Community First Health Plans
UFCP Preferred Drug List • Plan Year 2019
Three-tier Preferred Drug List effective January 1, 2019 This preferred drug list was developed by the Community First Health Plans Pharmacy and Therapeutics (P&T) Committee to ensure you receive cost-effective pharmaceutical care, emphasizing quality and safety. The P&T Committee is made up of Community First physicians and other health care providers. Using this list will allow Community First to keep its prescription benefits affordable for you. While you still will be able to receive any medication your physician chooses to prescribe for you, medications not listed below may require a higher co-pay and will not be available through UHS mail-order. Information about prior authorization requirements or limitations for certain medications is available to Prescribers via the Navitus Web Portal. For more information, please visit www.navitus.com or call (866) 333-2757.
All generic drugs are considered preferred, are 1st Tier medications and are displayed in lower case. Preferred brand name drugs are 2nd Tier medications and are capitalized. Medications not listed are considered non-preferred brand name drugs and are 3rd Tier medications. For additional outpatient prescription medication coverage information, you may contact Member Services at (210) 358-6090 or toll-free at 1-800-434-2347. Please refer to your Certificate of Coverage and your Outpatient Drug Rider for drug exclusions, quantity limits, and step edit, which may apply to certain medications. If you choose to get a brand name medication when a generic is available, you will be responsible for the generic copayment, plus the price difference between the generic medication and the brand name medication, even if the prescriber writes, “Brand Name Medically Necessary.”
Over-the-counter (OTC) medications and any prescription medication that contains the same active ingredient(s) as an existing over-the- counter medication are not covered. If you decide to try a non-prescription medication, talk to your doctor or pharmacist about the most economical way to purchase the drug and the appropriate dosing that matches your prescription strength brand.
Maintenance drugs are coded as such if they meet the following criteria: KEY 1. Medications that do not require frequent monitoring and dosage adjustments PA Prior authorization for side effects or therapeutic responses. Certain drugs that may have potential QL Quantity limit life-threatening toxicity when taken as an intentional overdose may be excluded. ST Step therapy 2. Medications that are used to treat a chronic condition with no therapy endpoint. * Maintenance medication These drugs are taken continuously, but do not provide a cure for the condition Allow 1-2 business days for the for which it is being treated. University System Pharmacy to order Available for mail-order through the 3. Medications that are typically used as outpatient type of drugs. University System Pharmacies
Third tier drugs available through UHS Pharmacies
-A- -F- -N- -T- ACTEMRA SC INJ PA FETZIMA PA NORVIR * TRIUMEQ ANORO ELLIPTA INHALER FLECTOR PATCH TRUVADA * APTIVUS -P- ATRIPLA -H- PREZISTA -V- HUMIRA PA PROVENTIL HFA * VESICARE -B- VIRACEPT * BYETTA * VIREAD * -I- -Q- -C- INTELENCE QVAR* INVIRASE * CHANTIX ISENTRESS QL CIMZIA -R- CLARINEX-D RESCRIPTOR * COMPLERA -K- REYATAZ * KALETRA -D- -L- -S- DYMISTA PA SELZENTRY LEXIVA * STRIBILD LYRICA -E- SUSTIVA * ENBREL PA QL -M- MYRBETRIQ
UFCP members are strongly encouraged to have their prescriptions filled at UHS pharmacies to take advantage of the prescription benefit. SPBD| 12.00286 Rev. 7 08/17 Community First Health Plans
UFCP Preferred Drug List • Plan Year 2019
-A- betamethasone valerate colchicine w/ probenecid * estropipate * abacavir tablets betaxolol * COMBIVENT RESPIMAT * ethambutol * abacavir-lamivudine-zidovudine tablets bethanechol chloride CORTIFOAM ethinyl estradiol/drospirenone acebutolol * BETOPTIC-S * cromolyn ethosuximide * acetaminophen w/ codeine bicalutamide cyclobenzaprine * ethynodiol diacet & eth estrad * acetaminophen w/ hydrocodone bisoprolol & HCTZ * cyclophosphamide etodolac * acetaminophen-butalbital bisoprolol * cyclosporine etodolac ER * acetaminophen-caffbutalbital brimonidine opthal * cyproheptadine * etoposide acetazolamide * bromocriptine * CYTOMEL * EURAX acetazolamide capsules bumetanide EXELDERM acetylcysteine bupropion SR QL* -D- acyclovir bupropion QL* desipramine * -F- adefovir dipivoxil buspirone * desmopressin * FARXIGA * ADVAIR * butalbital/aspirin/caffeine desoximetasone fenofibrate albuterol * w/codeine dexamethasone fenofibrate 145mg alclometasone BYDUREON dexmethylphenidate fenoprofen * alendronate dexmethylphenidate ER fentanyl alfuzosin -C- dextroamphetamine * finasteride ALKERAN CALCIFEROL diazepam flecanide * allopurinol * calcipotriene topical cream diclofenac * FLOVENT HFA * ALOMIDE calcitonin diclofenac ER * fluconazole alprazolam calcitriol * dicloxacillin fludrocortisone * amantadine * candesartan/HCTZ dicyclomine flunisolide * amiloride * captopril * didanosine fluocinolone amiloride and HCTZ * captopril and HCTZ * diflunisal * fluoromethalone aminocaproic acid carbachol * digoxin * fluorouracil amiodarone * carbamazepine * DILATRATE SR * fluoxetine * amitriptyline * carbamazepine ER* diltiazem * fluoxymesterone * amlodipine/atorvastatin carbidopa-levodopa * diltiazem SA * fluphenazine amlodipine and benazepril * carisoprodol w/ ASA * dipivefrin * flurbiprofen * amoxapine * cefaclor dipyridamole * flutamide * amoxicillin cefaclor ER disopyramide * fluvastatin amoxicillin & pot clavulanate cefadroxil divalproex sodium er fluvoxamine * amphetamine mixtures * cefpodoxime divalproex sodium sprinkles FOSAMAX PLUS D * ampicillin cefuroxime donepezil fosinopril & HCTZ * anagrelide * cephalexin dorzolamide HCl/timolol maleate * fosinopril * ANDRODERM * cevimeline doxazosin * furosemide * ANDROGEL chlordiazepoxide doxepin * anthralin chlorothiazide * doxercalciferol -G- APAPisometheptene-dichloral chlorpheniramine, phenylephrine doxycycline gabapentin * apraclonidine * and methscopolamine duloxetine capsule ganciclovir ASACOL * chlorpheniramine, phenylephrine gatafloxacin 0.5% ASMANEX and pyrilamine -E- gemfibrozil * aspirin w/ codeine chlorpromazine EFFIENT QL gentamicin sulfate aspirin/caffeine/butalbital chlorpropamide * ELIDEL ST QL glimepiride * atenolol & chlorthalidon * chlorthalidone * EMADINE glipizide * atenolol * cholestyramine * enalapril * glipizide ER * atorvastatin ciprofloxacin enalapril and HCTZ * glyburide * atropine sulfate citalopram * EPIDUO GLYXAMBI * aug betamethasone dipropionate clarithromycin EPIPEN, EPI PEN Jr. glyburide/metformin * AVANDIA ST * clemastine 2.68 mg tablets or syrup eplerenone granisetron QL PA AVIANE * CLIMARA PRO * ERGOMAR griseofulvin AZASITE clindamycin ergotamine and caff griesofulvin ultra azathioprine clindamycin and benzoyl peroxide gel erythromycin guanfacine * azelaic acid clindaymcin, benzyol peroxide erythromycin & sulfisoxazole azelastine clobetasol propionate * erythromycin base -H- azithromycin clomipramine erythromycin base (coated) halobetasol AZOPT * clonazepam * erythromycin estolate haloperidol * clonidine * erythromycin ethylsuccinate HUMALOG (all forms) *
-B- clonidine patches erythromycin Pellets (generic ERYC) HUMULIN (all forms) * baclofen * clopidogrel erythromycin stearate hydralazine & HCTZ * benazepril * clotrimazole (topical) escitalopram * hydrochlorothiazide * benazepril and HCTZ * clobetasol 0.05% lotion esterfied estrogens * hydrocortisone w/ pramoxine benzonatate clobetasol 0.05% topical shampoo ESTRACE VAG * hydromorphone HCl benztropine mesylate * clonidine HCl SR 12HR estradiol * hydroxychloroquine * betamethasone & clotrimazole clotrimazole troche ESTRING QL * hydroxyurea * betamethasone dipropionate cloxacillin estrogens & methyltestosterone * hydroxyzine codeine hyoscyamine
UFCP members are strongly encouraged to have their prescriptions filled at UHS pharmacies to take advantage of the prescription benefit. Community First Health Plans
UFCP Preferred Drug List • Plan Year 2019
-I- medroxyprogesterone * NOVOLOG *(all forms) prenatal multivitamin w/ Fe-Fa ibandronate * megestrol NUVARING QL* prenatal vitamin * ibandronate 150 mg tablets mercaptopurine nystatin primidone * ibuprofen/hydrocodone mesalamine nystatin vaginal PROAIR HFA * imipramine * metaproterenol * probenecid * indomethacin metformin * -O- prochlorperazine indomethacin ER metformin ER * ofloxacin PROCTOCREAM-HC ipratropium * methazolamide * olanzapine * promethazine irbesarten methimazole * olanzapine/fluoxetine promethazine with codeine irbesarten with HCTZ methotrexate * olapatadine propafenone * isometheptene, dichloralphenazone, methyclothiazide * olmesartan propranolol & HCTZ * APAP methyldopa * ondansetron QL PA propranolol * isoniazid * methylphenidate * orphenadrine citrate * propranolol LA * isosorbide dinitrate * methylphenidate ER orphenadrine/ASA/caffeine propylthiouracil * isosorbide mononitrate * methyltestosterone * oxaprozin * pyrazinamide * isotretinoin metoclopramide HCl oxazepam pyridostigmine * isoxsuprine * metolazone * oxcarbazepine itraconazole * metoprolol * OXISTAT -Q- metoprolol XL * oxybutynin * quetiapine -J- metronidazole oxybutynin er quinidine gluconate * JANUVIA * metronidazole gel oxycodone quinidine sulfate * JANUMET * mexiletine * oxycodone w/ aspirin JANUMET XR * MICROGESTIN * OZEMPIC -R- MICROGESTIN FE * JARDIANCE * rabeprazole tab midodrine -P- RIDAURA * MIGRANAL PANCREAZE * rifampin -K- minocycline PANDEL rifuzole ketoconazole mirtazapine QL * pantoprazole rimantadine ketoprofen * misoprostal * paroxetine * risperidone QL ketoprofen ER * MITIGARE PATADAY ST rizatriptan ketorolac modafinil pediatric multivitamins w/F1 & Fe ropinirole mometasone pediatric multivitamins w/F1 ropinirole extended-release tablets -L- montelukast pediatric vitamins ACD w/ fluoride labetalol * moexipril * pediatric vitamins ACD w/ fluoride & lamivudine morphine -S- iron lamivudine-zidovudine morphine ER salsalate * penicillin V potassium lamotrigne MOVANTIK * selegiline * pentazocin and naloxone LANOXICAPS * moxifloxicin selenium sulfide pentazocin/APAP lansop/amox /clarith mupiriocin SEREVENT INH and Diskus * pentoxifylline * LANTUS * mycophenolate sertraline * perphenazine leflunomide * MYLERAN sildenafil 20mg tabs
leucovorin perphenazine and amitriptyline silver sulfadiazine phenobarbital & belladonna alk LEVEMIR -N- simvastatin * phenobarbital * sirolimus tab levetiracetam nabumetone * phenyleph-CPM w/ hydrocod sodium fluoride * levobunolol * nadolol * phenyltoloxamine w/ APAP sodium polystyrene levocetirizine naltrexone phenytoin (all forms) * sodium sulfacetamide levofloxacin NARDIL * PHOSPHOLINE IODIDE sotalol * levonorgestrel & eth estradiol * NATACYN pilocarpine spironolactone & HCTZ * LEVORA * necon 0.5/35, 1/35, 1/50 * PILOPINE HS * spironolactone * levothyroxine * nefazodone * pindolol * stannous fluoride * lidocaine HCl neomycin pioglitazone stavudine lidocaine patch neomycin-polymy-dexameth pioglizazone/metformin sucralfate * LINZESS * nevirapine piroxicam * sulfacetamide sodium w/ sulfur lisinopril & HCTZ * niacin ER (Rx only) podofilox sulfacetamide sod-pred lisinopril * nicardipine * potassium bicarbonate * sulfadiazine lithium carbonate * nifedipine * potassium chloride * sulfamethoxazole lithium citrate * nifedipine ER * potassium citrate * sulfasalazine * lorazepam nitrofurantoin potassium gluconate * sulindac * losartan nitroglycerin (all forms) * pramoxine sumatriptan QL losartan - hctz norethindrone & eth estradiol * pravastatin QL * SYMPROIC * lovastatin QL * norethindrone * prazosin * SYNJARDY * loxapine * norethindrone acet & estradiol Fe prednisolone SYNJARDY XR * * prednisone SYNTHROID * -M- norgestimate & ethinyl estradiol * PREMARIN * maprotiline * norgestrel & ethinyl estradiol * PREMARIN VAG -T- MATULANE nortriptyline * PREMPHASE * tacrolimus mebendazole NOVOLIN *(all forms) PREMPRO * meclofenamate * tamoxifen *
UFCP members are strongly encouraged to have their prescriptions filled at UHS pharmacies to take advantage of the prescription benefit. Community First Health Plans
UFCP Preferred Drug List • Plan Year 2019 tamsulosin HCl telmisartan -X- VIAGRA / CIALIS / LEVITRA telmisartan/amlodipine XARELTO 6 tabs/month per RX and PA criteria temazepam XIGDUO XR * temozolomide XULANE PATCH QL XULANE PATCH terazosin * 3 per month terbinafine -Z- terbutaline * ZENPEP ZOMIG tetracycline zidovudine 5mg: 3 per month; theophylline * ziprasidone 2.5mg & spray: 6 per month thioridazine zolmitriptan SPECIAL HANDLING thiothixene * zolpidem MEDICATIONS: thyroid * ZOMIG QL Members may pick up these medications THYROLAR * zonisamide at the RBG or Pavilion pharmacy at a tiagabine $0 co-pay ticlopidine * QUANTITY LIMITS: timolol * 30 per 30-day supply unless otherwise Any medication requiring refrigeration timolol GFS * noted All insulins TOBRADEX QL Humira or Enbrel tobramycin neb bupropion Vitamin D capsules tolazamide * 90 per month Nuvaring tolbutamide * Restasis tolterodine * bupropion SR Byetta or Bydureon tolterodine immediate release (IR) 60 per month Victoza tablets Lovaza tolterodine SR ELIDEL tolmetin * must have tried/failed topiramate low potency corticosteroid first tramadol Medical Insurance Related Questions: tramadol er ENBREL Contact Community First: (210) 358-6090 tramadol with APAP 25mg INJ: 4 INJ per 28 days tranylcypromine * Prescription Insurance Related Questions: TRAVATAN Z ESTRING Contact Navitus: (866) 333-2757 trazodone * 1 every 3 months trentinoin gel 0.04% Questions about the Refill Order Form, Shipping Eligibility, etc. TRESIBA granisetron Contact Employee Pharmacy at tretinoin PA if >25y/o 10 tablets per prescription TREXIMET QL RBG: (210) 358-9654 or (210) 358-9657 triamcinolone acetonide ISENTRESS triamterene & HCTZ * 60 per 30 days triazolam trifluridine lovastatin If you’re unable to locate your medication on the list then trihexyphenidyl * 60 tablets per 30 days please contact trimethobenzamide Navitus at (866) 333-2757 trimethoprim NUVARING trimethoprim / sulfamethoxazole 1 ring per month trimethoprim-polymyxin b -U- ondansetron 10 tablets per prescription ursodiol * 50ml per prescription -V- risperidone valacyclovir HCl * 60 tablets per 30 days / valproate sodium * 120ml per 30 days valproic acid * 1mg/ml solution valsartan valsartan HCTZ sumatriptan venlafaxine QL * tabs: 9; spray: 6 per month verapamil * verapamil ER * TOBRADEX VEXOL 10ml per 6 months VIAGRA QL PA Criteria VICTOZA TREXIMET -W- 9 tablets per 30 days warfarin sodium * venlafaxine 60 per month
UFCP members are strongly encouraged to have their prescriptions filled at UHS pharmacies to take advantage of the prescription benefit. Community First Health Plans
UFCP Preferred Drug List • Plan Year 2019
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