2015 FORMULARY GUIDE
Transcription
2015 FORMULARY GUIDE
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 Pharmacy Benefits Management 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 Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 4 4 4 4 2 2 Specialty medication Specialty medication Specialty medication Specialty medication alendronate, ibandronate, risedronate alendronate, ibandronate, risedronate ketorolac, diclofenac, bromfenac 3 3 3 1 1 3 4 tretinoin, benzoyl peroxide, clindamycin, adapalene (PA) Specialty medication 4 4 4 4 Specialty medication Specialty medication Specialty medication EpiPen, Auvi-Q 1 3 2 3 atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, niacin ER Flovent HFA, QVAR, Asmanex Specialty medication clopidogrel, ticlopidine, dipyridamole, Effient 3 4 3 1 1 1 4 Specialty medication 4 Specialty medication 1 1 2 1 3 3 3 azelastine, epinastine, Pataday, Patanol 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 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 Specialty medication 4 Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 3 3 hydrocortisone/pramoxine hydrocortisone/pramoxine 3 testosterone injection (PA), Androgel 1.62% (PA) Androgel 1.62% (PA) 3 testosterone injection (PA), Androgel 1.62% (PA) testosterone injection (PA), Androgel 1.62% (PA) Premarin, estradiol, estropipate 1 2 2 1 3 2 1 3 3 4 ondansetron Humalog, Novolog Specialty medication 1 1 2 3 carbamazepine, oxcarbazepine, lamotrigine, valproic acid, levetiracetam, phenytoin, zonisamide 2 3 4 Caphosol Specialty medication 4 Specialty medication 4 3 3 Specialty medication Serevent, Foradil levothyroxine, liothyronine 3 alendronate, ibandronate, risedronate 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 2 2 4 Specialty medication 1 1 1 2 3 testosterone injection (PA), Androgel 1.62% (PA) 1 2 4 3 3 3 Specialty medication naratriptan, rizatriptan, sumatriptan, zolmitriptan testosterone injection (PA), Androgel 1.62% (PA) erythromycin 3 Generic topical acne agents 1 1 2 1 2 1 2 1 3 4 felbamate, lamotrigine, topiramate, valproate Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) 4 Suggested Alternative(s) Specialty medication 1 1 1 3 4 3 azelastine, epinastine, Pataday, Patanol Specialty medication ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Zymar, Moxeza, Vigamox 4 Specialty medication 4 3 Specialty medication timolol, Betoptic S 3 ammonium lactate, zenieva 1 2 2 1 1 1 4 Specialty medication 4 4 Specialty medication Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) 3 Suggested Alternative(s) Serevent, Foradil 1 1 1 1 4 Specialty medication 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 Specialty medication 4 Specialty medication 4 Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 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 Specialty medication 4 Specialty medication 3 1 1 1 1 2 1 1 1 1 1 1 1 1 3 Generic NSAIDS (diclofenac, etodolac, ibuprofen, meloxicam, naproxen) Premarin, estradiol, estropipate 3 1 4 Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) 3 Suggested Alternative(s) ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Zymar, Moxeza, Vigamox 4 4 Specialty medication Specialty medication 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 Suggested Alternative(s) 2 3 colestipol 3 estradiol-norethindrone, Jinteli, Prempro, Premphase 1 2 2 4 Specialty medication 4 4 Specialty medication Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) 3 hydrocortisone tablet hydrocortisone suppositories, proctozone Azopt, betaxolol, Betoptic S, carteolol, dorzolamide, dorzolamide-timolol, timolol maleate diltiazem, cartia XT, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR, Nifediac CC, amlodipine 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 Suggested Alternative(s) 4 Specialty medication 4 3 Specialty medication Advair, Dulera, Foradil, Serevent, Spiriva, Symbicort, Tudorza 3 testosterone injection (PA), Androgel 1.62% (PA) 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 (PA < 4 and ≥18 years of age) 1 Diastat Diastat Acudial Preferred Brand Drug Name Generic 2015 Drug Formulary (Effective January 1, 2015) 2 1 1 1 2 4 3 2 4 3 3 Specialty medication For cold sore treatment use over-the-counter agents Specialty medication testosterone injection (PA), Androgel 1.62% (PA) 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 4 Specialty medication 4 Specialty medication 1 1 1 1 1 1 1 1 1 1 3 balsalazide disodium, Apriso, Asacol HD, Delzicol 3 estradiol 3 estradiol-norethindrone, Jinteli, Prempro, Premphase 3 3 3 salicyclic acid fluorometholone, prednisolone fluticasone, flunisolide, Veramyst 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 Suggested Alternative(s) diltiazem, cartia XT, nifedipine, nifedipine ER, taztia XT, verapamil, verapamil SR, Nifediac CC, amlodipine 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 2015 Drug Formulary (Effective January 1, 2015) 3 triamterene-HCTZ Specialty medication losartan, eprosartan, irbesartan, candesartan, telmisartan, valsartan candesartan-HCTZ, irbesartan-HCTZ, losartan-HCTZ, telmisartan-HCTZ, valsartan-HCTZ 2 2 4 4 3 4 Specialty medication Specialty medication Generic topical steroids Specialty medication 1 1 2 3 levonorgestrel, Next Choice 2 3 4 azelastine, epinastine, Pataday, Patanol Specialty medication 4 Specialty medication 2 3 1 2 1 1 3 estradiol, estropipate, Premarin 1 1 1 1 4 Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 1 2 1 4 4 Specialty medication Specialty medication 4 Specialty medication 1 2 1 1 3 erythromycin 3 3 estradiol, estropipate, Premarin estradiol 3 3 estradiol, estropipate, Premarin Premarin 1 2 1 1 1 1 1 1 1 1 1 1 1 4 4 3 4 Specialty medication Specialty medication estradiol Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) 3 Suggested Alternative(s) rivastigmine tartrate capsules (PA), donepezil (PA), Namenda (PA) 1 4 4 Specialty medication Specialty medication Generic topical acne agents 4 Specialty medication ciprofloxacin, levofloxacin 3 3 1 1 1 3 4 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) Specialty medication 1 1 3 3 3 estradiol-norethindrone, Jinteli, Prempro, Premphase estradiol, estropipate, Premarin estradiol, estropipate, Premarin 3 fentanyl citrate (PA), Abstral (PA) Specialty medication venlafaxine ER, duloxetine (ST) Generic topical acne agents 1 1 1 1 1 4 3 3 1 4 4 3 Specialty medication Specialty medication testosterone injection (PA), Androgel 1.62% (PA) 3 testosterone injection (PA), Androgel 1.62% (PA) 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 2015 Drug Formulary (Effective January 1, 2015) 3 3 4 Suggested Alternative(s) diphenhydramine, lidocaine, nystatin fluorometholone, prednisolone Specialty medication 1 2 1 1 1 1 1 2 1 1 1 1 1 1 1 1 3 fluorometholone, prednisolone 2 1 2 4 3 Specialty medication testosterone injection (PA), Androgel 1.62% (PA) 1 1 3 4 3 4 calcium acetate, sevelamer carbonate, Renvela powder packet Specialty medication naratriptan, rizatriptan, sumatriptan, zolmitriptan Specialty medication 1 4 3 Specialty medication felbamate, lamotrigine, topiramate, valproate 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 3 1 1 2 4 4 4 4 4 Specialty medication Specialty medication Specialty medication Specialty medication Specialty medication 4 Specialty medication 1 1 1 1 3 Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral 4 4 4 4 Specialty medication Specialty medication Specialty medication Specialty medication 4 acarbose gabapentin ondansetron ondansetron Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 1 3 peg-3350, Suprep, Moviprep 3 Generic topical steroids 3 4 4 4 bismuth subsalicylate (OTC), metronidazole, tetracycline Specialty medication Specialty medication Specialty medication gabapentin, pramipexole, ropinirole 4 Specialty medication 4 Specialty medication 1 1 1 1 3 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 3 alendronate, ibandronate, risedronate 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 (ST <12 years of age) Invirase Invokana QL ipratropium ipratropium / albuterol solution irbesartan irbesartan / HCTZ Iressa PA, QL Isentress Isopto Carbachol Specialty Non-Preferred Brand Suggested Alternative(s) 1 1 4 4 3 4 Specialty medication Specialty medication ketorolac, diclofenac, bromfenac Specialty medication 1 4 Specialty medication Spiriva, Tudorza 4 4 Specialty medication Specialty medication atenolol, metoprolol, propranolol 4 Specialty medication 4 guanfacine risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) Specialty medication 3 1 3 2 1 3 3 2 3 metformin, glyburide, glipizide, Januvia, Tradjenta 1 1 1 1 4 Specialty medication 2 Isopto Homatropine isosorbide Preferred Brand Drug Name Generic 2015 Drug Formulary (Effective January 1, 2015) 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 3 timolol 1 4 Specialty medication 4 Specialty medication 4 4 Specialty medication Specialty medication 4 Specialty medication 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 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) Specialty medication Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Specialty medication Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) 4 4 Suggested Alternative(s) Specialty medication Specialty medication 1 1 1 1 1 1 1 1 2 1 1 3 azelastine, epinastine, Pataday, Patanol 3 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) fentanyl citrate (PA), Abstral (PA) 1 3 1 1 1 4 Specialty medication 4 4 Specialty medication Specialty medication 1 2 1 3 atenolol, metoprolol, propranolol 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 Suggested Alternative(s) 2 3 balsalazide disodium, Apriso, Asacol HD, Delzicol 3 For cold sore treatment use over-the-counter agents 3 Amitiza 3 3 fenofibrate atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Zetia 3 Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral 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 2015 Drug Formulary (Effective January 1, 2015) 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 1 1 1 1 3 4 fluorometholone, prednisolone Specialty medication 4 Specialty medication 4 4 4 4 Specialty medication Specialty medication Specialty medication gabapentin, Savella (PA) Specialty medication 4 Specialty medication 4 Specialty medication 1 1 1 2 3 1 1 1 3 3 3 Ventolin HFA ciprofloxacin, levofloxacin fluorometholone, prednisolone 1 1 1 4 Specialty medication 1 3 3 Premarin, estradiol, estropipate 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 (PA < 4 and ≥18 years of 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 3 1 1 1 1 testosterone injection (PA), Androgel 1.62% (PA) 4 Specialty Medication 1 1 1 1 1 1 1 1 1 3 alendronate, ibandronate, risedronate 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 2015 Drug Formulary (Effective January 1, 2015) 3 Suggested Alternative(s) 3 Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral estradiol patch, Premarin 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 Specialty medication 4 Specialty medication 4 Specialty medication 4 Specialty medication 4 Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 1 4 Specialty medication 2 2 1 1 3 flunisolide, fluticasone, Veramyst 3 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta Specialty medication Specialty medication Specialty medication pramipexole, ropinirole ketorolac, diclofenac, bromfenac 2 1 2 1 4 4 4 3 3 1 1 4 Specialty medication 4 Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 1 1 1 1 3 nitroglycerin 1 1 1 4 Specialty medication 1 3 ciprofloxacin, levofloxacin 1 1 2 2 2 2 2 2 2 4 4 4 4 3 Specialty medication Specialty medication Specialty medication Specialty medication Caphosol 2 3 amphetamine salts, amphetamine/dextroamphetamine ER, dexmethylphenidate, dexmethylphenidate ER, methylphenidate, methylphenidate ER, modafinil (PA) 3 hydrocortisone 1 4 Specialty medication 4 Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 4 3 Specialty medication omeprazole, clarithromycin, amoxicillin 1 1 3 4 fluticasone, flunisolide, Veramyst Specialty medication 1 2 2 3 3 3 3 felbamate, lamotrigine, topiramate, valproate Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta itraconazole (PA) fentanyl citrate (PA), Abstral (PA) 2 4 Specialty medication lidocaine, First-Mouthwash 4 4 4 Specialty medication Specialty medication Specialty medication 4 Januvia, Janumet, Janumet XR, Jentadueto, Tradjenta peg-3350, Suprep, Moviprep Specialty medication Acetic acid/hydrocortisone Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 1 1 4 Specialty medication 1 1 1 1 1 1 3 morphine sulfate ER, fentanyl patches, oxymorphone ER 3 3 3 Creon Creon Generic topical steroids Specialty medication 1 1 4 1 1 1 1 2 3 azelastine 3 carbamazepine, lamotrigine, oxcarbazepine, phenytoin, topiramate, valproic acid Specialty medication Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 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 Specialty medication 1 1 3 carbamazepine, phenytoin, oxcarbazepine, valproic acid, levetiracetam, topiramate, tiagabine, zonisamide 3 3 hydrocortisone/pramoxine metformin, repaglinide 3 fluorometholone, prednisolone 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 1 3 estradiol-norethindrone, Jinteli, Prempro, Premphase 3 3 3 generic prenatal vitamins peg-3350, Suprep, Moviprep sodium fluoride gel 3 4 citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, venlafaxine ER capsules, duloxetine (ST) Specialty medication Ventolin HFA Specialty medication 4 Specialty medication 4 4 Specialty medication Specialty medication ketorolac, diclofenac, bromfenac Specialty medication Specialty medication Specialty medication 2 2 2 2 2 1 4 3 2 1 3 4 4 4 1 1 1 1 3 Generic topical steroids 3 Ventolin HFA 1 1 3 4 QVAR, Flovent HFA, Asmanex Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) 3 3 Suggested Alternative(s) flunisolide, fluticasone, Veramyst Generic oral contraceptives, Beyaz, Natazia, Nuvaring, Ortho Tri-Cyclen LO, Safyral 1 1 1 1 4 Specialty medication 2 1 1 2 1 3 4 4 3 4 3 4 3 4 4 doxazosin, tamsulosin, terazosin, prazosin, alfuzosin er Specialty medication Specialty medication topical diltiazem compound, topical nifedipine compound Specialty medication amantadine Specialty medication naratriptan, rizatriptan, sumatriptan, zolmitriptan Specialty medication Specialty medication 1 2 1 1 2 3 latanoprost, Lumigan 2 4 Specialty medication 4 4 4 Specialty medication Specialty medication Specialty medication 2 38 iuhealthplans.org rifabutin rifampin riluzole PA, QL Riomet risedronate QL Risperdal Consta PA, QL (ST <12 years of age) 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 (ST <12 years of age) Serostim PA Specialty Non-Preferred Brand Preferred Brand Drug Name Generic 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 1 4 Specialty medication metformin 4 Specialty medication 4 Specialty medication 4 Specialty medication 4 Specialty medication ondansetron Specialty medication 3 1 1 1 1 1 1 1 2 2 1 3 4 2 3 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) 3 risperidone (ST), olanzapine (ST), quetiapine (PA, ST), Abilify (PA, ST), ziprasidone (ST) Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) \ 4 4 2 4 4 Specialty medication Specialty medication brimonidine, dorzolamide, Azopt, Combigan simvastatin, niacin ER Specialty medication Specialty medication 4 Specialty medication 4 Specialty medication 4 4 4 Specialty medication Specialty medication Specialty medication 4 3 Specialty medication cefpodoxime, cefdinir 3 itraconazole capsule (PA) 3 3 1 1 3 1 1 1 2 1 1 1 4 Specialty medication 4 4 Specialty medication Specialty medication 1 2 3 testosterone injection (PA), Androgel 1.62% (PA) 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 2015 Drug Formulary (Effective January 1, 2015) 3 3 4 Suggested Alternative(s) fentanyl citrate (PA), Abstral (PA) peg-3350, Suprep, Moviprep Specialty medication 1 1 1 1 1 1 1 3 4 naratriptan, rizatriptan, sumatriptan, zolmitriptan Specialty medication cefpodoxime, cefdinir 4 Specialty medication 4 4 Specialty medication Specialty medication 4 4 4 4 4 Specialty medication Specialty medication Specialty medication Specialty medication Specialty medication 4 Specialty medication amantadine 3 2 2 1 2 2 2 2 1 3 1 1 3 4 4 Bydureon, Victoza Specialty medication Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 4 Specialty medication entacapone Generic topical acne agents 4 Specialty medication 4 Specialty medication 3 3 1 2 2 2 1 1 1 1 1 1 1 3 3 3 testosterone injection (PA), Androgel 1.62% (PA) testosterone injection (PA), Androgel 1.62% (PA) testosterone injection (PA), Androgel 1.62% (PA) 3 testosterone injection (PA), Androgel 1.62% (PA) 1 1 1 2 4 Specialty medication theophylline ER 4 Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) 3 Suggested Alternative(s) levothyroxine 2 1 4 Specialty medication tobramycin/dexamethasone 4 Specialty medication 3 1 1 3 ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin, Zymar, Moxeza, Vigamox 2 4 Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 1 4 4 Specialty medication Specialty medication 4 4 4 4 Specialty medication Specialty medication Specialty medication Specialty medication 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 Premarin, estradiol, estropipate 1 1 1 1 4 Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) 3 Suggested Alternative(s) ganciclovir 1 1 1 1 3 4 3 3 3 4 benzoyl peroxide Specialty medication fenofibrate, atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin Santyl calcipotriene Specialty medication 1 3 calcium acetate, sevelamer carbonate 1 1 4 Specialty medication 2 2 1 1 1 1 3 podofilox, imiquimod 3 fluorometholone, prednisolone 3 paroxetine, sertraline, citalopram, venlafaxine ER capsules, duloxetine (ST) Specialty medication 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 Suggested Alternative(s) Creon 2 2 1 1 1 1 3 4 3 3 estradiol patch, Premarin Specialty medication testosterone injection (PA), Androgel 1.62% (PA) diclofenac, ibuprofen, naproxen 1 4 4 Specialty medication Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) 3 atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, Zetia amphetamine salts, dexmethylphenidate, methylphenidate, amphetamine-dextroamphetamine ER, methylin, methylin ER, methylphenidate ER, Strattera 3 levothyroxine 1 2 1 1 4 Specialty medication 4 4 4 Specialty medication Specialty medication Specialty medication 4 Specialty medication ciprofloxacin, loperamide lactulose Specialty medication 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 2015 Drug Formulary (Effective January 1, 2015) 3 Suggested Alternative(s) 4 Ventolin HFA Specialty medication 4 Specialty medication 4 Specialty medication carbidopa/levodopa, entacapone, ropinirole, pramipexole, carbidopa/levodopa/entacapone, Azilect Specialty medication Specialty medication 1 1 1 1 3 4 4 1 1 1 2 3 Creon 3 3 3 fluticasone, flunisolide, Veramyst acetic acid/hydrocortisone, Ciprodex latanoprost, Lumigan 3 3 4 4 Drithocreme azithromycin, clarithromycin, erythromycin Specialty medication Specialty medication 4 Specialty medication 1 2 1 2 1 1 1 3 naratriptan, rizatriptan, sumatriptan, zolmitriptan 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 (ST <12 years of age) Zytiga PA, QL Zyvox QL Specialty Non-Preferred Brand Preferred Brand Drug Name Generic 2015 Drug Formulary (Effective January 1, 2015) Suggested Alternative(s) 4 Specialty medication 4 4 montelukast montelukast Specialty medication tobramycin/dexamethasone Specialty medication 4 Specialty medication 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 Pharmacy Benefits Management 950 N Meridian Street Suite 600 Indianapolis, IN 46204 T 866.822.6504 F 855.398.8762 iuhealthplans.org