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Unitedhealthcare Community Plan of Indiana Drug List February 2021

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Unitedhealthcare Community Plan of Indiana Drug List February 2021 UnitedHealthcare Community Plan of Indiana Drug List February 2021 This document can be used as a searchable tool, by using the function CTRL+F, to find items on the preferred drug list (PDL) Please pay close attention to DRUG LABEL NAME, which shows either a brand version or a generic version of the drug. Important: many branded versions of drugs are nonpreferred on the UHC Community Plan of Indiana PDL, if the generically available version is available. For example, ABILIFY is brand name and is nonpreferred while ARIPIPRAZOLE is the available generic and is preferred). Information regarding formulary status, whether prior authorization is required, and other utilization management edits is contained in the right sided columns for each drug name in each row. This document is not listed in alphabetical order by drug name, rather drugs are grouped together by drug class. It is advised to use the search tool to find a drug name, brand or generic, that you are looking to locate. This list is a representative list of drug coverage and coverage changes may occur after publication. This list represents drugs covered under the pharmacy benefit and does not reflect medical benefit drugs or their coverage. CMS approved manufacturers are covered under the Medicaid program (“approved labelers”). The Indiana Preferred Diabetes Supply List (PDSL) aligns with the Indiana state covered list per FSSA and are not represented in this document. Please refer to the Indiana State Medicaid website at https://inm- providerportal.optum.com/providerportal/faces/PreLogin.jsp , click on “Preferred Products”, then “Preferred Diabetic Supply List” for a list of preferred blood glucose monitors, test strips and information relation to the manufacturers and customer assistance for each manufacturer. UnitedHealthcare Community Plan of Indiana Drug List, February 2021 Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) CEFADROXIL CEFADROXIL CAP 500MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEFADROXIL CAP 500 MG P N N Y N CEFADROXIL CEFADROXIL SUS 250/5ML 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEFADROXIL FOR SUSP 250 MG/5ML P N N Y N CEFADROXIL CEFADROXIL SUS 500/5ML 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEFADROXIL FOR SUSP 500 MG/5ML P N N Y N CEFADROXIL CEFADROXIL TAB 1GM 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEFADROXIL TAB 1 GM P N N Y N CEPHALEXIN CEPHALEXIN CAP 250MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN CAP 250 MG P N N Y N CEPHALEXIN CEPHALEXIN CAP 500MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN CAP 500 MG P N N Y N CEPHALEXIN CEPHALEXIN CAP 750MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN CAP 750 MG P N N Y N CEPHALEXIN CEPHALEXIN SUS 125/5ML 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN FOR SUSP 125 MG/5ML P N N Y N CEPHALEXIN CEPHALEXIN SUS 250/5ML 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN FOR SUSP 250 MG/5ML P N N Y N CEPHALEXIN CEPHALEXIN TAB 250MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN TAB 250 MG NP Y N N N CEPHALEXIN CEPHALEXIN TAB 500MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN TAB 500 MG NP Y N Y N KEFLEX KEFLEX CAP 750MG 1ST GENERATION CEPHALOSPORIN ANTIBIOTICS CEPHALEXIN CAP 750 MG NP Y N Y N CEFACLOR CEFACLOR CAP 250MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFACLOR CAP 250 MG P N N Y N CEFACLOR CEFACLOR CAP 500MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFACLOR CAP 500 MG P N N Y N CEFACLOR CEFACLOR SUS 125/5ML 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFACLOR FOR SUSP 125 MG/5ML P N N Y N CEFACLOR CEFACLOR SUS 375/5ML 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFACLOR FOR SUSP 375 MG/5ML P N N Y N CEFACLOR ER CEFACLOR ER TAB 500MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFACLOR MONOHYDRATE TAB ER 12HR 500 MG NP Y N Y N CEFPROZIL CEFPROZIL SUS 125/5ML 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPROZIL FOR SUSP 125 MG/5ML P N N Y N CEFPROZIL CEFPROZIL SUS 250/5ML 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPROZIL FOR SUSP 250 MG/5ML P N N Y N CEFPROZIL CEFPROZIL TAB 250MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPROZIL TAB 250 MG P N N Y N CEFPROZIL CEFPROZIL TAB 500MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPROZIL TAB 500 MG P N N Y N CEFUROXIME AXETIL CEFUROXIME TAB 250MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFUROXIME AXETIL TAB 250 MG P N N Y N CEFUROXIME AXETIL CEFUROXIME TAB 500MG 2ND GENERATION CEPHALOSPORIN ANTIBIOTICS CEFUROXIME AXETIL TAB 500 MG P N N Y N CEFDINIR CEFDINIR CAP 300MG 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFDINIR CAP 300 MG P N N Y N CEFDINIR CEFDINIR SUS 125/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFDINIR FOR SUSP 125 MG/5ML P N N Y N CEFDINIR CEFDINIR SUS 250/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFDINIR FOR SUSP 250 MG/5ML P N N Y N CEFIXIME CEFIXIME CAP 400MG 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME CAP 400 MG P N N Y N CEFIXIME CEFIXIME SUS 100/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME FOR SUSP 100 MG/5ML NP Y N Y Y CEFIXIME CEFIXIME SUS 200/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME FOR SUSP 200 MG/5ML NP Y N Y Y CEFPODOXIME PROXETIL CEFPODO PROX SUS 100/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPODOXIME PROXETIL FOR SUSP 100 MG/5ML NP Y NYN CEFPODOXIME PROXETIL CEFPODO PROX SUS 50MG/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPODOXIME PROXETIL FOR SUSP 50 MG/5ML NP Y NYN CEFPODOXIME PROXETIL CEFPODOXIME TAB 100MG 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPODOXIME PROXETIL TAB 100 MG NP Y N Y N CEFPODOXIME PROXETIL CEFPODOXIME TAB 200MG 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFPODOXIME PROXETIL TAB 200 MG NP Y N Y N SUPRAX SUPRAX CAP 400MG 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME CAP 400 MG NP Y N Y N SUPRAX SUPRAX CHW 100MG 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME CHEW TAB 100 MG NP Y N N N SUPRAX SUPRAX SUS 100/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME FOR SUSP 100 MG/5ML NP Y N Y Y SUPRAX SUPRAX SUS 200/5ML 3RD GENERATION CEPHALOSPORIN ANTIBIOTICS CEFIXIME FOR SUSP 200 MG/5ML NP Y N Y Y AVODART AVODART CAP 0.5MG 5-ALPHA-REDUCTASE INHIBITORS DUTASTERIDE CAP 0.5 MG NP Y N Y N DUTASTERIDE DUTASTERIDE CAP 0.5MG 5-ALPHA-REDUCTASE INHIBITORS DUTASTERIDE CAP 0.5 MG NP Y N Y N DUTASTERIDE/TAMSULOSIN HYDROCHLORDUTAST/TAMSU CAP 0.5-0.4 5-ALPHA-REDUCTASE INHIBITORS DUTASTERIDE-TAMSULOSIN HCL CAP 0.5-0.4 MG NP Y N Y N FINASTERIDE FINASTERIDE TAB 5MG 5-ALPHA-REDUCTASE INHIBITORS FINASTERIDE TAB 5 MG P N N Y N JALYN JALYN CAP 5-ALPHA-REDUCTASE INHIBITORS DUTASTERIDE-TAMSULOSIN HCL CAP 0.5-0.4 MG NP Y N Y N PROSCAR PROSCAR TAB 5MG 5-ALPHA-REDUCTASE INHIBITORS FINASTERIDE TAB 5 MG NP Y N Y N ANZEMET ANZEMET TAB 50MG 5-HT3 RECEPTOR ANTAGONISTS DOLASETRON MESYLATE TAB 50 MG NP Y N Y N GRANISETRON HCL GRANISETRON TAB 1MG 5-HT3 RECEPTOR ANTAGONISTS GRANISETRON HCL TAB 1 MG NP Y N Y N ONDANSETRON HCL ONDANSETRON SOL 4MG/5ML 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON HCL ORAL SOLN 4 MG/5ML NP Y N Y N ONDANSETRON HCL ONDANSETRON TAB 24MG 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON HCL TAB 24 MG P N N Y N ONDANSETRON HYDROCHLORIDE ONDANSETRON TAB 4MG 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON HCL TAB 4 MG P N N Y N Confidential 2/19/2021 Page 1 UnitedHealthcare Community Plan of Indiana Drug List, February 2021 Formulary Status PA (Y/N) Prior Step Therapy Quantity Age Limits DRUG NAME DRUG LABEL NAME CLASSIFICATION_DESCRIPTION - DRUG CLASS EXTENDED DRUG NAME/STRENGTH (P = preferred/NP = Authorization required Limits (Y/N) nonpreferred) Required (Y/N) (Y/N) ONDANSETRON HYDROCHLORIDE ONDANSETRON TAB 8MG 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON HCL TAB 8 MG P N N Y N ONDANSETRON ODT ONDANSETRON TAB 4MG ODT 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON ORALLY DISINTEGRATING TAB 4 MG P N N Y N SANCUSO SANCUSO DIS 3.1MG 5-HT3 RECEPTOR ANTAGONISTS GRANISETRON TD PATCH 3.1 MG/24HR (CONTAINS 34.3 MG) NP Y N Y N ZOFRAN ZOFRAN TAB 4MG 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON HCL TAB 4 MG NP Y N Y N ZUPLENZ ZUPLENZ MIS 4MG 5-HT3 RECEPTOR ANTAGONISTS ONDANSETRON ORAL SOLUBLE FILM 4 MG NP Y N Y N AMMONIUM CHLORIDE AMMONIUM GRA CHLORIDE ACIDIFYING AGENTS AMMONIUM CHLORIDE GRANULES NP Y N N N K-PHOS NO 2 K-PHOS TAB NO 2 ACIDIFYING AGENTS POTASSIUM & SODIUM ACID PHOSPHATES TAB 305-700 MG NP Y N N N RIMANTADINE HYDROCHLORIDE RIMANTADINE TAB 100MG ADAMANTANE ANTIVIRALS RIMANTADINE HYDROCHLORIDE TAB 100 MG P N N Y N AMANTADINE HCL AMANTADINE CAP 100MG ADAMANTANES (CNS) AMANTADINE HCL CAP 100 MG P N N Y N AMANTADINE HCL AMANTADINE SYP 50MG/5ML ADAMANTANES (CNS) AMANTADINE HCL SYRUP 50 MG/5ML P N N Y N AMANTADINE HCL AMANTADINE TAB 100MG ADAMANTANES (CNS) AMANTADINE HCL TAB 100 MG NP Y N N N AMANTADINE HYDROCHLORIDE AMANTADINE TAB 100MG ADAMANTANES (CNS) AMANTADINE HCL TAB 100 MG NP Y N N N GOCOVRI GOCOVRI CAP 68.5MG ADAMANTANES (CNS) AMANTADINE HCL CAP ER 24HR 68.5 MG (BASE EQUIVALENT) NP Y N Y N OSMOLEX ER OSMOLEX ER TAB ADAMANTANES (CNS) AMANTADINE HCL TAB ER 24HR PAK 129 MG & 193 MG (322 MG DOSE) NP Y N Y N OSMOLEX ER OSMOLEX ER TAB 129MG ADAMANTANES (CNS) AMANTADINE HCL TAB ER 24HR 129 MG (BASE EQUIVALENT) NP Y N Y N AIRDUO DIGIHALER 113/14 AIRDUO DGHLR INH 113-14 ADRENALS FLUTICASONE-SALMETEROL AER POWDER BA 113-14 MCG/ACT W/SENSOR NP Y N Y N AIRDUO DIGIHALER 232/14 AIRDUO DGHLR INH 232-14 ADRENALS FLUTICASONE-SALMETEROL AER POWDER BA 232-14 MCG/ACT W/SENSOR NP Y N Y N AIRDUO DIGIHALER 55/14 AIRDUO DGHLR INH 55-14 ADRENALS FLUTICASONE-SALMETEROL AER POWDER BA 55-14 MCG/ACT W/ SENSOR
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