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, methyldopa, reserpine,  terazosin Cardura, Catapres , Minipress  Beta-Blockers and Alpha/Beta-Blockers acebutolol, atenolol, betaxolol, bisoprolol, carvedilol, labetalol,  metoprolol, nadolol, pindolol, propranolol, timolol Bystolic, Coreg, Corgard, Hemangeol, Inderal LA/XL, Innopran XL,  ST, QL, PA Kerlone, Levatol, Lopressor, Sectral, Tenormin, Toprol XL, Trandate, Hemangeol Calcium Channel Blockers amlodipine, Cartia XT, diltiazem, felodipine, isradipine, nicardipine,  nifedipine, nimodipine, nisoldipine, Taztia XT, verapamil Adalat CC, Calan SR, Cardizem, Isoptin SR, Norvasc, Nymalize,  Procardia/XL, Sular, Tiazac, Verelan Combination Antihypertensives amlodipine-benazepril, amlodipine-atorvatatin, atenolol-  QL chlorthalidone, amlodipine-valsartan/HCTZ, benazepril-HCTZ, bisoprolol-HCTZ, candesartan HCTZ, captopril-HCTZ, enalapril_HCTZ, fosinopril-HCTZ, irbesartan-HCTZ, lisinopril-HCTZ, losartan-HCTZ, methyldopa-HCTZ, metoprolol-HCTZ, moexipril-HCTZ, nadolol- bendroflumethiazide, propranolol-HCTZ, quinapril-HCTZ, telmisartan- amlodipine, trandolapril/verapamil, valsartan-HCTZ telmisartan-HCTZ Accuretic, Atacand HCT, Avalide, Azor, Benicar HCT, Caduet,  QL Clorpres, Corzide, Diovan HCT, Dutoprol, Edarbyclor, Exforge/HCT, Hyzaar, Lopressor HCT, Lotrel, Lotensin HCT, Micardis HCT, Tarka, Tekturna HCT, Tenoretic, Teveten HCT, Tribenzor, Twynsta, Vaseretic, Zestoretic, Ziac Diuretics acetazolamide, bumetanide, furosemide, hydrochlorothiazide,  indapamide, methazolamide, spironolactone, triamterene-HCTZ, torsemide Demadex, Diamox, Edecrin, Lasix, Neptazane  Renin Inhibitors Tekturna  ARRHYTHMIA AGENTS amiodarone, disopyramide, flecainide, mexiletine, Pacerone,  propafenone, quinidine, sotalol/AF Multaq, Tikosyn  QL Multaq Betapace/AF, Cordarone, Norpace/CR, Rythmol/SR, Sorine  Sotylize  PA

6 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List

T1 T2 T3 T4 Limits CARDIOVASCULAR AGENTS, OTHER digoxin  Lanoxin  Northera  PA CHOLESTEROL THERAPY atorvastatin, cholestyramine, colestipol, fenofibrate (except Fenoglide  equivalent), fenofibric acid, fluvastatin, gemfibrozil, lovastatin, niacin, Niacor, pravastatin, simvastatin fenofibrate (Fenoglide equivalent), fenofibric cap, niacin ER, omega-3-  QL acid ethyl esters, rosuvastatin, Zetia Altoprev, Antara, Colestid, Crestor, Fenoglide, Fibricor, Lescol/XL,  ST, QL Lipitor, Lipofen, Liptruzet, Livalo, Lofibra, Lopid, Lovaza, Mevacor, Niaspan, Pravachol, Questran, Tricor, Trilipix, Triglide, Vascepa, Vytorin, Welchol, Zocor CENTRAL NERVOUS SYSTEM AGENTS ADHD/STIMULANTS amphetamine salts (mixed), dextroamphetamine,  QL dexmethylphenidate IR, methylphenidate IR dextroamphetamine ER,Concerta AB rated generic, guanfacine ER,  QL methylphenidate ER armodafinil, modafinil  PA, QL Adderall XR, Vyvanse  ST, QL Adderall, Aptensio XR, Concerta, Daytrana, Dexedrine, Evekeo,  ST, QL Focalin, Focalin XR, Intuniv, Kapvay, Metadate ER/CD, Methylin, ProCentra, Quillivant XR, Ritalin, Ritalin LA/SR, Strattera, Zenzedi ALZHEIMER AGENTS donepezil, galantamine, galantamine ER, memantine tab,  rivastigmine Aricept, Exelon oral/patch, Namenda, Namenda XR, Namzaric,  QL Razadyne, Razadyne ER AMYOTROPHIC LATERAL SCLEROSIS (ALS) AGENTS riluzole  PA ANTIDEPRESSANTS/ANTI-ANXIETY AGENTS (NON-BENZODIAZEPINE) amitriptyline, bupropion, bupropion ER, buspirone, citalopram,  desipramine, desvenlafaxine ER, doxepin, duloxetine, escitalopram, fluoxetine, fluvoxamine, imipramine, maprotiline, mirtazapine, nortriptyline, paroxetine, phenelzine, sertraline, trazodone, venlafaxine, venlafaxine ER Pristiq, Viibyrd  QL Aplenzin, Brintellix, Brisdelle, Celexa, Cymbalta, Effexor XR, Fetzima,  ST, QL Forfivo XL, Khedezla, Lexapro, Marplan, Nardil, Norpramin, Oleptro, Pamelor, Paxil, Paxil CR, Pexeva, Prozac, Remeron, Sarafem, Tofranil, Tofranil-PM, Wellbutrin, Wellbutrin SR/XL, Zoloft ANTIPSYCHOTICS/OTHER PSYCHIATRIC MEDICATIONS & COMBINATIONS chlorpromazine, clozapine, fluphenazine, haloperidol, lithium,  QL loxapine, olanzapine, olanzapine-fluoxetine, perphenazine, perphenazine-amitriptyline, pimozide, prochlorperazine, quetiapine, risperidone, thioridazine, thiothixene, trifluoperazine, ziprasidone aripiprazole, Seroquel XR  QL Abilify, Clozaril, Compazine, Fanapt, Fazaclo, Geodon,  ST, QL Latuda,Risperdal, Saphris, Seroquel, Symbyax, Versacloz, Zyprexa

7 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List

T1 T2 T3 T4 Limits MIGRAINE THERAPY acetaminophen-isometheptene-dichloralphenazone, almotriptan,  QL butalbital-apap-ceffeine-codeine, isometheptane-caffeine- acetaminophen, Migragesic, naratriptan, Prodrin, rizatriptan, sumatriptan, zolmitriptan dihydroergotamine nasal, frovatriptan  QL Relpax  ST, QL Alsuma, Amerge, Axert, Ergomar, Fioricet, Fioricet-codeine, Imitrex,  ST triptans, QL Maxalt, Maxalt-MLT, Migranal, Nodolor, Sumavel, Treximet, Zomig, Zomig-ZMT MULTIPLE SCLEROSIS AGENTS Corticotropin HP Acthar injection  PA General glatopa  PA Interferons Avonex, Rebif  PA Nrf2 Pathway Activators Tecfidera  PA Potassium Channel Blockers Ampyra  PA Pyrimidine Synthesis Inhibitors Aubagio  PA Sphingosine 1-Phosphate (S1P) Receptor Modulators Gilenya  PA NERVE PAIN THERAPY gabapentin (under seizure also)  Lyrica  QL Neurontin (under seizure also)  OTHER CNS AGENTS tetrabenazine  PA PARKINSON'S DISEASE THERAPY amantadine, benztropine, bromocriptine, carbidopa/levodopa,  carbidopa/levodopa ER, carbidopa/levodopa/entacapone, entacapone, pramipexole, ropinirole, ropinirole ER, selegiline, trihexyphenidyl Azilect, carbidopa, pramipexole ER  Comtan, Eldepryl, Emsam, Mirapex, Neupro, Parlodel, Requip, Requip  XL, Rytary, Sinemet, Sinemet CR, Stalevo, Zelapar Apokyn, Duopa, tolcapone  PA SEDATIVE/HYPNOTICS/ANXIETY (BENZODIAZEPINES) alprazolam, alprazolam XR, chlordiazepoxide, clonazepam,  QL clorazepate, diazepam, estazolam, eszopiclone, flurazepam, lorazepam, oxazepam, quazepam, temazepam, triazolam, zaleplon, zolpidem, zolpidem CR zolpidem sub  QL Ambien, Ambien CR, Ativan, Belsomra, Doral, Edluar, Halcion,  ST, QL Klonopin, Lunesta, Niravam, Onfi, Restoril, Rozerem, Silenor, Sonata, Tranxene-T, Valium, Xanax, Zolpimist

8 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List

T1 T2 T3 T4 Limits SEIZURE (NON-BENZODIAZEPINE) THERAPY carbamazepine, divalproex/ER, Epitol, ethosuximide, felbamate,  gabapentin, lamotrigine, levetiracetam, oxcarbazine, phenobarbital, phenytoin, primidone, topiramate, valproic acid, zonisamide Aptiom, Banzel, Carbatrol, Depakene, Depakote/ER, Dilantin,  QL, PA Aptiom Equetro, Felbatol, Fycompa, Gabitril, Keppra, Keppra XR, Lamictal, Mysoline, Neurontin, Onfi, Peganone, Potiga, Qudexy XR, Spritam, Stavzor, Tegretol, Tegretol XR, Topamax, Trileptal, Trokendi XR, Vimpat, Zonegran, Zarontin Sabril  PA DERMATOLOGICS ACNE adapalene, benzoyl peroxide (Rx), benzoyl peroxide-clindamycin,  QL benzoyl peroxide-erythromycin, Clindamax, clindamycin gel/foam/lotion/solution/swab, erythromycin gel/pad/solution, sulfacetamide/sulfur lotion/cream, tretinoin cream/gel Amnesteem, Claravis, Myorisan, tretinoin microsphere gel, Zenatane  QL Acanya, Atralin, Avita, Azelex, BenzaClin, Benzamycin, Branded  QL benzoyl peroxide Rx products, Branded sulfacetamide or sulfacetamide-sulfur products, Cleocin-T, Clindacin ETZ/P, Clindagel, Differin, Duac, Epiduo, Evoclin, Fabior, Finacea, Inova,Neuac, Nuox, Ovace, Plexion, Retin-A, Tazorac gel/cream (9Rx), Tretin-X, Vanoxide HC, Veltin, Ziana ANTIBIOTICS clindamycin, gentamicin, mafenide, metronidazole, mupirocin, silver  sulfadiazine, SSD cream, sulfacetamide Altabax, Bactroban, Centany, Cortisporin, Metrogel, MetroCream,  Nuvessa, Silvadene, Sulfamylon ANTIFUNGALS ciclopirox, clotrimazole, clotrimazole-betamethasone, econazole,  ketoconazole, Nyamyc, nystatin, nystatin-triamcinolone, Nystop, terbinafine iodoquinol-hydrocortisone, naftifine cream  Ala Quin, Ciclodan, Dermasorb AF, Ecoza, Ertaczo, Exelderm, Extina,  ST, QL Jublia, Ketodan, Kerydin, Loprox, Lotrisone, Luzu, Mentax, Nizoral, Oxistat, Penlac, Vusion, Vytone, Xolegel ANTIPSORIATIC/ECZEMA AGENTS calcipotriene, calcipotriene-betamethasone, calcitriol topical,  QL tacrolimus topical Dritho-Crème HP, Zithranol, Zithranol-RR  Dovonex, Elidel, Protopic, Sorilux, Taclonex, Vectical  ST, QL ANTIVIRALS acyclovir cream/ointment  QL Denavir, Xerese, Zovirax cream/ointment  QL TOPICAL CORTICOSTEROIDS Low-Mod Potency alclometasone, betamethasone dipropionate lotion, betamethasone  valerate cream, clocortolone pivalate cream, CortAlo, desonide, desoximetasone 0.05% cream, fluocinolone acetonide 0.01% or 0.025%, fluticasone external, hydrocortisone, mometasone, prednicarbate, triamcinolone 0.025-0.1% Aclovate, Capex, Cloderm, Cutivate, Derma-Smoothe/FS, Dermasorb  TA, Dermatop, Desonate, DesOwen, Elocon, Kenalog, Locoid, Pandel, Pediaderm TA, Synalar, Topicort 0.05% cream, Trianex, Triderm, Westcort

9 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List

T1 T2 T3 T4 Limits High-Very High Potency amcinonide, augmented betamethasone dipropionate cream/gel/oint,  betamethasone dipropionate cream/oint, betamethasone valerate oint, clobetasol cream/foam/gel/lotion/oint, Cormax, desoximetasone 0.25% cream/oint and 0.05% gel, diflorasone diacetate cream/oint, fluocinolone acetonide 0.2%, fluocinonide 0.05%, fluocinonide 0.1%, Halac, halobetasol, triamcinolone 0.5% AlphaTrex, Apexicon, Diprolene, Clobex, Clodan, Halog, Halonate,  Olux, Temovate, Topicort 0.25% cream/oint and 0.05% gel, Vanos

TOPICALS, OTHER fluorouracil solution, fluorouracil cream, imiquimod cream),  sulfacetamide sodium-sulfur cream/lotion, urea cream Aldara, Carac, Efudex, Fluoroplex, Keralac, Mirvaso, Picato, Zyclara  ENDOCRINE AND METABOLIC AGENTS ACROMEGALY/CUSHING'S DISEASE AGENTS Somatostatic Agents Sandostatin, Sandostatin LAR  PA Growth Hormone Receptor Antagonists Somavert  PA AGENTS FOR GOUT allopurinol, colchicine, colchicine/probenecid, probenecid  Colcrys, Mitigare, Uloric, Zyloprim  ST DIABETES THERAPY Diabetes Supplies General lancets, needles  QL Test Strips Bayer Breeze/Contour meters/test strips, Abbott Freestyle/Precision  QL Xtra meters/test strips Accu-Chek (all types), Glucocard (all types), OneTouch (all types),  QL TrueTrack (all types), and all other brands Oral Agents Alpha - Glucosidase Inhibitors acarbose  miglitol  Glyset, Precose  ST Biguanides metformin  metformin (500 and 1000mg)  Glucophage, Glucophage XR, Riomet  DPP-4 inhibitors/Combinations Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza  QL alogliptin, alogliptin-metformin, alogliptin-pioglitazone, Jentadueto,  QL Kazano, Nesina, Oseni, Tradjenta Meglitinides/Combinations nateglinide, repaglinide  Prandin, Starlix  ST SGLT2 inhibitors/Combinations Farxiga, Glyxambi, Invokamet, Invokana, Jardiance, Xigduo XR  ST, QL

10 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List

T1 T2 T3 T4 Limits Sulfonylureas/Combinations chlorpropamide, glimepiride, glipizide, glipizide XL, glipizide-  metformin, glyburide, glyburide-metformin, tolazamide, tolbutamide Amaryl, Diabeta, Glucotrol, Glucotrol XL, Glucovance, Glynase  Thiazolidinediones (TZDs)/Combinations pioglitazone, pioglitazone-glimepiride, pioglitazone-metformin  Actos, Actoplus Met, Actoplus Met XR, Avandamet, Avandia, Duetact  Insulins Lantus, Lantus Solostar, Levemir, Levemir FlexTouch, Novolin 70/30,  QL Novolin N, Novolin R, NovoLog, Novolog FlexPen, Novolog 70/30, Novolog 70/30 FlexPen Afrezza, Apidra, Humalog (all types), Humulin (all types)  QL, PA Afrezza Other Diabetes Injectables Bydureon, Byetta, Victoza  ST, QL SymlinPen 60/120, Tanzeum, Trulicity  ST, QL GROWTH HORMONE Genotropin, Humatrope, Norditropin, Omnitrope, Serostim  PA GROWTH HORMONE RELEASING HORMONES Egrifta  PA INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) Increlex  PA PARATHYROID AGENTS Sensipar  PA PERCOCIOUS PUBERTY UREA CYCLE DISORDER AGENTS Buphenyl (tablets/powder), Sodium Phenylbutyrate Oral Powder  PA VASOPRESSIN RECEPTOR ANTAGONISTS Samsca  PA ENZYME DEFICIENCY AGENTS DIGESTIVE ENZYMES Sucraid  PA GAUCHER DISEASE TREATMENT Cerdelga  PA EYE/EAR EYE Allergy azelastine, cromolyn, epinastine, ketotifen  Alocril, Alomide, Bepreve, Elestat, Emadine, Lastacaft, Pazeo  ST, QL Anti-infectives bacitracin, bacitracin-polymyxin B, ciprofloxacin, erythromycin,  gatifloxacin, gentamicin, neomycin-bacitracin-polymyxin, neomycin- polymyxin-gramicidin, ofloxacin, sulfacetamide, tobramycin Vigamox  AzaSite, Besivance, Bleph-10. Ciloxan, Moxeza, Ocuflox, Tobrex,  QL Zymaxid Zymaxid

11 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List

T1 T2 T3 T4 Limits Anti-inflammatory/NSAIDs bromfenac, diclofenac, fluorometholone, flurbiprofen, ketorolac  Durezol, Ilevro, Lotemax, Nevanac, prednisolone  QL Acular, Acular LS, Acuvail, Alrex, bromfenac sol, Flarex, FML, FML  QL Prolensa Forte, FML Liquifilm, Maxidex, Ocufen, Omnipred, Pred Forte, Pred Mild, Prolensa, Vexol Anti-infective/Antiinflammatory Combinations sulfacetamide-prednisolone, tobramycin-dexamethasone  Tobradex ST  Belphamide/S.O.P., Pred-G, Pred-G S.O.P. Tobradex oint  Glaucoma Agents apraclonidine, betaxolol, bimatoprost, brimonidine, carteolol,  dipivefin, dorzolamide-timolol, latanoprost, levobunolol, metipranolol, pilocarpine, timolol, travoprost Alphagan P, Azopt, Combigan, Lumigan, Simbrinza  ST, QL Betagan, Betimol, Betoptic-S, Cosopt, Iopidine, Isopto Carbachol,  ST, QL Isopto Carpine, Istalol, Phospholine Iodide, Rescula, Timoptic, Travatan Z, Trusopt, Xalatan, Zioptan Immunosuppressants Restasis  QL EAR antipyrine-benzocaine, ciprofloxacin, fluocinolone, neomycin-  polymyxin-HC, ofloxacin Ciprodex  Cetraxal, Cipro HC, Cortisporin Otic, Cortisporin-TC, DermOtic  GASTROINTESTINAL AGENTS ANTIEMETICS granisetron, hydroxyzine, meclizine, ondansetron, promethazine,  QL prochlorperazine, trimethobenzamide dronabinol, Transderm-Scop patch  QL Anzemet, Cesamet, Diclegis, Emend, Marinol, Sancuso, Zofran,  ST, PA Zuplenz Diclegis Akynzeo  PA ANTIULCER Ulcer, Other sucralfate  QL Carafate  QL BILE ACID SYNTHESIS DISORDER AGENTS Cholbam  PA CONSTIPATION AGENTS Amitiza, Entereg, Linzess, Movantik  PA DIGESTIVE ENZYMES Pancrelipase, Creon, Zenpep  QL Pancreaze, Pertzye, Ultresa, Viokace  QL GALLSTONE SOLUBILIZING AGENTS Chenodal  PA

12 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List

T1 T2 T3 T4 Limits IRRITABLE BOWEL DISEASE: ULCERATIVE COLITIS/CROHN'S DISEASE balsalazide, mesalamine enema, sulfasalazine  Asacol HD, alosetron, budesonide ER, Delzicol  Apriso, Azulfidine/EN, Canasa Suppositories, Colazal, Dipentum,  Entocort EC, Giazo, Lialda, Lotronex, Pentasa, Uceris

OTHER GI PRODUCTS calcium acetate, calcium carbonate, lactulose, metoclopramide  (except Metozolv equivalent), ursodiol, generic bowel prep metoclopramide (Metozolv equivalent), Renvela  Actigall, Auryxia, Eliphos, Fosrenol, Metozolv, Phoslo, Phoslyra,  QL Auryxia Renagel GERITOURINARY AGENTS CYSTINOSIS AGENTS Cystagon, Procysbi  PA DRUGS FOR BENIGN PROSTATIC HYPERTROPHY alfuzosin ER, doxazosin, finasteride, tamsulosin, terazosin  Avodart  Cardura XL, Flomax, Jalyn, Proscar, Rapaflo, Uroxatral  ST, QL Jalyn ERECTILE DYSFUNCTION Viagra  QL Cialis, Levitra, Staxyn, Stendra  QL OVERACTIVE BLADDER/URINARY INCONTINENCE oxybutynin, oxybutynin ER, tolterodine, tolterodine ER, trospium,  QL trospium ER darifenacin ER, Toviaz  Detrol, Detrol LA, Ditropan XL, Gelnique, Oxytrol, Oxytrol for Women,  ST, QL Myrbetriq, Vesicare VAGINAL PREPARATIONS clindamycin vaginal, metronidazole vaginal, miconazole 3 vaginal  supp, terconazole, Vandazole AVC Vaginal, Cleocin, Clindesse, Gynazole-1, MetroGel-Vaginal,  QL Terazol Terazol 3, Terazol 7, Zazole HORMONE THERAPY ANDROGENS First-Testosterone, Testosterone cypionate/enanthate  AndroGel  QL Androderm, Android, Aveed, Axiron, Depo-Testosterone, Fortesta,  QL Fortesta, Methitest, Natesto, Striant, Testim, Testone CIK, testosterone gel, Natesto Testred, Vogelxo, Vogelxo Pump ANTI-ANDROGENS bicalutamide, exemestane, flutamide, letrozole  Aromasin, Casodex, Femara  QL ANTI-ESTROGENS anastrozole, raloxifene, tamoxifen  Arimidex, Fareston, Soltamox  CONTRACEPTION Contraceptives, Emergency *levonorgestrel 0.75/1.5  QL *Ella Oral Tablet 30 MG  Plan B One-Step  QL

13 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List

T1 T2 T3 T4 Limits Contraceptives, Oral Monophasic *Altavera, Alyacen, Apri, Aubra, Aviane, Balziva, Briellyn, Chateal,  QL Cryselle-28 0.3-30, Cyclafem 1/35, Dasetta 1/35, Delyla, desogestrel/ethinyl estradiol, drospirenone-ethinyl estradiol, Elinest 0.3-30, Emoquette, Enskyce, Estarylla, Falmina, Gianvi, Gildagia, Gildess 1/20, Gildess 1.5/30, Gildess FE 1/20, Gildess 24 FE 1/20, Gildess FE 1.5/30, Introvale, Jolessa, Junel 1/20, Junel 1.5/30, Junel 24 FE 1/20, Junel FE 1/20, Junel FE 1.5/30. Kelnor, Kurvelo, Larin 1/20, Larin 1.5/30, Larin 24 FE 1/20, Larin FE 1/20, Larin FE 1.5/30, Layolis FE, Lessina, levonorgestrel-ethinyl estradiol, Levora, Lomedia Fe, Loryna, Low-Ogestrel 0.3-30, Lutera, Marlissa, Microgestin 1/20, Microgestin 1.5/30, Microgestin FE 1/20, Microgestin FE 1.5/30, Mono- Linyah, Mononessa, Necon 0.5/35, Necon 1/35, Nikki, Norethin-Eth Estradiol-FE, norethindrone-ethinyl estradiol 1/20, norethindrone- ethinyl estradiol FE 0.8-25 MG-MCG, norethindrone-ethinyl estradiol FE 1/20, norgestimate-ethinyl estradiol, Nortrel 0.5/35, Nortrel 1/35, Ocella, Orsythia, Philith, Pirmella 1/35, Portia, Previfem, Quasense, Reclipsen, Sprintec, Sronyx, Syeda, Tarina FE 1/20, Vestura, Vyfemla, Wera, Wymzya FE, Zarah, Zenchent, Zenchent FE, Zovia Amethyst, Beyaz, Brevicon, Desogen, FaLessa, Femcon Fe, Generess  QL FE, Loestrin 1/20 (21), Loestrin 1.5/30, Loestrin FE 1/20, Loestrin FE 1.5/30, Minastrin 24 Fe, Modicon, Necon 1/50, Norinyl 1+35, Norinyl 1+50, Ogestrel, Ortho-Cept, Ortho-Cyclen, Ortho-Novum 1/35, Ovcon-35, Safyral, Yasmin, YAZ, Zovia 1/50E Biphasic *Amethia, Amethia Lo, Azurette, Camrese, Camrese Lo, Daysee,  QL desogesetrel-ethinyl estradiol, Kariva, Kimidess, levonorgest-ethinyl estradiol 91-Day, Pimtrea, Solia, Viorele Lo Loestrin Fe, LoSeasonique, Mircette, Necon 10/11, Seasonique  ST, QL Triphasic *Alyacen 7/7/7, Aranelle, Caziant, Cesia, Cyclafem 7/7/7, Dasetta  QL 7/7/7, Enpresse-28,Leena, Levonest, Myzilra, Necon 7/7/7, norgestimate-ethinyl estradiol (triphasic), Nortrel 7/7/7, Pirmella 7/7/7, Tilia Fe, Tri-Estarylla, Tri-Linyah, Tri-Legest Fe, Tri-Previfem, Tri-Sprintec, TriNessa, Velivet Cyclessa, Estrostep Fe, Ortho-Novum 7/7/7, Ortho Tri-Cyclen, Ortho  QL Tri-Cyclen Lo, Tri-Norinyl, Trivora 4-Phasic *Natazia  QL Quartette  QL Norethindrone *Camila, Deblitane, Errin, Heather, Jencycla, Jolivette, Lyza, Nora-BE,  QL norethindrone, Norlyroc, Sharobel Nor-QD, Ortho Micronor  QL Contraceptives, other *Xulane  QL *cervical caps, diaphragms, female condoms, spermicides, sponges  *Nuvaring  QL Ortho Evra  QL

14 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List

T1 T2 T3 T4 Limits Hormone Replacement Therapy-- Estrogens/Progestins/Combinations Covaryx, Covaryx HS, EEMT, EEMT HS, esterified estrogens-  QL methyltestosterone, estradiol oral, estrodiol patch, estradiol- norethindrone, Jinteli, Lopreeza, medroxyprogesterone, megestrol (except Megace ES equivalent(, Mimvey, norethindrone-ethinyl estradiol, oral progesterone Duavee, megestrol (Megace ES equivalent), Premarin, Premarin Vag  QL Cream, Premphase, Prempro, Vagifem Alora, Activella, Angeliq, Aygestin, Climara, Climara Pro, CombiPatch,  QL Crinone, Divigel, Elestrin, Enjuvia, Estrace, Estrasorb, Estring, Estrogel, Estropipate, Evamist, Femhrt, Femring, First-Progesterone VGS, Menest, Menostar, Minivelle, Ortho-Est, Prefest, Premphase, Prometrium, Provera, Vivelle-Dot Miscellaneous Hormone Therapy danazol, desmopressin nasal/oral  QL DDAVP, Osphena, Stimate  QL Preterm Birth 17-alpha-hydroxyprogesterone caproate (17P)  hydroxyprogesterone caproate intramuscular solution  PA IMMUNOSUPPRESSANTS IMMUNOSUPPRESSANTS, ORAL azathioprine, cyclosporine oral, mycophenolate capsules, tacrolimus  oral Gengraf, Hecoria, Prograf, mycophenolate suspension, sirolimus  Astagraf XL, Cellcept, Imuran, Myfortic, Neoral, Rapamune,  QL Zortress Sandimmune, Zortress OSTEOPOROSIS alendronate, calcitonin nasal, etidronate, ibandronate, raloxifene  Fortical, risedronate  Actonel, Atelvia, Binosto, Boniva, Evista, Fosamax, Fosamax Plus D,  ST, QL Miacalcin Forteo  PA RESPIRATORY AGENTS ALLERGY Anaphylaxis Therapy epinephrine auto-injector  QL Adrenaclick  QL Oral levocetirizine  Xyzal  ST Nasal azelastine nasal, budesonide nasal, flunisolide nasal, fluticasone  nasal, olopatadine nasal, triamcinolone nasal mometasone spray, Qnasl  ST, QL ASTHMA/COPD Inhalation Therapy Maintenance/Controller Inhalers Inhaled Corticosteroids Asmanex, budesonide inh susp, Flovent Disk/HFA, Qvar  QL Aerospan, Alvesco, Arnuity Ellipta, Pulmicort Flexhaler  QL

15 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List

T1 T2 T3 T4 Limits Long Acting Beta Agonists Foradil  QL Arcapta Neohaler, Brovana neb, Perforomist neb, Serevent Diskus ,  QL Striverdi Long Acting Anticholinergic Inhalers Spiriva Aerrespimat, Spiriva HandiHaler, Tudorza  QL Incruse Ellipta  QL Long Acting Beta Agonist/Corticosteroid Combinations Advair Diskus/HFA, Breo Ellipta, Dulera, Symbicort  QL Long Acting Beta Agonist/ Long Acting Anticholinergic Combinations Anoro Ellipta, Stiolto Respimat  QL Mast Cell Stabilizers cromolyn inhalation neb  Rescue Inhalers Short Acting Beta Agonists albuterol inhalation neb, levalbuterol inhalation neb  QL Proair HFA, Proair Respiclick, Ventolin HFA  QL Proventil HFA, Xopenex HFA  QL Anticholinergics ipratropium  Atrovent HFA  Anticholinergic/Short Acting Beta Agonist Combinations ipratropium-albuterol  Combivent Respimat  QL Oral Therapy albuterol, albuterol ER, elixophyllin, metaproterenol, montelukast,  QL terbutalines, Theochron, theophylline, theophylline ER, zafirlukast Daliresp  Accolate, Lufyllin, Singulair, Theo-24, VoSpire, Zyflo/Zyflo CR  QL CYSTIC FIBROSIS Aminoglycosides Kitabis, Tobi Podhaler, tobramycin nebulizer solution  PA Anti-infectives, Miscellaneous Cayston  PA CFTR Potentiators Kalydeco  PA Hydrolytic Enzymes Pulmozyme  PA Miscellaneous Drugs Used for Cystic Fibrosis Sodium Chloride nebulizer solution for inhalation  IDIOPATHIC PULMONARY FIBROSIS Esbriet, Ofev  PA PULMONARY ARTERY HYPERTENSION Endothelin Receptor Antagonists Letairis, Opsumit  PA Guanylate Cyclase Stimulator Adempas  PA

16 Effective July 1, 2017 (Last updated July 2017) University of Utah Hospitals and Clinics Preferred Drug List

T1 T2 T3 T4 Limits Phosphodiesterase Inhibitors sildenafil 20 mg tablet  Adcirca  PA Prostaglandin Vaslodilators Orenitram  PA SMOKING CESSATION *bupropion (smoking det), nicotine gum, nicotine lozenge, nicotine  QL patch Chantix  QL, ST Zyban  QL, ST THYROID THERAPY levothyroxine, Levoxyl, liothyronine, NP Thyroid, Unithroid  Cytomel  Armour Thyroid, Nature-Throid, Synthroid, Thyrolar, Tirosint,  Westhroid, WP Thyroid VACCINES *Acthib, Adacel, Afluria, Bexsero, Boostrix, Cervarix, Comvax,  Daptacel, Decavac, Engerix-B, Fluarix, Flublok, Flucelvax, Flulaval, Flumist, Fluvirin, Fluzone, Gardasil, Havrix, Hiberix, Infanrix, Influenza A, Ipol, Kinrix, Menactra, Menomune, Menveo, M-M-R II, Pediarix, Pedvax HIB, Pentacel, Pneumovax 23, Prevnar, Proquad, Quadracel, Recombiva HB, Rotarix, Rotateq, Tenivac, Trumenba, Twinrix, Vaqta, Varivax, Zostavax VITAMINS/SUPPLEMENTS *certain vitamin D products, fluoride, folic acid, generic pre-natal  vitamins, iron certain branded pre-natal vitamins, Mephyton  certain other branded pre-natal vitamins 

17 Effective July 1, 2017 (Last updated July 2017)