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OFF Exchange Drug Formulary, December 2015

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OFF Exchange Drug Formulary, December 2015 UnitedHealthcare Prescription Drug List Please note: This Prescription Drug List(PDL) is accurate as of the date it was created and is subject to change after this date. Your estimated coverage and copay/co-insurance may vary based on the benefit plan you choose and the effective date of the plan. For additional details on specific medications, please refer to the drug search tool. Page Number ::1 Product Name Generic Name Benefit Prior Supply Step Specialty Tier Authorization Limit Therapy Medication 1ST BASE CRE *CREAM BASE** Tier 3 2-DEOXY-D POW -GLUCOSE 2-DEOXY-D-GLUCOSE POWDER Tier 4 8-MOP CAP 10MG METHOXSALEN CAP 10 MG Tier 2 A.A.G.C KIT CRE TERODERM *AMANTAD-AMITRIPT-GABA-CYCLOBEN CREAM 8- Tier 3 4-10-4% (CMPD KIT)** A/G PRO TAB *NUTRITIONAL SUPPLEMENT TABS** Tier 3 ABACAV/LAMIV TAB /ZIDOVUD ABACAV/LAMIV Tier 1 X ABACAVIR TAB 300MG ABACAVIR Tier 1 X ABILIFY SOL 1MG/ML ARIPIPRAZOLE ORAL SOLUTION 1 MG/ML Tier 4 ACAMPRO CAL TAB 333MG ACAMPRO CAL Tier 1 ACARBOSE TAB 100MG ACARBOSE Tier 1 ACARBOSE TAB 25MG ACARBOSE Tier 1 ACARBOSE TAB 50MG ACARBOSE Tier 1 ACCOLATE TAB 10MG ZAFIRLUKAST TAB 10 MG Tier 3 X ACCOLATE TAB 20MG ZAFIRLUKAST TAB 20 MG Tier 4 X ACCU-CHEK KIT FASTCLIX *LANCETS KIT*** Tier 1 ACCU-CHEK KIT MLTICLIX *LANCETS KIT*** Tier 1 ACCU-CHEK KIT SOFTCLIX *LANCETS KIT*** Tier 1 ACCU-CHEK LIQ ACT/GLUC *BLOOD GLUCOSE CALIBRATION - LIQUID*** Tier 1 ACCU-CHEK LIQ COMPACT *BLOOD GLUCOSE CALIBRATION - LIQUID*** Tier 1 ACCU-CHEK LIQ SMART *BLOOD GLUCOSE CALIBRATION - LIQUID*** Tier 1 ACCU-CHEK MIS ADAPTER *INSULIN INFUSION PUMP - ACCESSORIES*** Tier 3 ACCU-CHEK MIS BATTERY *INSULIN INFUSION PUMP - ACCESSORIES*** Tier 3 ACCU-CHEK MIS CLIP *INSULIN INFUSION PUMP - ACCESSORIES*** Tier 3 ACCU-CHEK MIS MLTICLIX *LANCETS*** Tier 1 ACCU-CHEK MIS SPRT COM *INSULIN INFUSION PUMP - ACCESSORIES*** Tier 3 ACCU-CHEK SOL *BLOOD GLUCOSE CALIBRATION - LIQUID*** Tier 1 ACCU-CHEK SOL COMFORT *BLOOD GLUCOSE CALIBRATION - LIQUID*** Tier 1 ACCU-CHEK SOL COMPACT *BLOOD GLUCOSE CALIBRATION - LIQUID*** Tier 1 ACCU-CHEK IN LIQ CONTROL *BLOOD GLUCOSE CALIBRATION - LIQUID*** Tier 1 ACCUPRIL TAB 10MG QUINAPRIL HCL TAB 10 MG Tier 4 ACCUPRIL TAB 20MG QUINAPRIL HCL TAB 20 MG Tier 4 ACCUPRIL TAB 40MG QUINAPRIL HCL TAB 40 MG Tier 4 ACCUPRIL TAB 5MG QUINAPRIL HCL TAB 5 MG Tier 4 ACCURETIC TAB 10-12.5 QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 10-12.5 Tier 4 MG ACCURETIC TAB 20-12.5 QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 Tier 4 MG ACCURETIC TAB 20-25MG QUINAPRIL-HYDROCHLOROTHIAZIDE TAB 20-25 MG Tier 4 ACCUTREND SOL GLUCOSE *BLOOD GLUCOSE CALIBRATION - LIQUID*** Tier 1 ACD/FLUORIDE DRO 0.25MG ACD/FLUORIDE Tier 1 ACE ACD/ALUM SOL 2% OTIC ACE ACD/ALUM Tier 1 ACEBUTOLOL CAP 200MG ACEBUTOLOL Tier 1 ACEBUTOLOL CAP 400MG ACEBUTOLOL Tier 1 ACEON TAB 4MG PERINDOPRIL ERBUMINE TAB 4 MG Tier 4 ACEON TAB 8MG PERINDOPRIL ERBUMINE TAB 8 MG Tier 4 ACETASOL HC SOL OTIC HYDROCORTISONE W/ ACETIC ACID OTIC SOLN 1- Tier 2 2% ACETAZOLAMID CAP 500MG ER ACETAZOLAMID Tier 1 ACETAZOLAMID TAB 125MG ACETAZOLAMID Tier 1 ACETAZOLAMID TAB 250MG ACETAZOLAMID Tier 1 ACETIC ACID SOL 2% OTIC ACETIC ACID Tier 1 ACETYLCYST SOL 10% ACETYLCYST Tier 1 ACETYLCYST SOL 20% ACETYLCYST Tier 1 ACITRETIN CAP 10MG ACITRETIN Tier 1 ACITRETIN CAP 17.5MG ACITRETIN Tier 1 ACITRETIN CAP 25MG ACITRETIN Tier 1 ACLOVATE CRE 0.05% ALCLOMETASONE DIPROPIONATE CREAM 0.05% Tier 3 ACTICIN CRE 5% ACTICIN Tier 1 ACTIGALL CAP 300MG URSODIOL CAP 300 MG Tier 4 ACTIMMUNE INJ 2MU/0.5 INTERFERON GAMMA-1B INJ 100 MCG/0.5ML Tier 2 X X X (2000000 UNIT/0.5ML) ACTIVE MEDIC KIT SPECIMEN ACTIVE MEDIC Tier 1 Page Number ::2 Product Name Generic Name Benefit Prior Supply Step Specialty Tier Authorization Limit Therapy Medication ACTIVE OB CAP *PRENATAL W/O A W/FE CBN-FA-DHA CAP 20-1-320 Tier 3 MG*** ACTIVELLA TAB 0.5-0.1 ESTRADIOL & NORETHINDRONE ACETATE TAB 0.5- Tier 4 0.1 MG ACTIVELLA TAB 1-0.5MG ESTRADIOL & NORETHINDRONE ACETATE TAB 1-0.5 Tier 4 MG ACTIVE-PREP CRE KIT I *FLURBIPROFEN-CYCLOBENZAPRINE CREAM Tier 3 (CMPD KIT)*** ACTIVE-PREP CRE KIT II *KETOPROFEN-BACLOFEN-GABAPENTIN CREAM Tier 3 (CMPD KIT)*** ACTIVE-PREP CRE KIT III *KETOPROFEN-LIDOCAINE-GABAPENTIN CREAM Tier 3 (CMPD KIT)*** ACTIVE-PREP CRE KIT IV *TRAMADOL-GABAPENTIN-MENTHOL-CAMPHOR Tier 3 CREAM (CMPD KIT)*** ACTIVE-PREP CRE KIT V *ITRACONAZOLE-PHENYTOIN SODIUM CREAM Tier 3 (CMPD KIT)*** ACTONEL TAB 150MG RISEDRONATE SODIUM TAB 150 MG Tier 4 X ACTONEL TAB 30MG RISEDRONATE SODIUM TAB 30 MG Tier 4 ACTONEL TAB 35MG RISEDRONATE SODIUM TAB 35 MG Tier 4 X ACTONEL TAB 5MG RISEDRONATE SODIUM TAB 5 MG Tier 4 ACTOPLUS MET TAB 15-500MG PIOGLITAZONE HCL-METFORMIN HCL TAB 15-500 Tier 4 X MG ACTOPLUS MET TAB 15-850MG PIOGLITAZONE HCL-METFORMIN HCL TAB 15-850 Tier 4 X MG ACTOPLUS MET TAB XR PIOGLITAZONE HCL-METFORMIN HCL TAB SR 24HR Tier 3 X 15-1000 MG ACTOPLUS MET TAB XR PIOGLITAZONE HCL-METFORMIN HCL TAB SR 24HR Tier 3 X 30-1000 MG ACULAR SOL 0.5% OP KETOROLAC TROMETHAMINE OPHTH SOLN 0.5% Tier 4 ACULAR LS SOL 0.4% KETOROLAC TROMETHAMINE OPHTH SOLN 0.4% Tier 4 ACUNOL TAB 600MG *HOMEOPATHIC PRODUCTS - TAB** Tier 3 ACYCLOVIR CAP 200MG ACYCLOVIR Tier 1 ACYCLOVIR SUS 200/5ML ACYCLOVIR Tier 1 ACYCLOVIR TAB 400MG ACYCLOVIR Tier 1 ACYCLOVIR TAB 800MG ACYCLOVIR Tier 1 ADALAT CC TAB 30MG ER NIFEDIPINE TAB SR 24HR 30 MG Tier 4 ADALAT CC TAB 60MG ER NIFEDIPINE TAB SR 24HR 60 MG Tier 4 ADALAT CC TAB 90MG ER NIFEDIPINE TAB SR 24HR 90 MG Tier 4 ADAPTADERM CRE *CREAM BASE** Tier 3 ADAPTADERM GEL *GEL BASE - GEL** Tier 3 ADASUVE INH 10MG LOXAPINE AEROSOL POWDER BREATH ACTIVATED Tier 3 10 MG ADDERALL XR CAP 10MG AMPHETAMINE-DEXTROAMPHETAMINE CAP SR Tier 2 X 24HR 10 MG ADDERALL XR CAP 15MG AMPHETAMINE-DEXTROAMPHETAMINE CAP SR Tier 2 X 24HR 15 MG ADDERALL XR CAP 20MG AMPHETAMINE-DEXTROAMPHETAMINE CAP SR Tier 2 X 24HR 20 MG ADDERALL XR CAP 25MG AMPHETAMINE-DEXTROAMPHETAMINE CAP SR Tier 2 X 24HR 25 MG ADDERALL XR CAP 30MG AMPHETAMINE-DEXTROAMPHETAMINE CAP SR Tier 2 X 24HR 30 MG ADDERALL XR CAP 5MG AMPHETAMINE-DEXTROAMPHETAMINE CAP SR Tier 2 X 24HR 5 MG ADEFOV DIPIV TAB 10MG ADEFOV DIPIV Tier 1 X ADEMPAS TAB 0.5MG RIOCIGUAT TAB 0.5 MG Tier 2 X X X ADEMPAS TAB 1.5MG RIOCIGUAT TAB 1.5 MG Tier 2 X X X ADEMPAS TAB 1MG RIOCIGUAT TAB 1 MG Tier 2 X X X ADEMPAS TAB 2.5MG RIOCIGUAT TAB 2.5 MG Tier 2 X X X ADEMPAS TAB 2MG RIOCIGUAT TAB 2 MG Tier 2 X X X ADRENALIN INJ 1MG/ML EPINEPHRINE INJ 1 MG/ML (1:1000) Tier 3 ADRENALIN SOL 1:1000 EPINEPHRINE HCL NASAL SOLN 0.1% Tier 2 ADV LANCING MIS DEVICE *LANCET DEVICES*** Tier 3 ADVAIR DISKU AER 100/50 FLUTICASONE-SALMETEROL AER POWDER BA 100- Tier 3 X 50 MCG/DOSE ADVAIR DISKU AER 250/50 FLUTICASONE-SALMETEROL AER POWDER BA 250- Tier 3 X 50 MCG/DOSE ADVAIR DISKU AER 500/50 FLUTICASONE-SALMETEROL AER POWDER BA 500- Tier 3 X 50 MCG/DOSE Page Number ::3 Product Name Generic Name Benefit Prior Supply Step Specialty Tier Authorization Limit Therapy Medication ADVAIR HFA AER 115/21 FLUTICASONE-SALMETEROL INHAL AEROSOL 115- Tier 3 X 21 MCG/ACT ADVAIR HFA AER 230/21 FLUTICASONE-SALMETEROL INHAL AEROSOL 230- Tier 3 X 21 MCG/ACT ADVAIR HFA AER 45/21 FLUTICASONE-SALMETEROL INHAL AEROSOL 45-21 Tier 3 X MCG/ACT ADVANCED BAS CRE PLUS *CREAM BASE** Tier 3 ADVANCED DNA KIT COLLECTI ADVANCED DNA Tier 1 ADVATE INJ 1000UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM FOR INJ 1000 Tier 2 X UNIT ADVATE INJ 1500UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM FOR INJ 1500 Tier 2 X UNIT ADVATE INJ 2000UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM FOR INJ 2000 Tier 2 X UNIT ADVATE INJ 250UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM FOR INJ 250 Tier 2 X UNIT ADVATE INJ 3000UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM FOR INJ 3000 Tier 2 X UNIT ADVATE INJ 4000UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM FOR INJ 4000 Tier 2 X UNIT ADVATE INJ 500UNIT ANTIHEMOPHILIC FACTOR RAHF-PFM FOR INJ 500 Tier 2 X UNIT ADVERA LIQ CHOCOLAT *NUTRITIONAL SUPPLEMENT LIQUID** Tier 3 ADVERA LIQ VANILLA *NUTRITIONAL SUPPLEMENT LIQUID** Tier 3 AERCHMBR PLS MIS FLOW-VU *SPACER/AEROSOL-HOLDING CHAMBERS - Tier 3 DEVICE*** AERCHMBR PLS MIS LRG MASK *SPACER/AEROSOL-HOLDING CHAMBERS - Tier 3 DEVICE*** AERCHMBR PLS MIS SM MASK *SPACER/AEROSOL-HOLDING CHAMBERS - Tier 3 DEVICE*** AERO OTIC HC SOL AERO OTIC HC Tier 1 AEROCHAMBER MIS PLUS *SPACER/AEROSOL-HOLDING CHAMBERS - Tier 3 DEVICE*** AEROSPAN AER 80MCG FLUNISOLIDE HFA INHAL AEROSOL 80 MCG/ACT Tier 3 X AFEDITAB TAB 30MG CR AFEDITAB Tier 1 AFEDITAB TAB 60MG CR AFEDITAB Tier 1 AFINITOR TAB 10MG EVEROLIMUS TAB 10 MG Tier 2 X X X AFINITOR TAB 2.5MG EVEROLIMUS TAB 2.5 MG Tier 2 X X X AFINITOR TAB 5MG EVEROLIMUS TAB 5 MG Tier 2 X X X AFINITOR TAB 7.5MG EVEROLIMUS TAB 7.5 MG Tier 2 X X X AFINITOR DIS TAB 2MG EVEROLIMUS TAB FOR ORAL SUSP 2 MG Tier 2 X X X AFINITOR DIS TAB 3MG EVEROLIMUS TAB FOR ORAL SUSP 3 MG Tier 2 X X X AFINITOR DIS TAB 5MG EVEROLIMUS TAB FOR ORAL SUSP 5 MG Tier 2 X X X AFTERA TAB 1.5MG AFTERA Tier 1 AGGRENOX CAP 25-200MG ASPIRIN-DIPYRIDAMOLE CAP SR 12HR 25-200 MG Tier 3 AGRYLIN CAP 0.5MG ANAGRELIDE HCL CAP 0.5 MG Tier 4 AIF #2 DRUG CRE PREP KIT AIF #2 DRUG Tier 1 AIF #3 DRUG CRE PREP KIT *FLURBIPROFEN-BACLOFEN-CYCLOBEN-LIDO Tier 3 CREAM (CMP KIT)** AIRSHIELD TAB *SPECIALITY VITAMIN PRODUCT EFFER TAB** Tier 3 AKNE-MYCIN OIN 2% ERYTHROMYCIN OINT 2% Tier 2 AK-POLY-BAC OIN OP AK-POLY-BAC Tier 1 AKTEN GEL 3.5% LIDOCAINE HCL OPHTH GEL 3.5% Tier 3 AKYNZEO CAP NETUPITANT-PALONOSETRON CAP 300-0.5 MG Tier 4 X ALA SCALP LOT 2% HYDROCORTISONE LOTION 2% Tier 4 ALAGESIC LQ SOL ALAGESIC LQ Tier 1 X ALA-QUIN CRE 3-0.5% ALA-QUIN Tier 1 ALBA-DERM CRE *CREAM BASE** Tier 3 ALBATUSSIN CAP PHENYLEPHRINE-CARBETAPENTANE-GG CAP 10-25- Tier 3 400 MG ALBATUSSIN LIQ NN *PHENYLEPH-DM-PYRIL-POT GUAI-SOD CIT-CIT Tier 2 ACID LIQUID*** ALBENZA TAB 200MG
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