OHSU HEALTH SERVICES FORMULARY Effective January 1, 2020 LAST UPDATED: September 27, 2021 Introduction The formulary is a list of drugs that are covered. The list is from a healthcare team that makes sure drugs are safe and effective. We update the formulary at least once a year. We will tell you about changes that affect you at least 30 days ahead of time. How to search You can look for drugs on the formulary in a couple of ways: By Use: Drugs used for the same medical reason are listed together. For example, drugs used to treat infections are listed under “Antibiotics.” Alphabetically: Drugs are also listed in alphabetical order with page number. Limits and restrictions Drugs that have limits or need more information before they are covered, are listed in these ways: Type Description Your provider will need to fill out a form and send it to us so Prior Approval (PA) we can review if the drug is covered Step Therapy (ST) You may need to first try another drug or series of drugs Quantity Limit (QL) A limited amount of drug is covered without our approval These drugs are covered only for certain ages. If you are Age Limit (AL1) younger or older than the age listed, we will need more information from your provider before we will cover the drug Specialty Drug (S) You will need to fill the drug at a specialty pharmacy Drugs not covered Drugs that are not covered include the following: Drugs not on the formulary Drugs not used for approved medical reasons Drugs used for conditions not covered by the Oregon Health Plan Drugs used for research Drugs used for cosmetic reasons Mental health drugs are not listed on the formulary, but are covered by the Oregon Health Authority drug program. How to request an exception Drugs not listed on the formulary may not be covered. Your provider can send in a form asking that we cover the drug for you. This form can be found on our website at: www.ohsu.edu/healthshare. Once we receive this form, we will see if we are able to cover the drug. We may contact your provider for more information. OHP-HSO-18-231 Pharmacy network Most of the drugs on the formulary can be filled at our retail pharmacies. Specialty drugs are filled at a specialty pharmacy. For information about pharmacies in our network, contact Member Services at the number below. More information If you have questions or need information, visit our website or contact Member Services Monday through Friday 8:00am to 5:00pm PST. Website: www.ohsu.edu/healthshare Phone: 844-827-6572 TTY: 1-800-735-2900 OHP-HSO-18-231 LEGEND TYPE DESCRIPTION There is a limit on the amount of this drug that is covered per QL Quantity Limit prescription, or within a specific time frame. You (or your physician) are required to get prior authorization before PA Prior Authorization you fill your prescription for this drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat ST Step Therapy your medical condition before we will cover another drug for that condition. GL Gender Limit This prescription drug may only be covered for a single gender. This prescription drug may only be covered if you meet the minimum AL1 Age Limit or maximum age limit. Specialty drugs are high-cost drugs used to treat complex or rare S Specialty Drug conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. PAGE 1 LAST UPDATED 09/2021 LIST OF COVERED PRESCRIPTION MEDICATIONS DRUG LIMITS & RESTRICTIONS ANALGESICS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS all day pain relief 220 mg tab all day pain rlf 220 mg caplet all day relief 220 mg caplet all day relief 220 mg tablet arthritis pain reliever 1% gel aspir ec 81 mg tablet aspir-low ec 81 mg tablet aspir-trin ec 325 mg tablet aspirin 325 mg tablet aspirin 81 mg chewable tablet aspirin ec 325 mg caplet aspirin ec 325 mg tablet aspirin ec 81 mg tablet bayer aspirin 325 mg caplet bayer aspirin 325 mg tablet BAYER ASPIRIN 81 MG CHEW TAB aspirin butalbital-asa-caffeine cap celecoxib 100 mg capsule QL 60 capsules / 30 days celecoxib 200 mg capsule QL 60 capsules / 30 days celecoxib 50 mg capsule QL 60 capsules / 30 days child aspirin 81 mg chew tab child aspirin 81 mg tab chew child ibuprofen 100mg/5ml syrg child ibuprofen 200 mg/10 ml children ibuprofen 100 mg/5 ml PAGE 2 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS cvs aspirin 325 mg caplet cvs aspirin 325 mg tablet cvs aspirin 81 mg chewable tab cvs aspirin ec 325 mg tablet cvs aspirin ec 81 mg tablet cvs chld ibuprofen 100 mg/5 ml cvs diclofenac sodium 1% gel cvs ibuprofen 200 mg caplet cvs ibuprofen 200 mg tablet cvs ibuprofen jr str 100 mg tb cvs inf ibuprofen 50 mg/1.25ml cvs naproxen sod 220 mg caplet cvs naproxen sod 220 mg tablet diclofenac sod dr 50 mg tab diclofenac sod dr 75 mg tab diclofenac sod ec 50 mg tab diclofenac sod ec 75 mg tab diclofenac sod er 100 mg tab diclofenac sodium 1% gel ec-naproxen dr 375 mg tablet ec-naproxen dr 500 mg tablet ECOTRIN EC 325 MG TABLET aspirin ecotrin ec 81 mg tablet ecpirin ec 325 mg tablet eq aspirin 325 mg tablet eq aspirin 81 mg chewable tab eq aspirin ec 325 mg tablet eq aspirin ec 81 mg tablet eq child ibuprofen 100 mg/5 ml eq ibuprofen 200 mg caplet PAGE 3 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS eq ibuprofen 200 mg tablet eq ibuprofen jr str 100 mg tab eq inf ibuprofen 50 mg/1.25 ml eq naproxen sod 220 mg caplet eq naproxen sod 220 mg tablet eql aspirin 325 mg tablet eql aspirin 81 mg chewable tab eql aspirin ec 325 mg tablet eql aspirin ec 81 mg tablet eql chld ibuprofen 100 mg/5 ml eql ibuprofen 200 mg caplet eql ibuprofen 200 mg tablet eql ibuprofen jr 100 mg tb chw eql inf ibuprofen 50 mg/1.25ml eql naproxen sod 220 mg caplet eql naproxen sod 220 mg tablet flanax 220 mg tablet gnp all day pain rlf 220 mg tb gnp aspirin 325 mg tablet gnp aspirin 81 mg chewable tab gnp aspirin ec 325 mg tablet gnp aspirin ec 81 mg tablet gnp chld ibuprofen 100 mg/5 ml gnp ibuprofen 100 mg chew tab gnp ibuprofen 200 mg caplet gnp ibuprofen 200 mg tablet gnp ibuprofen jr str 100 mg tb gnp inf ibuprofen 50 mg/1.25ml gnp naproxen sod 220 mg caplet gnp naproxen sod 220 mg tablet PAGE 4 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS gs aspirin 325 mg tablet gs aspirin 81 mg chewable tab gs aspirin ec 325 mg tablet gs aspirin ec 81 mg tablet gs child ibuprofen 100 mg/5 ml gs ibuprofen 100 mg chew tab gs ibuprofen 200 mg caplet gs ibuprofen 200 mg tablet gs inf ibuprofen 50 mg/1.25 ml gs naproxen sod 220 mg caplet gs naproxen sod 220 mg tablet gs naproxen sodium 220 mg tab hm arthritis pain 1% gel hm aspirin 325 mg tablet hm aspirin 81 mg chewable tab hm aspirin ec 325 mg tablet hm aspirin ec 81 mg tablet hm child ibuprofen 100 mg/5 ml hm ibuprofen 200 mg caplet hm ibuprofen 200 mg tablet hm ibuprofen ib 100 mg chew tb hm ibuprofen ib 200 mg caplet hm ibuprofen ib 200 mg tablet hm ibuprofen jr str 100 mg chw hm inf ibuprofen 50 mg/1.25 ml hm naproxen sod 220 mg caplet i-prin 200 mg tablet ibu 400 mg tablet ibu 600 mg tablet ibu 800 mg tablet PAGE 5 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS ibu-200 200 mg tablet ibuprofen 100 mg/5 ml susp ibuprofen 200 mg caplet ibuprofen 200 mg tablet ibuprofen 400 mg tablet ibuprofen 600 mg tablet ibuprofen 800 mg tablet ibuprofen jr str 100 mg chew ibuprofen jr str 100 mg tb chw indomethacin 25 mg capsule indomethacin 50 mg capsule indomethacin er 75 mg capsule infant ibuprofen 50 mg/1.25 ml infant ibuprofen 50 mg/1.25 ml infant ibuprofen 50 mg/1.25 ml ketorolac 10 mg tablet QL 20 tablets / 30 days ketorolac 30 mg/ml vial QL 10 / 30 day(s) kro all day rlf 220 mg caplet kro aspirin 325 mg tablet kro aspirin 81 mg chewable tab kro aspirin ec 81 mg tablet kro chld ibuprofen 100 mg/5 ml kro ibuprofen 200 mg caplet kro ibuprofen 200 mg tablet kro ibuprofen jr str 100 mg tb kro naproxen sod 220 mg caplet low dose aspirin ec 81 mg tab meloxicam 15 mg tablet meloxicam 7.5 mg tablet QL 60 / 30 day(s) nabumetone 500 mg tablet PAGE 6 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS nabumetone 750 mg tablet naproxen 250 mg tablet naproxen 375 mg tablet naproxen 500 mg kit naproxen 500 mg tablet naproxen dr 375 mg tablet naproxen dr 500 mg tablet naproxen sodium 220 mg caplet naproxen sodium 220 mg tablet naproxen sodium 275 mg tab naproxen sodium 550 mg tab naproxen sodium ds 550 mg tab piroxicam 10 mg capsule piroxicam 20 mg capsule provil 200 mg tablet pub all day relief 220 mg tab pub all day rlf 220 mg caplet pub aspirin 325 mg tablet pub aspirin 81 mg chewable tab pub children's profen ib susp pub children's profenib susp pub ibuprofen 200 mg tablet pub ibuprofen jr 100 mg chew pub inf profenib 50 mg/1.25 ml pub naproxen sod 220 mg tablet qc aspirin 325 mg tablet qc aspirin 81 mg chewable tab qc aspirin ec 325 mg tablet qc aspirin ec 81 mg tablet qc child ibuprofen 100 mg/5 ml PAGE 7 LAST UPDATED 09/2021 DRUG LIMITS & RESTRICTIONS qc diclofenac sodium 1% gel qc ibuprofen 200 mg caplet qc ibuprofen 200 mg tablet qc ibuprofen ib 200 mg caplet qc ibuprofen ib 200 mg tablet qc inf ibuprofen 50 mg/1.25 ml qc lo-dose aspirin ec 81 mg tb qc naproxen sod 220 mg tablet ra aspirin 325 mg tablet ra aspirin 81 mg chewable tab ra aspirin ec 325 mg tablet ra aspirin ec 81 mg tablet ra child ibuprofen 100 mg/5 ml ra ibuprofen 100 mg/5 ml susp ra ibuprofen 200 mg caplet ra ibuprofen 200 mg tablet ra ibuprofen jr str 100 mg chw ra inf ibuprofen 50 mg/1.25 ml ra naproxen sod 220 mg tablet sm all day relief 220 mg caplt sm all day relief 220 mg tab sm arthritis pain 1% gel sm aspirin 325 mg tablet sm aspirin 81 mg chewable