Use of Generic Drugs Can Save Both You and Your Health Plan Money

University of Arkansas January 2015

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.

Branded products with an available generic equivalent may be subject to the highest copayment1 according to Benefit Design. When members choose the brand product over the generic equivalent, the member will pay the highest tier copayment plus a cost difference between the brand and the generic.

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, SUPRAX 400mg only* (QL) CEFTIN susp (Quantity Limit) cefpodoxime, cefprozil, Note: all other Suprax strengths cefditoren,cefuroxime, cephalexin are 100% copay

Antibiotics - Macrolides azithromycin, clarithromycin, ERY-TAB, ZMAX clarithromycin ext-rel, PCE erythromycin delayed-rel, erythromycin ethylsuccinate, erythromycin stearate

Antibiotics - Fluoroquinolones ciprofloxacin, ciprofloxacin ext-rel, CIPRO susp, FACTIVE levofloxacin,moxifloxacin Antibiotics - Penicillins amoxicillin, amoxicillin- clavulanate, dicloxacillin, penicillin VK Antibiotics – Other* (Prior clindamycin HCl, doxycycline ZYVOX*(PA) Authorization) hyclate, minocycline, tetracycline Antifungals* (Prior Authorization) fluconazole, itraconazole* (QL), FULVICIN U/F (Quantity Limit) ketoconazole, terbinafine tabs* (PA)

Antivirals - Influenza* (Quantity amantadine, rimantadine TAMIFLU RELENZA* (QL) Limit) Antivirals - Herpes acyclovir, famciclovir, VALCYTE susp valacyclovir, valganciclovir tab Antivirals - Other - ribasphere, ribavirin PEGASYS* (PA), PEGINTRON* SOVALDI (PA) Interferons/Interferon Combinations (PA), REBETOL susp (Prior Authorization) VICTRELIS* (PA) Cardiovascular Anti-Adrenergic Blockers Peripherally doxazosin, prazosin, terazosin 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

Other Antihyperlipidemic Agents cholestyramine, colestipol, LIPOCHOL PLUS WELCHOL gemfibrozil

University of Arkansas January 2015

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 Antagonists* candesartan/-HCTZ (ST), BENICAR* (ST), BENICAR HCT* (ST), (Step Therapy) eprosartan*(ST),irbesartan (ST), TEVETEN HCT* (ST) (ST)/-HCTZ (ST),losartan, losartan-HCTZ, telmisartan/- HCTZ, valsartan/-HCTZ Antihypertensive Combinations (Step amlodipine-benazepril, AZOR*(ST), TARKA, TRIBENZOR*(ST), 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* (Step Therapy) RANEXA* (ST) Direct Renin Inhibitors/Combo* (Step AMTURNIDE*(ST),TEKTURNA* (ST), 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), LETAIRIS (PA) (Prior Authorization) 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), NAMENDA*(age) AEXELON patches (age edit) galantamine, rivastigmine caps Analgesics - Narcotic* (Quantity butalbital-APAP-caffeine, KADIAN (200mg), OXYCONTIN* ABSTRAL*(PA), , FENTORA* (QL), Limit)(Prior Authorization) butalbital-aspirin-caffeine, (QL), STAGESIC-10 KADIAN (40mg,70mg), SUBOXONE* codeine-APAP, fentanyl (PA), transdermal/- buccal*(QL), hydrocodone-APAP, hydromorphone, morphine/-ER, morphine supp, oxycodone- /APAP ER, oxycodone ibuprofen, propoxyphene, propoxyphene napsylate-APAP, tramadol/-ER 2

University of Arkansas January 2015

Drug Type Tier 1 Tier 2 Tier 3 Analgesics - Anti-Inflammatory/ choline magnesium trisalicylate, NSAIDs diclofenac, etodolac, ibuprofen, indomethacin ext-rel, meloxicam, nabumetone, naproxen, naproxen sodium, oxaprozin, sulindac Anticonvulsants carbamazepine, clonazepam, CELONTIN, GABITRIL DEPAKENE, DEPAKOTE, DEPAKOTE (Prior Authorization) clonazepam ODT, diazepam (12mg,16mg), STAVZOR ER, DILANTIN, FYCOMPA, LYRICA (PA), (rectal), divalproex ONFI (PA) sodium,ethosuximide, gabapentin, lamotrigine, levetiracetam/-XR, oxcarbazepine, phenobarbital, phenytoin, primidone, valproic acid, zonisamide Antianxiety alprazolam/- ext-rel, buspirone, diazepam, lorazepam, oxazepam Antidepressants - Other* amitriptyline, bupropion/-ext-rel, EMSAM* (QL) (Quantity Limit) clomipramine, desipramine, doxepin, mirtazapine, nortriptyline, trazodone Antidepressants - SSRIs citalopram, escitalopram ,fluoxetine, paroxetine/-ER, sertraline Antidepressants - SNRIs duloxetine, venlafaxine/-ER Antiparkinsonian Agents amantadine, benztropine, TASMAR AZILECT, MIRAPEX ER, ZELAPAR bromocriptine, cabergoline, carbidopa-levodopa, carbidopa- levodopa ext-rel, entacapone, pramipexole, ropinirole/-XL, selegiline, trihexyphenidyl Antimanic Agents lithium carbonate Antipsychotic Agents* chlorpromazine, clozapine, MOBAN, NAVANE, SEROQUEL ABILIFY* (PA), INVEGA (Prior Authorization) fluphenazine, haloperidol, XR olanzapine, perphenazine, quetiapine (IR), risperidone, thioridazine, thiothixene, trifluoperazine,ziprasidone Migraine Products* (Quantity Limit) dihydroergotamine inj, AXERT* (QL) CAFERGOT, FROVA* (QL),RELPAX* ergotamine-caffeine tabs, (QL), ZOMIG NS* (QL) naratriptan (QL), rizatriptan (QL), sumatriptan (QL) Multiple Sclerosis Drugs (Prior COPAXONE 20mg* (QL), REBIF* AVONEX* (QL), AUBAGIO (PA), Authorizatiion)(Quantity Limit) (QL) BETASERON* (QL), GILENYA*(PA)(QL), TECFIDERA (PA) Sedative Hypnotics – flurazepam, temazepam Benzodiazepines (BZD) (except 7.5mg and 22.5mg), triazolam 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) 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),

University of Arkansas January 2015

Drug Type Tier 1 Tier 2 Tier 3 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, NOVOLIN, NOVOLOG Diabetes - Insulin Sensitizing metformin/-XR, pioglitazone AVANDIA*(PA), Agents*(Prior Authorization) Diabetes - Insulin Secreting Agents chlorpropamide, glimepiride, DIABETA glipizide, glipizide ext-rel, glyburide, tolazamide

Diabetes - Combinations glyburide-metformin, glipizide- metformin, pioglitazone- AVANDAMET, AVANDARYL, JANUMET metformin, metformin ext-rel, pioglitazone-glimepiride

Diabetes - Other Medications acarbose GLYSET, GLUCAGON BYETTA*(ST), JANUVIA,SYMLIN (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 peg 3350-electrolytes, KRISTALOSE, OSMOPREP, polyethylene glycol VISICOL

Digestive Aids pancrelipase PANCREASE MT, CREON, PANCREAZE PANCREALIPASE EC, ULTRASE/-MT, VIOKASE Gallstone Solubilizing Agents ursodiol

H2-Antagonists cimetidine, famotidine, nizatidine, ranitidine

Proton Pump Inhibitors* (QL) omeprazole, pantoprazole, RBP: PLAN WILL PAY $0.64/PILL; REMAINING COST WILL BE APPLIED TO REFERENCE BASED PRICING Prilosec OTC ($10 copay/30 MEMBER SHARE PROGRAM (RBP) days supply)

DEXILANT* (QL,RBP), lansoprazole*(QL,RBP), NEXIUM* (QL,RBP), omeprazole-sodium bicarbonate* (QL,RBP), rabeprazole (QL,RBP), ZEGERID* (QL,RBP)

University of Arkansas January 2015

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 (RPB), GELNIQUE (RPB), OXYTROL (RPB), Copay) TOVIAZ (RPB), VESICARE (RPB)

Inflammatory Bowel* (Quantity Limit) balsalazide, budesonide, DELZICOL*(QL), APRISO*(QL) CANASA, ENTOCORT EC, UCERIS* (ST) (Step Therapy) mesalamine, sulfasalazine, sulfasalazine delayed-rel Immunosuppressive Agents Immunosuppressive* (Prior azathioprine, cyclosporine, RAPAMUNE, ZORTRESS*(PA) Authorization) cyclosporine modified, 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, finasteride, AVODART tamsulosin

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

Anti-Infective/Antiviral Agents bacitracin, ciprofloxacin, NATACYN AZASITE, VIGAMOX, ZYMAR 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 (QL), 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 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), NASONEX* (QL,RBP), OMNARIS* (QL,RBP), QNASL* (RBP), , VERAMYST* (QL,RBP)

University of Arkansas January 2015

Drug Type Tier 1 Tier 2 Tier 3 Asthma -Leukotriene Modulators* montelukast, zafirlukast* (ST) ZYFLO CR* (ST) (Step Therapy) Asthma - Steroid Inhalants budesonide neb soln FLOVENT DISKUS/-HFA ALVESCO, ASMANEX, AEROBID, PULMICORT, QVAR AEROBID-M, AZMACORT, DULERA, Asthma - Beta Agonists Short Acting Albuterol/-ER albuterol FORADIL, MAXAIR, PROAIR VOSPIRE ER inhalation soln, metaproterenol, HFA, PROVENTIL HFA terbutaline VENTOLIN HFA Asthma - Beta Agonists - Long Acting FORADIL, SEREVENT BROVANA, PERFOROMIST Asthma - Other* (Prior Autorization) ipratropium soln, theophylline ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, SYMBICORT,XOLAIR* anhydrous ATROVENT HFA, COMBIVENT (PA) Topical Ears acetic acid, acetic acid- COLY-MYCIN S, CORTISPORIN- CIPRODEX aluminum acetate, acetic acid- TC, CIPRO HC hydrocortisone, fluocinolone, neomycin-polymyxin B- hydrocortisone, ofloxacin otic Miscellaneous ciclopirox soln Skin - All betamethasone dipropionate ELIDEL CLOBEX spray, FINACEA augmented, calcipotriene soln, clobetasol propionate, clotrimazole-betamethasone, lidocaine, mometasone furoate

Skin – Acne* (Prior Authorization) benzoyl peroxide, clindamycin, BENZACLIN, NORITATE ATRALIN 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 Combination HRT estradiol-norethindrone CLIMARA PRO, COMBIPATCH, ANGELIQ FEMHRT (0.5MG-2.5), PREFEST, PREMPHASE, PREMPRO, PREMPRO LOW DOSE Hormone Replacement Therapy estradiol,estradiol patches ALORA, CENESTIN, CLIMARA PRO, ELESTRIN, ESTRACE (HRT) estropipate,progesterone ESTRADERM, MENEST, vaginal cream, ESTRING, FEMRING micronized*(PA) MENOSTAR, PREMARIN, , NOTE: If a product may be used to treat infertility prior authorization will be required. 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, MIACALCIN Fortical,raloxifene,zoledronic acid Prenatal Vitamins generics

University of Arkansas January 2015

Drug Type Tier 1 Tier 2 Tier 3 Vaginal Products* (Quantity Limit) clindamycin, clotrimazole, , fluconazole* (QL on 150mg), metronidazole, terconazole Miscellaneous Antiemetics* (Quantity Limit) granisetron* (QL), ondansetron* EMEND* (QL) ANZEMET* (QL), CESAMET* (PA), (QL), trimethobenzamide caps SANCUSO* (QL), Antineoplastic Enzyme Inhibitors* NEXAVAR* (PA), SPRYCEL* (PA), (Prior Authorization) SUTENT* (PA) Antineoplastic Immunomodulator REVLIMID* (PA) Agents* (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 Neurological Disease, misc (Prior NUEDEXTA*(PA),TYSABRI*(PA) Authorization) Rheumatoid Arthritis (Prior methotrexate HUMIRA* (PA), TREXALL ACTEMRA SC* (PA), ENBREL* (PA), Authorization) ORENCIA* (PA), REMICADE* (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 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.