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University of Utah Hospitals and Clinics Preferred Drug List

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University of Utah Hospitals and Clinics Preferred Drug List University of Utah Hospitals and Clinics Preferred Drug List This Preferred Drug List (PDL) is a list of frequently prescribed medications and does not include all drugs covered under your pharmacy drug‐ benefit. Inclusion of a drug does not guarantee coverage. Drugs that are not listed may be non-covered or excluded drugs. • Most non specialty, generic drugs are covered at the generic tier and are preferred, if available. High cost generic drugs are covered at a higher tier than other generics as noted in this list. • Please note that additional coinsurance will apply if a member requests a brand name medication when a generic alternative is available. • The Affordable Care Act (ACA) requires that certain drugs be provided without cost to the member, such as generic oral contraceptives and most recommended vaccinations. Drugs noted by * are considered preventive and may be covered at a different benefit level than listed. Limits may apply. • Most specialty medications require prior authorization and are covered under one of the specialty drugs tiers. Generic and brand name antiretroviral medications with no generics available are covered on the specialty tier without a prior authorization. • Quantity Limits (QL), Step Therapy (ST), and Prior Authorization (PA) may also apply and are noted below. Preferred Brands Non- Preferred Preferred and Non- Preferred Generics Specialty Limits Preferred Brands (T1) (T4) Generics (T3) (T2) ANALGESICS NON-STEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDS) AND COMBINATIONS Oral celecoxib, diclofenac/ER oral, diclofenac/misoprostol, etodolac/ER, QL celecoxib fenoprofen, flurbiprofen, ibuprofen, indomethacin/ER, ketoprofen/ER, ketorolac, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen (except Naprelan equivalent), oxaprozin, piroxicam, sulindac, tolmetin diclofenac gel, naproxen (Naprelan equivalent) Anaprox/DS, Arthrotec, Cambia, Celebrex, Daypro, EC-Naprosyn, ST, QL Feldene, Indocin, Mobic, Nalfon, Naprelan, Ponstel, Tivorbex, Voltaren/XR, Zipsor, Zorvolex Topical diclofenac solution ST, QL diclofenac gel, ketorolac gel ST, QL, PA ketorolac Flector, NaPro, Pennsaid, Rexaphenac cream, Solaraze, Voltaren, ST, QL Vopac OPIOIDS AND OPIOID COMBINATIONS acetaminophen/codeine, codeine, Endocet, Endodan, fentanyl, QL hydrocodone, hydrocodone/acetaminophen, hydrocodone/ibuprofen, hydromorphone/ER, levorphanol, meperidine, Meperitab, methadone, Methadose tablet, morphine/ER, oxycodone, oxycodone/acetaminophen, oxycodone/aspirin, oxycodone/ibuprofen, oxymorphone/ER, Reprexain, Roxicet, tramadol/ER, Xylon Oxycodone ER, Oxycontin QL meperidine/promethazine QL Abstral, Actiq, Butrans, Conzip, Demerol, Dilaudid, Dolophine, ST, QL Duragesic, Exalgo, Fentora, Hysingla ER, Kadian, Methadose concentrate/SF, MS Contin, Nucynta/ER, Opana/ER, Oxecta, Percocet, Percodan, Primlev, Roxicodone, Sublimaze, Subsys, Synapryn, Ultracet, Ultram/ER, Vicoprofen, Xartemis XR, Xtampza ER, Zohydro ER MISCELLANEOUS lidocaine patch, fentanyl patch QL lidocaine-menthol patch, fentanyl OT LOZ PA Fentanyl Lidoderm QL SALICYLATES aspirin*, choline-mag trisalicylate, diflunisal, salsalate Disalcid 1 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List T1 T2 T3 T4 Limits ANTIDOTES IRON OVERLOAD THERAPY Exjade, Ferriprox tab, Jadenu PA OPIOID ANTAGONISTS Narcan ANTI-INFECTIVE AGENTS ANTIBIOTICS Aminoglycosides neomycin, paromomycin Cephalosporins cefadroxil, cefdinir, cefpodoxime, cefprozil, ceftibuten, cefuroxime axetil, cephalexin cefditoren, cefixime Ceftin, Cedax, Spectracef, Suprax Macrolides azithromycin, clarithromycin, erythromycin Biaxin/XL, E.E.S., EryPed, Ery-Tab, PCE, Zithromax Dificid PA Miscellaneous clindamycin, First-Vancomycin, metronidazole, nitrofurantoin vancomycin oral capsules QL, ST Alinia, Ketek, Macrobid, Macrodantin, Mepron, Sivextro oral, Xifaxan QL Sivextro Penicillins amoxicillin, amoxicillin/clavulanate, ampicillin, dicloxacillin, penicillin VK Augmentin, Augmentin XR/ES, Moxtag Quinolones ciprofloxacin, levofloxacin, moxifloxacin Avelox, Cipro, Factive, Levaquin, Noroxin QL Sulfonamides sulfadiazine, TMP-SMX/DS Bactrim/DS Tetracyclines doxycycline, minocycline doxycycline DR Adoxa, Dynacin, Monodox, Periostat, Solodyn, Vibramycin, tetracycline ANTIFUNGALS fluconazole, flucytosine, griseofulvin suspension, ketoconazole, nystatin griseofulvin tablets, itraconazole, voriconazole PA itraconazole Ancobon, Bio-Statin, Diflucan, Grifulvin V, Gris-PEG, Lamisil oral Cresemba PA ANTIRETROVIRAL AGENTS Antiretrovials Adjuvants Tybost CCR5 Antagonists Selzentry 2 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List T1 T2 T3 T4 Limits Combinations abacavir-lamivudine- zidovudine, lamivudine-zidovudine Atripla, Complera, Descovy, Evotaz, Kaletra, Odefsey, Prezcobix, Stribild, Triumeq, Truvada Integrase Inhibitors Isentress, Tivicay, Vitekta Protease Inhibitors Aptivus, Crixivan, Invirase, Lexiva, Norvir, Prezista, Reyataz, Viracept RTI-Non-Nucleoside Analogues nevirapine/ER Edurant, Intelence, Rescriptor, Sustiva RTI-Nucleotide Analogues Viread RTI-Nucleotide Analogues-Purines abacavir, didanosine Videx oral solution, Ziagen RTI-Nucleoside Analogues-Pyrimidines lamivudine Emtriva RTI-Nucleoside Analogues-Thymidines zidovudine, stavudine ANTIVIRALS-GENERAL acyclovir, amantadine, famciclovir, rimantadine, valacyclovir QL Tamiflu QL Relenza QL Famvir, Flumadine, Sitavig, Valtrex, Zovirax oral ST, QL valganciclovir, Synagis PA ANTIVIRALS-HEPATITIS B adefovir, entecavir, lamuvidine (HBV) Tyzeka PA ANTIVIRALS-HEPATITIS C ribavirin Copegus, Moderiba, Rebetol, Ribasphere, RibaTab QL Peg-Intron PA ANTIVIRALS-HEPATITIS C COMBINATIONS Epclusa, Zepatier PA DRUGS FOR MALARIA atovaquone/proguanil, chloroquine, hydroxychloroquine, mefloquine, primaquine, quinine Aralen, Coartem, Daraprim, Malarone, Plaquenil, Qualaquin DRUGS FOR PARASITES ivermectin Albenza, Biltricide, Stromectol QL DRUGS FOR TUBERCULOSIS cycloserine, ethambutol, isoniazid, pyrazinamide, ribabutin, rifampin Myambutol, Mycobutin, Rifamate, Rifater 3 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List T1 T2 T3 T4 Limits ANTINEOPLASTIC AGENTS (CANCER) ORAL CHEMOTHERAPEUTIC AGENTS Alkylating Agents Haxalen, lomustine PA Androgen Biosynthesis Inhibitors Zytiga PA Antiadrenals Lysodren PA Antiandrogens Xtandi PA Antimetabolites capecitabine PA Antineoplastic Retinoids Panretin PA BRAF Kinase Inhibitors Tafinlar, Zelboraf PA Cyclin-Dependent Kinases (CDK) Inhibitors Ibrance PA Hedgehog Pathway Inhibitors Erivedge PA Histone Deacetylase Inhibitors Farydak, Zolinza PA Imidazotetrazines temozolomide QL Immunomodulators - Antileprotics Thalomid PA Immunomodulators - Antineoplastic Pomalyst PA Immunomodulators for Myelodysplastic Revlimid PA Interferons Alferon N, Intron-A, Sylatron PA LHRH Analogs Eligard PA MEK Inhibitors Mekinist PA Miscellaneous Antineoplastics Matulane PA mTOR Kinase Inhibitors Afinitor PA Multikinase Inhibitors Nexavar, Stivarga, Sutent PA Poly (ADP-ribose) Polymerase (PARP) Inhibitors Lynparza PA Phosphatidylinositol 3-Kinase (PI3K) Inhibitors Zydelig PA Selective Retinoid X Receptor Agonists Targretin Oral/Topical PA 4 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List T1 T2 T3 T4 Limits Topoisomerase I Inhibitors Hycamtin Oral PA Tyrosine Kinase Inhibitors Bosulif, Caprelsa, Cometriq, Gilotrif, Iclusig, imatinib mesylate, PA Imbruvica, Inlyta, Lenvima, Sprycel, Tarceva, Tasigna, Tykerb, Xalkori, Votrient, Zykadia HEMATOLOGIC AGENTS BLOOD CELL STIMULATORS ERYTHROPOIESIS-STIMULATING AGENTS (ESAs) Epogen PA GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF) Granix, Neulasta, Neupogen PA HEMATOPOIETIC GROWTH FACTORS - THROMBOPOIETIN AGONISTS Promacta PA STEM CELL MOBILIZERS Mozobil PA AUTOIMMUNE/IMMUNE/INFLAMMATORY ANTIPSORIATICS - SYSTEMIC Stelara PA INTERLEUKIN AGENTS Interleukin-1 Receptor Antagonists (IL-1Ra) Kineret PA Interleukin-6 Inhibitors Actemra Subcutaneous PA MISCELLANEOUS AUTOIMMUNE AGENTS Phosphodiesterase 4 (PDE4) Inhibitors Otezla PA Selective Costimulation Modulators Orencia PA TUMOR NECROSIS FACTOR AGENTS Anti-TNF-alpha - Monoclonal Antibodies Humira, Simponi PA Soluble Tumor Necrosis Factor Receptor Agents Enbrel PA ANTI-ANGINA isosorbide dinitrate, isosorbide mononitrate, nitroglycerin oral/transdermal Nitro-Bid Oint 2%, Nitrostat, Ranexa Minitran, Nitro-Dur, Nitrolingual, NitroMist QL ANTICOAGULANTS Antiplatelet cilostazol, clopidogrel, dipyridamole, ticlopidine Brilinta QL Aggrenox, Agrylin, Effient, Plavix, Pletal, Zontivity QL 5 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List T1 T2 T3 T4 Limits CARDIOVASCULAR AGENTS Antithrombotics Jantoven, warfarin Eliquis, enoxaparin, fondaparinux, Xarelto QL Fragmin, Iprivask, Pradaxa, Savaysa QL BLOOD PRESSURE THERAPY AND COMBINATIONS Ace Inhibitors benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, trandolapril Accupril, Aceon, Altace, Epaned, Lotensin, Mavik, Prinivil, Vasotec, Zestril Antiotensin antagonists (ARBs) candesartan, eprosartan, irbesartan, losartan, valsartan Atacand, Avapro, Benicar, Cozaar, Diovan, Edarbi, Micardis, Teveten ST, QL Antiadrenergic Agents - Central and Peripheral clonidine, doxazosin, prazosin, guanfacine,
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