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Drug Formulary

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Drug Formulary University of Arkansas March 2017 Use of generic drugs can save both you and your health plan money. This list is not all-inclusive and is not a guarantee of coverage. Plan Benefit design is the final determinate of coverage. Certain drugs (*) may be subject to Prior Authorization (PA), Quantity Limits (QL), Step Therapy (ST), or Reference Based Pricing (RBP) requirements according to Benefit Design. Unless noted, multisource brand drugs (brand drugs with generic equivalent) are covered at 100% copay. If you have any questions about these requirements or other formulary questions, please contact a MedImpact Healthcare customer service representative at 800-788-2949. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Drug Type Tier 1 Tier 2 Tier 3 Anti-Infectives Antibiotics – Cephalosporins cefaclor, cefadroxil, cefdinir, CEFTIN susp, SUPRAX 400mg only* (Quantity Limit) cefpodoxime, cefprozil, (QL) cefditoren,cefuroxime, Note: all other Suprax strengths are 100% cephalexin copay Antibiotics - Macrolides azithromycin, clarithromycin, ERY-TAB, ZMAX susp clarithromycin ext-rel, PCE erythromycin delayed-rel, erythromycin ethylsuccinate, erythromycin stearate Antibiotics - Fluoroquinolones ciprofloxacin, ciprofloxacin ext- FACTIVE rel, levofloxacin ,moxifloxacin Antibiotics - Penicillins amoxicillin, amoxicillin- clavulanate, dicloxacillin, penicillin VK Antibiotics – Other* (Prior clindamycin HCl, doxycycline ZYVOX susp*(PA) Authorization) hyclate, linezolid* (PA), minocycline, tetracycline Antifungals* (Prior Authorization) fluconazole, itraconazole* (QL), NOXAFIL (Quantity Limit) ketoconazole, terbinafine tabs , voriconazole Antivirals - Influenza* (Quantity amantadine, rimantadine TAMIFLU RELENZA* (QL) Limit) Antivirals - Herpes acyclovir, famciclovir, VALCYTE susp valacyclovir, valganciclovir tab Antivirals - Other - ribasphere, ribavirin EPCLUSA*(PA), PEGASYS* DAKLINZA* (PA), TECHINIVIE* (PA) Interferons/Interferon (PA), PEGINTRON* (PA), Combinations (Prior REBETOL susp, ZEPATIER*(PA) Authorization) Cardiovascular Anti-Adrenergic Blockers - doxazosin, prazosin, terazosin Peripherally Acting Anticoagulants/Antiplatelet Agents cilostazol, clopidogrel, AGGRENOX, ELIQUIS (QL), ( Quantity Limits) dipyridamole, ticlopidine, PRADAXA (QL), XARELTO (QL) warfarin Antihyperlipidemics - HMG (Statins) atorvastatin,lovastatin, RBP: PLAN WILL PAY $0.50/PILL; REMAINING COST WILL BE APPLIED TO pravastatin, simvastatin MEMBER SHARE REFERENCE BASED PRICING PROGRAM (RBP) ADVICOR, ALTOPREV, CRESTOR, LIVALO, SIMCOR, VYTORIN 1 University of Arkansas March 2017 Other Antihyperlipidemic Agents cholestyramine, colestipol, LIPOCHOL PLUS WELCHOL gemfibrozil Drug Type Tier 1 Tier 2 Tier 3 ACE Inhibitors and ACE Inhibitor captopril, captopril-HCTZ, Combinations enalapril, fosinopril, fosinopril- hydrochlorothiazide, lisinopril, lisinopril-HCTZ, quinapril, quinapril HCTZ, ramipril, trandolapril Angiotensin II Receptor candesartan/-HCTZ (ST), BENICAR* (ST), BENICAR HCT* (ST), Antagonists* (Step Therapy) eprosartan*(ST),irbesartan (ST), TEVETEN HCT* (ST) (ST)/-HCTZ (ST),losartan, losartan-HCTZ, telmisartan/- HCTZ, valsartan/-HCTZ Antihypertensive Combinations amlodipine-benazepril, AZOR*(ST), TRIBENZOR*(ST), (Step Therapy) amlodipine- TEKAMLO*(ST) valsartan(ST) ,nadolol- bendroflumethiazide, trandolapril/verapamil Antihypertensive - Others eplerenone Beta-blockers* (Quantity Limit) atenolol, carvedilol, carvedilol LEVATOL BYSTOLIC, COREG CR* (QL), ext-rel, metoprolol, metoprolol ext-rel, propranolol, propranolol ext-rel Calcium Channel Blockers amlodipine, diltiazem ext-rel, isradipine, nimodipine, nisoldipine, verapamil ext-rel Chronic Angina* (Prior RANEXA* (PA) Authorization) Direct Renin Inhibitors/Combo* AMTURNIDE*(ST),TEKTURNA* (ST), (Step Therapy) TEKTURNA HCT* (ST) Diuretics furosemide, hydrochlorothiazide, metolazone, spironolactone/- HCTZ, triamterene-HCTZ, torsemide Paroxysmal Nocturnal SOLIRIS* (PA) Hemoglobinuria Agents* (Prior Authorization) Pulmonary Arterial Hypertension sildenafil (PA) ADCIRCA* (PA), ADEMPAS* (PA), (Prior Authorization) LETAIRIS, TRACLEER Central Nervous System ADHD Medications* (Prior dexmethylphenidate, STRATTERA DAYTRANA* (ST), VYVANSE* (QL) Authorization) (Quantity Limit) (Step dexmethylphenidate ext-rel, Therapy) dextroamphetamine, methylphenidate, EFFECTIVE 1/1/13 - Extended- methylphenidate ext-rel, Release ADHD medications will not modafinil (PA), ADDERALL XR be covered for members who are 26 years and older. Regular release ADHD drugs will continued to be covered at existing tiers. Alzheimer’s Disease* donepezil/-ODT*(age), (age edit) galantamine,memantine* (age), rivastigmine Analgesics - Narcotic* (Quantity butalbital-APAP-caffeine, KADIAN (200mg), OXYCONTIN* ABSTRAL, , FENTORA* (QL), KADIAN Limit)(Prior Authorization) codeine-APAP, fentanyl (QL), (40mg,70mg, 130mg, 150mg), transdermal/- buccal*(QL), SUBOXONE* (PA) hydrocodone-APAP, hydromorphone, morphine/- ER, morphine supp, 2 University of Arkansas March 2017 oxycodone/APAP ER, oxycodone ibuprofen, propoxyphene, propoxyphene napsylate-APAP. Tramadol IR Drug Type Tier 1 Tier 2 Tier 3 Analgesics - Anti-Inflammatory/ choline magnesium NSAIDs trisalicylate, diclofenac, etodolac, ibuprofen, indomethacin ext-rel, meloxicam, nabumetone, naproxen, naproxen sodium, oxaprozin, sulindac Anticonvulsants carbamazepine, clonazepam, CELONTIN, GABITRIL BANZEL* (PA), DEPAKENE, (Prior Authorization) clonazepam ODT, diazepam (12mg,16mg), STAVZOR DEPAKOTE, DEPAKOTE ER, DILANTIN, (rectal), divalproex FYCOMPA, LYRICA (PA), ONFI (PA), sodium,ethosuximide, OXTELLAR XR VIMPAT gabapentin, lamotrigine, levetiracetam/-XR, oxcarbazepine, phenobarbital, phenytoin, primidone, valproic acid, zonisamide Antianxiety alprazolam/- ext-rel, buspirone, diazepam, lorazepam, oxazepam Antidepressants - Other* amitriptyline, bupropion/-ext- EMSAM* (QL) (Quantity Limit) rel, clomipramine, desipramine, doxepin, mirtazapine, nortriptyline, trazodone Antidepressants - SSRIs citalopram, escitalopram ,fluoxetine, paroxetine/-ER, sertraline Antidepressants - SNRIs duloxetine, venlafaxine/-ER Antiparkinsonian Agents amantadine, benztropine, AZILECT, MIRAPEX ER, ZELAPAR bromocriptine, cabergoline, carbidopa-levodopa, carbidopa-levodopa ext-rel, entacapone, pramipexole, ropinirole/-XL, selegiline, tolcapone, trihexyphenidyl Antimanic Agents lithium carbonate Antipsychotic Agents* aripiprazole* (PA), MOBAN, NAVANE 20mg only, (Prior Authorization) chlorpromazine, clozapine, SEROQUEL XR fluphenazine, haloperidol, olanzapine, perphenazine, paliperidone tabs, quetiapine (IR), risperidone, thioridazine, trifluoperazine,ziprasidone Migraine Products* (Quantity Limit) almotriptan* (QL), CAFERGOT, RELPAX* (ST,QL), ZOMIG dihydroergotamine inj, NS* (QL) ergotamine-caffeine tabs, naratriptan (QL), rizatriptan (QL), sumatriptan (QL), zolmitriptan (QL) Multiple Sclerosis Drugs (Prior Glatopa REBIF* (QL) AVONEX, AUBAGIO (PA), BETASERON, Authorizatiion)(Quantity Limit) GILENYA*(PA)(QL), PLEGRIDY* (PA), TECFIDERA (PA) Sedative Hypnotics – flurazepam, temazepam Benzodiazepines (BZD) (except 7.5mg and 22.5mg), triazolam 3 University of Arkansas March 2017 Sedative Hypnotics* - Non- zaleplon* (QL), zolpidem* (QL) RBP: PLAN WILL PAY $0.19/PILL; REMAINING COST WILL BE APPLIED TO Benzodiazepine (Quantity Limit) MEMBER SHARE REFERENCE BASED PRICING PROGRAM (RBP) zolpidem tartrate ER* (QL,RBP), EDLUAR*(QL,RBP),eszopiclone (QL,RBP)INTERMEZZO*(RBP),ROZEREM* (QL,RBP), SILENOR*(QL,RBP), ZOLPIMIST*(RBP) Drug Type Tier 1 Tier 2 Tier 3 Skeletal Muscle Relaxants baclofen, carisoprodol, RBP: PLAN WILL PAY $0.09/PILL; REMAINING COST WILL BE APPLIED TO REFERENCE BASED PRICING chlorzoxazone, MEMBER SHARE PROGRAM (RBP) cyclobenzaprine, methocarbamol, tizanidine orphenadrine (RBP), orphenadrine compound (RBP), metaxalone (RBP), AMRIX (RBP), Dermatologicals Other Dermatologicals*(Prior fluorouracil, spinosad*(PA) ALTABAX Authorization) Rectal Preparations lidocaine HC ANAMANTLE HC (0.5 %-3 %) Endocrine Diabetes - Insulin HUMALOG, HUMALOG MIX, APIDRA, LEVEMIR HUMULIN, LANTUS/-SOLOSTAR Diabetes - SGLT2 Inhibitors JARDIANCE* (PA)) Diabetes - Insulin Sensitizing metformin/-XR, pioglitazone Agents*(Prior Authorization) Diabetes - Insulin Secreting Agents chlorpropamide, glimepiride, DIABETA glipizide, glipizide ext-rel, glyburide, tolazamide Diabetes - Combinations glyburide-metformin, glipizide- GLYSET metformin, pioglitazone- AVANDIA* (PA), AVANDAMET* (PA), metformin, metformin ext-rel, AVANDARYL* (PA), JANUVIA, pioglitazone-glimepiride JANUMET/-XR, SYNJARDY* (PA Diabetes - Other Medications acarbose GLYSET, GLUCAGON SYMLIN, VICTOZA* (PA) (Step Therapy) EMERGENCY KIT* (QL) Diabetic - Supplies $0 copay for ABBOTT and BAYER Test Strips, Lancets, Alcohol Swabs, Insulin Needles, and Syringes. GLUCOMETER**, HUMAPEN MEMOIR, LIFESCAN TEST STRIPS, ROCHE TEST STRIP and all other NON-ABBOTT/NON- BAYER Test strips Thyroid Agents levothyroxine Gastrointestinal/Urinary Antispasmodic/GI Motility belladonna alkaloids- phenobarbital, chlordiazepoxide-clidinium, dicyclomine, diphenoxylate- atropine, glycopyrrolate, hyoscyamine/-ext rel, loperamide,methscopolamine Bowel Evacuants lactulose, peg 3350- KRISTALOSE GOLYTELY, MOVIEPREP, SUPREP electrolytes, polyethylene glycol 4 University of Arkansas March 2017 Digestive Aids pancrelipase VIOKASE CREON, PANCREAZE, ULTRESA, ZENPEP (EXCEPT ZENPEP 5K-17K-27K CAPS) Gallstone Solubilizing Agents ursodiol H2-Antagonists cimetidine, famotidine,
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