Your 2016 Prescription Drug List - Myuhc
Your 2016Prescription Drug Listeffective July 1, 2016Please read: This document contains information about commonly prescribedmedications.For additional information:Call the toll-free member phone number on your health plan ID card.Visit myuhc.com Locate a participating retail pharmacy by ZIP code. Look up possible lower-cost medication alternatives. Compare medication pricing and options.1
Your Prescription Drug ListThis Prescription Drug List (PDL) outlines the most commonly prescribed medications for certainconditions and organizes them into cost levels, also known as tiers. An important part of the PDL isgiving you choices so you and your doctor can choose the best course of treatment for you.Go to myuhc.com for complete drug informationSince the PDL may change, we encourage you to visit our website, myuhc.com. This website is thebest source for up-to-date information about the medications your pharmacy benefit covers, possiblelower-cost options, and cost comparisons.2
Table of ContentsDrug tiers and cost . . . . . . . . . . . . . . . . . . . . . . . 5GastrointestinalAcid Suppression. . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Nausea/Vomiting. . . . . . . . . . . . . . . . . . . . . . . . . . . 18Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Programs and Limits . . . . . . . . . . . . . . . . . . . . . . 7Drugs by category . . . . . . . . . . . . . . . . . . . . . . . 10Anti-InfectivesAntibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Hepatitis C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18HIV/AIDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Inflammatory Conditions: RheumatoidArthritis, Crohn’s Disease, Psoriasis,Ulcerative Colitis. . . . . . . . . . . . . . . . . . . . . . . . . 19Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Cardiovascular/Heart DiseaseCoagulation Therapy . . . . . . . . . . . . . . . . . . . . . . . .High Blood Pressure. . . . . . . . . . . . . . . . . . . . . . . .High Cholesterol. . . . . . . . . . . . . . . . . . . . . . . . . . . .Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11111212Central Nervous SystemAttention Deficit Disorder. . . . . . . . . . . . . . . . . . . .Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . .Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sedatives/Hypnotics. . . . . . . . . . . . . . . . . . . . . . . .Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . .13131314141414Men’s HealthErectile Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . 19Prostate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Testosterone Therapy . . . . . . . . . . . . . . . . . . . . . . . 19Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . 19MusculoskeletalOsteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Pain Relief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Overactive Bladder. . . . . . . . . . . . . . . . . . . . . . . 21RespiratoryAllergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Asthma/COPD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Pulmonary Arterial Hypertension. . . . . . . . . . . . . 22Dermatology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Diabetes/EndocrineBlood Glucose Monitoring. . . . . . . . . . . . . . . . . . . 16Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . 22Transplant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23EndocrineGrowth Hormone. . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Thyroid Hormone Replacement. . . . . . . . . . . . . . 17Vitamins/Electrolytes. . . . . . . . . . . . . . . . . . . . 23Women’s HealthContraceptives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Hormone Replacement. . . . . . . . . . . . . . . . . . . . . .Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Prenatal Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . .Eye ConditionsAllergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1723242424Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
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At UnitedHealthcare, we want to help you betterunderstand your medication options.Your pharmacy benefit offers flexibility and choice in determining the right medicationfor you. To help you get the most out of your pharmacy benefit, we’ve included some ofthe most commonly asked questions about the Prescription Drug List.What is a Prescription Drug List (PDL)?This document is a list of commonly prescribed medications. Drugs are listed by common categoriesor class. They are placed into cost levels known as tiers. It includes both brand and generic prescriptionmedications approved by the U.S. Food and Drug Administration (FDA).Please note: Where differences are noted between this PDL and your benefit plan documents, thebenefit plan documents will rule. It is not a complete list of medications, and not all medications listedmay be covered under your plan. Please look at your benefit plan documents provided by your employeror health plan to see what medications are covered under your plan. You may also log on to myuhc.com orcall the toll-free member phone number on your health plan ID card for more information.How do I use my Prescription Drug List?When choosing a medication, you and your doctor should consult the PDL. It will help you and yourdoctor choose the most cost-effective prescription drugs. This guide tells you if a medication is genericor brand, and if special programs apply. Bring this list with you when you see your doctor. It is organizedby common medical conditions. Medications are then listed alphabetically.If your medication is not listed in this document, please visit myuhc.com or call the toll-free memberphone number on your health plan ID card.5
What are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which isdetermined by your employer or health plan. This is how much you will pay when you fill a prescription.Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see ifthere is a Tier 1 option available. Discuss these options with your doctor.Check your benefit plan documents to find out your specific pharmacy plan costs. Drug TierIncludesHelpful TipsTier 1Lowest CostLower-cost drugs.Some brands and genericsare also included.Use Tier 1 drugs for the lowestout‑of-pocket costs.Tier 2Mid-range CostMix of brands andgenerics.Use Tier 2 drugs, instead ofTier 3 to help reduce yourout-of-pocket costs.Tier 3Highest CostMostly higher-cost brandas well as select genericdrugs.Many Tier 3 drugs havelower‑cost options in Tier 1 or 2.Ask your doctor if they couldwork for you.Please note: Some plans may have two or four tiers, while others may not have any. If you have a highdeductible plan, the tier cost levels may apply once you hit your deductible. Refer to your enrollmentand plan materials on myuhc.com, or call the toll-free number on your health plan ID card for moreinformation about your benefit plan.When does the Prescription Drug List change? Medications may move to a lower tier at any time. Medications may move to a higher tier when a generic becomes available. Medications may move to a higher tier or be excluded from coverage most often onJanuary 1 or July 1.When a medication changes tiers, you may have to pay a different amount for that medication.For the most up-to-date list, call customer service at the number on your ID card.6
Programs and LimitsSome medications are noted with letters next to them. The letters refer to our pharmacy benefitprograms. Your benefit plan determines how these medications are covered and may differ than whatis noted in the PDL. Call the number for Member Services listed on your ID card if you have anyquestions about your prescription drug coverage.DSPDesignated Specialty Program – Specialty medications need to be filledat a designated specialty pharmacy for network coverage. Call the number on yourID card or call 1-888-739-5820 for more information.EMay be excluded from coverage or subject to prior authorization and/or trial/failure of another medication(s). Lower-cost options are available and covered.HHealth Care Reform Preventive – This medication is part of a Health Care Reformpreventive benefit and may be available at no cost to you.MCMultiple Copay – More than one month’s worth of medication included in package soadditional copay applies.PAPrior Authorization required* – Your doctor is required to provide additionalinformation to us to determine coverage.RSRefill and Save Program – Save money on your copayment when you refill yourprescription on time as prescribed. Program eligibility may vary.SDPSelect Designated Pharmacy – Must use a lower cost medication at retail ortransfer the impacted medication to the mail service pharmacy for network coverage.SLSupply Limit – Amount of medication covered per copayment or in a specifictime period.ST Step Therapy – Trial of a lower cost medication is required before a higher costmedication is covered.*Depending on your benefit you may have notification or medical necessity requirements for select medications. For New Jersey fully insured members this program is referred to as First Start.To learn more about a pharmacy program or to find out if it applies to you, please visit myuhc.com orcall the toll-free member phone number on your health plan ID card.7
Why are some medications excluded from coverage?Medications may be excluded from coverage under your pharmacy benefit when it works the same orsimilar as another prescription medication or an over-the-counter (OTC) medication. There may beother medication options available.Should I talk to my doctor about over-the-counter (OTC)medications?An over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to yourdoctor about available OTC options.What is the difference between brand-name and genericmedications?Generic medications contain the same active ingredients (what makes the medication work) as brandname medications, but they often cost less. Once the patent of a brand-name medication ends, the FDAcan approve a generic version with the same active ingredients. These types of medications are knownas generic medications. Sometimes, the same company that makes a brand-name medication also makesthe generic version.Is it a generic or brand-name drug?The drug list shows brand-name drugs in bold type (for example, Crestor) and generic drugs in plaintype (for example, Simvastatin).What if my doctor writes a brand-name prescription?The next time your doctor gives you a prescription for a brand-name medication, ask if a genericequivalent or lower-cost option is available and if it might be right for you. Generic medicationsare usually your lowest-cost option, but not always. For some benefit plans if a brand-name drugis prescribed and a generic equivalent is available, your cost share may be the copay PLUS the costdifference between the brand-name drug and generic equivalent. Visit myuhc.com to make sure.Are you taking a specialty medication?Specialty medications are high-cost and may be used to treat rare or complex conditions. For mostplans, these medications are managed through the Specialty Pharmacy Program. Take advantageof personalized support designed to help you get the most out of your treatment plan. VisitUHCSpecialtyRx.com or call the toll-free phone number on your health plan ID card to learn more.Please note, not all specialty medications are listed here. If you’re taking a specialty medication that ison Tier 3, call the toll-free number on your health plan ID card to talk with a pharmacist about findinglower-cost options or a financial assistance program.8
What is Mail Service Member Select?Your plan may include a home delivery program called Mail Service Member Select, which encourages youto use the OptumRx Mail Service Pharmacy for medication you take regularly. Choosing home deliverycan help you better manage the medication you take on a regular basis, and may save you time and money.You can either confirm enrollment in the OptumRx Mail Service Pharmacy or you can disenroll frommail service and continue to fill your maintenance medications at a retail pharmacy. You can get up totwo fills at a retail pharmacy before you have to decide. However, please be aware that you must make adecision about whether or not to enroll in Mail Service Member Select.If you do nothing and continue to fill your medications at a retail pharmacy, you may pay more for yourmedication until you make a decision and take action. You must confirm your decision every year.To learn more, you may log on to myuhc.com or call the toll-free member phone number on your healthplan ID card for more information.How do I get updated information about my pharmacy benefit?Since the PDL may change during your plan year, we encourage you to visit myuhc.com or call thetoll-free member phone number on your health plan ID card for more current information.Log on to myuhc.com for the following pharmacy information and tools: Pharmacy benefit and coverage information Possible lower-cost medication options Medication interactions and side effects Participating retail pharmacies by zip code Your prescription historyAnd, if Mail Service is included in your pharmacy benefit, you can also: Refill prescriptions Check the status of your order Set-up e-mail reminders for refills Manage your accountFor more informationCall the toll-free member phone number on your health plan ID card.Or, visit myuhc.com Where else can I go for information?HealthCareLane.com includes short videos to help you learn more about UnitedHealthcarebenefits and health insurance information.UHCTV.com is a fun and easy way to learn about health terms and other health-related topics.In certain documents, the Prescription Drug List (PDL) was referred to as the “Preferred Drug List (PDL).” This change in terms does not affect your benefit coverage.Medications are categorized by common therapeutic conditions in this PDL for ease of reference only. These categories do not determine coverage for the medication for your condition.Your benefit plan determines coverage for these medications.9
Drug NameDrug RequirementsTier & LimitsOraceaPenicillin V PotassiumTabletSolodynSulfamethoxazoleTrimethoprim TabletSuprax Capsule,Chewable Tablet,TabletAnti-Infectives: AntibioticsAmoxicillin Capsule,Chewable TabletAmoxicillin/PotassiumClavulanate ChewableTablet, TabletAzithromycin TabletCefadroxil Capsule,TabletCefdinir CapsuleCefixime SuspensionCefprozil TabletCefuroxime TabletCephalexin CapsuleCiprofloxacin TabletClarithromycin TabletClindamycin CapsuleDificidDoryxDoxycycline Hyclate50, 100 mg Capsule,TabletDoxycycline Monohydrate50, 100 mg CapsuleLevofloxacin TabletMetronidazole TabletMinocycline CapsuleMinocycline TabletMoxifloxacin TabletNitrofurantoin CapsuleNitrofurantoinMacrocrystal CapsuleOfloxacin Tablet1111131111113321111331Drug NameDrug RequirementsTier & Limits31313Anti-Infectives: AntifungalsSLECresembaEconazole CreamFluconazole TabletItraconazole CapsuleKetoconazole CreamNoxafil Tablet,SuspensionNystatin Cream,OintmentTerbinafine Tablet33111SLSLSL211SLAnti-Infectives: AntiviralsAcyclovir OintmentAcyclovir TabletFamciclovir TabletTamifluValacyclovir TabletValaganciclovirZovirax Cream3123213PA, SL, STSLSLSLE, SL11Bold type Brand-name drug[Plain type Generic drug]DSP Designated Specialty ProgramE May be excluded from coverageH Health Care Reform PreventiveMC Multiple CopayPA Prior Authorization requiredRS May be eligible for the Refill and Save ProgramSDP Select Designated PharmacySL Supply LimitST Step Therapy10
Drug NameDrug RequirementsTier & LimitsDrug NameBenicarBenicar tolicCartia XTCarvedilolChlorthalidoneClonidine TabletDiltiazem 24 Hour CDDiltiazem SustainedRelease CapsuleDiltiazem SustainedRelease l Succinate50, 100, 200 mgMetoprolol arotene Capsule3 DSP, E, PA, SLBicalutamide1Bosulif2 DSP, PA, SL, STCyclophosphamide2CapsuleGleevec2DSP, PA, SLHydroxyurea Capsule1Imatnib Tablet3 DSP, E, PA, SLImbruvica2DSP, PA, SLLeucovorin Calcium1TabletMercaptopurine Tablet1Revlimid2DSP, PA, SLSutent2DSP, PA, SLTargretin Capsule2DSP, PA, SLTargretin Gel3PA, SLTasigna2DSP, PA, SLXeloda1DSP, SLZytiga2DSP, PA, SLCardiovascular/Heart Disease:Coagulation TherapyClopidogrel1Effient3SLEliquis3SLEnoxaparin Sodium2SLPradaxa2SLSavaysa3SLWarfarin Sodium1Xarelto2SLCardiovascular/Heart Disease:High Blood enazepril1Benazepril1Hydrochlorothiazide11Drug RequirementsTier & Limits2221SLSL1221112221233111111111112111SLSLSLSL
Drug NameDrug RequirementsTier & LimitsPropranolol Extended2Release CapsulePropranolol d-ReleaseCardiovascular/Heart Disease:High CholesterolAtorvastatin1SLCholine Fenofibrate3ECrestor2SLFenofibrate 43, 50 , 67,130, 134, 150, 200 mg3ECapsuleFenofibrate3E48, 145 mg TabletFenofibrate254, 160 mg TabletFenoglide3EFluvastatin Extended3SL, STRelease TabletGemfibrozil1Bold type Brand-name drug[Plain type Generic drug]DSP Designated Specialty ProgramE May be excluded from coverageH Health Care Reform PreventiveMC Multiple CopayDrug NameLescol XLLipitorLipofenLivaloLovastatinNiacin ExtendedRelease TabletNiaspanOmega-3-Acid EthylEsters Tricor 48, 145 mgTrilipixVascepaVytorinWelcholZetiaDrug RequirementsTier & Limits33331E, SL, STE, SLESL, ST323PA21331333323DSP, PA, SL, STDSP, PA, SL, STSLEEPASLSLCardiovascular/Heart Disease: osorbideMononitrate ERNitrostatRanexaSotalol13131PA, SLPA, SL1221PA Prior Authorization requiredRS May be eligible for the Refill and Save ProgramSDP Select Designated PharmacySL Supply LimitST Step Therapy12
Drug NameDrug RequirementsTier & LimitsCentral Nervous System:Attention Deficit DisorderAdderall XR2Amphetamine Salt1ComboAptensio 1Amphetamine TabletDextroamphetamine3Sulfate TabletFocalin XR3Guanfacine2Extended-ReleaseMetadate CD2Methylphenidate3Chewable lphenidateExtended-Release3TabletMethylphenidate Tablet1Strattera3Vyvanse2Drug NameBupropion SustainedRelease TabletBupropion TabletCitalopram TabletCymbaltaDoxepinDuloxetine CapsuleEscitalopram TabletFetzimaFluoxetine Tablet,CapsuleFluvoxamine TabletLexaproMirtazapine TabletNortriptyline CapsuleParoxetine TabletPristiq ERSertraline TabletTrazodone TabletVenlafaxine ExtendedRelease CapsuleVenlafaxine TabletViibrydPA, SLPAE, PA, SLPA, SLE, PA, SLE, PA, SLPAE, PA, SLPAPAE, PA, SLSLPA, SL1311131313E, SLSLSL, ST113111311ERS, SL113SLCentral Nervous System: MigrainePAAcetaminophen/Butalbital/Caffeine325 mg/50 mg/40 mgNaratriptanRelpaxRizatriptan ODT, TabletSumatriptan Nasal SpraySumatriptanSuccinate Tablet,InjectionSumavel DoseProE, PA, SLE, PA, SLPASLPA, SLCentral Nervous System: DepressionAmitriptyline TabletBrintellixBupropion ExtendedRelease TabletDrug RequirementsTier & LimitsSL, ST1131SL1212SLSLSLSL1SL3SL
Drug NameDrug RequirementsTier & LimitsCentral Nervous System:Multiple Gilenya3Glatopa3RebifTecfidera32DSP, PA, SLDSP, PA, SL, STDSP, PA, SLDSP, PA, SLDSP, PA, SLDSP, PA, SL, STDSP, E, PA,SL, STDSP, PA, SL, STDSP, PA, SLCentral Nervous System: OtherAbilify TabletAlprazolam ExtendedRelease TabletAlprazolam TabletAripiprazole TabletBuprenorphine/Naloxone TabletBuspirone TabletCarbidopa-LevodopaDiazepam TabletDonepezil 5, 10 mgODT, TabletLatudaLithium CapsuleLorazepam TabletMemantine TabletModafinil TabletNamenda XRNuvigilOlanzapine TabletPramipexole TabletQuetiapine Tablet3E, SL112SL3E, PA, SL11113112333111SLPA, SLEE, PA, SLSLBold type Brand-name drug[Plain type Generic drug]DSP Designated Specialty ProgramE May be excluded from coverageH Health Care Reform PreventiveMC Multiple CopayDrug NameDrug RequirementsTier & LimitsRisperidone Tablet1Ropinirole Tablet1Seroquel XR3Suboxone Film3Tolcapone2Xyrem3Zelapar3Ziprasidone Capsule2Zubsolv2Central Nervous System:Sedatives/HypnoticsEszopiclone Tablet2Temazepam Capsule1Triazolam Tablet1Zaleplon Capsule1Zolpidem Extended3Release TabletZolpidem Tablet1Central Nervous System:Seizure DisordersCarbamazepine Tablet1Clonazepam Tablet1Diazepam Tablet1Divalproex Delayed1Release TabletDivalproex Extended1Release TabletGabapentin Capsule,1TabletLamotrigine acetam Tablet1Lyrica3Oxcarbazepine Tablet1SLE, PA, SLPA, SLSLPA, SLSLSLE, SLSLSDP, SL, STPA Prior Authorization requiredRS May be eligible for the Refill and Save ProgramSDP Select Designated PharmacySL Supply LimitST Step Therapy14
Drug NamePhenytoin Capsule,SuspensionTopiramate TabletZonisamide CapsuleDrug RequirementsTier & LimitsDrug NameCondylox GelDesonide 0.05% Cream,Lotion, OintmentDesoximetasone Gel,OintmentDifferin 1%Cream, GelDiflorasone Diacetate0.05% Cream, OintmentEpiduoFinaceaFluocinolone Cream, Oil,Ointment, SolutionFluocinonide 0.05%CreamHalobetasol OintmentHydrocortisone 2.5%Cream, OintmentImiquimod 5% CreamMetronidazole 0.75%Topical GelMirvasoMometasone FuroateCream, Lotion, OintmentMupirocin OintmentNystatin-TriamcinoloneAcetonide Cream,OintmentOxsoralen-UlPicatoRegranexTacrolimus OintmentTazoracTretinoinTretinoin MicrospheresTriamcinolone AcetonideCream, Lotion, ene 0.1%Cream, GelAdapalene 0.3% GelBetamethasoneDiproionate 0.05%Augmented Lotion,OintmentBetamethasoneDipropionate 0.05%Cream, OintmentCaracCiclopirox Cream, Gel,Lotion, SolutionClaravisClindamycin 1%/Benzoyl Peroxide 5% GelClindamycin 1.2%/Benzoyl Peroxide 5% GelClindamycin GelClindamycin LotionClindamycin Solution,SwabsClobetasol PropionateCream, OintmentClobetasol PropionateSolutionClotrimazoleBetamethasone CreamClotrimazoleBetamethasone Lotion33E, PASL3PA, SL3PA, SL32212PA3E, SL3SL33SL12SL1SL1SL115Drug RequirementsTier & Limits33SL3SL2PA, SL3SL33SL3SL1212SL13SL113E2322313SLPA, SLPA, SLPA, SLPA, SLE, PA, SL13SL
Drug NameDrug RequirementsTier & LimitsHumulin 70-30 VialsHumulin N KwikPenHumulin N VialsHumulin R VialsLantus SolostarLantus VialsLevemir FlexTouchLevemir VialsNovolin 70-30 VialsNovolin N VialsNovolin R VialsNovolog FlexTouchNovolog Mix70/30 FlexTouchNovolog Mix70/30 VialsNovolog VialsToujeo SoloStarDiabetes: Blood Glucose MonitoringAccu-ChekTest StripsContour Test StripsDexcom ContinuousGlucose MonitoringSystemDexcom SensorDexcom TransmitterFreeStyle Test StripsOneTouchTest StripsOneTouch UltraMeterOneTouch Ultra MiniOneTouch UltraTest StripsOneTouch VerioOneTouch Verio IQOneTouch Verio SyncOneTouch VerioTest Strips3E, SL3E, SL3PA, SL333PA, SLPA, SLE, SL1SL111SL111Drug RequirementsTier & Limits121133113333SLSLSLSLSLSLSLSLSDP, SL, STSDP, SL, STSDP, SL, STSDP, SL, ST3SDP, SL, ST3SDP, SL, ST33SDP, SL, STE, SL22311SLSLSL, STDiabetes: Non-Insulin1SL32E, PA, SL, STSL2SL2SL1SL2SLDiabetes: InsulinAfrezzaHumalog KwikPenHumalog Mix 50-50KwikPenHumalog Mix 75-25KwikPenHumalog VialsHumulin 70-30KwikPenDrug NameBold type Brand-name drug[Plain type Generic drug]DSP Designated Specialty ProgramE May be excluded from coverageH Health Care Reform PreventiveMC Multiple okanaJanumetJanuviaJardiance11322332E, SL, STSLSL, STSL, STSL, STSL, STPA Prior Authorization requiredRS May be eligible for the Refill and Save ProgramSDP Select Designated PharmacySL Supply LimitST Step Therapy16
Drug NameJentaduetoKazanoKombiglyze XRMetforminMetformin ExtendedRelease Tablet (genericGlucophage rulicityVictoza 2-PakVictoza 3-PakXigduo XRDrug RequirementsTier & Limits2221Drug NameSLSLSLEye Conditions: AllergiesAzelastine 0.05%Ophthalmic SolutionLastacaftOlopatadine 0.1%Ophthalmic SolutionPataday12221223233SLSLSLSLSLSLSL, STSLSLE, SL, ST2Erythromycin 0.5%Ophthalmic OintmentGentamicin OphthalmicOintment, SolutionMoxezaOfloxacin 0.3%Ophthalmic SolutionTobramycin/Dexamethasone0.3%-0.1% OphthalmicSuspensionTobramycin OphthalmicSolutionVigamoxDSP, PA, SLEndocrine: OtherCalcitriol Capsule1Desmopressin Tablet1Dexamethasone Tablet1Methylprednisolone1TabletPrenisolone Oral1SolutionPrednisone Tablet1Endocrine: Thyroid HormoneReplacementArmour Thyroid3Levothyroxine Sodium1TabletLiothyronine Sodium2TabletMethimazole Tablet1NP Thyroid Tablet1Synthroid2Tirosint31SL3SL3SL3E, SLEye Conditions: AntibioticsEndocrine: Growth HormoneNutropin,Nutropin AQDrug RequirementsTier & Limits1131213Eye Conditions: GlaucomaAlphagan P 0.1%AzoptCombiganLatanoprost 0.005%Ophthalmic SolutionLumiganTimolol Maleate 0.25%,0.5% OphthalmicSolutionTravatan ZE17222SLSLSL12SL12SL
Drug NameDrug RequirementsTier & LimitsGastrointestinal: Acid SuppressionDexilantEsomeprazole CapsuleLansoprazole CapsulesNexium CapsuleOmeclamox-PakOmeprazole CapsulePantoprazole TabletPyleraRanitadine SyrupRabeprazole TabletSucralfate Tablet33333113131SLE, SLE, SLE, SLSLSLSL32113SLSL3232223PA, SL, STGastrointestinal: OtherAmitizaAprisoAsacol HD ropineTabletGolytelyHyoscyamine TabletLialdaLinzessMetoclopramide TabletMovantikMoviprepPolyethyleneGlycol 3350PrepopikSuclearSulfasalazine TabletSuprepUcerisZenpepDrug RequirementsTier & Limits2123PA, SLPA, SL2331332Hepatitis CGastrointestinal: Nausea/VomitingAkynzeoEmendOndansetronOndansetron ODTTransderm-ScopDrug Name1212Bold type Brand-name drug[Plain type Generic drug]DSP Designated Specialty ProgramE May be excluded from coverageH Health Care Reform PreventiveMC Multiple CopayEEDaklinzaHarvoniRibapakRibavirin TabletSovaldiTechnivieViekira Pak2231233DSP, PA, SL, STDSP, PA, SLDSP, EDSPDSP, PA, SL, STDSP, PA, SLDSP, PA, SL, ed-ReleasePA Prior Authorization requiredRS May be eligible for the Refill and Save ProgramSDP Select Designated PharmacySL Supply LimitST Step Therapy18
Drug ivicayTriumeqTruvadaTybostVireadVitektaDrug RequirementsTier & Limits222232322222DSPDSPDSPDSPDSP, STDSPDSPDSPDSPDSPDSPDSP21223DSPDSPDSPDSPDSPDrug NameMen’s Health: Erectile en’s Health: ProstateAlfuzosin Tablet
Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications.
Select 4 Tier Drug List. Drug list — Four Tier Drug Plan . Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA). The following is a list
coinsurance for covered health care benefits. Your insurance company pays the rest. Drug Tier means a group of Prescription Drug Products that correspond to a specified cost sharing tier in your health insurance policy. The drug tier in which a Prescription Drug Product is placed determines your portion of the cost for the drug.
Prescription drug abuse can lead to addiction. Prescription drug abuse is illegal. Prescription drug abuse can have serious health consequences. Just one instance of accidental misuse or intentional abuse of prescription drugs can be deadly. Knowledge and understanding of these concepts will help prevent the
The SPDAP provides a prescription drug benefit subsidy, which was determined by MDH for CY2017, which may pay all or some of the premiums for Federal Medicare Part D prescription drug coverage. Medicare Prescription Drug Program rate information for Maryland is determined by the Centers for Medicare and Medicaid Services (CMS). During CY2017, the
Prescribed Drug Spending in Canada, 2020: A Focus on Public Drug Programs — Methodology Notes. Data sources. National Prescription Drug Utilization Information System . The drug claims and formulary data used in this analysis comes from the National . Prescription Drug Utilization Information System (NPDUIS) at the Canadian Institute
17.SWOT Analysis II. Prescription Drug Segment 1. Prescription Drug Segment Highlights 2. Prescription Drug Sales III. Over-the-counter Drug Segment . Brazil’s health expenditure is expected to grow at a CAGR of 9.2% through 2018, supported by increased investments in the country’s universal and
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare.
2 - DRUG LIST Updated 10/2018 Welcome to Humana-The Humana Drug List (also known as a formulary) is effective on January 1st unless otherwise specified. This is an all-inclusive list and may change throughout the year. What is the Drug List? The Drug List is a list of covered medicines s
