Your Choice Pharmacy Benefit Guide

Transcription

Your Choice
Pharmacy Benefit Guide
Effective July 1, 2016
TABLE OF CONTENTS
Your Choice Overview......................................................... 1
Your Choice Contact Numbers......................................... 1
Understanding Coverage and Cost Sharing................. 2
About Generic Drugs ................................................ 2
Formulary Overview........................................................... 2
For Prospective Members......................................... 3
Understanding Our Symbols ........................................... 3
Prior Authorization...................................................... 3
Step Therapy................................................................. 3
Quantity Limits............................................................. 3
Filling Your Prescription.................................................... 3
Retail............................................................................... 3
Mail Order.....................................................................4
Specialty Provider........................................................4
Filling Your Prescription When Traveling.............4
Medication Supplies Not Covered by
UPMC Health Plan......................................................4
Your Choice Formulary....................................................... 5
Medications Not Covered by Your Choice.................29
Non-Covered Medications with Covered
Alternatives................................................................ 30
Your Choice Brand/Generic Reference Guide...........35
YOUR CHOICE OVERVIEW
The Your Choice pharmacy program provides
both value and freedom of choice. It does so by
offering a variety of high-quality, effective generic
and brand-name prescription drugs. This guide
provides information that is applicable to most
members. For information specific to your plan,
refer to your plan’s prescription drug rider.
When you need a prescription medication, you and
your doctor can choose from four different levels,
or “tiers.” Each tier has a different copayment. This
gives you and your doctor the freedom to choose
the medication that is right for you. At the same
time, this will help you to better budget your health
care dollars.
This guide provides an overview of your pharmacy
benefit with UPMC Health Plan. It explains the
copayment structure, the process for getting
certain drugs covered, your options for filling
prescriptions, important phone numbers, and more.
YOUR CHOICE
CONTACT NUMBERS
Current Members:
UPMC Health Plan Health Care Concierge team:
1-888-876-2756
UPMC Health Plan Pharmacist Support Line:
1-800-396-4139
UPMC Physician’s Pharmacy Support Line: 1-800-979-8762
TTY Services: 1-800-361-2629
Prospective Members:
Prospective members should direct their questions to their
company’s benefits administrator or to the UPMC Health
Plan Health Care Concierge team at 1-888-876-2756.
Online information is available at
www.upmchealthplan.com/pharmacy.
1
About Generic Drugs
UNDERSTANDING COVERAGE
AND COST SHARING
Generic drugs have the same active ingredients as their
brand-name equivalents but cost significantly less. Not
all drugs have a generic equivalent. Generally, new drugs
receive patent protection. Once the patent expires, other
pharmaceutical companies can produce the same drug in a
generic formulation. Companies that make generic drugs do
not have to invest large amounts of money in research, since
the company making the brand-name equivalent has already
done this. Also, generic companies do not need to advertise
their drugs. As a result, generic drug makers can pass these
savings on to you.
Our formulary is the list of Food and Drug Administration
(FDA)-approved drugs that we cover. UPMC Health Plan’s
Pharmacy and Therapeutics (P&T) Committee researches
and evaluates medications it may cover. Committee
members include local doctors and pharmacists who meet
regularly during the year to review and update the formulary.
Committee members base their decision on the drug’s safety,
effectiveness, and cost.
Your Choice prescription drugs are organized into four
copayment tiers on the formulary:
Generic drugs have the same active ingredients as brandname drugs, but their inactive ingredients can vary. This is
why the generic drug might look different from the brandname 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.
Tier 1 is for generic medications, which have the lowest
copayment. 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.
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 brandname drug.
Your Choice requires you to use a generic version
of the drug if one is available. This means that if
you receive a brand-name drug when a generic is
available, you must pay the brand copayment in
addition to the retail cost difference between the
brand-name and generic forms of the drug.
Tier 2 is for preferred-brand medications. UPMC Health Plan
classifies these drugs as “preferred” because of their value
and effectiveness.
FORMULARY OVERVIEW
Tier 3 is for non-preferred brand medications.
The most commonly prescribed Your Choice drugs are listed
in the formulary section of this booklet. Please note that there
are other drugs that Your Choice covers in addition to the
ones listed in this booklet. For the latest information on the
complete Your Choice formulary and other pharmacy benefits,
visit our website at www.upmchealthplan.com/pharmacy.
Select “Your Choice” to access the searchable drug list.
Tier 4 is for specialty medications.
Specialty medications usually treat complex
and rare conditions. These drugs are created
because of advancements in drug development.
These drugs can be high-cost medications
and biologicals regardless of how they are
administered (injectable, oral, transdermal, or
inhalant).
You may also call our Health Care Concierge team at the
number listed on the back of your member ID card or on
page 1 of this booklet.
Specialty drugs require close management by a
physician. Physicians need to monitor these drugs
because of potential side effects and the need for
frequent dosage adjustments.
Some medications not covered on our formulary are listed in
the sections of the booklet titled Medications Not Covered
by Your Choice and Non-Covered Medications with Covered
Alternatives.
2
If you are a current UPMC Health Plan member, refer to
your Schedule of Benefits for your copayment amounts. If
you did not receive a Schedule of Benefits in your Welcome
Kit, contact our Health Care Concierge team at the number
on the back of your member ID card. Your member ID card
should also list your copayment amounts.
Step therapy is built into the electronic system that checks
your medication history. A drug with step therapy will be
automatically approved if there is a record that you have
already tried the preferred drug(s). If there is no record that
you tried the preferred drug(s) in your medication history,
your physician must submit relevant clinical information to
the UPMC Health Plan Pharmacy Services Department before
it will be covered.
For Prospective Members
If you are thinking about joining UPMC Health Plan and
would like information about copayment amounts, review
the Schedule of Benefits. You may have received one from
your company’s benefits administrator or Human Resources
Department. If you did not receive a Schedule of Benefits,
contact your benefits administrator or the UPMC Health Plan
Health Care Concierge team at the number listed on page 1 of
this booklet.
Quantity Limits
You will see the symbol QL next to certain drugs on
the formulary tables in this booklet. QL stands for
quantity limits.
Quantity limits are drug-specific and limit the amount of
certain drugs that can be dispensed during a specified period
of time. These limits are based on FDA guidelines, clinical
literature, and manufacturer’s instructions. Quantity limits
promote appropriate use of the drug, prevent waste, and help
control costs.
UNDERSTANDING OUR SYMBOLS
Prior Authorization
For some drugs the dosing guidelines may recommend
that patients take the drug one time a day in a larger dose
instead of several times a day in smaller doses. The quantity
limits follow the guidelines and cover one larger dose per
day. Your physician can request an exception to the quantity
limit through the UPMC Health Plan Pharmacy Services
Department.
You will see the symbol PA next to certain drugs on
our formulary tables in this booklet. PA stands for prior
authorization.
If a drug requires prior authorization, the UPMC Health Plan
Pharmacy Services Department must authorize the use of
this drug before it will be covered.
Prescriptions for controlled substances and specialty
medications are limited to a 30-day supply.
Drugs that require prior authorization are often:
• Newer drugs for which UPMC Health Plan wants to track
usage.
• Drugs not used as a standard first option in treating a
medical condition.
• Drugs with potential side effects that UPMC Health Plan
wants to monitor for patient safety.
• Drugs categorized as specialty medications.
FILLING YOUR PRESCRIPTION
Retail
UPMC Health Plan’s network of retail pharmacies includes
hundreds of locations — independent pharmacies as well as
multistore chains — throughout the region. You can take your
prescription to any pharmacy in the network. You must use
75 percent of your medication before you can get a refill.
Step Therapy
You will see the symbol ST next to certain drugs on the
formulary tables in this booklet. ST stands for step therapy.
For specific pharmacy names, locations, and telephone
numbers, visit www.upmchealthplan.com/pharmacy or call
our Health Care Concierge team. The phone number is listed
on the back of your member ID card and on page 1 of this
booklet.
Step therapy is the practice of using specific medications
first when beginning drug therapy for a medical condition.
The preferred first course of treatment may be generic
medications or drugs that are considered as the standard
first-line treatment.
3
Mail Order
Specialty providers also improve care by providing education
for our members and expanded access to health care
professionals trained in the proper use of these specialty
medications. A specialty provider offers cost-effective health
care and medication management and compliance programs.
If you take maintenance medications for a chronic
condition, you can get them through a mail-order pharmacy.
Maintenance medications are drugs that are taken on a
regular, long-term basis. These may include drugs to treat
high blood pressure, diabetes, asthma, high cholesterol,
and more.
Filling Your Prescription When Traveling
With convenient mail-order service:
• You receive a 90-day supply of most drugs, plus refills, as
prescribed by your doctor.
• You usually pay a lower out-of-pocket cost for a 90-day
supply at a mail-order pharmacy than you would pay at a
retail pharmacy.
• You get these drugs delivered right to your door.
When you travel outside of the western Pennsylvania area,
thousands of pharmacies across the country will honor your
UPMC Health Plan member ID card.
Most mail-order prescriptions are written for a 90-day
supply. If your doctor writes for a 30-day supply with two
refills, the mail-order facility may combine the prescription to
make a 90-day supply. If you do not want a 90-day supply,
you should indicate this on the mail-order form.
To fill a prescription at a participating out-of-area pharmacy,
present your UPMC Health Plan member ID card. Some
pharmacies may ask you to pay the full price of the
medication. If that happens and your claim is approved,
you will be reimbursed the amount that you paid for the
medication, less the appropriate copayment.
For a first-time prescription or a new medication, UPMC
Health Plan recommends that you try a 30-day supply of
the drug from a retail pharmacy. That way your doctor has a
chance to make sure that it is the right dose for you and that
it does not cause any side effects.
You can request a “Pharmacy Program Direct Reimbursement
Claim Form” by calling our Health Care Concierge team or
requesting the form on the UPMC Health Plan website at
www.upmchealthplan.com/pharmacy.
To locate a participating pharmacy, contact our Health Care
Concierge team at the phone number listed on the back of
your member ID card or on page 1 of this booklet.
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.
Once you’re confident that the medication is appropriate,
ask your doctor to write a prescription for a 90-day supply
of each maintenance drug that you need (plus refills if
appropriate). Then order the supply through the mail-order
pharmacy.
Medication Supplies Not Covered by
UPMC Health Plan
To avoid running out of your mail-order prescription, reorder
your medication while you still have an adequate supply
remaining, allowing a few weeks for processing and delivery.
To request refills, you may order online or over the telephone.
• 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 were written more than a year ago
will not be covered. Your doctor will need to write a new
prescription.
You can request a mail-order form by calling our Health Care
Concierge team or requesting the form on the UPMC Health
Plan website at www.upmchealthplan.com/pharmacy.
Specialty Provider
Most specialty medications must be obtained through our
designated specialty provider. When you are prescribed a
specialty medication and use a specialty provider, you get
mail-order delivery and improved access to drugs, as many
retail pharmacies do not carry these types of medications.
4
8-MOP PA
3
abacavir QL
1
abacavir/lamivudine/
zidovudine QL
1
Abilify Maintena QL (ST
<12 years of age)
3
Abstral PA, QL
3
Afinitor PA, QL
Specialty medication
3
3
Humalog, Novolog,
Apidra (ST)
Akynzeo QL
3
Emend
1
2
Albenza
fentanyl citrate (PA)
Suggested
Alternative(s)
Afrezza PA
alagesic
Specialty
Non-preferred
Preferred
Drug Name
Generic
Suggested
Alternative(s)
albuterol solution QL
1
albuterol ER tablets
1
1
alclometasone
dipropionate
1
acetaminophen/caffeine/
dihydrocodone QL
1
Aldurazyme PA
3
acetaminophen/codeine
QL
1
Alecensa PA, QL
3
3
acamprosate
1
acarbose QL
1
acebutolol
alendronate
1
acetazolamide ER capsule
1
Alferon N PA
acetic acid
1
alfuzosin ER
acetic acid/hydrocortisone
1
Alinia
2
2
1
acitretin
3
Alkeran
Actemra PA, QL
3
allopurinol
1
Acthar gel PA, QL
3
almotriptan ST, QL
1
Actimmune PA
3
Acuvail QL
3
acyclovir
1
acyclovir ointment
1
Aczone PA
adapalene (PA >35 years
of age)
tretinoin, benzoyl
peroxide (BPO 4%
and 8%), clindamycin,
adapalene (PA)
3
3
Adempas PA, QL
3
Adrenaclick
Alomide
3
azelastine, epinastine,
Pataday, Patanol
Alora QL
3
estradiol patch,
Premarin
3
3
3
EpiPen, Auvi-Q
Aerospan ST
3
Arnuity Ellipta,
Asmanex, Flovent HFA
1
alprazolam ODT ST
1
QL = Quantity limits
PA = Prior authorization required ST = Step therapy required ondansetron
alprazolam
3
fluorometholone,
prednisolone
3
Arnuity Ellipta,
1
Alvesco ST
1
2
alprazolam
Altavera
2
KEY
Pataday, Patanol
Alrex
3
afeditab CR
3
Alphagan P 0.1%
1
Advair
Alocril
Aloxi ST, QL
adefovir PA
naratriptan, rizatriptan,
sumatriptan,
zolmitriptan
alosetron PA, QL
1
Adcirca PA, QL
Adderall XR QL (PA < 4
and >18 years of age)
ketorolac, diclofenac,
bromfenac
3
Adagen PA
Specialty
Non-preferred
Preferred
Drug Name
Generic
Alyacen
1
amantadine
1
amcinonide
1
Amethia
1
COPAYMENT TIER
1 = Generic Medications
2= Preferred Brand Medications
3= Non-preferred Brand Medications & Specialty Medications *Age restrictions apply to some medications.
5
Amethia Lo
1
Amethyst
1
amiloride
1
amiloride/
hydrochlorothiazide
1
amiodarone
1
Aptiom PA, QL
Aptivus QL
Amitiza QL
3
1
amlodipine besylate
1
amlodipine besylate/
benazepril
1
ammonium lactate
1
Arcalyst PA, QL
Amnesteem
1
Arcapta ST
amoxapine
1
amoxicillin
1
aripiprazole PA, QL (ST
<12 years of age)
amoxicillin/clavulanate
1
amoxicillin/clavulanate ER
1
Arnuity Ellipta
2
amphetamine salts QL
1
Asacol HD
2
ampicillin
1
Ascensia Blood Glucose
Meters
2
Asmanex
2
arbinoxa
anastrozole
1
Androderm PA
3
Androgel 1.62% PA
testosterone gel (PA),
testosterone injection
(PA), Androgel 1.62%
(PA)
2
Android PA
androxy PA
3
3
Angeliq
atenolol
1
atenolol/chlorthalidone
1
atorvastatin
1
atovaquone suspension
1
Premarin, estradiol,
estropipate
Atrovent HFA
atropine drops
ondansetron
Auryxia
2
Humalog, Novolog
Auvi-Q QL
2
Aveed PA
1
Apriso ER
Aviane
2
Avonex QL
KEY
PA = Prior authorization required ST = Step therapy required Specialty
Serevent, Foradil
3
levothyroxine,
liothyronine
3
Incruse Ellipta, Spiriva
3
3
Apri
3
1
3
1
2
Apidra ST, QL
3
3
1
Anzemet ST, QL
Apokyn PA, QL
3
Aubagio PA, QL
Aubra
3
1
1
Atripla QL
2
apraclonidine
Caphosol
1
aspirin/dipyridamole
1
Anoro Ellipta
3
1
Armour Thyroid
3
1
carbamazepine,
lamotrigine,
oxcarbazepine,
levetiracetam,
phenytoin, valproic
acid, zonisamide
Aranesp PA
Ampyra PA, QL
anagrelide
3
Aralast NP PA
amitriptyline
Aranelle
Suggested
Alternative(s)
2
Aquoral
Linzess, Movantik
Non-preferred
Drug Name
Preferred
Suggested
Alternative(s)
Generic
Specialty
Non-preferred
Preferred
Drug Name
Generic
3
(PA)
1
3
COPAYMENT TIER
6
Axiron PA
3
azathioprine
1
azelastine
1
(PA)
Betaseron ST, QL
erythromycin
Bethkis QL
Generic topical acne
agents
bethanechol
1
bicalutamide
Biltricide
1
bimatoprost 0.03% ST
1
baclofen
1
bisoprolol
1
1
1
bisoprolol/
hydrochlorothiazide
Balziva
1
Bivigam PA
Banzel PA
3
Bayer Blood Glucose
Meters
2
Bayer Blood Glucose Test
Strips (QL > 18 years of
age)
2
Bayer Lancets (QL > 18
years of age)
2
Bekyree
1
benazepril
1
benazepril/
hydrochlorothiazide
1
Benlysta PA
3
3
Botox PA, QL
3
Blisovi FE
1
Blisovi 24 FE
1
BPO 4% (benzoyl
peroxide) gel
1
BPO 8% (benzoyl
peroxide) gel
1
Breeze Blood Glucose
Meters
2
Breo Ellipta
2
Briellyn
1
Brilinta QL
1
brimonidine tartrate
1
benztropine
1
bromfenac ophthalmic
solution
1
bromocriptine
1
3
3
Besivance
betamethasone
Pataday, Patanol
KEY
PA = Prior authorization required ST = Step therapy required 2
Brovana
ciprofloxacin,
gatifloxacin,
levofloxacin, ofloxacin,
Moxeza, Vigamox
budeprion XL
1
budesonide EC
1
budesonide nasal spray ST
1
budesonide respules
1
1
Specialty
Bosulif PA, QL
2
1
Berinert PA
Non-preferred
benzonatate
3
latanoprost
3
benprox
Bepreve
ammonium lactate,
zenieva
2
Blephamide
felbamate, lamotrigine,
topiramate, valproate
1
bacitracin eye ointment
balsalazide disodium
timolol, Betoptic S
3
1
2
2
Azurette
Bactroban nasal ointment
3
3
Biafine
2
2
Beyaz
1
Suggested
Alternative(s)
3
3
bexarotene PA
2
Azopt
1
Betoptic S
3
Azilect
betaxolol
Preferred
Drug Name
Generic
Suggested
Alternative(s)
Betimol
Azelex ST
Specialty
3
Azasite
azithromycin
Non-preferred
Preferred
Generic
Drug Name
3
Foradil, Serevent
fluticasone, flunisolide
COPAYMENT TIER
7
bumetanide
3
Suboxone film (PA),
Zubsolv (PA)
3
1
3
1
bupropion XL
1
buspirone
1
butalbital/acetaminophen/
caffeine
1
butorphanol nasal spray
QL
1
captopril
1
captopril/
hydrochlorothiazide
1
Butrans PA, QL
Suboxone film (PA),
Zubsolv (PA)
3
ibuprofen, meloxicam,
oxycodone immendiate
release, morphine
sulfate immediate
release, tramadol
carbamazepine
1
carbamazepine ER
1
carbidopa
1
carbidopa/levodopa
1
carbidopa/levodopa/
entacapone
1
carbinoxamine
1
3
Trulicity, Victoza
Carimune NF PA
3
atenolol, metoprolol,
propranolol
carisoprodol
1
carisoprodol/aspirin
1
carteolol
1
cartia XT
1
carvedilol
1
calcipotriene
1
calcitonin nasal spray
1
calcitriol
1
calcitriol ointment QL
1
calcium acetate
1
Camila
1
Camrese
1
Camrese Lo
1
Cayston QL
3
Canasa
Apriso, Asacol HD,
Delzicol, mesalamine,
balsalazide disodium,
sulfasalazine,
sulfasalazine EC
Caziant
1
cefaclor
1
cefaclor ER
1
cefadroxil
1
cefdinir
1
cefditoren
1
cefpodoxime
1
cefprozil
1
ceftazidime
1
candesartan
1
ceftibuten
1
candesartan/
hydrochlorothiazide
1
cefuroxime
1
celecoxib ST, QL
1
capecitabine PA
Caphosol
KEY
3
2
Non-preferred
alfuzosin ER, doxazosin,
tamsulosin, terazosin,
prazosin
2
Migergot suppository
3
Byetta ST, QL
3
3
Cardura XL ST, QL
Trulicity, Victoza
Cafergot
amlodipine besylate,
cartia XT, diltiazem,
Nifediac CC, nifedipine,
nifedipine ER, taztia XT,
verapamil, verapamil SR
3
1
3
3
2
Bystolic ST
Suggested
Alternative(s)
Cardene SR
Bydureon QL
cabergoline
Preferred
Carbaglu PA
buprenorphine/naloxone
tablet PA, QL
bupropion
Generic
Drug Name
Caprelsa PA, QL
Buphenyl tablet PA
Suggested
Alternative(s)
1
Bunavail PA, QL
buprenorphine PA, QL
Specialty
Non-preferred
Preferred
Drug Name
Generic
3
3
Generic NSAIDS
(diclofenac, etodolac,
ibuprofen, meloxicam,
naproxen)
COPAYMENT TIER
8
estropipate
1
3
Cerezyme PA
3
2
citalopram QL
1
Claravis
1
clarithromycin
1
clarithromycin ER
1
generic nicotine
replacement products
clindamycin
1
clobetasol topical cream
1
1
clobetasol topical gel
1
1
clobetasol topical solution
1
Cheratussin DAC oral
syrup
1
clomipramine ST
1
chlordiazepoxide
1
chlordiazepoxide/
amitriptyline
1
clonazepam
1
chlordiazepoxide/
clindinium
1
clonazepam ODT ST
1
chlorhexidine rinse
1
clonidine
1
chlorpromazine (ST <12
years of age)
1
clonidine ER ST, QL
1
clopidogrel
1
chlorpropamide QL
1
clorazepate
1
chlorthalidone
1
1
chlorzoxazone
1
clorpres (clonidine/
chlorthalidone)
cholestyramine
1
clotrimazole
1
ciclopirox
1
clotrimazole/
betamethasone
1
cilostazol
1
clozapine (ST <12 years
of age)
1
clozapine ODT QL (ST <12
years of age)
1
3
3
Ciloxan
cimetidine
ciprofloxacin,
gatifloxacin,
levofloxacin, Moxeza,
ofloxacin, Vigamox
Cimzia PA, QL
3
Cinryze PA, QL
3
Cipro HC
2
Ciprodex
2
1
ciprofloxacin 0.2% ear
drops
1
ciprofloxacin 0.3% eye
drops
1
ciprofloxacin ER QL
1
KEY
Specialty
estradiol
PA = Prior authorization required ST = Step therapy required codeine sulfate
citalopram, duloxetine,
escitalopram,
fluoxetine, paroxetine,
sertraline, venlafaxine
ER capsules
clonazepam
clonidine
2
Coartem
1
ciprofloxacin
Non-preferred
3
Suggested
Alternative(s)
clobetasol topical ointment 1
Chemet PA
Cheratussin AC oral syrup
Preferred
Climara-PRO QL
1
Chantix ST, QL
Chateal
Drug Name
Generic
Suggested
Alternative(s)
Cerdelga PA, QL
cevimeline
Specialty
3
Cenestin
cephalexin
Non-preferred
Preferred
Generic
Drug Name
1
2
Colcrys
Colestid granules
colestipol
2
Combigan
2
Combipatch QL
Cometriq PA, QL
colestipol
3
estradiolnorethindrone, Jinteli,
Prempro, Premphase
1
Coly-Mycin S ear drops
Combivent Respimat
3
2
3
COPAYMENT TIER
9
Complera QL
Concerta QL (PA < 4 and
≥18 years of age)
2
Daliresp PA
2
Copaxone QL
Specialty
Non-preferred
3
3
danazol PA
1
dantrolene
1
dapsone
1
Dasetta
1
Corlanor PA, QL
3
Cortef
3
hydrocortisone tablet
Daysee
1
Cortifoam
3
hydrocortisone
25mg suppository,
Proctozone-HC cream
Delyla
1
cortisone tablet
Preferred
Drug Name
Generic
Suggested
Alternative(s)
demeclocycline
Cosentyx PA, QL
3
3
Cosopt PF
Cotellic PA, QL
3
Demser PA
Azopt, betaxolol,
Betoptic S, carteolol,
dorzolamide,
dorzolamide-timolol,
timolol maleate
Denavir
Cresemba QL
3
1
3
3
Depen PA
2
Creon
2
Delzicol
1
2
desipramine
1
desmopressin tablets
1
desmopressin nasal spray
1
Crinone 4% gel
2
desogestrel/ethinyl
estradiol
1
Crixivan QL
2
desonide
1
cromolyn
1
desoximetasone
1
Cryselle
1
desvenlafaxine ER ST, QL
Cuprimine PA
2
Cuvposa (PA > 16 years
of age)
3
3
dexamethasone
1
cyclobenzaprine
1
1
dexedrine QL (PA < 4 and
≥18 years of age)
1
cyclopentolate drops
dexmethylphenidate QL
1
dexmethylphenidate ER
QL (PA < 4 and ≥18 years
of age)
1
dextroamphetamine QL
(PA < 4 and ≥18 years of
age)
1
dextroamphetamine ER
QL (PA < 4 and ≥18 years
of age)
1
3
3
Cycloset
cyclosporine
1
cyclosporine modified
1
cyproheptadine
1
Cystadane powder PA
Specialty Medication
bromocriptine
3
Cystaran PA, QL
3
Daklinza PA, QL
3
Cystagon PA
KEY
2
PA = Prior authorization required ST = Step therapy required Diastat
Diastat Acudial
3
escitalopram,
ER capsules
3
diazepam, diazepam
rectal gel
glycopyrrolate tablet
1
For cold sore treatment
use over-the-counter
agents
3
Cyclafem
cyclophosphamide
capsules
Suggested
Alternative(s)
Advair, Breo Ellipta,
Foradil, Incruse Ellipta,
Serevent, Spiriva
1
Contour Blood Glucose
Meters
Specialty
Non-preferred
Preferred
Drug Name
Generic
2
COPAYMENT TIER
10
1
Duavee
2
diazepam rectal gel
1
Dulera
2
3
diclofenac ophthalmic
solution
1
diclofenac tablet
1
diclofenac 1% topical gel
QL
1
diclofenac/misoprostol
1
dicloxacillin
1
dicyclomine
1
didanosine QL
1
duloxetine QL
dutasteride
1
dutasteride/tamsulosin
1
3
amlodipine besylate,
cartia XT, diltiazem,
Nifediac CC, nifedipine,
nifedipine ER, taztia XT,
verapamil, verapamil SR
Dyrenium
3
triamterene/
hydrochlorothiazide
1
Dysport PA, QL
diflunisal
1
econazole cream
digoxin
1
Edurant QL
2
dihydroergotamine
1
Effient QL
2
diltiazem
1
Elaprase PA
diltiazem ER
1
Elelyso PA
1
Eligard PA, QL
dipyridamole
1
Elinest
1
disopyramide
1
eliphos
1
disulfuram
1
Eliquis QL
divalproex sodium
1
Ella
divalproex sodium ER
1
3
Emadine
dorzolamide
1
Emcyt PA
dorzolamide/timolol
1
Emend capsule QL
doxazosin
1
Emend vial QL
doxepin
1
Emoquette
doxercalciferol
1
Emtriva QL
doxycycline
1
enalapril
1
Drithocreme Hp 1% cream
1
1
dronabinol
1
enalapril/
hydrochlorothiazide
KEY
PA = Prior authorization required ST = Step therapy required Endocet QL
Generic topical
steroids, tacrolimus
ointment (PA)
3
levonorgestrel, Next
Choice
3
Pataday, Patanol
3
3
2
3
1
2
Enbrel PA, QL
OTC antiperspirants
3
2
1
3
2
donepezil PA
Drysol 20% solution
3
3
Elmiron
estradiol
3
diphenoxylate/atropine
Divigel
3
1
Elidel PA
Apriso, Asacol HD,
Delzicol
Dynacirc CR
diflorasone
3
Specialty
3
2
Durezol
3
Suggested
Alternative(s)
1
Duopa PA
Dificid ST, QL
Dipentum ST
Non-preferred
Preferred
Drug Name
Generic
Suggested
Alternative(s)
diazepam
Dibenzyline PA
Specialty
Non-preferred
Preferred
Generic
Drug Name
1
COPAYMENT TIER
11
3
Enjuvia
enoxaparin QL
1
Enpresse
1
Enskyce
1
entacapone
1
entecavir PA
Entresto PA, QL
epinastine ophthalmic
solution
1
epinephrine
1
EpiPen QL
3
3
ethosuximide
1
etidronate
1
etodolac
1
etodolac ER
1
1
3
Specialty
Non-preferred
3
Euflexxa PA, QL
3
Evamist
3
Evotaz QL
3
exemestane
1
Epzicom QL
2
Erivedge PA, QL
3
estradiol
3
3
1
3
EryPed
erythromycin
1
2
Ery-tab EC 500mg
erythromycin
1
erythromycin/benzoyl
peroxide gel
1
donepezil (PA),
rivastigmine tartrate
capsules (PA),
memantine (PA)
Exjade PA
3
Eylea PA
3
Fabrazyme PA
3
Falmina
1
famciclovir QL
1
famotidine
1
Fanapt PA, QL (ST <12
years of age)
Esbriet PA, QL
3
1
Farydak PA, QL
Estarylla
1
felbamate
1
estazolam
1
felodipine
1
Estrace cream
3
estradiol, estropipate,
Premarin
Femring QL
Estraderm QL
3
estradiol
fenofibrate
1
1
fenofibric acid ST
1
estradiol/norethindrone
1
fenoprofen
1
estradiol patch QL
1
fentanyl citrate PA, QL
1
fentanyl transdermal QL
1
Premarin
Estrogel QL
3
Premarin
Fentora PA, QL
Ferriprox PA
1
KEY
PA = Prior authorization required ST = Step therapy required ciprofloxacin,
levofloxacin
3
aripiprazole (PA,
ST), olanzapine (ST),
risperidone (ST),
quetiapine (ST),
ziprasidone (ST)
3
3
3
estradiol
3
3
Fareston PA
escitalopram QL
Estring QL
1
Factive QL
Suggested
Alternative(s)
etoposide PA
2
epoprostenol PA
estropipate
Preferred
Generic
1
Exelon patch PA
Ery-tab EC
eszopiclone QL
Evzio PA, QL
3
Errin
Drug Name
Premarin
Epogen PA
eprosartan
Suggested
Alternative(s)
2
Entyvio PA, QL
eplerenone
Specialty
Non-preferred
Preferred
Drug Name
Generic
Premarin
fenofibrate
3
fentanyl citrate (PA)
3
COPAYMENT TIER
12
3
duloxetine, venlafaxine
ER, citalopram,
escitalopram,
fluoxetine, sertraline,
paroxetine
Finacea
3
Generic topical acne
agents
3
Firmagon PA, QL
3
3
Flarex
Flebogamma PA
1
fosinopril
1
fosinopril/
hydrochlorothiazide
1
frovatriptan ST, QL
furosemide
fluconazole QL
1
fludrocortisone
1
flunisolide
1
fluocinolone
1
gabapentin
fluocinonide
1
Gablofen
Fluor-A-Day chew
1
Specialty
Non-preferred
3
Auryxia, calcium
acetate, Renvela
3
1
sumatriptan,
zolmitriptan
3
3
1
Fuzeon QL
Fycompa PA, QL
2
Fluor-A-Day drops
(PA)
Fulyzaq PA, QL
2
Suggested
Alternative(s)
3
Fragmin QL
1
Flovent HFA
fortical
Fosrenol ST
fluorometholone,
prednisolone
3
Preferred
Fortesta PA
1
Firazyr PA, QL
flecainide
Drug Name
Generic
Suggested
Alternative(s)
Fetzima PA, QL
finasteride
3
1
3
galantamine PA
1
galantamine ER PA
1
fluorometholone
1
Galzin PA
fluoxetine
1
Gammagard PA
3
fluoxetine DR QL
1
Gammaked PA
3
fluphenazine (ST <12 years 1
of age)
Gammaplex PA
3
Gamunex PA
3
Gamunex-C PA
3
3
2
flurazepam
1
flurbiprofen
1
fluorouracil 5% topical
cream
1
fluticasone
1
gavilyte-g
1
fluvastatin
1
gavilyte-h
1
fluvoxamine
1
gemfibrozil
1
gatifloxacin
1
Gattex PA, QL
3
FML Forte
fluorometholone,
prednisolone
3
Generess FE
2
FML S.O.P.
folic acid tablets
1
fondaparinux QL
1
Foradil
gentamicin
KEY
3
3
PA = Prior authorization required ST = Step therapy required generic oral
contraceptives, Beyaz,
Natazia, Nuvaring,
Safyral
1
Genvoya QL
2
Forteo ST, QL
Specialty
Non-preferred
Preferred
Generic
Drug Name
2
Gianvi
1
Gildagia
1
COPAYMENT TIER
13
Gildess
1
Gildess FE
1
Gildess 24 FE
1
Gilotrif PA, QL
3
Glassia PA
3
Gleevec PA, QL
3
Gleostine PA
3
1
glipizide QL
1
glipizide ER QL
1
glipizide/metformin QL
1
1
glyburide/metformin QL
1
glycopyrrolate
1
Grastek PA, QL
haloperidol (ST <12 years
of age)
1
Harvoni PA, QL
1
Heather
1
1
hydrocodone/
acetaminophen
5mg/325mg QL
1
hydrocodone/
acetaminophen
7.5mg/325mg QL
1
1
hydrocortisone ointment
1
hydrocortisone 25mg
suppository
1
hydrocortisone/pramoxine
1%-1% cream with
applicator
1
2.5%-1% cream with
applicator
1
hydromorphone
1
hydroxychloroquine
1
hydroxyurea
1
hydroxyzine
1
hyoscyamine
1
guanfacine
Hexalen
3
Hizentra PA
3
HyQvia PA
1
PA = Prior authorization required ST = Step therapy required hydralazine
hydrocortisone cream
3
KEY
2
1
Hetlioz PA, QL
homatropine drops
Humulin R QL
hydrocortisone tablet
3
hydrochlorothiazide
2
1
3
1
Humulin N QL
hydrocodone/homatropine
oral liquid
3
halobetasol
2
1
Granix PA
1
Humulin 70/30 QL
hydrocodone/ibuprofen
7.5mg/200mg QL
ondansetron
guanfacine ER ST, QL
2
gabapentin
1
1
Humulin 50/50 QL
3
granisol ST, QL
guanfacine
2
1
ondansetron
1
Humalog 75/25 QL
hydrocodone/
acetaminophen
10mg/325mg QL
1
guaifenesin/codeine oral
liquid
2
acarbose
granisetron ST, QL
1
2
Humalog 50/50 QL
3
2
Gralise PA, QL
griseofulvin
Humalog QL
Hycamtin PA
Glyset QL
Glyxambi QL
ibandronate IV ST, QL
Specialty
Non-preferred
3
Humira PA, QL
2
glyburide QL
Preferred
Horizant PA, QL
3
glimepiride QL
Drug Name
Generic
Suggested
Alternative(s)
Gilenya PA, QL
Glucagon kit QL
Specialty
Non-preferred
Preferred
Drug Name
Generic
Suggested
Alternative(s)
gabapentin,
pramipexole, ropinirole
3
3
3
1
COPAYMENT TIER
14
ibandronate tablet QL
Isopto Homatropine
3
Iclusig PA, QL
3
isosorbide
1
Ilaris PA, QL
3
isosorbide ER
1
bromfenac
isradipine
1
itraconazole capsule PA,
QL
1
1
ibuprofen
Specialty
Non-preferred
Preferred
Drug Name
Generic
Suggested
Alternative(s)
1
Ibrance PA, QL
3
Iluvien PA, QL
3
Imbruvica PA, QL
3
Istalol
Suggested
Alternative(s)
3
atropine,
cyclopentolate,
homatropine,
tropicamide
3
timolol
1
Ilevro
imipramine
1
ivermectin
imiquimod
1
Jadenu PA
3
Jakafi PA, QL
3
3
3
3
3
Increlex PA
3
indomethacin
Jantoven
2
Incruse Ellipta
3
Innopran XL ST
3
Intelence PA, QL
2
Janumet XR QL
2
propranolol
Januvia QL
2
Jardiance QL
2
2
Jencycla
Intron A PA
3
Invega Sustenna QL (ST
<12 years of age)
3
Invega Trinza QL (ST <12
years of age)
3
Introvale
1
Janumet QL
1
Inlyta PA, QL
1
Jentadueto QL
1
2
Jetrea PA, QL
Jevantique
1
Jevantique Lo
1
Jinteli
1
Invirase QL
2
Jolessa
1
Invokamet QL
2
Jolivette
1
Invokana QL
2
Junel
1
ipratropium
1
Junel FE
1
ipratropium/albuterol
solution
1
Junel FE 24
1
irbesartan
1
irbesartan/
hydrochlorothiazide
1
Juxtapid PA, QL
Kaitlib 24 FE
3
Isentress QL
isoniazid
Kaletra QL
1
Isopto Carbachol
Kalydeco PA, QL
2
KEY
1
Kalbitor PA
Iressa PA, QL
Specialty
Non-preferred
Preferred
Generic
Drug Name
3
Azopt, betaxolol,
Betoptic S brimonidine,
carteolol, Combigan,
dorzolamide,
latanoprost,
levobunolol, timolol
Kariva
1
Kelnor
1
Ketek QL
3
ketoconazole
1
ketoprofen
1
COPAYMENT TIER
15
1
Lenvima PA, QL
ketorolac ophthalmic
solution
1
Lessina
3
Khedezla ST, QL
3
escitalopram,
ER capsules
Leukine PA
3
3
letrozole
1
leucovorin calcium tablet
1
3
Korlym PA, QL
3
levalbuterol ST
Krystexxa PA, QL
3
Levatol ST
Kuvan PA
3
Kynamro PA, QL
3
3
lactulose
1
lamivudine QL
1
lamivudine/zidovudine QL
1
lamivudine HBV PA
1
lamotrigine
1
lansoprazole/amoxicillin/
clarithromycin pack
1
lansoprazole QL
1
Larin FE
1
Larin 24 FE
1
Pataday, Patanol
1
Latuda ST, QL (ST <12
years of age)
Layolis FE
3
aripiprazole (PA,
risperidone (ST),
quetiapine (ST),
ziprasidone (ST)
1
Lazanda PA, QL
3
Leena
1
leflunomide
1
Lemtrada PA
KEY
1
levetiracetam ER QL
1
levobunolol
1
levocetirizine
1
levofloxacin
1
levofloxacin ophthalmic
1
Levonest
1
levonorgestrel
1
Levora
1
levothyroxine
1
PA = Prior authorization required ST = Step therapy required fentanyl citrate (PA)
3
lidocaine cream
1
lidocaine patch ST, QL
1
lidocaine-hc gel
1
lidocaine jelly
1
Lifescan Blood Glucose
Meters
2
Lifescan Blood Glucose
Test Strips (QL > 18 years
of age)
2
Lifescan Lancets (QL > 18
years of age)
2
lindane
1
linezolid QL
1
Linzess QL
liothyronine
3
propranolol
3
Apriso, Asacol HD,
Delzicol
2
Lialda ST
3
Lastacaft
albuterol
2
levetiracetam
Lexiva QL
2
Larin
latanoprost
Restasis
1
Lantus QL
1
Levemir QL
1
Lacrisert
2
Leukeran
1
Specialty
3
Kineret PA, QL
labetalol
Non-preferred
1
Letairis PA, QL
Suggested
Alternative(s)
3
leuprolide PA
Kurvelo
Preferred
Drug Name
Generic
Suggested
Alternative(s)
ketorolac QL
Keveyis PA, QL
Specialty
Non-preferred
Preferred
Drug Name
Generic
2
1
COPAYMENT TIER
16
1
Lyza
lisinopril/
hydrochlorothiazide
1
Makena PA
lithium
1
lithium ER
1
3
Lomedia 24 FE
Generic oral
Natazia, Nuvaring,
Safyral
3
Lonsurf PA
Generic oral
Natazia, Nuvaring,
Safyral
3
malathion
1
Marlissa
1
matzim LA
fluorometholone,
prednisolone
meclizine
1
medroxyprogesterone
acetate injection QL
1
1
mefenamic acid
1
1
megestrol
1
Lorcet HD QL
1
Mekinist PA, QL
Lorcet plus QL
1
meloxicam
1
Lortab QL
1
memantine PA
1
Loryna
1
Menest
losartan
1
losartan/
hydrochlorothiazide
1
1
loxapine (ST <12 years of
age)
1
3
Menostar QL
meperidine tablet
1
meprobamate
1
mercaptopurine
1
mesalamine
1
metadate ER QL (PA < 4
and ≥18 years of age)
1
metaxalone
1
metformin QL
1
1
3
Lumizyme PA
3
Lupaneta PA, QL
3
metformin ER (generic
Glucophage XR) QL
3
methadone
1
methamphetamine QL (PA
< 4 and ≥18 years of age)
1
3
methazolamide
1
methenamine
1
methimazole
1
2
Lumigan
Lupron PA, QL
Lutera
1
Lynparza PA, QL
Lyrica PA, QL
Lysodren PA
KEY
gabapentin,
amitriptyline,
cyclobenzaprine,
duloxetine
3
3
estropipate
3
estradiol
3
Mesnex tablets
Lucentis PA
Specialty
3
lorazepam
Low-ogestrel
Non-preferred
Maxidex
loratadine
1
ciprofloxacin,
levofloxacin
1
lovastatin
3
3
medroxyprogesterone
tablets
fluorometholone,
prednisolone
Maxaquin
1
3
3
1
loperamide capsules
Lotemax
Suggested
Alternative(s)
1
Matulane
1
Lo Minastrin FE
Preferred
Drug Name
Generic
Suggested
Alternative(s)
lisinopril
Lo Loestrin FE
Specialty
Non-preferred
Preferred
Generic
Drug Name
COPAYMENT TIER
17
Methitest PA
3
(PA)
minoxidil
1
mirtazapine
1
Mirvaso PA
methotrexate
1
methoxsalen PA
1
methylin tablets QL
1
misoprostol
1
methylin ER QL (PA < 4
and ≥18 years of age)
1
modafinil PA, QL
1
methylphenidate CD QL
age)
1
methylphenidate LA QL
age)
1
methylphenidate tablets
QL
1
methylprednisolone
1
metipranolol
1
metoclopramide
1
metolazone
1
metoprolol
1
metoprolol/
hydrochlorothiazide
1
metoprolol ER
1
metronidazole
1
Microgestin
1
Microgestin FE
1
midazolam syrup
1
midodrine
1
Migergot suppository
1
Mimvey
1
Mimvey Lo
1
Minivelle QL
minocycline
mometasone
1
Mono-linyah
1
MonoNessa
1
montelukast QL
1
morphine sulfate IR
1
morphine sulfate ER
tablets QL
1
Movantik QL
2
Moviprep
2
Moxeza
2
mupirocin
mycophenolate mofetil
1
mycophenolate sodium
1
Myrbetriq ER QL
Specialty
3
3
3
3
2
Myzilra
1
nabumetone
1
nadolol
1
nadolol/
bendroflumethiazide
1
Naglazyme PA
1
Myozyme PA
estradiol patch,
Premarin
3
1
Myobloc PA, QL
Generic oral
Natazia, Nuvaring,
Safyral
2
Myalept PA, QL
Myorisan
3
1
Multaq
1
Mozobil PA, QL
3
KEY
1
moexipril/
hydrochlorothiazide
moxifloxacin
3
Minastrin 24 FE
moexipril
Suggested
Alternative(s)
adapalene (PA),
metronidazole, sodium
sulfacetamide-sulfur
10-5% cleanser,
tretinoin
Moderiba QL
3
Non-preferred
3
1
3
Preferred
Drug Name
Generic
Suggested
Alternative(s)
methocarbamol
methyltestosterone
capsule PA
Specialty
Non-preferred
Preferred
Drug Name
Generic
COPAYMENT TIER
18
1
nitrofurantoin capsule
1
naratriptan QL
1
nitroglycerin
1
Narcan QL
2
Nitrostat
Natazia
2
nizatidine
1
nodolor
1
Nora-BE
1
1
Natpara PA, QL
3
2
Nebupent
3
Noxafil PA, QL
3
Nplate PA
3
Norlyroc
1
Northera PA, QL
1
Neulasta PA
3
Nortrel
1
Neumega
3
nortriptyline
1
Neupogen PA
3
Norvir QL
2
Neupro
3
Novolin 70/30 QL
2
Nevanac
3
bromfenac
Novolin N QL
2
Novolin R QL
2
Novolog QL
2
Novolog Mix 70/30 QL
2
1
Nexavar PA, QL
3
nitroglycerin
1
nevirapine ER QL
Suggested
Alternative(s)
3
nefazodone
1
Specialty
3
Norditropin PA
Necon
nevirapine QL
Non-preferred
Preferred
Drug Name
Generic
Suggested
Alternative(s)
naproxen
nateglinide QL
Nexium ST, QL
1
Nucala PA, QL
3
Next Choice
1
Nuedexta PA, QL
3
Next Choice One Dose
1
Nulojix PA
3
niacin ER
1
Nuvaring QL
nicotine gum QL
1
Nuvigil PA, QL
3
nicotine lozenges QL
1
nystatin
1
nicotine patches QL
1
nystatin/triamcinolone
1
3
omeprazole,
lansoprazole,
pantoprazole
2
Nicotrol Inhaler ST, QL
2
generic nicotine
nystop
1
Nicotrol Nasal Spray ST,
QL
2
generic nicotine
Ocella
1
octreotide
nifediac CC
1
Odefsey QL
nifedipine
1
Odomzo PA, QL
3
nifedipine ER
1
Ofev PA, QL
3
Nikki
1
ofloxacin
1
Ogestrel
1
olanzapine QL (ST <12
years of age)
1
olanzapine vial
1
Nilandron PA
nimodipine
3
3
1
Ninlaro PA, QL
nisoldipine
1
nisoldipine ER
1
KEY
Non-preferred
Preferred
Generic
Drug Name
2
COPAYMENT TIER
19
olanzapine/fluoxetine PA,
QL (ST <12 years of age)
1
olopatadine 0.6% nasal
spray
1
3
3
Omeclamox-Pak
omega-3 acid ethyl esters
1
omeprazole QL
1
One Touch Blood Glucose
Meters
2
Lancets (QL > 18 years of
age)
2
Test Strips (QL > 18 years
of age)
2
oxycodone/aspirin QL
1
oxycodone/ibuprofen QL
1
Oxycontin PA, QL
oxymorphone
1
oxymorphone ER QL
1
paliperidone PA, QL (ST
<12 years of age)
1
3
Pancreaze ST
Onmel PA, QL
3
itraconazole (PA)
pantoprazole QL
1
paricalcitol
1
paroxetine
1
paroxetine CR ST, QL
1
Opsumit PA, QL
Orencia PA, QL
3
Pataday
2
Orenitram PA
3
Patanol
2
Orfadin PA
3
Pazeo
Orkambi PA, QL
3
Oralair PA, QL
3
orphenadrine
1
peg-3350
Orsythia
1
Peganone PA
3
Osmoprep
3
Otrexup PA, QL
3
1
Oxsoralen PA
1
oxybutynin IR
1
KEY
Specialty
Non-preferred
Creon
PA = Prior authorization required ST = Step therapy required Specialty medication
paroxetine
3
Pataday, Patanol
3
carbamazepine,
lamotrigine,
oxcarbazepine,
phenytoin, topiramate,
valproic acid
1
Pegasys PA, QL
3
Peg-Intron PA, QL
3
penicillin
1
3
Pentasa
3
oxybutynin
3
peg-3350, Moviprep,
Suprep
Otezla PA, QL
oxcarbazepine
fentanyl patches,
morphine sulfate ER,
oxymorphone ER
3
3
1
3
Panretin PA
2
oxazepam
fentanyl patches,
morphine sulfate ER,
oxymorphone ER
oxycodone/acetaminophen 1
7.5mg/325mg QL
Onfi PA, QL
1
3
5mg/325mg QL
1
oxaprozin
Suggested
Alternative(s)
2.5mg/325mg QL
amoxicillin,
clarithromycin,
omeprazole
3
Opana ER QL
Preferred
Generic
Drug Name
10mg/325mg QL
Omontys PA
Suggested
Alternative(s)
oxycodone ER PA, QL
Olysio PA, QL
ondansetron QL
Specialty
Non-preferred
Preferred
Drug Name
Generic
pentazocine/
acetaminophen QL
Apriso, Asacol HD,
Delzicol, sulfasalazine,
sulfasalazine EC
1
COPAYMENT TIER
20
pentazocine/naloxone
1
pramipexole ER ST
1
pentoxifylline
1
pravastatin
1
prazosin
1
3
Perforomist
perindopril
1
permethrin cream
1
perphenazine (ST <12
years of age)
1
Foradil, Serevent
Pertzye ST
3
Creon
fluorometholone,
prednisolone
3
estradiolnorethindrone, Jinteli,
Prempro, Premphase
Prenate
3
generic prenatal
vitamins
prednicarbate
1
prednisolone
1
prednisone
1
Prefest
1
phenelzine
1
Premarin
2
phenobarbital
1
Premarin Vaginal Cream
2
phenytoin
1
Premphase
2
Philith
1
Prempro
2
3
pilocarpine
Specialty
3
phenazopyridine
Phospholine Iodide
pilocarpine
1
pimozide (ST <12 years
of age)
1
Prepopik
3
peg-3350, Suprep,
Moviprep
Pimtrea
1
Prevident
3
sodium fluoride gel
pindolol
1
Prezcobix QL
3
pioglitazone QL
1
Prezista QL
pioglitazone/glimepiride
QL
1
primidone
2
1
Pristiq ST, QL
3
escitalopram,
ER capsules
pioglitazone/metformin QL 1
Pirmella
1
piroxicam
1
Plegridy QL
podofilox topical solution
3
3
Portia
1
potassium chloride
1
potassium citrate ER
1
Potiga PA, QL
ProAir HFA PA, QL
3
probenecid/colchicine
1
prochlorperazine
1
Proctozone-Hc 2.5%
cream
progesterone capsule
Eliquis, Xarelto
Prolastin-C PA
Prolensa
Ventolin HFA
3
3
3
3
1
Procysbi PA, QL
1
KEY
3
probenecid
Proctofoam-Hc
carbamazepine,
phenytoin,
oxcarbazepine, valproic
acid, levetiracetam,
topiramate, tiagabine,
zonisamide
3
Praluent PA, QL
3
Procrit PA
3
Pradaxa QL
pramipexole
Privigen PA
1
Pomalyst PA, QL
Suggested
Alternative(s)
Pred Mild
perphenazine/amitriptyline 1
Non-preferred
Drug Name
Preferred
Suggested
Alternative(s)
Generic
Specialty
Non-preferred
Preferred
Generic
Drug Name
1
3
bromfenac
COPAYMENT TIER
21
Specialty
Non-preferred
Preferred
Drug Name
Generic
Suggested
Alternative(s)
Suggested
Alternative(s)
Proleukin
3
Ravicti PA, QL
3
Prolia PA, QL
3
Rebif ST, QL
3
Promacta PA, QL
3
Reclipsen
promethazine
1
promethazine/codeine oral
liquid
1
propafenone ER
1
propranolol
1
propranolol/
hydrochlorothiazide
1
propranolol SA
1
propylthiouracil
1
protriptyline
1
3
Relistor PA, QL
3
Ventolin HFA
3
3
renalpren
3
Pulmozyme PA, QL
3
Quartette QL
3
1
1
Pulmicort Flexhaler ST
1
Renvela
2
Arnuity Ellipta,
Renvela powder packet
2
repaglinide QL
1
repaglinide/metformin QL
1
Generic oral
Natazia, Nuvaring,
Safyral
Repatha PA, QL
reprexain QL
1
Rescriptor QL
Quasense
1
quetiapine QL (ST <12
years of age)
1
quinapril
1
Revlimid PA, QL
1
Reyataz QL
2
Rescula ST
3
Restasis QL
3
QVAR ST
2
Ragwitek PA, QL
3
raloxifene
1
ramipril
1
ribavirin QL
Arnuity Ellipta,
rifabutin
1
rifampin
1
riluzole PA, QL
Riomet QL
2
Ranexa
1
Rapaflo ST
Rasuvo PA, QL
KEY
alfuzosin er, doxazosin,
prazosin, tamsulosin,
terazosin
3
3
3
3
3
2
3
latanoprost, Lumigan
2
Ribasphere QL
Qutenza PA, QL
sumatriptan,
zolmitriptan
3
pyridostigmine bromide
3
3
Remicade PA
Remodulin PA
pyridostigmine bromide ER
amantadine
3
Relpax ST, QL
Remeven (urea) 50%
cream
topical diltiazem
compound, topical
nifedipine compound
3
Relenza QL
1
ranitidine tablet
3
Regranex QL
pruvate 21-7
quinapril/
hydrochlorothiazide
1
Rectiv PA
Proventil HFA PA, QL
Specialty
Non-preferred
Preferred
Drug Name
Generic
3
metformin
risedronate ST, QL
1
alendronate,
ibandronate
risedronate DR ST, QL
1
alendronate,
ibandronate
risedronate monthly ST,
QL
1
alendronate,
ibandronate
COPAYMENT TIER
22
Risperdal Consta QL (ST
<12 years of age)
3
risperidone QL (ST <12
years of age)
1
risperidone ODT QL (ST
<12 years of age)
1
Seroquel XR PA, QL (ST
<12 years of age)
3
3
Suggested
Alternative(s)
aripiprazole (PA,
risperidone (ST),
quetiapine (ST),
ziprasidone (ST)
3
Signifor PA, QL
3
sertraline
Specialty
Non-preferred
Preferred
Drug Name
Generic
Suggested
Alternative(s)
Serostim PA
Rituxan PA
1
rivastigmine tartrate
capsules PA
1
Signifor LAR PA, QL
3
rizatriptan QL
1
sildenafil 20mg PA, QL
3
ropinirole
1
ropinirole ER
1
silver sulfadiazine cream
(SSD) 1%
rosuvastatin PA
1
Simponi PA, QL
3
Simponi Aria PA, QL
3
3
3
3
Sabril PA, QL
3
2
salacyn 6% cream
1
salacyn 6% lotion
1
salicylic acid 6% shampoo
1
salicylic acid 27.5% liquid
film
1
3
Sandostatin LAR PA, QL
3
Saphris ST, QL (ST <12
years of age)
3
Savella PA, QL
3
Seebri Neohaler ST
3
1
sirolimus PA
1
sodium sulfacetamidesulfur 10-5% cleanser
1
Solia
1
Soliris PA
3
aripiprazole (PA,
risperidone (ST),
quetiapine (ST),
ziprasidone (ST)
Somatuline PA, QL
3
Somavert PA, QL
3
gabapentin,
amitriptyline,
cyclobenzaprine,
duloxetine
Sovaldi PA, QL
3
Spiriva, Incruse Ellipta
spironolactone
1
spironolactone/
hydrochlorothiazide
1
sotalol
1
Spectracef
Sporanox solution PA
Sensipar
2
Sprintec
Serevent
2
Sprycel PA, QL
3
cefpodoxime, cefdinir
3
itraconazole capsule
(PA)
2
Spiriva
2
ondansetron
Selzentry PA, QL
KEY
3
sodium phenylbutyrate
powder PA
2
selenium sulfide shampoo
1
sodium fluoride gel
Sancuso ST, QL
1
simvastatin
Sivextro QL
3
selegiline
2
Sirturo PA
Samsca PA, QL
Santyl
1
Simbrinza
Ruconest PA
Safyral
Specialty
Non-preferred
Preferred
Generic
Drug Name
1
3
Sronyx
1
stavudine QL
1
COPAYMENT TIER
23
3
tacrolimus capsule
1
Stivarga PA, QL
3
tacrolimus ointment PA,
QL
1
3
2
Strensiq PA
Striant PA
3
Stribild QL
(PA)
3
3
Striverdi Respimat
Suboxone film PA, QL
3
Sucraid PA
3
sulfacetamide sodium
1
sulfamethoxazole/
trimethoprim
1
Specialty
Non-preferred
Targretin Gel PA
3
Tagrisso PA, QL
3
Taltz PA, QL
3
3
amantadine
3
Trulicity, Victoza
tamoxifen
1
tamsulosin
1
Foradil, Serevent
Tanzeum ST, QL
Tarceva PA, QL
3
fentanyl citrate (PA),
Abstral (PA)
Tasigna PA, QL
3
2
Subsys PA, QL
3
2
Stiolto Respimat
Suggested
Alternative(s)
Tafinlar PA, QL
Tamiflu QL
2
Stimate Nasal Spray
Preferred
Drug Name
Generic
Suggested
Alternative(s)
Stelara PA, QL
Strattera QL
Tazorac (PA >35 years of
age)
taztia XT
3
benzoyl peroxide
(BPO 4% and 8%),
salicylic acid, tretinoin,
clindamycin topical,
erythromycin topical
1
sulfasalazine
1
Tecfidera PA, QL
sulfasalazine EC
1
Technivie PA, QL
sulfisoxazole
1
Tekturna ST
2
sulindac
1
sumatriptan QL
1
candesartan, enalapril,
eprosartan, irbesartan,
lisinopril, losartan,
telmisartan, valsartan
Tekturna HCT ST
2
candesartan/HCTZ,
enalapril/HCTZ,
lisinopril/HCTZ,
irbesartan/HCTZ,
losartan/HCTZ,
telmisartan/HCTZ,
valsartan/HCTZ
Supprelin LA PA, QL
3
3
Suprax
Suprep
2
Sustiva QL
2
Sutent PA, QL
Sylatron PA
3
Sylvant PA
3
1
Symbicort
2
Symlin ST, QL
2
Synagis PA, QL
Synarel PA, QL
Synjardy QL
2
Syprine PA
2
Tabloid PA
2
KEY
3
cefpodoxime, cefdinir
3
Syeda
Specialty
Non-preferred
Preferred
Drug Name
Generic
telmisartan
1
telmisartan/amlodipine
1
telmisartan/
hydrochlorothiazide
1
temazepam
1
temozolomide PA
3
3
Tencon
1
3
terazosin
1
terbinafine QL
1
3
terconazole vaginal cream
1
terconazole vaginal
suppositories
1
COPAYMENT TIER
24
(PA)
Tobrex
Testopel PA
3
(PA)
tolazamide QL
1
tolbutamide
1
tolmetin
1
tolterodine
1
tolterodine ER
1
topiramate
1
topiramate sprinkle QL
1
torsemide
1
1
testosterone injection PA
1
3
tetracaine ophthalmic
1
tetracycline
1
tetrabenazine PA, QL
3
Thalomid PA, QL
3
2
Theo-24 ER
theophylline ER
1
thermazene cream
1
thioridazine (ST <12 years
of age)
1
thiothixene (ST <12 years
of age)
1
3
tiagabine
ticlopidine
Tracleer PA, QL
1
tramadol ER tablet QL
1
tramadol/acetaminophen
QL
1
trandolapril
1
trandolapril/verapamil
1
tranexamic acid PA, QL
1
Transderm-Scop
1
tranylcypromine
Tilia FE
1
travoprost ST
1
timolol
1
trazodone
1
1
Trelstar PA, QL
tinidazole
3
Tirosint
Tivicay QL
tizanidine tablet
Tresiba QL
levothyroxine
tretinoin topical
1
Tri-Estarylla
1
tobramycin/
dexamethasone
Tri-Legest FE
1
Tri-Linyah
1
tobramycin/
dexamethasone
Tri-Lo-Estarylla
1
Tri-Lo-Marzia
1
Tri-Lo-Sprintec
1
Tri-Previfem
1
Tri-Sprintec
1
1
TOBI Podhaler QL
3
3
Tobradex ointment
3
Tobradex
tobramycin
1
tobramycin/
dexamethasone
1
tobramycin solution for
nebulization QL
KEY
Specialty
meclizine
3
latanoprost
3
3
2
tretinoin oral
2
3
1
Travatan Z ST
2
Tikosyn
2
tramadol QL
1
ciprofloxacin,
gatifloxacin,
levofloxacin, Moxeza,
ofloxacin, Vigamox
3
Tradjenta QL
Suggested
Alternative(s)
2
Toviaz
theophylline ER
3
Thyrogen
Non-preferred
3
3
testosterone gel PA
Preferred
Drug Name
Generic
Suggested
Alternative(s)
Testim PA
Testred PA
Specialty
Non-preferred
Preferred
Generic
Drug Name
COPAYMENT TIER
25
1
urea 40% lotion
1
triamterene/
hydrochlorothiazide
1
ursodiol
1
triazolam
1
triderm cream
1
trifluoperazine (ST <12
years of age)
1
trifluridine eye drops
1
Valchlor PA
trihexyphenidyl
1
valganciclovir
1
Trilyte
1
valproate
1
trimethobenzamide
1
valproic acid
1
trimethoprim
1
valsartan
1
trimipramine
1
1
Trinessa
1
valsartan/
hydrochlorothiazide
Trinessa-Lo
1
vancomycin capsules
1
vandazole vaginal gel
1
Triumeq QL
ER capsules
Vagifem
3
Premarin
Vascepa
tropicamide drops
1
Veletri PA
trospium
1
Velivet
trospium ER
1
Velphoro ST
Truvada QL
2
Tudorza Pressair ST
2
Tybost QL
2
3
Incruse Ellipta, Spiriva
3
Tysabri PA, QL
3
Tyvaso PA
3
Tyzeka PA
3
Uceris PA
3
Uceris Rectal Foam PA
3
2
Uloric ST, QL
2
unithroid
urea 40% cream
3
budesonide
3
lindane, malathion,
permethrin
venlafaxine
1
venlafaxine ER capsule QL
1
Ventolin HFA QL
2
Veramyst
2
verapamil
1
verapamil ER PM
1
verapamil extended
release
1
verapamil SR
1
Vestura
3
3
3
3
Auryxia, calcium
acetate, Renvela
3
3
podofilox topical
solution, imiquimod
2
Vesicare
3
benzoyl peroxide
(BPO 4% and 8%),
hydrocortisone
1
Veregen
allopurinol
2
Ventavis PA
1
Uptravi PA, QL
3
Veltassa PA, QL
Tykerb PA, QL
Ulesfia
1
Vantas PA, QL
1
2
Specialty
Anoro Ellipta, Stiolto
Respimat
Trivora
Trulicity
Non-preferred
3
Vanoxide-HC
2
Suggested
Alternative(s)
Utibron Neohaler ST
valacyclovir QL
3
Preferred
Drug Name
Generic
Specialty
Suggested
Alternative(s)
triamcinolone
Trintellix PA, QL
1
1
KEY
PA = Prior authorization required ST = Step therapy required Non-preferred
Preferred
Drug Name
Generic
COPAYMENT TIER
26
3
Vexol
Viberzi PA, QL
2
Videx solution QL
2
3
3
Vimizim PA
3
Viokace ST
2
2
vitamins (generic
pediatric)
1
vitamins (generic prenatal)
1
Vitekta QL
3
(PA)
VPRIV PA
3
warfarin
1
3
3
atorvastatin, fluvastatin,
lovastatin, pravastatin,
simvastatin, Zetia
KEY
amphetamine salts,
dexmethylphenidate,
methylphenidate,
Adderall XR, methylin,
methylin ER, Concerta,
Strattera
Specialty
Non-preferred
Preferred
Generic
Xeomin PA, QL
3
Xgeva PA, QL
3
3
ciprofloxacin,
loperamide
Xifaxan 550mg PA, QL
3
Xolair PA, QL
3
3
Ventolin HFA
3
3
3
1
zafirlukast
1
zaleplon
1
Zarah
1
3
Azilect, carbidopa/
levodopa, entacapone,
ropinirole, pramipexole,
carbidopa/levodopa/
entacapone
Zelboraf PA, QL
3
Zemaira PA
3
Zenatane
1
Zenchent Fe
1
zenieva
1
Zeosa
2
3
3
1
Zioptan ST
ziprasidone QL (ST <12
years of age)
2
Zetia
zidovudine QL
Creon
1
Zepatier PA, QL
2
PA = Prior authorization required ST = Step therapy required Specialty medication
Zenpep ST
1
Welchol
3
Zelapar
3
Vyvanse PA, QL
3
Xeljanz XR PA, QL
Xtandi PA, QL
1
Vytorin ST
Xeljanz PA, QL
2
Zavesca PA
Votrient PA, QL
Vyfemla
Xyrem PA, QL
3
levothyroxine
3
Xulane QL
Vivitrol PA
Suggested
Alternative(s)
1
Xopenex HFA PA, QL
Creon
3
Vogelxo PA
3
Xifaxan 200mg QL
1
Viread QL
1
Xarelto QL
carbamazepine,
lamotrigine,
oxcarbazepine,
phenytoin, zonisamide
3
Viracept QL
1
westhroid
Xalkori PA, QL
ER capsules
3
Vimpat PA
Wera
WP Thyroid
2
Viibryd PA, QL
1
Vigamox
voriconazole QL
Drug Name
Wymzya Fe
Viekira Pak PA, QL
Viorele
Suggested
Alternative(s)
fluorometholone,
prednisolone
3
Victoza ST
Vienva
Specialty
Non-preferred
Preferred
Generic
Drug Name
3
1
COPAYMENT TIER
27
Suggested
Alternative(s)
2
Zirgan gel
Zithranol-RR cream
3
Zmax QL
3
drithocreme HP
Zoladex PA, QL
3
zoledronic acid 4mg
3
3
zoledronic acid 5mg QL
1
Zolinza PA, QL
zolmitriptan QL
1
zolpidem tartrate QL
1
Zomig nasal spray QL
zonisamide
3
almotriptan (ST),
frovatripan (ST),
sumatriptan,
zolmitriptan
3
Brilinta, clopidogrel,
Effient
1
Zontivity PA, QL
Zorbtive PA
Zortress PA
Zovia
3
3
3
2
1
Zubsolv PA, QL
2
Zydelig PA, QL
Zykadia PA, QL
Zylet
3
tobramycin/
dexamethasone
Zyprexa Relprevv QL (ST
<12 years of age)
3
Zytiga PA, QL
3
KEY
Non-preferred
Preferred
Drug Name
Generic
COPAYMENT TIER
28
MEDICATIONS NOT COVERED BY YOUR CHOICE
The following medications are benefit exclusions and will not be covered under the pharmacy benefit:
Anabolic steroids
Antimalarial agents
Antiobesity medications, including, but not limited to, appetite suppressants and lipase inhibitors
Blood or blood plasma products*
Compounded products containing excluded ingredients (examples are compounded hormone replacement therapies and compounded
narcotic analgesics)
Drugs labeled for investigational use
Drugs used for cosmetic purposes or hair growth
Drugs used to treat sexual dysfunction (examples are Viagra, Levitra, Cialis, Muse, Caverject, Osphena, Stendra, Addyi)
Fertility agents
Legend vitamins (other than prenatal, fluoride, and certain therapeutic vitamins)
Most over-the-counter medications**
Needles/Syringes (other than insulin)*
Nutrition and dietary supplements*
Ostomy supplies*
Therapeutic devices/appliances*
Urine strips (Because our doctors feel blood glucose strips are more accurate than urine test strips in measuring blood glucose, urine strips
are not a covered benefit.)
This is not a complete list, and there may be other medications that are not covered. For more information, please contact
Member Services.
*Please note that, under certain circumstances, your medical benefits may cover the items marked with an asterisk (*). For information on
these items, you can contact our Health Care Concierge team at the number listed on the back of your member ID card. If you have not yet
received an ID card, call the Health Care Concierge team number listed on page 1 of this booklet.
**Additional over-the-counter medications may be covered in accordance with the Patient Protection and Affordable Care Act.
The Preventive Service Guide available on the UPMC Health Plan website contains information regarding this coverage.
29
NON-COVERED MEDICATIONS WITH COVERED ALTERNATIVES
Non-Covered Drug
Alternative Drugs
Non-Covered Drug
Alternative Drugs
Absorica
Amnesteem, Claravis, Myorisan,
Zenatane
Azasan
azathioprine
Azor
candesartan, candesartan/HCTZ,
eprosartan, irbesartan, irbesartan/
HCTZ, losartan, losartan/
HCTZ, telmisartan, telmisartan/
amlodipine, telmisartan/HCTZ,
valsartan, valsartan/HCTZ
Acanya gel
benzoyl peroxide (BPO 4% and
8%), clindamycin
Aciphex Sprinkle
omeprazole, lansoprazole,
pantoprazole, Nexium
Actoplus Met XR
pioglitazone/metformin,
pioglitazone, metformin ER
(generic Glucophage XR)
Beconase AQ
fluticasone, flunisolide, Veramyst
Belsomra
zolpidem, zaleplon, eszopiclone
Akten
lidocaine
Benicar
Ala-Scalp
hydrocortisone, fluocinonide,
clobetasol, betamethasone
Allfen
codeine
Aloquin gel
clotrimazole, miconazole, nystatin
Benicar HCT
Alsuma
sumatriptan
Altoprev
lovastatin, pravastatin, simvastatin,
atorvastatin, fluvastatin
Aluvea
urea 40% cream, urea 50% cream,
urea 40% lotion
Benzamycin Pak
benzoyl peroxide/erythromycin
amlodipine/atorvastatin
amlodipine, atorvastatin,
simvastatin, pravastatin
BenzEFoam
8%)
amlodipine/valsartan
BenzePrO topical foam
8%)
Benziq
8%)
betamethasone/calcipotriene
ointment
betamethasone, calcipotriene
Bidil
hydralazine, isosorbide dinitrate
Binosto
alendronate, ibandronate,
risedronate
Blood Glucose Meters
Bayer meters (such as Contour,
Ascensia, or Breeze), Lifescan
meters (such as One Touch)
Blood Glucose Test Strips
Bayer and Lifescan test strips
Brisdelle
paroxetine, venlafaxine, fluoxetine
Brontex
codeine
Butisol
Butrans
morphine sulfate, oxycodone,
oxymorphone, tramadol,
hydrocodone
Cambia
diclofenac
Cantil
Carac 0.5% cream
fluorouracil 5% cream
Carmol
urea 40% lotion
amlodipine/valsartan/HCTZ
Amrix
cyclobenzaprine
Analpram Advanced Kit
pramoxine/hydrocortisone
Analpram E Kit
Analpram HC cream
Apexicon E cream
diflorasone, betamethasone,
desoximetasone, fluocinonide
Aplenzin ER
bupropion SR, bupropion XL
Aptensio XR (PA)
Adderall XR, Concerta
Aristada
Abilify Maintena, Invega Sustenna,
Invega Trinza, Risperdal Consta,
Zyprexa Relprevv
Astagraf XL
tacrolimus
Atopiclair
ammonium lactate, Zenieva
Atralin
tretinoin, adapalene
Avandamet
pioglitazone, metformin, Januvia,
Tradjenta, Janumet, Janumet XR,
Jentadueto
Centany Ointment
mupirocin
Chenodal
ursodiol
pioglitazone/glimepiride,
metformin, glimepiride, Januvia,
Tradjenta
Claritin-D
loratadine, levocetirizine
Cleanse & Treat
8%)
Avandaryl
Avandia
pioglitazone, metformin, Januvia,
Tradjenta
clindamycin/benzoyl peroxide
clindamycin and benzoyl peroxide
Avar
sodium sulfacetamide-sulfur
cleanser 10-5%
Clindareach
clindamycin
Clobex
clobetasol
Avidoxy DK Kit
doxycycline, topical salicylic acid
products OTC
30
Non-Covered Drug
Alternative Drugs
Non-Covered Drug
Alternative Drugs
Cloderm
betamethasone, fluocinonide,
desoximetasone, triamcinolone,
mometasone, hydrocortisone
Edecrin
furosemide, torsemide,
bumetanide
Colchicine
Colcrys
Edluar
Compounded Hormone
Replacement Therapy
Prempro, Premphase, estradiol,
estradiol-norethindrone, Jinteli
Embeda
morphine sulfate ER
Emsam
Compounded Narcotic Analgesics
hydrocodone/acetaminophen
5mg/325mg, hydrocodone/
acetaminophen 7.5mg/325mg,
10mg/325mg, commercially
available pain products
tranylcypromine sulfate, fluoxetine,
paroxetine, citalopram, sertraline
Epaned solution
enalapril tablet
Epiduo gel
8%), adapalene, tretinoin
Equagesic
acetaminophen/butalbital/
caffeine, dihydroergotamine
Conzip
tramadol, tramadol ER tablet
Cordran cream, lotion, ointment,
tape
betamethasone, fluticasone,
fluocinonide, triamcinolone
Equetro
lithium, risperidone, ziprasidone,
olanzapine
Coreg CR
carvedilol
Ergomar
Cyclobenzaprine ER
cyclobenzaprine
Darifenacin ER
oxybutynin, oxybutynin ER,
trospium, trospium ER, tolterodine,
tolterodine ER, Myrbetriq, Toviaz,
Vesicare
Extavia
Avonex, Rebif, Copaxone,
Betaseron
Fabior foam
Farxiga
Invokana, Jardiance, metformin,
glyburide, glipizide, Januvia,
Tradjenta
Fenoglide
fenofibrate
Fexmid
cyclobenzaprine
Fibricor
fenofibrate
Flagyl ER
metronidazole
Flector patch
diclofenac 1% topical gel,
diclofenac tablets
Daytrana
amphetamine salts,
dexmethylphenidate,
dexmethylphenidate ER,
methylphenidate, Adderall XR,
methylin, methylin ER, Concerta,
Strattera
desloratadine
Desonate
desonide
Desonil Plus
desonide
Dexilant
fluorouracil 0.5% cream
Diclegis
doxylamine, pyridoxine,
diphenhydramine, meclizine,
ondansetron
Fluoroplex 1% cream
fluvoxamine ER
fluvoxamine
diclofenac 3% gel
diclofenac tablet
Fosamax Plus D
alendronate, ibandronate,
risedronate
Differin lotion
Gelnique
Dilatrate SR
isosorbide dinitrate ER
Vesicare
Dilaudid liquid
hydromorphone
Gel-One
Euflexxa
Dolgic Plus
Genotropin
Norditropin
Giazo
balsalazide
Glycate
glycopyrrolate tablets, Cuvposa
oral solution
doxycycline hyclate delayed release
doxycycline hyclate
Droxia
hydroxyurea
Duac
8%), clindamycin
Halonate
triamcinolone, betamethasone,
clobetasol
Duexis
celecoxib, cimetidine, famotidine,
ibuprofen, meloxicam, ranitidine
Hemmorex-HC 30mg suppository
hydrocortisone 25mg suppository
Dutoprol
atenolol/chlorthalidone,
bisoprolol/HCTZ, metoprolol/
HCTZ, propranolol/HCTZ
Humatrope
Norditropin
Hyalgan
Euflexxa
Dymista
Hycet
solution
Edarbi
5mg/300mg
10mg/325mg
Edarbyclor
7.5mg/300mg
10mg/325mg
31
Non-Covered Drug
Alternative Drugs
Non-Covered Drug
Alternative Drugs
10mg/300mg
10mg/325mg
Midamor
spironolactone, triamterene,
eplerenone, amiloride
Millipred
prednisolone
Mimyx
Mitigare
Colcrys
molindone
haloperidol, fluphenazine,
perphenazine, chlorpromazine
hydromorphone ER
hydromorphone, morphine sulfate
ER, fentanyl patch, oxymorphone
ER
Hylatopic Plus-Aurstat
generic topical corticosteroids,
tacrolimus ointment, Elidel
Momexin Combo Pack
mometasone, ammonium lactate
Monodox
doxycycline
Hysingla ER
morphine sulfate ER, oxymorphone
ER, fentanyl patch
Monovisc
Euflexxa
Ibudone
hydrocodone/ibuprofen
Monurol
Inderal XL
propranolol
nitrofurantoin capsule,
ciprofloxacin, sulfamethoxazole/
trimethoprim
Indocin suppository
oral indomethacin, ibuprofen,
naproxen
morphine sulfate ER capsules
morphine sulfate ER tablets
Motofen
Inova
salicylic acid: cream, shampoo, gel,
topical liquid
loperamide, diphenoxylateatropine
Moxatag
amoxicillin, penicillin
Intermezzo
MuGard
Caphosol, Aquoral
Jublia
terbinafine, itraconazole, ciclopirox
Myoxin Otic suspension
Kazano (alogliptin/metfomin)
Janumet, Janumet XR, Jentadueto
polymyxin/hydrocortisone, Cipro
HC
Kenalog aerosol spray
Namenda XR
donepezil, memantine
Namzaric
donepezil, memantine
Naprelan CR
naproxen
Kerafoam
urea 40% lotion
Nasonex
Keralac
urea 40% lotion
Natesto
testosterone gel, testosterone
injection, Androgel 1.62%
Keralyt
salicylic acid: cream, shampoo, gel,
topical liquid
Neobenz
8%)
Kombiglyze XR
Janumet, Janumet XR, Jentadueto
Nesina (alogliptin)
Januvia, Tradjenta
Kristalose
lactulose oral solution
Neutrasal
Caphosol, Aquoral
Lamisil Granules
terbinafine
Nexiclon XR
clonidine
lamotrigine ER
lamotrigine
Nitrofurantoin suspension
Lescol XL
nitrofurantoin capsule,
ciprofloxacin, sulfamethoxazole/
trimethoprim
Levorphanol
oxycodone, hydromorphone,
oxymorphone
NitroMist
nitroglycerin, Nitrostat, Nitroquick,
Nitrolingual spray
Liquicet
solution
Novacort
betamethasone, fluticasone,
fluocinonide, triamcinolone
Livalo
Nucort
Locoid
hydrocortisone butyrate
Nucynta
morphine sulfate, oxycodone,
oxymorphone, tramadol
loratadine-D
Nucynta ER
Lorzone
chlorzoxazone, carisoprodol,
cyclobenzaprine, methocarbamol,
orphenadrine
morphine sulfate ER, oxycodone,
oxymorphone ER, tramadol ER
Nutropin
Norditropin
Oleptro
trazodone, nefazodone
Olux, Olux E
clobetasol
Omnaris
omeprazole/sodium bicarbonate
Nexium, omeprazole, lansoprazole,
pantoprazole
Luzu
clotrimazole, econazole,
ketoconazole
Lycelle
lindane, malathion, permethrin,
Ulesfia
Megace ES
megestrol oral suspension
meperidine solution
meperidine tablet
Omnitrope
Norditropin
methadone intensol
methadone tablet
Onglyza
Januvia, Tradjenta
metformin ER (generic Fortamet,
generic Glumetza) (PA)
metformin ER (generic Glucophage
XR)
Oracea
doxycycline
Metozolv ODT
metoclopramide
Orapred ODT
prednisolone sodium phosphate
oral solution, prednisone
metronidazole 1% gel
metronidazole 0.75% gel
32
Non-Covered Drug
Alternative Drugs
Non-Covered Drug
Alternative Drugs
Oravig
fluconazole, clotrimazole, nystatin,
itraconazole
Rheumatrex
methotrexate
Riax
8%)
Ribapak
ribavirin
Rosadan
metronidazole, tretinoin,
clindamycin, erythromycin
Rosula
sodium sulfacetamide-sulfur 105% cleanser
Rowasa
Asacol HD, balsalazide disodium,
sulfasalazine, sulfasalazine EC,
Apriso, mesalamine, Delzicol
Roxicet caplet
oxycodone/acetaminophen
Rozerem
Rybix ODT
tramadol, tramadol ER tablet
Ryneze
Saizen
Norditropin
Salex
salicylic acid 6% shampoo
Orbivan
Orthovisc
Euflexxa
Oseni
Januvia, Tradjenta, pioglitazone
Oxecta
oxycodone
Oxtellar XR
oxcarbazepine
Oxytrol
Vesicare
Pacnex Wash
8%)
Pediaderm AF kit
nystatin
Pediaderm TA complete kit
triamcinolone
Pennsaid, diclofenac topical drops
diclofenac tablets
Perloxx
salicylic acid 6% gel
Pexeva
paroxetine, sertraline, citalopram,
escitalopram, fluoxetine,
venlafaxine
salacyn 6% cream, salacyn 6%
lotion, salicylic acid 6% lotion
salicylic acid 6% lotion ER
Phoslyra
calcium acetate, eliphos
Salkera
Phrenilin Forte
Salvax
Picato 0.05% cream, gel
Pramosone
Sarafem tablets
fluoxetine
ODT
oral solution, prednisone
Savaysa
Xarelto, Eliquis, Pradaxa
Scalacort
Prevacid
Silenor
Prilosec
doxepin, zolpidem, zaleplon,
eszopiclone
Sklice
Primlev
2.5mg/325mg, oxycodone/
acetaminophen 5mg/325mg,
acetaminophen 10mg/325mg
Ulesfia
Solodyn ER
minocycline
Soltamox
tamoxifen
Soolantra
sodium sulfacetamide-sulfur 105% cleanser, metronidazole 0.75%
gel, Finacea
Protonix
Sorilux
calcipotriene
Prumyx
Spinosad
Pylera
metronidazole, tetracycline
Ulesfia
Qnasl
Spritam
levetiracetam
Qudexy XR
topiramate
Sprix
ketorolac
Quillivant XR
amphetamine salts,
dexmethylphenidate,
Strattera
Sumavel DosePro
almotriptan, frovatriptan,
sumatriptan, zolmitriptan, Relpax
Sumaxin
Supartz
Euflexxa
Synalgos
hydrocodone
rabeprazole
ranitidine capsule
ranitidine tablet
Synera Patch
lidocaine
Rayos
prednisone
Synvisc, Synvisc One
Euflexxa
Refissa
Terbinex
terbinafine
Retin-A micro, Tretinoin micro
tretinoin
Tetravisc Forte
tetracaine, Tetravisc
Rexulti
aripiprazole, olanzapine,
quetiapine, risperidone,
ziprasidone
33
Non-Covered Drug
Alternative Drugs
Non-Covered Drug
Alternative Drugs
Teveten HCT
Vimovo
naproxen, lansoprazole
Virasal
salicylic acid 27.5%
Vituz
hydrocodone/chlorpheniramine
Vraylar
aripiprazole, olanzapine,
quetiapine, risperidone,
ziprasidone
Xartemis XR
Xclair
ammonium lactate
Xigduo XR
Synjardy, Invokamet
Xodol
10mg/325mg
Xolox
acetaminophen 5mg/325mg,
acetaminophen 10mg/325mg
Zamicet
10mg/325mg
Zantac EFFERdose
famotidine, ranitidine
Zencia
Zenzedi
amphetamine salts,
dexmethylphenidate,
Strattera
Zetonna
Ziana gel
clindamycin and tretinoin
Zipsor
diclofenac, ibuprofen, naproxen
Zithranol shampoo
drithocreme, Dritho-Scalp
Zoderm
8%)
Zohydro ER (PA)
fentanyl patch, morphine sulfate
ER, oxymorphone ER, methadone
zolpidem ER
Zolpimist
Zonatuss
benzonatate
Zomacton
Norditropin
Zorvolex
diclofenac
Zovirax cream
acyclovir ointment
Z-Pram
Zuplenz
ondansetron
Zyclara
imiquimod, tretinoin, adapalene,
fluorouracil
Zyflo, Zyflo CR
montelukast, zafirlukast
Zypram
theophylline solution
oral theophylline
Tivorbex
indomethacin
tizanidine capsule
tizanidine tablet
Toujeo
Lantus, Levemir, Tresiba
tramadol ER capsule
tramadol ER tablet
Trexall
methotrexate
Treximet
almotriptan, frovatriptan,
sumatriptan, sumatriptan and
naproxen, zolmitriptan, Relpax
Triaz
8%)
Triamcinolone aerosol spray
Tribenzor
Triglide
fenofibrate
TriOxin otic
polymyxin/hydrocortisone, Cipro
HC
Trokendi XR
topiramate
Ultravate X
halobetasol, triamcinolone,
betamethasone, clobetasol
Umecta
urea 40% lotion
Uramaxin
urea 40% lotion
urea nail film
urea 50% nail stick
urea nail kit
urea 50% nail stick
urea nail gel
urea 50% nail stick
Urelle
Uro-Blue, pyridium
Varubi
Emend, Akynzeo
venlafaxine ER tablet
venlafaxine ER capsule,
paroxetine, sertraline, citalopram,
escitalopram, fluoxetine
Veripred
prednisolone
Versacloz
clozapine, clozapine ODT
Vicodin 5mg/300mg
10mg/325mg
Vicodin ES 7.5mg/300mg
Vicodin HP 10mg/300mg
10mg/325mg
10mg/325mg
34
YOUR CHOICE BRAND/GENERIC REFERENCE GUIDE
Brand
Generic
Brand
Generic
Abilify
Aripiprazole
Bactroban
Mupirocin
Accolate
Zafirlukast
Baraclude
Entecavir
Accupril
Quinapril
Biaxin
Clarithromycin
Aceon
Perindopril
Boniva
Ibandronate
Aciphex
Rabeprazole
Buphenyl powder
Sodium Phenylbutyrate powder
Actiq
Fentanyl Citrate
Buspar
Buspirone
Activella
Estradiol-Norethindrone, Mimvey,
Lopreeza
Caduet
Amlodipine/Atorvastatin
Actonel
Risedronate
Calan
Verapamil
ActoPlus Met
Pioglitazone/Metformin
Campral
Acamprosate
Actos
Pioglitazone
Cardizem CD
Diltiazem ER
Acular
Ketorolac
Cardizem LA
Diltiazem ER
Adderall
Amphetamine salts
Casodex
Bicalutamide
Aggrenox
Aspirin/Dipyridamole
Catapres
Clonidine
Aldactazide
Spironolactone/HCTZ
Ceclor
Cefaclor
Aldactone
Spironolactone
Cedax
Ceftibuten
Aldara
Imiquimod
Ceftin
Cefuroxime
Alesse
Aviane, Delyla
Cefzil
Cefprozil
Alphagan
Brimonidine
Celebrex
Celecoxib
Altace
Ramipril
Celexa
Citalopram
Amaryl
Glimepiride
Cellcept
Mycophenolate Mofetil
Ambien
Zolpidem Tartrate
Cetraxal
Ciprofloxacin 0.2% ear drops
Amerge
Naratriptan
Cipro
Ciprofloxacin
Amoxil
Amoxicillin
Claritin OTC
Loratadine OTC
Analpram HC cream
Hydrocortisone-Pramoxine cream
Cleocin
Clindamycin
Antabuse
Disulfuram
Climara
Estradiol Patch
Antara
Fenofibrate
Clobex
Clobetasol
Antivert
Meclizine
Cogentin
Benztropine
Arava
Leflunomide
Colazal
Balsalazide Disodium
Aricept
Donepezil
Colestid
Colestipol
Arimidex
Anastrozole
Combivir
Lamivudine/Zidovudine
Arixtra
Fondaparinux
Comtan
Entacapone
Aromasin
Exemestane
Concerta
Methylphenidate ER
Arthrotec
Diclofenac/Misoprostol
Condylox
Podofilox
Astelin
Azelastine
Coreg
Carvedilol
Atacand
Candesartan
Cosopt
Dorzolamide/Timolol
Atacand HCT
Candesartan/hydrochlorothiazide
Coumadin
Warfarin
Atelvia
Risedronate DR
Cozaar
Losartan
Ativan
Lorazepam
Crestor
Rosuvastatin
Augmentin
Amoxicillin/Clavulanate
Cutivate (topical)
Fluticasone
Avalide
Irbesartan/hydrochlorothiazide
Cyclocort
Amcinonide
Avapro
Irbesartan
Cyclogyl 2% eye drops
Cyclopentolate 2% drops
Avelox
Moxifloxacin
Cymbalta
Duloxetine
Avodart
Dutasteride
Cytomel
Liothyronine
Axert
Almotriptan
Depakote, Depakote ER
Divalproex Sodium, Divalproex
Sodium ER
Azulfidine, Sulfazine
Sulfasalazine
Depo-Provera
Bactrim
Sulfamethoxazole/Trimethoprim
Medroxyprogesterone acetate
injection
Derma-Smoothe/FS
Fluocinolone
35
Brand
Generic
Brand
Generic
Desoxyn
Methamphetamine
Fosamax
Alendronate
Desyrel
Trazodone
Frova
Frovatriptan
Detrol
Tolterodine
Gabitril
Tiagabine
Detrol LA
Tolterodine ER
Generess Fe
Layolis Fe
Dexedrine
Dextroamphetamine
Gengraf
Cyclosporine modified
Diabeta, Micronase
Glyburide
Geodon
Ziprasidone
Diamox Sequels
Acetazolamide ER
Glucophage
Metformin
Differin
Adapalene
Glucotrol
Glipizide
Diflucan
Fluconazole
Glucovance
Glyburide/Metformin
Diovan
Valsartan
Golytely
GaviLyte-G
Diovan HCT
Valsartan/Hydrochlorothiazide
HalfLytely
GaviLyte-H
Ditropan
Oxybutynin
Hectorol
Doxercalciferol
Dovonex
Calcipotriene
Hepsera
Adefovir
Duac gel
Clindamycin/Benzoyl Peroxide
1%-5% gel
Hyzaar
Losartan/hydrochlorothiazide
Ilotycin
Erythromycin
Imitrex
Sumatriptan
Inderal
Propranolol
Indocin
Indomethacin
Inspra
Eplerenone
Intuniv
Guanfacine ER
Invega
Paliperidone
Iopidine
Apraclonidine
Jalyn
Dutasteride/Tamsulosin
Kapvay
Clonidine ER
Keflex
Cephalexin
Kenalog (topical)
Triamcinolone
Keppra
Levetiracetam
Keppra XR
Levetiracetam ER
Klonopin
Clonazepam
Kytril
Granisetron
Lamictal
Lamotrigine
Lamisil
Terbinafine
Lasix
Furosemide
Lescol
Fluvastatin
Levaquin
Levofloxacin
Lexapro
Escitalopram
Lidoderm
Lidocaine Patch
Lipitor
Atorvastatin
Lodine
Etodolac
Lodosyn
Carbidopa
Loestrin Fe
Gildess Fe, Junel Fe, Larin Fe,
Microgestin Fe, Tarina Fe
Duetact
Pioglitazone/Glimepiride
Duoneb
Ipratropium/Albuterol solution
Duragesic
Fentanyl
Duricef
Cefadroxil Hydrate
Effexor
Venlafaxine
Effexor XR
Venlafaxine ER capsules
Elavil
Amitriptyline
Elestat
Epinastine
Eliphos
Calcium Acetate
Elocon
Mometasone
Entocort EC
Budesonide EC
Epivir
Lamivudine
Epivir HBV
Lamivudine HBV
Evista
Raloxifene
Evoxac
Cevimeline
Exelon
Rivastigmine
Famvir
Famciclovir
Fazaclo
Clozapine ODT
Feldene
Piroxicam
Femara
Letrozole
Femcon Fe
Zeosa, Wymzia Fe, Zenchent Fe
Femhrt 1/5
Jinteli, Ethinyl EstradiolNorethindrone Acetate
Femhrt Lo
Ethinyl Estradiol-Norethindrone
Acetate
Flagyl
Metronidazole
Flexeril
Cyclobenzaprine
Flolan
Epoprostenol
Flomax
Tamsulosin
Loestrin 24 Fe
Lomedia 24 Fe, Glidess 24 Fe
Flonase
Fluticasone
Lofibra
Fenofibrate
Focalin
Dexmethylphenidate
Lomotil
Diphenoxylate/Atropine
Focalin XR
Dexmethylphenidate ER
Lopid
Gemfibrozil
Fortamet
Metformin ER
Lopressor
Metoprolol
Ceftazidime
Loprox, Penlac
Ciclopirox
Fortaz
36
Brand
Generic
Brand
Generic
LoSeasonique
Amethia Lo, Camrese Lo
Ortho-Cyclen
Lotrel
Amlodipine Besylate/Benazepril
Mono-Linyah, Mononessa,
Estarylla, Sprintec
Lotronex
Alosetron
Ortho Evra
Xulane
Lovaza
Omega-3 Acid Ethyl Esters
Ortho Tri-Cyclen
Tri-Linyah, Trinessa, Tri-Estarylla,
Tri-Sprintec
Lovenox
Enoxaparin
Ortho Tri-Cyclen Lo
Lunesta
Eszopiclone
Tri-Lo-Marzia Trinessa Lo, Tri-LoEstarylla, Tri-Lo-Sprintec
Lybrel
Amethyst
Ovcon
Briellyn, Gildagia, Philith, Pirmella,
Vyfemla
Lysteda
Tranexamic Acid
Ovide
Malathion
Macrodantin
Nitrofurantoin
Oxsoralen Ultra
Methoxsalen
Marinol
Dronabinol
Palgic
Arbinoxa
Maxalt
Rizatriptan
Parcopa
Carbidopa/Levodopa
Metadate CD
Methylphenidate ER
Patanase
Olopatadine
Metadate ER
Methylphenidate ER
Paxil
Paroxetine
Metaglip
Glipizide/Metformin
Pepcid
Famotidine
Mevacor
Lovastatin
Percocet
Oxycodone/Acetaminophen
Miacalcin
Calcitonin Nasal Spray
Peridex, Periogard
Chlorhexidine
Micardis
Telmisartan
PhosLo
Calcium Acetate
Micardis HCT
Telmisartan/hydrochlorothiazide
Plan B
Levonorgestrel, Next Choice
Micronor
Camila, Heather, Jencycla, Lyza,
Norlyroc, Sharobel
Plan B One-Step
Next Choice One Dose
Migranal
Dihydroergotamine
Plavix
Clopidogrel
Minocin
Minocycline
Plendil
Felodipine
Mirapex
Pramipexole
Pletal
Cilostazol
Mirapex ER
Pramipexole ER
Ponstel
Mefenamic Acid
Mobic
Meloxicam
PrandiMet
Repaglinide/Metformin
Motrin
Ibuprofen
Prandin
Repaglinide
MS Contin
Morphine Sulfate ER
Pravachol
Pravastatin
Myfortic
Mycophenolate Sodium
Precose
Acarbose
Namenda
Memantine
Prevacid
Lansoprazole
Naprosyn
Naproxen
Prevident
Sodium fluoride gel
Neoral
Cyclosporine modified
Prevpac
Lansoprazole/Amoxicillin/
Clarithromycin pack
Neurontin
Gabapentin
Prilosec
Omeprazole
Niaspan
Niacin ER
Prinivil, Zestril
Lisinopril
Nizoral
Ketoconazole
Prinzide, Zestoretic
Lisinopril/Hydrochlorothiazide
Nordette
Portia, Chateal, Kurvelo
Procardia
Nifedipine
Norvasc
Amlodipine Besylate
Prograf
Tacrolimus
Nulytely
Peg-3350
Prometrium
Progesterone capsule
Ocupress
Carteolol ophthalmic
Proscar
Finasteride
Omnicef
Cefdinir
Protonix
Pantoprazole
Omnipred 1% drops
Prednisolone Acetate 1% drops
Protopic
Tacrolimus ointment
Opana
Oxymorphone
Provigil
Modafinil
Opana ER
Oxymorphone ER
Prozac
Fluoxetine
Optivar
Azelastine
Prozac Weekly
Fluoxetine DR
Orap
Pimozide
Pulmicort respules
Budesonide respules
Ortho-Cept
Apri, Enskyce, Desogestrel-Ethinyl
Estradiol
Questran
Cholestyramine
Quixin
Levofloxacin opthalmic
Rapamune
Sirolimus
37
Brand
Generic
Brand
Generic
Razadyne
Galantamine
Tindamax
Tinidazole
Reclast
Zoledronic Acid 5mg
TOBI
Reglan
Metoclopramide
Tobramycin solution for
nebulization
Relafen
Nabumetone
Tobradex
Tobramycin-Dexamethasone
Remeron
Mirtazapine
Topamax
Topiramate
Renvela
Sevelamer carbonate
Topicort
Desoximetasone
Requip
Ropinirole
Toprol XL
Metoprolol ER
Requip XL
Ropinirole XL
Travatan
Travoprost
Restoril
Temazepam
Trexall
Methotrexate
Retin A
Tretinoin
Tricor
Fenofibrate
Revatio
Sildenafil
Tridesilon
Desonide
Rilutek
Riluzole
Trileptal
Oxcarbazepine
Risperdal
Risperidone
Trilipix
Fenofibric acid
Ritalin
Methylphenidate
Trizivir
Abacavir/Lamivudine/Zidovudine
Ritalin LA
Methylphenidate ER
Trusopt
Dorzolamide
Rowasa
Mesalamine
Twynsta
Telmisartan/Amlodipine
Rythmol SR
Propafenone ER
Tylenol # 3
Acetaminophen/Codeine
Sanctura
Trospium
Ultram
Tramadol
Sanctura XR
Trospium ER
Urocit-K
potassium citrate ER
Sandimmune
Cyclosporine
Uroxatral
Alfuzosin ER
Seasonale
Jolessa, Quasense
Urso
Ursodiol
Seasonique
Amethia, Ashlyna, Camrese
Valcyte
Valganciclovir
Seroquel
Quetiapine
Valium
Diazepam
Singulair
Montelukast Sodium
Valtrex
Valacyclovir
Skelaxin
Metaxalone
Vancocin
Vancomycin
Soma
Carisoprodol
Vasotec
Enalapril
Sonata
Zaleplon
Vectical Ointment
Calcitriol Ointment
Soriatane
Acitretin
Veetids
Penicillin
Sporanox
Itraconazole
Vermox
Mebendazole
Stalevo
Carbidopa/Levodopa/Entacapone
Vfend
Voriconazole
Starlix
Nateglinide
Vibramycin
Doxycycline
Stromectol
Ivermectin
Vicodin, Vicodin ES
Hydrocodone/Acetaminophen
Suboxone
Buprenorphine/Naloxone
Vicoprofen
Hydrocodone/Ibuprofen
Subutex
Buprenorphine
Videx EC
Didanosine
Sular
Nisoldipine ER
Viramune
Nevirapine
Symbyax
Olanzapine/Fluoxetine
Vivactil
Protriptyline
Tagamet
Cimetidine
Voltaren
Diclofenac
Targrentin
Bexarotene
Voltaren 1% topical gel
Diclofenac 1% topical gel
Tarka
Trandolapril/Verapamil
Wellbutrin
Bupropion
Tasmar
Tolcapone
Wellbutrin XL
Budeprion XL
Tegretol
Carbamazepine
Xalatan
Latanoprost
Tegretol XR
Carbamazepine ER
Xanax
Alprazolam
Temodar
Temozolomide
Xeloda
Capecitabine
Temovate
Clobetasol
Xenazine
Tetrabenazine
Tenex
Guanfacine
Xibrom
Bromfenac
Tenormin
Atenolol
Xopenex
Levalbuterol
Teveten
Eprosartan
Xyzal
Levocetirizine
38
Brand
Generic
Yasmin
Ocella, Syeda, Zarah
Yaz
Gianvi, Loryna, Vestura, Nikki
Zantac
Ranitidine
Zemplar
Paricalcitol
Zerit
Stavudine
Ziagen
Abacavir
Zithromax
Azithromycin
Zocor
Simvastatin
Zofran
Ondansetron
Zoloft
Sertraline
Zometa
Zoledronic Acid 4mg
Zomig
Zolmitriptan
Zonegran
Zonisamide
Zovirax
Acyclovir
Zyloprim
Allopurinol
Zymaxid
Gatifloxacin
Zyprexa
Olanzapine
Zyvox
Linezolid
UPMC Health Plan Inc. administers group and individual
products for UPMC Health Coverage Inc., UPMC Health
Network Inc., UPMC Health Options Inc., and UPMC Health
Plan Inc. Please note that throughout this document, we use
the terms “UPMC Health Plan” and “the Health Plan” to refer
to UPMC Health Coverage Inc., UPMC Health Network Inc.,
UPMC Health Options Inc., and UPMC Health Plan Inc. as
well as plans administered by UPMC Benefit Management
Services Inc.
This Pharmacy Benefit Guide is current as of July 1, 2016. For
the latest information on the Your Choice drug formulary and
other pharmacy benefits, visit www.upmchealthplan.com/
pharmacy. Select “Your Choice” to access the searchable
drug list. You may also call our Health Care Concierge team
at the number listed on the back of your member ID card and
on page 1 of this booklet.
This managed care plan may not cover all of your health
care expenses. Read your contract carefully to determine
which health care services are covered.
39
U.S. Steel Tower, 600 Grant Street
Pittsburgh, PA 15219
www.upmchealthplan.com
Copyright 2016 UPMC Health Plan Inc. All rights reserved.
YC_PHARM_GD 16PH0084 (MCG) 7/15/16

Your Choice Pharmacy Benefit Guide

Transcription

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