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

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

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, nizatidine, ranitidine

Drug Type Tier 1 Tier 2 Tier 3 Genitourinary Medications bethanechol, oxybutynin RBP: PLAN WILL PAY $0.30/PILL; REMAINING COST WILL BE APPLIED TO REFERENCE BASED PRICING chloride, phenazopyridine, MEMBER SHARE PROGRAM (RBP) potassium citrate oxybutynin ext-rel (2nd Tier tolterodine/-XL (RBP), trospium (RBP), GELNIQUE (RBP), MYRBETRIQ Copay) (RBP), OXYTROL (RPB), TOVIAZ (RBP), VESICARE (RBP)

Inflammatory Bowel* (Quantity Limit) balsalazide, budesonide, APRISO*(QL), DELZICOL*(QL), CANASA, , ENTOCORT EC, GIAZO, (Step Therapy) mesalamine, sulfasalazine, LIALDA, PENTASA, UCERIS* (ST) sulfasalazine delayed-rel Immunosuppressive Agents Immunosuppressive* (Prior azathioprine, cyclosporine, AZASAN, RAPAMUNE, Authorization) cyclosporine modified, ZORTRESS*(PA) Gengraf,mycophenolate (caps/tabs), tacrolimus caps

Men’s Health Erectile Dysfunction* (Prior MUSE* (PA) (QL), VIAGRA* (PA) CIALIS* (PA) (QL), LEVITRA* (PA) (QL), Authorization) (Quantity Limit) (QL) STENDRA*(PA), STAXYN* (PA)

Hormone Replacement * testosterone cyprionate, (Prior Authorization) testosterone enanthate EFFECTIVE ON 1/1/15 – TOPICAL TESTOSTERONES ARE COVERED AT 100% COPAY

Prostate Health alfluzosin, dutasteride, RAPAFLO finasteride, tamsulosin

Ophthalmics Anti-Allergic Agents azelastine,cromolyn, ALAMAST, ALOCRIL, ALOMIDE, epinastine EMADINE, LASTACAFT, PATADAY

Anti-Infective/Antiviral Agents bacitracin, ciprofloxacin, NATACYN AZASITE, VIGAMOX erythromycin, gentamicin, neomycin-polymyxin B- gramicidin, ofloxacin, levofloxacin, polymyxin B- bacitracin, polymyxin B- trimethoprim, sulfacetamide, tobramycin, trifluridine

Anti-Glaucoma Agents/ Beta- betaxolol, brimonidine, AZOPT ALPHAGAN P (0.10%), BETIMOL, blockers (Quantity Limit) dipivefrin, latanoprost, BETOPTIC S, COMBIGAN, COSOPT levobunolol, metipranolol, PF,LUMIGAN (0.01%), RESCULA pilocarpine, timolol, Carboptic

Anti-Inflammatory Agents bromfenac, dexamethasone, FLAREX, FML FORTE, FML ACUVAIL, ALREX, LOTEMAX diclofenac sodium, S.O.P., MAXIDEX, NEVANAC, fluorometholone, VEXOL, XIBROM ketotifen,ketorolac, prednisolone acetate, prednisolone phosphate 5

University of Arkansas March 2017

Respiratory Nasal Products* (Quantity Limit) azelastine*(QL), flunisolide, RBP: PLAN WILL PAY $22.42/inhaler; REMAINING COST WILL BE APPLIED REFERENCE BASED PRICING fluticasone* (QL) TO MEMBER SHARE PROGRAM (RBP) budesonide spray/pump (QL,RBP), triamcinolone* (QL,RBP), BECONASE AQ* (QL,RBP), DYMISTA (RBP), NASONEX* (QL,RBP), OMNARIS* (QL,RBP), QNASL* (RBP), VERAMYST* (QL,RBP), ZETONNA (RBP)

Drug Type Tier 1 Tier 2 Tier 3 Asthma -Leukotriene Modulators* montelukast, zafirlukast* (ST) (Step Therapy) Asthma - Steroid Inhalants budesonide neb soln FLOVENT DISKUS/-HFA QVAR AEROBID, AEROBID-M, ALVESCO, ASMANEX, AZMACORT, DULERA

Asthma - Beta Agonists Short Albuterol/-ER albuterol PROAIR HFA, PROVENTIL HFA VOSPIRE ER Acting inhalation soln, VENTOLIN HFA metaproterenol, terbutaline Asthma - Beta Agonists - Long FORADIL, SEREVENT BROVANA, PERFOROMIST Acting Asthma - Other* (Prior ipratropium soln, theophylline ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, DALIRESP* (PA), Authorization) anhydrous ANORO ELLIPTA, ATROVENT STRIVERDI RESPIMAT, HFA, COMBIVENT, SPIRIVA/- SYMBICORT,TUDORZA, XOLAIR* (PA) RESPIMAT Topical Ears acetic acid, acetic acid- CIPRODEX, COLY-MYCIN S, CIPRO HC aluminum acetate, acetic acid- CORTISPORIN-TC hydrocortisone, ciprofloxacin, fluocinolone, neomycin- polymyxin B-hydrocortisone, ofloxacin otic Miscellaneous ciclopirox soln Skin - All betamethasone dipropionate ELIDEL, CORTISPORIN CORDRAN, FINACEA (15%) gel , 0.05% gel/oint/cream/lotion, fluocinolone scalp oil, triamcinolone spray betamethasone valerate 0.1% lot/cream/oint, calcipotriene soln, clobetasol 0.05% sol/cream, , clotrimazole- betamethasone, fluocinolone, lidocaine, mometasone furoate, triamcinolone 0.1%, 0.25% cream/oint/lotion or 0.5% cream/oint Skin – Acne* (Prior Authorization) adapalene, benzoyl peroxide, ALA-QUIN, AZELEX NORITATE clindamycin, metronidazole, sulfacetamide-sulfur, isotretinoin*(PA), tretinoin Women's Health Antineoplastic - Hormonal Agents tamoxifen Contraceptives* (All Contraceptives $0 copay for contraceptives subject to Quantity Limit) nclude: generic oral contraceptives such as ethinyl estradiol-drospirenone, medroxyprogesterone acetate, Apri, Kariva, Levora, Low- Ogestrel, Necon Sprintec, Trinessa, ORTHO-EVRA patch, NUVARING

University of Arkansas March 2017

Combination HRT estradiol-norethindrone CLIMARA PRO, COMBIPATCH, ANGELIQ PREFEST, PREMPHASE, PREMPRO, PREMPRO LOW DOSE Hormone Replacement Therapy estradiol,estradiol patches ALORA, CENESTIN, MENEST, CLIMARA PRO, DIVIGEL, ELESTRIN, (HRT) estropipate,progesterone MENOSTAR, MINIVELLE, ENJUVIA, ESTRACE vaginal cream, micronized*(PA) PREMARIN ESTRING, FEMRING, FEMTRACE NOTE: If a product may be used to treat infertility prior authorization will be required. Drug Type Tier 1 Tier 2 Tier 3

Osteoporosis alendronate RBP: PLAN WILL PAY $0.26/PILL; REMAINING COST WILL BE APPLIED TO REFERENCE BASED PRICING MEMBER SHARE PROGRAM (RBP) ACTONEL (RBP), ATELVIA (RBP), ibandronate 150mg (RBP)

Osteoporosis etidronate,

Fortical,raloxifene,zoledronic acid Prenatal Vitamins generics

Vaginal Products* (Quantity Limit) clindamycin, clotrimazole, , fluconazole* (QL on 150mg), metronidazole, terconazole Miscellaneous Antiemetics* (Quantity Limit) granisetron* (QL), EMEND caps* (QL) ANZEMET* (QL), CESAMET* (PA), ondansetron* (QL), SANCUSO* (QL), trimethobenzamide caps Antineoplastic Enzyme Inhibitors* NEXAVAR* (PA), SPRYCEL* (Prior Authorization) (PA), SUTENT* (PA) Antineoplastic Immunomodulator REVLIMID* (PA) Agents* (Prior Authorization) Antineoplastic Monoclonal LARTRUVO* (PA) Antibodies * (Prior Authorization) Growth Hormone (Prior GENOTROPIN* (PA), HUMATROPE* (PA), OMNITROPE* (PA), Authorization) NORDITROPIN* (PA), SAIZEN* (PA), SEROSTIM* (PA), TEV- NUTROPIN* (PA), NUTROPIN TROPIN * (PA) AQ* (PA)

Hematopoietic Growth Factors ARANESP * (PA), EPOGEN* (PA), PROCRIT* (PA) Insulin-Like Growth Factors* (Prior INCRELEX* (PA) Authorization) Miscellaneous cevimeline CUVPOSA,NASCOBAL, NARCAN Neurological Disease, misc (Prior NUEDEXTA*(PA),TYSABRI*(PA) Authorization) Rheumatoid Arthritis (Prior methotrexate HUMIRA* (PA), ENBREL* (PA), ACTEMRA SC* (PA), ORENCIA* (PA), Authorization) TREXALL INFLECTRA* (PA), SIMPONI* (PA) Smoking Cessation bupropion ext-rel, nicotine CHANTIX, NICOTROL INHALER transdermal

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. Specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. The plan participant’s prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. Listed products may be available generically in certain

University of Arkansas March 2017 strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to www.medimpact.com to check coverage and copay information for a specific medicine.

1 Copayment, copay or coinsurance means the amount a plan participant is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.

2 Atacand should be reserved for plan participants who meet CHARM (Candesartan in Heart Failure – Assessment of Reduction in Mortality and Morbidity) trial criteria.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber.