaptopurine
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
1
1
1
1
3
4
4
4
4
4
4
gabapentin, Savella (PA)
4
4
1
1
1
2
3
1
1
1
3
3
3
Ventolin HFA
1
1
1
4
1
3
3
estradiol
1
1
29
iuhealthplans.org
mesalamine
metaxalone
metformin
metformin ER
Methadose
methamphetamine QL (PA
< 4 and ≥18 years of age)
methazolamide
Methitest PA
methocarbamol
methotrexate
methoxsalen PA
methylin ER QL (PA < 4
and ≥18 years of age)
methylin QL (PA < 4 and
≥18 years of age)
methylphenidate ER QL
age)
1
1
1
1
1
1
methylphenidate QL (PA <
4 and ≥18 years of age)
methylprednisolone
metipranolol
metoclopramide
metoprolol
metoprolol / HCTZ
metoprolol ER
metronidazole
Miacalcin
Microgestin
Microgestin FE
midazolam syrup
Migergot
migragesic IDA
Mimvey
Mimvey Lo
1
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
3
1
1
1
1
4
Specialty Medication
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
30
iuhealthplans.org
Minastrin 24 Fe
Minivelle QL
minocycline
Mirapex ER ST
mirtazapine
Mirvaso PA
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
3
3
pramipexole, ropinirole
3
metronidazole, sodium sulfacetamide/sulfur, tretinoin,
adapalene
1
1
modafinil PA, QL
Moderiba QL
moexipril
moexipril / HCTZ
mometasone
Mono-linyah
MonoNessa
montelukast QL
Monurol
morphine sulfate ER tablet
QL
morphine sulfate IR
Moviprep
Moxeza
moxifloxacin
Mozobil PA, QL
Multaq
mupirocin
Myalept PA, QL
mycophenolate mofetil
mycophenolate sodium
Myobloc PA, QL
Myorisan
Myozyme PA
Myrbetriq ER QL
1
Myzilra
nabumetone
1
1
4
4
4
4
4
oxybutynin, oxybutynin ER, trospium, trospium ER,
tolterodine, tolterodine ER, Toviaz, Vesicare
1
1
1
1
1
1
2
1
1
2
2
1
2
1
1
1
1
3
31
iuhealthplans.org
nadolol
nadolol /
bendroflumethiazide
Naglazyme PA
Namenda PA
Namenda XR PA
naproxen
naratriptan QL
Nasonex ST
Natazia
nateglinide
Nebupent
Necon
Nesina ST
Neulasta PA
Neumega
Neupogen PA
Neupro
Nevanac
nevirapine
nevirapine ER
Nexavar PA, QL
Next Choice
Next Choice One Dose
niacin ER
nicotine gum QL
nicotine lozenges QL
nicotine patches QL
Nicotrol Inhaler ST, QL
Nicotrol Nasal Spray ST,
QL
nifediac CC
nifedipine
nifedipine ER
Nikki
Nilandron PA
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
1
4
2
2
1
1
3
flunisolide, fluticasone, Veramyst
3
pramipexole, ropinirole
2
1
2
1
4
4
4
3
3
1
1
4
4
1
1
1
1
1
1
2
2
3
3
1
1
1
1
32
iuhealthplans.org
nimodipine
nisoldipine
nisoldipine ER
nitrofurantoin
nitroglycerin
Nitrostat
nizatidine
nodolor
Nora-BE
Norditropin PA
Norlyroc
Noroxin
Nortrel
nortriptyline
Norvir
Novolin 70/30 QL
Novolin N QL
Novolin QL
Novolin R QL
Novolog Mix 70/30 QL
Novolog QL
Noxafil PA
Nplate PA
Nuedexta PA, QL
Nulojix PA
Numoisyn
Nuvaring QL
Nuvigil PA, QL
NuZon
Ocella
octreotide
ofloxacin
Oforta PA
Ogestrel
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
1
1
1
1
3
nitroglycerin
1
1
1
4
1
3
1
1
2
2
2
2
2
2
2
4
4
4
4
3
Caphosol
2
3
amphetamine salts, amphetamine/dextroamphetamine
ER, dexmethylphenidate, dexmethylphenidate ER,
methylphenidate, methylphenidate ER, modafinil (PA)
3
hydrocortisone
1
4
4
1
1
33
iuhealthplans.org
olanzapine / fluoxetine PA,
QL (ST <12 years of age)
1
olanzapine QL (ST <12
years of age)
olanzapine vial
Olysio PA, QL
Omeclamox-Pak
omega-3 acid ethyl esters
omeprazole QL
Omnaris ST
Omontys PA
ondansetron QL
One Touch Blood Glucose
Meters
One Touch Blood Glucose
Test Strips (QL > 18 years
of age)
1
Onfi PA, QL
Onglyza ST
Onmel PA, QL
Onsolis PA, ST, QL
Opana ER QL
Opsumit PA, QL
OramagicRx
Orap (ST <12 years of age)
Orencia PA, QL
Orenitram PA
Orfadin PA
Orsythia
Ortho Tri-Cyclen LO
Oseni
Osmoprep
Otezla PA, QL
Otosporin ear drops
Otrexup PA, QL
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
4
3
omeprazole, clarithromycin, amoxicillin
1
1
3
4
1
2
2
3
3
3
3
itraconazole (PA)
2
4
lidocaine, First-Mouthwash
4
4
4
4
Acetic acid/hydrocortisone
3
2
1
2
3
3
3
4
34
iuhealthplans.org
oxaprozin
oxazepam
oxcarbazepine
Oxsoralen PA
oxybutynin
oxybutynin ER
oxycodone /
acetaminophen QL
oxycodone / aspirin QL
oxycodone / ibuprofen QL
oxycodone IR
Oxycontin PA, QL
oxymorphone
oxymorphone ER QL
Pancreaze ST
Pancrelipase ST
Pandel
Panretin PA
pantoprazole QL
paricalcitol
paroxetine
paroxetine CR QL
Pataday
Patanase
Patanol
peg-3350
Peganone PA
Pegasys PA, QL
Peg-Intron PA, QL
pemoline
penicillin
Pentasa
pentazocine /
acetaminophen QL
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
1
1
4
1
1
1
1
1
1
3
morphine sulfate ER, fentanyl patches, oxymorphone ER
3
3
3
Creon
Creon
1
1
4
1
1
1
1
2
3
azelastine
3
carbamazepine, lamotrigine, oxcarbazepine, phenytoin,
topiramate, valproic acid
2
1
4
4
1
1
3
balsalazide disodium, sulfasalazine, sulfasalazine EC,
Apriso, Asacol HD, Delzicol
1
35
iuhealthplans.org
pentazocine/ naloxone
Perforomist
perindopril
permethrin cream
perphenazine (ST <12
years of age)
Pertzye ST
phenelzine
phenobarbital
phenytoin
Philith
Phospholine Iodide
Picato PA
pilocarpine
Pilopine HS
Pimtrea
pindolol
pioglitazone
pioglitazone / glimepiride
pioglitazone / metformin
Pirmella
piroxicam
podofilox
Pomalyst PA, QL
Portia
potassium chloride
Potiga PA, QL
Pradaxa QL
pramipexole
Pramosone
Prandimet
pravastatin
prazosin
Pred Mild
prednicarbate
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
3
Serevent, Foradil
3
Creon
3
3
pilocarpine
5-fluorouracil, imiquimod
3
pilocarpine
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
4
1
1
3
carbamazepine, phenytoin, oxcarbazepine, valproic acid,
levetiracetam, topiramate, tiagabine, zonisamide
3
3
metformin, repaglinide
3
2
1
1
1
1
36
iuhealthplans.org
prednisolone
prednisone
Prefest
Premarin
Premarin Vaginal Cream
Premphase
Prempro
Prenate
Prepopik
Prevident
Prezista
primidone
Pristiq ST, QL
Privigen PA
ProAir HFA ST, QL
Procrit PA
Proctofoam-HC
Procysbi PA, QL
progesterone capsule
Prolastin PA
Prolastin-C PA
Prolensa
Proleukin
Prolia PA, QL
Promacta PA, QL
propafenone ER
propranolol
propranolol / HCTZ
propranolol SA
Protopic PA
protriptyline
Proventil HFA ST, QL
pruvate 21-7
Pulmicort Flexhaler ST
Pulmozyme PA, QL
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
1
3
3
3
3
generic prenatal vitamins
sodium fluoride gel
3
4
Ventolin HFA
4
4
4
2
2
2
2
2
1
4
3
2
1
3
4
4
4
1
1
1
1
3
3
Ventolin HFA
1
1
3
4
QVAR, Flovent HFA, Asmanex
37
iuhealthplans.org
QNASL ST
Quartette
Quasense
quetiapine PA, QL (ST <12
years of age)
quinapril
quinapril / HCTZ
Qutenza PA, QL
QVAR
raloxifene
ramipril
Ranexa
ranitidine
Rapaflo ST
Ravicti PA, QL
Rebif ST, QL
Rectiv PA
Regranex QL
Relenza QL
Relistor PA
Relpax ST, QL
Remicade PA
Remodulin PA
renalpren
Renvela powder packet
repaglinide
reprexain
Rescriptor
Rescula ST
Restasis QL
Revlimid PA, QL
Reyataz
Ribasphere QL
Ribatab QL
ribavirin QL
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
3
flunisolide, fluticasone, Veramyst
1
1
1
1
4
2
1
1
2
1
3
4
4
3
4
3
4
3
4
4
doxazosin, tamsulosin, terazosin, prazosin, alfuzosin er
topical diltiazem compound, topical nifedipine compound
amantadine
1
2
1
1
2
3
latanoprost, Lumigan
2
4
4
4
4
2
38
iuhealthplans.org
rifabutin
rifampin
riluzole PA, QL
Riomet
risedronate QL
Risperdal Consta PA, QL
risperidone ODT QL (ST
<12 years of age)
risperidone QL (ST <12
years of age)
Rituxan PA, QL
rivastigmine tartrate
capsules PA
rizatriptan QL
ropinirole
ropinirole ER
Roxicet solution
Sabril PA, QL
Safyral
salicylic acid
Samsca PA, QL
Sancuso ST, QL
Sandostatin LAR PA, QL
Santyl
Saphris ST, QL (ST <12
years of age)
Savella PA, QL
selegiline
selenium sulfide shampoo
Selzentry PA
Sensipar
Serevent
Seroquel XR PA, ST, QL
Serostim PA
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
1
4
metformin
4
4
4
4
ondansetron
3
1
1
1
1
1
1
1
2
2
1
3
4
2
3
3
2
1
1
2
2
2
4
39
iuhealthplans.org
sertraline
sevelamer carbonate
Signifor PA, QL
sildenafil 20mg PA, QL
Simbrinza
Simcor ST
Simponi Aria PA, QL
Simponi PA, QL
simvastatin
sirolimus PA
Sirturo PA
Sivextro QL
sodium fluoride gel
sodium phenylbutyrate
powder PA
sodium sulfacetamide /
sulfur / urea
Soliris PA
Somatuline PA, QL
Somavert PA, QL
sotalol
Sovaldi PA, QL
Spectracef
Spiriva
spironolactone
spironolactone / HCTZ
Sporanox solution PA
Sprintec
Sprycel PA, QL
stavudine
Stelara PA, QL
Stivarga PA, QL
Strattera QL
Striant PA, ST
Stribild
Suboxone film PA, QL
1
1
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
\
4
4
2
4
4
brimonidine, dorzolamide, Azopt, Combigan
simvastatin, niacin ER
4
4
4
4
4
4
3
cefpodoxime, cefdinir
3
itraconazole capsule (PA)
3
3
1
1
3
1
1
1
2
1
1
1
4
4
4
1
2
3
2
2
40
iuhealthplans.org
Subsys PA, ST, QL
Suclear
Sucraid PA
sulfacetamide sodium
sulfamethoxazole /
trimethoprim
sulfasalazine
sulfasalazine EC
sulfisoxazole
sulindac
sumatriptan QL
Sumavel DosePro QL
Supprelin LA PA, QL
Suprax
Suprep
Sustiva
Sutent PA, QL
Syeda
Sylatron PA
Sylvant PA
Symbicort
Symlin ST, QL
Synagis PA, QL
Synarel PA, QL
Synvisc One PA, QL
Synvisc PA, QL
Syprine PA
Tabloid PA
tacrolimus
Tafinlar PA, QL
Tamiflu QL
tamoxifen
tamsulosin
Tanzeum QL ST
Tarceva PA, QL
Targretin PA
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
3
4
1
1
1
1
1
1
1
3
4
cefpodoxime, cefdinir
4
4
4
4
4
4
4
4
4
amantadine
3
2
2
1
2
2
2
2
1
3
1
1
3
4
4
Bydureon, Victoza
41
iuhealthplans.org
Tasigna PA, QL
Tasmar
Tazorac (PA >35 years of
age)
taztia XT
Tecfidera PA, QL
Tekamlo ST
Tekturna HCT ST
Tekturna ST
telmisartan
telmisartan / amlodipine
telmisartan / HCTZ
temazepam
temozolomide PA
Tencon
terazosin
terbinafine QL
Testim PA, ST
Testopel PA
Testosterone gel PA, ST
testosterone injection PA
Testred PA, ST
tetracaine ophthalmic
tetracycline
Thalomid PA, QL
Theo-24 ER
theophylline ER
thioridazine (ST <12 years
of age)
thiothixene (ST <12 years
of age)
Thyrogen
tiagabine
ticlopidine
Tikosyn
Tilia FE
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
4
entacapone
4
4
3
3
1
2
2
2
1
1
1
1
1
1
1
3
3
3
3
1
1
1
2
4
theophylline ER
4
3
1
1
1
1
1
2
1
42
iuhealthplans.org
timolol
tinidazole
Tirosint
Tivicay
tizanidine tablet
TOBI Podhaler QL
Tobradex ST
tobramycin
tobramycin /
dexamethasone
tobramycin solution for
nebulization QL
Tobrex
1
1
tolazamide
tolbutamide
tolmetin
tolterodine
tolterodine ER
topiragen QL
topiramate
topiramate sprinkle QL
Toviaz
Tracleer PA, ST, QL
Tradjenta
tramadol / acetaminophen
QL
tramadol ER tablet QL
tramadol QL
trandolapril
trandolapril / verapamil
tranexamic acid PA, QL
Transderm-Scop
tranylcypromine
Travatan Z ST
travoprost ST
1
1
1
1
1
1
1
1
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
levothyroxine
2
1
4
tobramycin/dexamethasone
4
3
1
1
3
Moxeza, Vigamox
2
4
2
1
1
1
1
1
1
3
meclizine
3
latanoprost, Lumigan, travoprost (ST)
1
1
43
iuhealthplans.org
trazodone
Trelstar PA, QL
tretinoin oral
tretinoin topical
Trezix
triamcinolone
triamterene / HCTZ
Tri-estarylla
trifluoperazine (ST <12
years of age)
Tri-legest FE
Tri-linyah
Trilyte
Trinessa
Tri-previfem
Tri-sprintec
Trivora
trospium
trospium ER
Truvada
Tudorza Pressair
Tykerb PA, QL
Tysabri PA, ST, QL
Tyvaso PA
Tyzeka PA
Uceris PA
Ulesfia
Uloric ST, QL
Ultresa ST
unithroid
urea
Urocit-K
ursodiol
Vagifem
valacyclovir QL
Valchlor PA
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
1
4
4
4
4
4
4
budesonide
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
3
3
3
allopurinol
Creon
3
potassium citrate
3
1
1
1
1
4
44
iuhealthplans.org
Valcyte
valproate
valsartan
valsartan / HCTZ
vancomycin capsules
Vanoxide-HC
Vantas PA, QL
Vascepa
Vasolex
Vectical QL
Veletri PA
Velivet
Velphoro
venlafaxine
venlafaxine ER capsule QL
Ventavis PA
Ventolin HFA QL
Veramyst
verapamil
verapamil ER PM
verapamil extended
release
verapamil SR
Veregen
Vesicare
Vestura
Vexol
Victoza ST
Videx solution
Vigamox
Viibryd PA, QL
Vimizim PA
Vimpat PA
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
ganciclovir
1
1
1
1
3
4
3
3
3
4
benzoyl peroxide
fenofibrate, atorvastatin, fluvastatin, lovastatin,
pravastatin, simvastatin
Santyl
calcipotriene
1
3
calcium acetate, sevelamer carbonate
1
1
4
2
2
1
1
1
1
3
podofilox, imiquimod
3
3
paroxetine, sertraline, citalopram, venlafaxine ER
capsules, duloxetine (ST)
carbamazepine, lamotrigine, oxcarbazepine, phenytoin,
zonisamide
2
1
2
2
2
4
3
45
iuhealthplans.org
Viokace ST
Viracept
Viread
visqid a/a
vistra
vitamins (generic
pediatric)
vitamins (generic prenatal)
Vivelle-DOT QL
Vivitrol PA
Vogelxo PA, ST
Voltaren Gel QL
voriconazole QL
Votrient PA, QL
VPRIV PA
Vyfemla
Vytorin ST
Specialty
3
Creon
2
2
1
1
1
1
3
4
3
3
diclofenac, ibuprofen, naproxen
1
4
4
1
3
Vyvanse QL (PA < 4 and
>18 years of age)
warfarin
Welchol
Wera
WP Thyroid
Wymzya Fe
Xalkori PA, QL
Xarelto QL
Xeljanz PA, QL
Xenazine PA, QL
Xeomin PA, QL
Xerac AC
Xgeva PA, QL
Xifaxan 200mg QL
Xifaxan 550mg PA, QL
Xolair PA, QL
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
simvastatin, Zetia
amphetamine salts, dexmethylphenidate,
methylphenidate, amphetamine-dextroamphetamine ER,
methylin, methylin ER, methylphenidate ER, Strattera
3
levothyroxine
1
2
1
1
4
4
4
4
4
ciprofloxacin, loperamide
lactulose
2
2
3
3
4
46
iuhealthplans.org
Xopenex HFA ST, QL
Xtandi PA, ST, QL
xulane QL
Xyrem PA, QL
zafirlukast
zaleplon
Zarah
Zavesca PA
Zelapar
Zelboraf PA, QL
Zemaira PA
Zenatane
Zenchent Fe
zenieva
Zenpep ST
Zeosa
Zetia
Zetonna ST
Zinotic ES
Zioptan ST
ziprasidone QL (ST <12
years of age)
Zirgan gel
Zithranol-RR cream
Zmax QL
Zoladex PA, QL
zoledronic acid 4mg
zoledronic acid 5mg ST,
QL
Zolinza PA, QL
zolmitriptan QL
zolpidem tartrate
Zomig nasal spray QL
zonisamide
Zontivity PA, QL
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
3
4
Ventolin HFA
4
4
carbidopa/levodopa, entacapone, ropinirole, pramipexole,
carbidopa/levodopa/entacapone, Azilect
1
1
1
1
3
4
4
1
1
1
2
3
Creon
3
3
3
acetic acid/hydrocortisone, Ciprodex
latanoprost, Lumigan
3
3
4
4
Drithocreme
azithromycin, clarithromycin, erythromycin
4
1
2
1
2
1
1
1
3
3
clopidogrel, Effient
1
47
iuhealthplans.org
Zorbtive PA
Zortress PA
Zovia
Zubsolv PA, QL
Zyflo
Zyflo CR
Zykadia PA, QL
Zylet
Zyprexa Relprevv PA, QL
Zytiga PA, QL
Zyvox QL
Specialty
Non-Preferred Brand
Preferred Brand
Drug Name
Generic
4
4
4
montelukast
montelukast
tobramycin/dexamethasone
4
2
1
2
3
3
3
2
For questions, please contact our pharmacy staff at 877.769.0191 or 866.822.6504.
48
IU Health Plans
950 N Meridian Street
Suite 600
Indianapolis, IN 46204
T 866.822.6504
F 855.398.8762
iuhealthplans.org

2015 FORMULARY GUIDE

Transcription

Similar documents