Medication Therapy Management Guide - Portland, TX

MTMP Guide 2018-2019

2018-2019

Medication Therapy Management Guide

Choice and Select MTMP Plan Options, Effective June 1, 2019

The Medication Therapy Management approach is a progressive model of prescription utilization and

consumer centered purchase options. The program offers the consumer a variety of options for prescription

access and out of pocket cost management. Over the Counter, vaccines/immunizations, generic, best brand,

non-best brand, and cost share prescriptions are available. Step therapy, prior authorization, and cost share

prescriptions (Choice MTMP) are management tools incorporated into the program to assist in managing

evidence-based prescription cost. Enclosed are the prescription resources to assist in effective prescription

purchasing.

● Prescription Flowsheet ● OptumRx Single Sign-On Access

● Step Therapy/RxResults ● OptumRx Consumer Portal

● Clinical Prior Authorization/RxResults ● OptumRx Mail Order Service

● OptumRx Vaccine/Immunization Network ● OptumRx Mobile Friendly Website: m.optumrx.com

● Value Based Benefits for Chronic Conditions (Diabetes, ● OptumRx Mobile Application

Hypertension & High Cholesterol) ● Covered and Non-Covered Drugs

BriovaRx, The OptumRx Specialty/Biotech Pharmacy ● Qualified High Deductible Health Savings Account

● Cost Share Prescription Copays/Sample Cost Share Letter Benefit Plans Wellness Drug List

● OptumRx Accessing the Pharmacy Locator - ● Political Subdivision Preferred/Formulary

● Internet Direct Access (IDA) » Choice MTMP: Select Formulary

» Select MTMP: Premium Formulary and Cost Share

Medications Excluded

The popularity of pharmacy compounding has grown in recent years due to significant sterilization

requirements and profit potential for pharmacies. When combining ingredients to make a “customized”

medication, pharmacies may price the final product at a premium - which can result in additional plan

costs. There are legitimate clinical reasons for compounding, such as dye allergies or difficulty in

swallowing pills. However, there is growing concern about the quality of compound medications, which

are not monitored by the Food and Drug Administration (FDA).

A thoughtful and comprehensive approach is needed to help members address the safety and rising costs of

compound prescriptions. As a result, OptumRx has enhanced the Pharmacy Compound Network

Management Strategy - effective January 1, 2017. Compound claims filled at non-credentialed pharmacies

will no longer be covered. Members may continue to fill covered compound medications at a broad range

of credentialed pharmacies. To locate a credentialed pharmacy, members can access the NCCP Pharmacy

Locator Guide or call the OptumRx phone number on the ID card.

http://m.optumrx.com/

https://campaign.optum.com/content/dam/optum/resources/Guides/PharmacyLocatorGuide.pdf

https://campaign.optum.com/content/dam/optum/resources/Guides/PharmacyLocatorGuide.pdf

http://www.tmlhealthbenefits.org/

MTMP Guide 2018-2019 2

Healthcare Services for our Bilingual (English and Spanish) Membership

Translation Line: (800) 385-9952 [email protected]

Current Documents in Spanish Spanish Translation Support Per Request

» Benefit Documents » Enrollment/Change/Termination Forms

Summary of Benefits and Coverage (SBC) » Online Enrollment System (OES)

Enrollment Poster » Medical Intelligence Denials

Teladoc FAQs » Explanation of Benefits (EOB)

Teladoc Getting Started

» Forms

Right of Recovery Form (Subrogation)

Other Insurance Form

Protected Health Information Authorization

Form

» Medical Intelligence Documents

CM and DM Welcome Letter

Health Coach Flyer

CM and DM Education Letter

CM and DM Outreach Letter

Call Letter

CM-Self-Management Plan Letter

CM-Transition in Care for Parent Letter

CM-Transition in Care for Unable to Reach

Letter

Wellbeing Assessment

mailto:[email protected]


Helpful Resources

Please visit our website at tmlhealthbenefits.org for current benefit information 24 hours/7days a

week.

Address: PO Box 149190, Austin, Texas 78714-9190

Secured Customer Care E-mail: Login at tmlhealthbenefits.org >> "Contact Us" >> "I have a

general question"

Mobile Access: iPhone App Store, Android Google Play, or

tmlhealthbenefits.org for all other phones

Medical Information

Customer Care Helpline (800) 282-5385 7:00 AM - 6:00 PM Central

Translation Line (800) 385-9952 [email protected]

Medical Authorizations (800) 847-1213 8:30 AM - 5:00 PM Central

Where to Mail Paper Medical Claims TML Health, PO Box 149190, Austin, Texas 78714-9190

Telehealth (Teladoc) 1-800-Teladoc or (800) 835-2362 member.teladoc.com/signin

Prescription Information

Prescription Authorizations

(RxResults)

Toll Free

(844) 853-9400

Local

(501) 367-8402

Fax

(855) 856-3291

7:00 AM - 7:00 PM

Central

Where to Mail Paper OptumRx Claims OptumRx, PO Box 29044 Hot Springs, AR 71903

OptumRx Member Customer Service (888) 543-1369 optumrx.com

OptumRx Pharmacy Help Desk -

Pharmacist and Mail Customer Service (800) 788-7871 (TTY 711) optumrx.com

BriovaRx, The OptumRx

Specialty/Biotech Pharmacy (866) 218-5445 or (855) 4BRIOVA | Fax: (800) 491-7997

http://tmlhealthbenefits.org/



mailto:[email protected]

https://member.teladoc.com/signin

http://www.optumrx.com/



Table of Contents

Helpful Resources ............................................................................................................................... 3

How to get the most out of your Medication Therapy Management Program (MTMP) ......................... 5

MTMP Alliance Partners .............................................................................................................................5

TML Health will offer two MTMP Plans as Employer Choice .....................................................................5

MTMP MAC Options ...................................................................................................................................6

Covered Individual Copayments/Financial Responsibility .........................................................................7

Step Therapy ..................................................................................................................................... 10

Clinical Prior Authorization ................................................................................................................ 11

OptumRx Vaccine/Immunization Network Services ........................................................................... 16

Value Based Benefits for Chronic Conditions (Diabetes, Hypertension & High Cholesterol) ................. 19

BriovaRx Specialty/Biotech Pharmacy ............................................................................................... 20

Cost Share Prescription Copays for Choice MTMP .............................................................................. 25

Prescription Benefits ......................................................................................................................... 28

Covered and Non-Covered Drugs ....................................................................................................... 30

Drugs Covered under this Benefit ............................................................................................................30

Drugs Not Covered under this Benefit .....................................................................................................30

Miscellaneous Exclusions .........................................................................................................................32

Qualified High Deductible Health Savings Account Benefit Plans Wellness Drug List ........................... 34

Political Subdivision Choice Select Formulary .................................................................................... 39

Political Subdivision Select Premium Formulary ................................................................................. 51

OptumRx Pharmacy Resources .......................................................................................................... 65

Mobile Application ...................................................................................................................................65

Mobile Friendly Website ..........................................................................................................................65

Consumer Portal .......................................................................................................................................67

Mail Order Service ....................................................................................................................................68


How to get the most out of your Medication Therapy Management Program (MTMP)

MTMP Alliance Partners

Pharmacy Benefit Manager Network: OptumRx Membership: (888) 543-1369 | optumrx.com | 24 hours

a day/7 days a week

OptumRx Online Pharmacy Locator Tool: Members can locate a Value Network pharmacy near them

by using the OptumRx Online Pharmacy Locator Tool at optumrx.com.

OptumRx Pharmacy and Mail Service Customer Service: (800) 788-7871 (TTY 711) | optumrx.com

BriovaRx, The OptumRx Specialty Pharmacy: (866) 218-5445 or (855) 4BRIOVA | Fax: (800) 491-

7997

Submit OptumRx Paper Prescription Claims to: OptumRx | PO Box 29044 | Hot Springs, AR 71903

Evidence-Based Medication Review: RxResults | Toll Free: (844) 853-9400 | Local: (501) 367-8402 |

Fax: (855) 856-3291

RxResults provides both clinical and economical evaluations of drugs through its Pharmacy and

Therapeutics (P&T) Committee.

TML Health will offer two MTMP Plans as Employer Choice

1. Select MTMP Plan: MAC A Only

A. Premium Formulary (Exclusive Formulary)

B. Cost Share Prescriptions Excluded

C. New to Market Medications OptumRx Pharmacy and Therapeutic Committee Release

2. Choice MTMP Plan: MAC A or MAC C Options

A. Select Formulary (Broad Formulary)

B. Cost Share Prescriptions Copays: 1-30 days $150.00/31-60 days $300.00/61-90 days $450.00

C. New to Market Medications OptumRx and RxResults Pharmacy and Therapeutic Committee

Review and Release

Note: Consumer Centered Plans are MAC A only.





MTMP MAC Options

1. MAC A Plan

If a brand name drug is dispensed and a generic alternate drug exists, the Covered Individual pays the

difference between the brand name and generic price in addition to the appropriate copayment for the

brand name. The cost difference between the brand name and generic price does not apply to any

individual deductibles or out of pocket amounts. The MAC differential applies to all prescriptions

purchased through this program when a generic alternate is available.

2. MAC C Plan

If a brand name drug is dispensed and a generic alternate drug exists, the Covered Individual pays the

appropriate brand copay.

3. Lessor of Benefit

Through the OptumRx network contract, the covered individual’s out of pocket expense is managed

by the pharmacy network agreement that the covered individual will receive the most advantageous

pricing. This would be determined by the lessor of pharmacy contracts, Usual & Customary cost

(U&C), copayments or the discounted cost the covered individual would be charged. Due to the Lessor

of Benefit, the OptumRx Reportal will be an important price transparency resource to ensure covered

individual is purchasing the prescription from the most cost effective pharmacy.

4. Eligible Prescriptions

Lessor of U&C, Market Price, and Copay

5. Ineligible Prescriptions

Lessor of U&C and Calculated Cost


Covered Individual Copayments/Financial Responsibility

Preferred Retail Pharmacies*

Benefit 1-30 Days Supply 31-60 Days Supply 61-90 Days Supply

Generic medications $5 $10 $15

Preferred/Formulary branded medications $38 $76 $114

Non-Preferred branded medications $60 $120 $180

* The OptumRx Preferred Network of Pharmacies includes HEB and Walmart (not Sam’s Club)

National/Broad Network Retail Pharmacies





Value Based Benefits for Chronic Conditions (Diabetes, Hypertension & High Cholesterol)*

Benefit 1-30 Days Supply** 31-60 Days Supply 61-90 Days Supply




* Not all medications for diabetes, hypertension and high cholesterol qualify (e.g., Cost Share prescription copays

and medication exclusions). Refer to the Medication Therapy Management Guide for the value based prescription

list). The Qualified High Deductible Plans Wellness drug list will override the value tiered list.

** Value Based Benefit Copays are applicable at the preferred, national/broad network.

Prescription Mail Service

Benefit 31-90 Days Supply

Generic medications $15

Preferred/Formulary branded Medications $114

Non-Preferred branded Medications $180

Take advantage of home delivery by online registration: Visit optumrx.com: register and follow the simple step-by-

step instructions. You can manage your medication online, including filing new prescriptions and transferring other

prescriptions to home delivery. You can also set up text message reminders to help manage your medication schedule.

Be sure to have your ID card and medication bottles on hand to have the required information.



Retail/Mail Order Cost Share Prescriptions*


Branded or generic Cost Share prescription

copays (regardless of pharmacy or pharmacy

network)

$150 $300 $450

* Cost Share prescription copays are certain branded and generic medications for which there are lower cost

therapeutic alternative medications. These therapeutic alternatives should provide equal or similar medication

therapy for a covered individual when properly dosed. Cost Share prescription copays are identified in the Cost

Share Prescription Copays section of this guide. Cost Share prescriptions are excluded from the Select Medication

Therapy Management Plan.

BriovaRx Specialty Pharmacy

Benefit 1-30 Days Supply 31-60 Days Supply** 61-90 Days Supply**

Specialty medications* $100 N/A N/A

Biosimilar and generic specialty medications $75 N/A N/A

* Specialty medications are typically medications requiring special storage, handling, administration and patient

monitoring; or is taken for complex or rare patient conditions. Some specialty medications are sometimes

biotechnology medications.

** Specialty medications are limited to no more than a 30-day supply of the medication per prescription fill.

Affordable Care Act Benefits*

Benefit 1-30 Days Supply 31-60 Days Supply 61-90 Days Supply*

Smoking cessation medications - Nicorette Gum,

Nicotine Replacement Lozenge, Nicotine

Replacement Patch, Nicotrol Inhaler, Nicotrol

Nasal Spray. Quantity limits apply (six month's

supply per plan year).

$0 $0 N/A

Preventative statin medications – Includes low to

mid-strength statin medications, atorvastatin,

lovastatin, and simvastatin. Lovastatin covered

without a prior authorization.

$0 N/A N/A

Other preventative medications – aspirin (men

aged 45-79, women aged 55-79); folic acid

(women of childbearing age); fluoride tablets

and solution (for children aged zero to five years

old – toothpastes and rinses do not qualify);

chemoprevention supplements, iron deficiency

supplements; vitamin D (65 years and over); and

bowel preparation medications OTC (Bisacodyl

EC Tab, magnesium citrate solution,

polyethylene glycol 3350).

$0 N/A N/A

* Over the counter medications covered with this benefit require a prescription from your provider.


Affordable Care Act Benefits – Women’s Preventative Health Services

Benefit

Retail Rx Medical Plan

Prescription

Plan

Oral Contraceptives Generic N/A $0 cost share

IUD Device $0 cost share $0 cost share

Implant Device $0 cost share $0 cost share

Permanent Implantable Contraceptive Coil and hysterosalpingography

services related to the fitting $0 cost share N/A

Insertion and/or Removal of Contraceptive Devices $0 cost share N/A

Urine Pregnancy Test, Urinalysis, Sonogram to Detect Placement of Device $0 cost share N/A

Injectable Contraceptives $0 cost share $0 cost share

Injectable Administration Fee $0 cost share N/A

Diaphragm (cervical), Hormone Vaginal Ring, Hormone Patch, Cervical

Cap, Spermicides, Sponges N/A $0 cost share

Diaphragm (cervical) Instruction and Fitting Fee $0 cost share N/A

Emergency Contraceptives N/A $0 cost share

Over-The-Counter (OTC) Contraceptives (contraceptive films, foams, gels) N/A $0 cost share

Contraceptive Management $0 cost share N/A

Female Condoms N/A $0 cost share

Female Surgical Sterilization $0 cost share N/A

Medications for risk reduction of breast cancer in women (age thirty-five

(35) or older) who are at increased risk for breast cancer and at low risk for

adverse medication effects: Tamoxifen or Raloxifene

N/A $0 cost share

Women found to be at increased risk using a screening tool designed to identify a family history that may be

associated with an increased risk of having a potentially harmful gene mutation must receive coverage w/o cost-

sharing for genetic counseling, and, if indicated, testing for harmful BRCA mutations. This is true regardless of

whether the woman has previously been diagnosed with cancer, as long as she is not currently symptomatic of

receiving active treatment for breast, ovarian, tubal, or peritoneal. Jan 1, 2016 genetic counseling for BRCA

testing is covered 100% as a preventive benefit.

Mandate to provide a list of the lactation counseling providers available within the network under the plan or

coverage. Grandfathered plans cannot apply cost-share expenses for OON lactation services. Services for lactation

support services w/o cost-sharing must extend for the duration of breastfeeding.

MTMP Guide 2018-2019 10

Step Therapy

For Clinical Authorization, doctor/prescription prescribers should call RxResults toll free: (844) 853-9400

or local: (501) 367-8402. Your doctor/prescription prescriber will be asked a series of questions and

RxResults will then approve or deny the authorization request.

Sample of what will occur at pharmacy: Claim is processing for Advair® & the following message will alert

the pharmacist: Step Therapy after inhaled steroid 1st or Prior Authorization call toll free: (844) 853-9400

or local: (501) 367-8402.

Asthma

Required for members <40 years of age who have not demonstrated adherence to an inhaled corticosteroid

(ICS) (at least 90 days of therapy in the past 120 days).

Category A

Inhaled corticosteroid (ICS) - Member must demonstrate adherence to an inhaled steroid and/or satisfy

specific clinical criteria as determined by RxResults prior to obtaining a Category B medication.

Category B

(Only after demonstrated compliance and/or failure with a Category A medication)

Advair® • fluticasone-salmeterol inhaler

Airduo® • Perforomist®

Breo Ellipta® • Serevent®

Brovana® • Symbicort®

Dulera® • Wixela Inhub®

Treatment Plan Adherence is required for authorization to be approved.

Note: All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Prescription Copays,

etc.) are subject to change without notice to accommodate new drug entries to the marketplace and

adjustments in established medical and pharmacy practice guidelines.

MTMP Guide 2018-2019 11

Clinical Prior Authorization

The list of conditions below may change as appropriate for the plan. For prior authorization requests, please

have your doctor/prescription prescriber call RxResults toll free: (844) 853-9400 or local: (501) 367-8402.

Your doctor/prescription prescriber will be asked a series of questions and RxResults will approve or deny

the request. A prior authorization is active for no more than one year.

The following medications may be reimbursed when approved by prior authorization review:

Acne Medications Tretinoin all dosage forms (e.g. Retin-A, Differin, Tazorac) for individuals 26 years of age or older

Analgesics/Anti-inflammatory/Pain Agents Actiq® fentanyl lozenges Fentora®

Antifungals VFEND® voriconazole

Congestive Heart Failure Corlanor® Entresto®

Gastrointestinals Amitiza® Linzess® Movantik® Trulance® (excluded from the SELECT MTMP)

Gout Uloric®

Lipid Reducers Vascepa®

Major Specialty/Biotech Medications Refer to the Specialty/Biotech section in this guide.

Migraine Medications Aimovig® Ajovy® Emgality®

Narcolepsy Medications armodafinil modafinil Nuvigil® Provigil® Xyrem®

Topical Anesthetics 5% lidocaine patches 5% Lidoderm® patch

Note: All clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Prescription Copays,

etc.) are subject to change without notice to accommodate new drug entries to the marketplace and

adjustments in established medical and pharmacy practice guidelines.

MTMP Guide 2018-2019 12

Sample Denial Member Letter

RxResults

320 Executive Ct, Ste 201

Little Rock, AR 7220

«Decision Date»

«Patient Name»

«Patient Address Line 1»«Patient Address Line 2»

«Patient City», «Patient State Code»«Patient Zip»

Dear Prescription Benefit Plan Participant:

RxResults is an organization that provides prior authorization services, or clinical reviews, for your prescription

benefit plan. This letter is to inform you that your physician, «Prescriber Name», recently requested plan coverage

authorization for «Drug Name» on your behalf. Unfortunately, the plan cannot provide plan coverage approval for

this drug at this time due to the following reason(s):

X Your plan’s coverage policy for this medication is associated with specific requirements. Based on your

medication history available to us, these requirements do not appear to have been met.

X «Patient Explanations»

We have communicated the denied authorization, or initial adverse benefit determination, for the above drug and the

reason(s) for the denial to your physician. Information located in the following clinical resources were used to make

this decision:

«General Explanation»

As a result of this denial, your physician may choose to prescribe a substitute medication for you that is covered by

the plan. However, he or she may believe that an alternative medication is not appropriate for you and may choose to

appeal this denial by providing additional clinical information. In our communication to your physician, we also

provided instructions for submitting an appeal to the RxResults Evidence-Based Prescription Drug Program (EBRx).

As a prescription benefit plan participant, you have the right to appeal our decision to deny coverage for the above

drug. If you wish to appeal, you may request your physician to submit a written clinical appeal request to RxResults.

If your physician has not submitted an appeal already and is in agreement that an appeal is appropriate, he or she may

submit their written appeal request by facsimile to:

Attn: Physician Appeals/Medical Director

Fax #: (501) 367-7672

If you have any questions about the appeals process, please contact RxResults Member Services at 844-853-9400.

What if my situation is urgent?

If your situation meets the definition of urgent under the law, your review will generally be conducted within 72

hours. Generally, an urgent situation is one in which your health may be in serious jeopardy or, in the opinion of your

physician, you may experience pain that cannot be adequately controlled while you wait for a decision on your appeal.

If you believe your situation is urgent, you may request an expedited appeal by following the instructions above for

filing an internal appeal and also you have the right to request an external review to be conducted by an independent

review organization for consideration of coverage for the above drug at the same time as this review. This request

may be submitted to your health plan administrator as explained in your health plan’s summary plan description.

Sincerely,

Clinical Pharmacist, PharmD

RxResults

MTMP Guide 2018-2019 13

Member Appeals Rights

Appeal Submission Options

Mail: TML Health, Medical Intelligence, 1821 Rutherford Lane, Austin, TX 78754-5151

Phone: (800) 847-1213 | Fax: (512) 719-6587 | Online: http://tmlhealthbenefits.org/

Appeals must be submitted twelve (12) months after receiving the denial.

Appeals may be submitted as Routine or Urgent/Emergent.

Appellant's clinician may request a peer-to-peer review with the physician or appropriate reviewer.

Appellant may request an independent review of the benefit denial.

Appellants are not required to bear costs of the independent review, including filing fees.

Appellant may request an Executive Director Appeal review.

Appellant may request an Executive Committee Board appeal review.

Appellant may request a copy of information used in denial process.

Covered Individual has the right to member representation of their choosing including an attorney and the

representative may act upon their behalf at all levels of appeals.

Covered Individual, Clinician, or designated Representative may submit written comments, documents or other

information relevant to the appeal.

Expedited external review can occur concurrently with internal appeals for urgent care.

For additional resources on appeals rights, you may contact the Texas Department Insurance consumer assistance

program at 1-855-839-2427 (1-855-TEX-CHAP).

Regulatory Timelines for Appeals

Appeal of Urgent/Emergent Request for Benefits (Adverse Pre-Determination/Notification Request) Prior to Claim

Submission

Type of Request for Benefits or Appeal

Internal/External Appeal

Process Hours/Calendar Days

If the appellant appeals the adverse notification

determination or declination of notification, the

appellant must appeal within: Internal

Twelve (12) months after receiving the

denial based on a completed review process

If the appellant’s request for emergent benefits is

incomplete TML Health will send the urgent/emergent

incomplete pre-determination/notification information

declination letter within:

Internal twenty-four (24) hours of receipt of

appellant’s information

The appellant must provide a completed information

request within: Internal

forty-eight (48) hours after receiving the

TML Health declination due to incomplete

information

If the request for urgent/emergent benefits is complete

and not approved, TML Health will send an

urgent/emergent pre-determination/notification denial

letter within:

Internal seventy-two (72) hours

If the request for concurrent review is complete and not

approved, TML Health will send a concurrent review

denial: Internal twenty-four (24) hours


MTMP Guide 2018-2019 14

Appeal of Urgent/Emergent Request for Benefits (Adverse Pre-Determination/Notification Request) Prior to Claim

Submission




If the appellant requests an Independent Review

Organization (IRO), the external review appeal request

must be submitted for the review within:

External

one hundred twenty (120) calendar days of

receipt of the original denial or response to

your appeal

The IRO will complete the review and TML Health

will submit the response of an expedited

urgent/emergent pre-determination/notification of a

benefit appeal within:

External seventy-two (72) hours

Appeal of Non-Emergent Request for Benefits (Adverse Pre-Determination/Notification Request) Prior to Claim Submission




The appellant must appeal the denial no later than: Internal Twelve (12) months after receiving the


If the request for a pre-determination/notification is

benefit information incomplete, TML Health will notify

the appellant within:

Internal five (5) calendar days

If the request for pre-determination/notification is

clinical information incomplete, TML Health will

notify you within:

Internal fifteen (15) calendar days

The appellant must then provide completed information

within: Internal

forty-five (45) calendar days after receiving

an extension notice*

TML Health will notify you of the first level appeal

decision within: Internal

fifteen (15) calendar days after receiving the

first level appeal

The appellant must appeal the first level appeal (file a

second level appeal) within: Internal

sixty (60) calendar days after receiving the

first level appeal decision

TML Health will notify you of the second level appeal

decision within: Internal

fifteen (15) calendar days after receiving the

second level appeal*

The appellant may request the appeal be submitted to

an IRO. The External Review Request must be

submitted within:

External



your appeal

The IRO must complete the review of a non-emergent

claim or benefit appeal within: External thirty (30) calendar days

* A one-time extension of no more than fifteen (15) days only if more time is needed due to circumstances beyond the appellant’s

control.

Post-Service Claims

Type of Claim or Appeal



The appellant must appeal the claim denial no later

than: Internal

Twelve (12) months after receiving the


If the appellant’s claim is incomplete, TML Health will

notify the appellant within: Internal thirty (30) calendar days

The appellant must then provide completed claim

information within: Internal

forty-five (45) calendar days after receiving

an extension notice

TML Health will notify the appellant of the first level

appeal decision within: Internal

thirty (30) calendar days after receiving the

first level appeal

The appellant must file the second level appeal within: Internal sixty (60) calendar days after receiving the

first level appeal decision

The appellant will be notified of the second level

appeal decision generally within: Internal

thirty (30) calendar days after receiving the

second level appeal

MTMP Guide 2018-2019 15

Post-Service Claims

Type of Claim or Appeal



The appellant may request an appeal be submitted to an

IRO. This request must be submitted for the review

within:

External



your appeal

The IRO must complete the review of a non-emergent

claim or benefit appeal within: External thirty (30) calendar days

The IRO must complete a requested expedited review

of an emergent claim or benefit appeal within: External seventy-two (72) hours

MTMP Guide 2018-2019 16

OptumRx Vaccine/Immunization Network Services

Get Your Flu Shot and Other Routine Vaccines

Flu Shots The flu affects millions of people each year and can lead to serious illness, or even death. The flu can be a

contagious illness caused by influenza viruses that infect the lungs, throat and nose. According to the

Centers for Disease Control and Prevention (CDC), one of the best ways to prevent the flu is by getting

vaccinated each year.1 The CDC recommends a yearly flu vaccine for everyone 6 months of age and older,

as the first and most important step in protecting against this serious disease.2

Routine Vaccines You can also keep yourself and your family members healthy with routine vaccines that prevent illnesses

like tetanus, pneumonia and shingles. Routine vaccines are available on most plans, and can help you and

your family maintain better overall health.

Easy Access to Flu Shots and Other Vaccines

OptumRx contracts with a variety of national pharmacy chains to provide members with easy access to flu

shots and other routine vaccines. Plus, members get the highest level of benefit coverage (100% for many

plans) for vaccines obtained from contracted pharmacies that participate in the Vaccine

Immunization/Injection Network administered by OptumRx.3

Many vaccines can be accessed on a walk-in network pharmacy basis. Show your ID card at an OptumRx

vaccine immunization/injection network pharmacy before getting your flu shot or vaccine and the 100%

benefit should apply. For a complete OptumRx vaccine immunization/injection network list, members will

need to register first, then log in to optumrx.com or call the number on their health plan or prescription ID

card.

Retail Pharmacies

This list represents the larger retail chain pharmacies in our network, but is not the full list. Pharmacists

administer the vaccines at these locations.

Ahold USA (Giant Food Stores, Giant of Maryland, Stop and Shop Supermarkets, Ukrop's Super

Markets)

Albertsons

CVS Pharmacy

Four B Corporation (Hen House, Price Chopper)

H-E-B Pharmacy

Hy-Vee Pharmacy

Kmart Pharmacy


http://www.giantfoodstores.com/

http://www.henhouse.com/

MTMP Guide 2018-2019 17

The Kroger Co. (Dillons, King Soopers, Fry’s, Fred Meyer, Ralphs, QFC, Harris Teeter Roundy’s, Pick

N’ Save, Copps Food Center, Metro Market, Baker’s Pharmacy, City Market, Mariano’s, Pay Less,

Owens, Jay C Food Stores, Gerbes Pharmacy)

K-VA-T Food Stores, Inc. (Food City)

Marsh Drugs LLC

Meijer Pharmacies

Publix

Safeway Affiliated Pharmacies (Carr's, Pavilion’s, Randall's, Safeway, Tom Thumb, Vons)

Shopko Stores

SUPERVALU Affiliated Pharmacies (BIGGS, Osco, Sav-On, Shaw’s Supermarket)

Thrifty White Pharmacy

Tops Markets

Walgreens Pharmacy (Duane Reade, Rite Aid, featuring a Walgreens pharmacy)

Walmart Pharmacy

Wegmans

Routine Vaccines4

Most of the following routine vaccines are available at the OptumRx vaccine immunization/injection

network pharmacies. Age restrictions or limitations may apply. The Affordable Care Act requires most

health plans to cover routine vaccines under either the medical or pharmacy benefit.

Flu Shots Flu (Influenza)*

Afluria Afluria Quad Fluad Fluarix Quad Flublok Flublok Quad

Flucelvax Quad Flulaval Quad Fluvirin Fluzone HD Fluzone ID Quad Fluzone Quad

Fluzone Quad (pediatric dose)

Routine Adult Vaccines Hepatitis A* (Adult and Pediatric)

Havrix Vaqta

Hepatitis B* (Adult and Pediatric)

Engerix-B Heplisav-B (adult only) Recombivax-HB

Human Papilloma Virus (HPV)* – Vaccine prevents HPV related cancers

Gardasil Gardasil 9

Measles, Mumps, Rubella*

MMR-II

Meningococcal* – Vaccine prevents meningitis Groups A, C, Y and W-135

Menactra Menveo

Meningococcal* – Vaccine prevents meningitis Group B

Bexsero Trumenba

Pneumococcal* – Vaccine prevents pneumonia

Prevnar13 Pneumovax 23

Tdap* – Vaccine prevents tetanus, diptheria, pertussis

Adacel Boostrix

Tetanus Diptheria* – TD

Tenivac

Varicella* – Vaccine prevents chicken pox

Varivax

http://www.safeway.com/flushots

MTMP Guide 2018-2019 18

Zoster* – Vaccine prevents shingles

Shingrix

* Vaccine type

1 Sources: http://www.cdc.gov/flu/

2 http://www.cdc.gov/flu/protect/keyfacts.htm#flu-vaccination

3 There may be some instances where a particular location of one of the vaccine providers is not participating in the national

OptumRx Vaccine Immunization/Injection network.

4 Not all vaccines on this list are available at all participating pharmacies. Members should contact their participating

pharmacy of choice to confirm vaccine availability.

All trademarks are the property of their respective owners. © 2018 Optum, Inc. All rights reserved.

http://www.cdc.gov/flu/

http://www.cdc.gov/flu/protect/keyfacts.htm#flu-vaccination

MTMP Guide 2018-2019 19

Value Based Benefits for Chronic Conditions (Diabetes, Hypertension & High Cholesterol)

Diabetes

Generic Copay

glimepiride

glipizide

glyburide

glyburide/metformin

metformin

metformin ER (generic Glucophage XR only)

pioglitazone

Insulin

Brand Copay

Humulin - vials only

Humalog - vials only

Lantus - vials only

High Blood Pressure

Generic Copay

amlodipine

atenolol

benazepril

benazepril/hctz

carvedilol

clonidine

diltiazem ER

doxazosin

furosemide

hydrochlorothiazide (hctz)

lisinopril

lisinopril/hctz

metoprolol

propranolol

verapamil

verapamil ER/SR

High Cholesterol

Generic Copay

atorvastatin

lovastatin

simvastatin

MTMP Guide 2018-2019

BriovaRx Specialty/Biotech Pharmacy

BriovaRx, The OptumRx Specialty Pharmacy is the Specialty/Biotech prescription alliance partner. Our

goal is to provide the highest quality pharmaceutical care, at lower costs.

BriovaRx Smart Fill Program

Specialty medications are an important component to managing complex diseases and conditions, and

sometimes it takes time for members to find the right dose and comfort level before they’re able to follow

their regimen. Forty-nine percent discontinue their oncology drug therapy within ninety days due to

incompatibility with medication. The Smart Fill program from BriovaRx, specialty pharmacy, offers two

strategies for dispensing specialty medications so that members get the medications they need, adhere to

their therapy, and reduce waste due to intolerance. The mandatory opt-in oncology drug therapy split fill

strategy enables twice-monthly prescription refills for the first 6 fills, while the 90-day fill program is a

voluntary offering that provides refills every three months.

BriovaRx Smart Fill Solution Overview

Split Fill

(1/2 Monthly Supply) 90-Day Supply

Conditions/Drugs Oral Oncology HIV, Multiple Sclerosis, Rheumatoid Arthritis, Transplant

Patient Stability Unstable on medication Stable on medication

Clinical Intent Adjust to medication Adherence

Program Intent Avoid waste Member convenience

Member Experience Increased clinical oversight Improved satisfaction

# Fills/Duration 6 fills over first 3 months 4 fills over 12 months

Copays 1/2 copay 3x copay

Opt in Mandatory Voluntary

Program Offering BriovaRx Exclusivity program required

No grace fills allowed

Steps Necessary for Specialty/Biotech Medication

For prior authorization requests, your provider will be required to call RxResults toll free: (844) 853-9400

or local: (501) 367-8402 for a prior authorization form.

RxResults Phone: Toll Free: (844) 853-9400 | Local: (501) 367-8402 | Fax: (855) 856-3291

BriovaRx, The OptumRx Specialty Pharmacy Phone: (866) 218-5445 or (855) 4BRIOVA | Fax: (800)

491-7997

Oncology Medication: (800) 847-1213

MTMP Guide 2018-2019 21

Ordering Specialty/Biotech Prescriptions

You can order directly from BriovaRx, The OptumRx Specialty Pharmacy by calling (866) 218-5445 or

(855) 4BRIOVA.

Disclaimer. Not all Biotech/Biosimilar medications are eligible under the MTMP. This Specialty

Pharmacy Drug List may not be a complete representation of all available specialty drugs; this list is subject

to change at any time without prior notice. Non-specialty alternatives may be a recommended first-line

therapy to treat your condition. Please consult your physician.

Generic specialty medications may not be included in the list below. Although it is not on the list, if the

brand name drug requires a prior authorization, the generic medication will require a prior authorization as

well.

Please note: Biotech = $100.00 copay, Biosimilar = $75.00 copay

Bold Underlined = non-covered

medication (Choice and Select Plan)

*Sample = Medication requires prior authorization through RxResults

(844) 853-9400

Bold Double-Underlined = non-covered

medication (Select Plan only)

*SampleDU (dual diagnosis utilization) = Oncology Diagnosis

Medication requires prior authorization through Medical Management

(800) 847-1213

Adult Incontinence

Solesta

Ammonia Detoxicants

*Ravicti

Anemia

*Aranesp DU

*Epogen DU

*Mircera DU

*Procrit DU

Anticoagulation

Arixtra

Enoxaparin

Fondaparinux

Fragmin

Lovenox

Anti-Gout Agent

*Krystexxa

Antihyperlipidemic

Juxtapid

Kynamro

*Praluent

*Repatha

*RepathaPushtro

nex System

*Repatha

Sureclick

Anti-Infective

*Daraprim

*Prevymis

Asthma

*Cinqair

*Fasenra

*Nucala

*Xolair

Birth Control

Nexplanon

Cardiovascular

*Northera

Central Nervous System Agents

*Austedo

*Brineura

*Hetlioz

*Radicava

*Sabril

*Tetrabenazin

*Vigabatrin

*Xenazine

Cystic Fibrosis

*Bethkis

*Cayston

*Kalydeco

*Kitabis Pak

*Orkambi

*Pulmozyme

*Symdeko

*Tobi Neb

*Tobi Podhalr

*Tobramycin Neb

Diagnostic

Acthrel

Duchenne Muscular Dystrophy

*Emflaza

Endocrine

*Crysvita

*Cuprimine DU

*Egrifta DU

*Firmagon

*Hydroxy Capr DU

*Jynarque

*Korlym DU

*Kuvan DU

*Lupaneta DU

*Makena

*Myalept DU

*Natpara DU

*Nityr

*Octreotide DU

*Parsabiv DU

*Procysbi

*Samsca DU

*Sandostatin DU

*Signifor DU

*Somatuline DU

*Somavert DU

*Supprelin LA DU

*Syprine DU

*Thiola DU

*Thyrogen DU

*Trientine DU

*Triptodur

*Vantas

*XuridenDU

Enzyme Therapy

Adagen

*Aldurazyme

*Aralast NP

Buphenyl

Carbaglu

*Cerdelga

*Cerezyme

*Cholbam

Cystagon

MTMP Guide 2018-2019 22

*Elaprase

*Elelyso

*Fabrazyme

*Glassia

*Kanuma

*Lumizyme

*Mepsevii

*Miglustat

*Naglazyme

*Orfadin

Phenylbutyra

*Prolastin-C

*Sodium Pheny

*Strensiq

Sucraid

*Vimizim

*Vpriv

*Zavesca

*Zemaira

Gastrointestinal Agents

*Gattex

*Ocaliva

*Xermelo

Growth Hormone Deficiency

*Genotropin

*Humatrope

*Increlex

*Norditropin

*Nutropin AQ

*Omnitrope

*Saizen

*Serostim

*Zomacton

*Zorbtive

Hematological Agents

*Fibryga

*Mozobil

*Nplate

*Panhematin

*Promacta

*Riastap

*Soliris

*Tavalisse

*Thrombat III

Hemophilia

*Advate

*Adynovate

*Afstyla

*Alphanate

*Alphanine SD

*Alprolix

*Bebulin

*Benefix

*Ceprotin

*Coagadex

*Corifact

*Eloctate

*Feiba

*Helixate FS

*Hemlibra

*Hemofil M

*Humate-P

*Idelvion

*Ixinity

*Koate

*Koate-DVI

*Kogenate FS

*Kovaltry

*Monoclate-P

*Mononine *Novoeight

*Novoseven RT

*Nuwiq

*Obizur

*Profilnine

*Rebinyn

*Recombinate

*Rixubis

*Tretten

*Vonvendi

*Wilate

*Xyntha

Hepatitis B

Adefov Dipiv

Baraclude

Entecavir

Epivir HBV

Hepsera

Lamivudine Vemlidy

Hepatitis C

Copegus

*Daklinza

Epclusa

Harvoni

*ledipasvir-sofosbuvir

Mavyret

Moderiba

*Olysio

*Pegasys

*Pegintron

Rebetol

Ribapak

Ribasphere

*Ribavirin

*sofosbuvir-velpatasvir

*Sovaldi

*Technivie

*Viekira

*Vosevi

*Zepatier

Hereditary Angioedema

*Berinert

*Cinryze

*Firazyr

*Haegarda

*Kalbitor

*Ruconest

HIV

ABACAV/LAMIV

Abacavir

Aptivus

Atazanavir

Atripla

Biktarvy

Cimduo

Combivir

Complera

Crixivan

Descovy

Didanosine

Edurant

Efavirenz

Emtriva

Epivir

Epzicom

Evotaz

Fosamprenavi

Fuzeon

Genvoya

Intelence

Invirase

Isentress

Juluca

Kaletra

Lamivud/zido

Lamivudine

Lexiva

Lopin/riton

Nevirapine

Norvir

Odefsey

Prezcobix

Prezista

Rescriptor

Retrovir

Reyataz

Ritonavir

Selzentry

Stavudine

Stribild

Sustiva

Symfi

Tenofovir

Tivicay

Triumeq

Trizivir

Trogarzo

Truvada

Tybost

Videx

Videx EC

Viracept

Viramune

Viread

Zerit

Ziagen

Zidovudine

Immune Globulin

*Atgam

*Bivigam

*Carimune NF

*Cuvitru

*Cytogam

*Flebogamma

*Gamastan S/D

*Gammagard

*Gammaked

*Gammaplex

*Gamunex-C

*Hizentra

*Hyperrab

*Hyperrab S/D

*Hyperrho S/D

*Hyqvia

*Imogam Rabie

*Kedrab

*Micrhogam

*Octagam

*Privigen

Immunological Agents

*Actimmune

*Arcalyst

*Benlysta

*Ilaris

*Lemtrada

Infertility

Bravelle

Cetrotide

Chor Gonadot

Follistim AQ

Ganirelix AC

Gonal-F

Menopur

Novarel

Ovidrel

Pregnyl

MTMP Guide 2018-2019 23

Inflammatory Conditions

*Actemra

*Cimzia

*Cosentyx

*Dupixent

*Enbrel

*Entyvio

*Humira

*Humira Pedia

*Humira Pen

*Inflectra *Kevzara

*Kineret

*Orencia

*Otezla

*Remicade

*Renflexis

*Siliq

*Simponi

*Simponi Aria

*Stelara

*Taltz

*Tremfya

*Xeljanz

*Xeljanz XR

Metabolic Bone Disease

*Reclast

*Zoledronic

*Zometa

Multiple Sclerosis

*Ampyra

*Aubagio

*Avonex

*Betaseron

*Copaxone

*Extavia

*Gilenya

*Glatiramer

*Glatopa

*Ocrevus

*Plegridy

*Rebif

*Tecfidera

*Tysabri

*Zinbryta

Musculoskeletal Agents

*Exondys 51

*Spinraza

*Xiaflex

Narcolepsy

*Xyrem

Neurological Agents

*Botox

*Dysport

*Myobloc

*Xeomin

Neutropenia

*Granix

H.P. Acthar

*Leukine

*Neulasta

*Neupogen

*Zarxio

Oncology - Injectable

*AbraxaneDU

*AdcetrisDU

*AdriamycinDU

*AdrucilDU

*Alferon NDU

*AlimtaDU

*AliqopaDU

*AlkeranDU

*ArranonDU

*ArzerraDU

*AvastinDU

*AzacitidineDU

*BavencioDU

*BeleodaqDU

*BendekaDU

*BesponsaDU

*BicnuDU

*BleomycinDU

*BlincytoDU

*BortezomibDU

*BusulfanDU

*BusulfexDU

*CampathDU

*CamptosarDU

*CarboplatinDU

*CisplatinDU

*CladribineDU

*ClofarabineDU

*ClolarDU

*CosmegenDU

*CyclophosphamideDU

*CyramzaDU

*CytarabineDU

*DacarbazineDU

*DacogenDU

*DarzalexDU

*DaunorubicinDU

*DecitabineDU

*DexrazoxaneDU

*DocetaxelDU

*DoxilDU

*DoxorubicinDU

*EligardDU

*EllenceDU

*EmplicitiDU

*EpirubicinDU

*ErbituxDU

*ErwinazeDU

*EtopophosDU

*EtoposideDU

*EvomelaDU

*FaslodexDU

*FloxuridineDU

*FludarabineDU

*Fluorouracil InjectableDU

*FolotynDU

*FusilevDU

*GazyvaDU

*GemcitabineDU

*GemzarDU

*HalavenDU

*HerceptinDU

*HycamtinDU

*IdarubicinDU

*IfexDU

*IfosfamideDU

*ImfinziDU

*ImlygicDU

*Intron ADU

*IrinotecanDU

*Istodax OVRDU

*Ixempra kitDU

*JevtanaDU

*KadcylaDU

*KepivanceDU

*KeytrudaDU

*KymriahDU

*KyprolisDU

*LartruvoDU

*LevoleucovorDU

*Lipodox 50DU

*Lupron DepotDU

*Lupron Depot PedDU

*MarqiboDU

*MelphalanDU

*MesnaDU

*MesnexDU

*MitomycinDU

*MitoxantronDU

*MustargenDU

*MutamycinDU

*MylotargDU

*NavelbineDU

*NipentDU

*OncasparDU

*OnivydeDU

*OpdivoDU

*OxaliplatinDU

*PaclitaxelDU

*PamidronateDU

*PerjetaDU

*PhotofrinDU

*PortrazzaDU

*ProleukinDU

*RituxanDU

*RomidepsinDU

*SylatronDU

*SylvantDU

*SynriboDU

*TaxotereDU

*TecentriqDU

*TemodarDU

*TeniposideDU

*TepadinaDU

*TheracysDU

*ThiotepaDU

*Tice BCGDU

*ToposarDU

*TopotecanDU

*ToriselDU

*TotectDU

*TreandaDU

*Trelstar mixDU

*TrisenoxDU

*UnituxinDU

*ValstarDU

*VectibixDU

*VelcadeDU

*VidazaDU

*VinblastineDU

*Vincasar PFSDU

*VincristineDU

*VinorelbineDU

*VyxeosDU

*XgevaDU

*YervoyDU

*YescartaDU

*YondelisDU

*ZaltrapDU

*ZanosarDU

*ZevalinDU

*ZinecardDU

*ZoladexDU

Oncology - Oral

*AfinitorDU

*AlecensaDU

*AlunbrigDU

*BexaroteneDU

*BosulifDU

*CabometyxDU

*CalquenceDU

*CapecitabineDU

MTMP Guide 2018-2019 24

*CaprelsaDU

*CometriqDU

*CotellicDU

*ErivedgeDU

*ErleadaDU

*EtoposideDU

*FarydakDU

*GilotrifDU

*GleevecDU

*Gleostine HycamtinDU

*IbranceDU

*IclusigDU

*IdhifaDU

*Imatinib MesDU

*ImbruvicaDU

*InlytaDU

*IressaDU

*JakafiDU

*KisqaliDU

*LenvimaDU

*LonsurfDU

*LynparzaDU

*MatulaneDU

*MekinistDU

*MercaptopurineDU

*MesnexDU

*NerlynxDU

*NexavarDU

*NilandronDU

*NilutamideDU

*NinlaroDU

*OdomzoDU

*PomalystDU

*PurixanDU

*RevlimidDU

*RubracaDU

*RydaptDU

*SprycelDU

*StivargaDU

*SutentDU

*TabloidDU

*TafinlarDU

*TagrissoDU

*TarcevaDU

*TargretinDU

*TasignaDU

*TemodarDU

*TemozolomideDU

*ThalomidDU

*TretinoinDU

*TykerbDU

*VenclextaDU

*VerzenioDU

*VotrientDU

*XalkoriDU

*XelodaDU

*XtandiDU

*ZejulaDU

*ZelborafDU

*ZolinzaDU

*ZydeligDU

*ZykadiaDU

*ZytigaDU

Oncology - Topical

*Valchlor

Ophthalmic Agents

Bevacizumab

Cystaran

Eylea

Iluvien

Jetrea

Keveyis

Lucentis

Luxturna

Macugen

Ozurdex

Retisert

Visudyne

Opioid Antagonists

*Sublocade

Osteoarthritis

*Durolane

*Euflexxa

*Gel-one

*Gelsyn-3

*Genvisc 850

*Hyalgan

*Hymovis

*Monovisc

*Orthovisc

*Supartz

*Synvisc

*Synvisc One

*Visco-3

Osteoporosis

*Forteo

*Prolia

*Tymlos

Pain Management

*Prialt

Parkinson's Disease

*Apokyn

Pulmonary Fibrosis

*Esbriet

*Ofev

Pulmonary Hypertension

*Adcirca

*Adempas

*Epoprostenol

*Flolan

*Letairis

*Opsumit

*Orenitram

*Remodulin

*Revatio

*Sildenafil

*Tadalafil

*Tracleer

*Tyvaso

*Uptravi

*Veletri

*Ventavis

RSV

*Ribavirin inhal

*Synagis

*Virazole

Substance Abuse Treatment

*Vivitrol

Transplant

Astagraf XL

Cellcept

Cellcept IV

Cyclosporine

Envarsus XR

Gengraf

Mycophenolat

Mycophenolic

Myfortic

Neoral

Nulojix

Prograf

Rapamune

Sandimmune

Sirolimus

Tacrolimus

Zortress

MTMP Guide 2018-2019 25

Cost Share Prescription Copays for Choice MTMP

COST SHARE PRESCRIPTIONS ARE EXCLUDED FROM SELECT MTMP

We will impose a higher copayment for drugs for which there is no clinical evidence to show that non-preferred

Cost Share prescriptions perform any better than therapeutic doses of less costly preferred "Alternative Drugs".

Drugs on the Cost Share list may also be on the OptumRx formulary. Always check the Cost Share Prescriptions

section of the Prescription Drug Plan booklet first. The Cost Share copay will apply to the drug regardless of

where it is located on the OptumRx formulary.

Drugs starting with an Upper-case letter or that have the ® symbol are brand name drugs. Drugs starting with a

lower-case letter are generic drugs.

Analgesics/Anti-Inflammatory/Pain Agents

Impacts utilization on: Duragesic®, Lazanda®, Subsys®

Alternative Drugs: fentanyl patch, fentanyl lozenge

Impacts utilization on: Anaprox®, Arthrotec®, Celebrex®, celecoxib, Daypro®, diclofenac/misoprostol

combination, Feldene®, indomethacin ER, Ketoprofen ER®, Meclofen Sod®, mefenamic acid, Mobic®,

Naprelan®, naproxen sodium 550mg, Naproxen CR®, oxaprozin, piroxicam, Ponstel®, Tivorbex®, Vivlodex®,

Zipsor®, Zorvolex®

Alternative Drugs: diclofenac, ibuprofen, meloxicam, naproxen

Impacts utilization on: Allzital®, Bupap®, butalbital/acetaminophen tablet, butalbital/acetaminophen/caffeine

capsule, Esgic® tablet, Fioricet®, Fiorinal®, Tencon®, Vanatol LQ® Solution

Alternative Drugs: anolor, butalbital/acetaminophen 50-325mg tablet (for Bupap® and Allzital®),

butalbital/acetaminophen/caffeine tablet, butalbital/aspirin/caffeine tablet (for Fiorinal®), capacet, esgic

capsule, marten tablet, zebutal

Impacts utilization on: Conzip®, tramadol ER, Ultracet®, Ultram®, Ultram ER®

Alternative Drug: tramadol, tramadol/acetaminophen

Antibiotics/Anti-Infective Agents

Impacts utilization on: Acticlate®, Adoxa®, Amoxicillin® (brand only), Doryx®, doxycycline monohydrate

capsules (except 50 and 100mg), doxycycline monohydrate tablets 150mg, doxycycline hyclate, doxycycline

hyclate DR, Minocin®, minocycline tablets, minocycline ER, Minolira®, Monodox®, Moxatag®, Oracea®,

Solodyn®, Targadox®, Vibramycin®, Xepi® cream, Ximino ER®

Alternative Drugs: amoxicillin, doxycycline, doxycycline monohydrate capsules 50 or 100mg, doxycycline

monohydrate tablets (except 150mg), minocycline capsules, mupirocin ointment

MTMP Guide 2018-2019 26

Anticonvulsants

Impacts utilization on: Sympazan® oral film

Alternative Drugs: clobazam

Antidepressants/Fibromyalgia

Impacts utilization on: Aplenzin tab

Alternative Drugs: bupropion, citalopram, duloxetine, escitalopram, fluoxetine, paroxetine, sertraline,

venlafaxine, venlafaxine ER (capsules only)

Antihypertensive Agents

Impacts utilization on: amlodipine/olmesartan, amlodipine/olmesartan/HCTZ, amlodipine/valsartan,

amlodipine/valsartan/HCTZ, Atacand®, Atacand HCT®, Avalide®, Avapro®, Azor®, Benicar®, Benicar HCT®,

Coreg CR®, Cozaar®, Diovan®, Diovan HCT®, Edarbi®, Edarbyclor®, Eprosartan®, Exforge®, Exforge HCT®,

Hyzaar®, Inderal LA, Inderal XL, InnoPran XL®, Micardis®, Micardis HCT®, olmesartan, olmesartan HCTZ,

Tekturna®, Tekturna HCT®, telmisartan/amlodipine, Tribenzor®, Twynsta®

Alternative Drugs: Any generic ACE Inhibitor; Generic ARB Agents: candesartan, candesartan HCTZ,

losartan, losartan/HCTZ, Irbesartan, irbesartan/HCTZ, telmisartan, telmisartan HCTZ, valsartan,

valsartan/HCTZ; Generic Beta Blocker Agents: carvedilol for Coreg CR; propranolol IR/ER for Inderal LA/XL

and InnoPran XL

Central Nervous System: Sedative Hypnotics

Impacts utilization on: Ambien®, Ambien CR®, Belsomra®, Edluar®, Intermezzo®, Lunesta®, Rozerem®,

Silenor®, Sonata®, zolpidem ER®, zolpidem sublingual, Zolpimist®

Alternative Drugs: doxepin, zaleplon, zolpidem immediate release

Lipid-Lowering Agents (Statins)

Impacts utilization on: Altoprev®, amlodipine/atorvastatin combination, Caduet®, Crestor®, ezetimibe,

ezetimibe-simvastatin, Lescol®, Lescol XL®, Lipitor®, Livalo®, Mevacor®, Pravachol®, Vytorin®, Zetia®,

Zocor®

Alternative Drugs: atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

Migraine Headaches

Impacts utilization on: almotriptan, Amerge®, Axert®, Frova®, frovatriptan, eletriptan, Imitrex® (brand),

Imitrex® Spray, Maxalt®, Maxalt-MLT®, naratriptan, Onzetra XSAI®, Relpax®, sumatriptan spray,

sumatriptan/naproxen, Sumavel®, Treximet®, Zembrace, zolmitriptan, Zomig®, Zomig® nasal spray, Zomig

ZMT®

Alternative Drugs: rizatriptan, sumatriptan

MTMP Guide 2018-2019 27

Osteoporosis Drugs

Impacts utilization on: Actonel®, Alendronate® (brand), Atelvia®, Binosto®, Boniva®, Fosamax®, Fosamax-

D®, ibandronate, risedronate

Alternative Drug: alendronate

Overactive Bladder Drugs

Impacts utilization on: darifenacin, Detrol®, Detrol LA®, Ditropan XL®, Enablex®, Gelnique®, Myrbetriq®,

oxybutynin ER®, Oxytrol® patches, tolterodine, tolterodine ER, Toviaz®, trospium CL, trospium CL ER,

Vesicare®

Alternative Drug: Generic: oxybutynin immediate release

Skeletal Muscle Relaxants

Impacts utilization on: Amrix®, carisoprodol 250mg tablet, Chlorzoxazone®, Fexmid®, Lorzone®, metaxalone,

Parafon Forte®, Robaxin®, Skelaxin®, Soma®, Tabradol®, tizanidine (capsules only), Zanaflex®

Alternative Drugs: Generic: carisoprodol (except 250mg tablet), chlorzoxazone, cyclobenzaprine,

methocarbamol, tizanidine tablets

MTMP Guide 2018-2019 28

Prescription Benefits

Coverage for eligible injectable and non-injectable biotech and/or biosimilar prescriptions that are available

through the MTMP, but are purchased from Medical Providers will be paid per the Medical Benefit Plan.

MTMP non-injectable prescriptions purchased outside of the Pharmacy Benefit Manager will not be an eligible

benefit under the Medical Benefit Plan other than the biotech/biosimilar prescriptions mentioned above.

MAC A Rx Plan

If a brand name drug is dispensed and a generic alternate drug exists, the Covered Individual pays the difference

between the brand name and generic price in addition to the appropriate copayment for the brand name. The

cost difference between the brand name and generic price does not apply to any individual deductibles or out

of pocket amounts. The MAC differential applies to all prescriptions purchased through this program when a

generic alternate is available.

MAC C Rx Plan

Covered individual will pay the appropriate copayment amount of the prescription.

Qualified High Deductible Health Savings Account (H.S.A.) Health Plans

The qualified high deductible H.S.A. health plan wellness drug list may be accessed at the copay out of pocket

cost. The qualified high deductible H.S.A. health plan deductible will have to be met prior to

non-wellness/preventive medications being accessed at the copay out of pocket cost. Please see the qualified

high deductible wellness drug list within this guide.

Authorized Generics

The use of authorized generics undermines the Hatch-Waxman Act by devaluing the 180 day exclusive patent

period incentive. Ultimately, consumers pay the prices as brand companies keep drug prices high and access to

affordable alternative medicine is delayed. Once a generic (single or multi source) medication alternative is

allowed on the market the generic copay will be applied. The generic company that is first to successfully

challenge a questionable brand patent, file an abbreviated new drug application with the FDA and receive

approval to market that drug is awarded 180 days exclusivity. During the 180 day period, that generic company

alone is permitted to compete with the brand company, allowing the generic company to bring affordable

medicines to consumers faster.

Patents are generally good for 20 years from the date of filing. The abbreviated new drug application approval

allows manufacturers to bring generic competitors to market which allows the generic to challenge the current

patent on the brand medication. Authorized generics are generally coded as brand drugs by Medispan and First

Databank due to single source classification and manufactured by the brand name manufacturer. This brand

coding is what causes the higher dollar out of pocket cost.

MTMP Guide 2018-2019 29

Maximum Out Of Pocket Accumulation

The Qualified High Deductible/H.S.A. Health Plan will require the individual and/or family out-of-pocket

maximum to be met before the plan pays at 100% medical and/or prescription. Medical and Prescription

copayments for most cost effective eligible Network benefit and services will accumulate to the Federal

Government H.S.A. or PPO maximum out-of-pocket (MOOP) amount. Once the Federal Government defined

MOOP is met, eligible network services within the scope of the benefit plan will be paid at 100%.

New Drugs to Market (NDTM)

NDTM drugs will be excluded until otherwise decided by the plan efficacy of medication. Quarterly Review

will be conducted and prescription eligibility will be decided by the sixth (6th) month and quarterly thereafter.

MTMP Guide 2018-2019 30

Covered and Non-Covered Drugs

Plan exclusions (Drugs Not Covered under this Benefit) apply to both the brand and generic version of the

medication unless otherwise noted. This is not a complete list and is subject to change as new drugs are added

to the market. The absence of a medication from the exclusions list does not guarantee payment by the plan.

Drugs Covered under this Benefit

1. Legend Drugs;

2. Insulin or oral diabetic prescription;

3. Disposable insulin needles/syringes and physician prescribed needles/syringes/supplies;

4. Disposable blood/urine/glucose/acetone testing agents (e.g. Acetest Tablets, Clinitest Tablets, Glucometer

(one per calendar year), Lancets, Diastix Strips, Tes-Tape and Chemstrips);

5. Diabetic supplies will be purchased with order for insulin or oral diabetic prescription. The plan will allow

needles, syringes, lancets and testing strips at no charge if ordered within 30 days of a prescription at the

same pharmacy;

6. Compound medication of which at least one ingredient is a legend drug to maximum $200.00 per

prescription payment;

7. Any other drug which under the applicable State Law may only be dispensed upon the written prescription

of a physician or other lawful prescriber;

8. Contraceptives: Oral, Brand Extended cycle (mail order only), Generic Extended cycle (Network at 90

days copay), Transdermal patches, Contraceptive devices, Levonorgestrel (Norplant), Prescription

Strength Only;

9. Depo Provera;

10. Prescribed smoking deterrent medications containing nicotine or any other smoking cessation aids, all

dosage forms;

11. Growth hormones (requires a prior authorization through RxResults);

12. Extended Release anti-depressive agents: Wellbutrin XL, Effexor XR;

13. Extended Release migraine prophylactic agents: Depakote ER.

Drugs Not Covered under this Benefit

This is not a complete list of medications excluded by the plan. This list is subject to change as new drugs are

added to the market. The absence of a medication from this list does not guarantee payment by the plan. The

exclusion applies to both the brand and generic (if available) versions of medications listed below as well as all

doses and dosage forms unless specifically noted otherwise.

1. Non-legend drugs other than those listed above;

2. Non-FDA approved medications;

MTMP Guide 2018-2019 31

3. Therapeutic devices or appliances, including support garments and other non-medicinal substances,

regardless of intended use;

4. Charges for the administration or injection of any drug;

5. Drugs labeled "Caution - limited by Federal Law to investigational use" or experimental drugs even

though a charge is made to the individual;

6. Medications which are to be taken by or administered to an individual, in whole or in part, while he or she

is a patient in a licensed hospital, rest home, sanitarium, extended care facility, convalescent hospital,

nursing home or similar premises which operates on its premises or allows to be operated on its premises,

a facility for dispensing pharmaceuticals;

7. Any prescription refilled more than the number specified by the physician or any refill dispensed after one

year from the physician’s original order;

8. Prescription which an eligible individual is entitled to receive without charges from any Workers’

Compensation Laws or which is prescribed for an injury or illness which is excluded from any medical

coverage which is provided in conjunction with this prescription benefit;

9. Prescribed prenatal vitamins are not covered under the prescription card. Claims for prescribed prenatal

vitamins with a pregnancy diagnosis may be submitted to us for payment consideration;

10. Immunization agents, biological sera blood or blood plasma;

11. Dietary supplements, vitamins or formulas, vitamins individually or in combination;

12. Nutritional supplements (i.e. Deplin®, Metanx®);

13. Fertility medications;

14. Anti-obesity medications;

15. Agents used for cosmetic purposes;

16. Male pattern baldness medications; hair growth stimulants;

17. Lifestyle convenience prescriptions (i.e. erectile dysfunction prescriptions);

18. All non-injectable testosterone (including pellet and buccal formulations), Brand injectable testosterone

is also excluded;

19. All nasal steroids (e.g. Beconase® AQ, Nasonex®, QNASL®, etc.);

20. All non-sedating/low-sedating antihistamines (e.g. Claritin®, Clarinex®, desloratadine, levocetirizine,

Zyrtec®, etc.);

21. All proton pump inhibitors (e.g. Dexilant®, Nexium®, Prilosec®, Protonix®, etc.);

22. All topical non-narcotic pain medications (e.g. Sinelee®, Flector®, Solaraze®, etc.);

23. Certain acne medications: Absorica®, all benzoyl peroxide, Altreno®, Cleocin-T® gel, Clindagel®,

Clindamycin® gel, Duac® gel, Fabior®, Refissa®, Renova®, tretinoin emulsion cream, Retin-A®, Riax®;

24. Certain analgesic/anti-inflammatory/pain agents: Acetaminophen/Caffeine/Dihydrocodone®,

Aspirin/Caffeine/Dihydrocodone®, Arymo® ER, Belbuca®, Bunavail®, Embeda®, Exalgo®,

hydromorphone ER (generic Exalgo only), Hysingla® ER, Kadian® CR/ER, Morphabond® ER,

morphine sulphate ER capsules (generic Kadian only), Nalocet®, Nucynta®, Nucynta® ER, Opana® ER,

Oxaydo®, Roxybond®, Sprix spray®, Suboxone®, bupren/naloxone (generic Suboxone®), Synalgos-DC®,

Trezix®, Zohydro® ER; Zubsolv®;

25. Certain combination analgesic and gastric reflux/stomach ulcer medications: Duexis®, Vimovo® and

Yosprala®;

MTMP Guide 2018-2019 32

26. Certain antibiotics: Impavido®, Furadantin® suspension and its generic if over 7 years old;

27. Certain anticonvulsants: Briviact®, Keppra® XR; Lamictal®, Lamictal® XR, levetiracetam ER, Qudexy

XR®, roweepra XR, Topiramate® ER, Trokendi® XR;

28. Certain antidiabetic medications: Glumetza®, metformin ER (certain 1000mg and certain 500mg

strengths), Fortamet®; Symlin®; Invokana®, Invokamet®, Invokamet® XR;

29. Certain antiemetics: Akynzeo®; Bonjesta®; Cinvanti®; Diclegis®; Emend® (suspension and tripack),

Emend® for injection, Sustol®; and Varubi®;

30. Certain antifungals: Cresemba®, Extina® Aer 2%, Jublia®, Kerydin®, Luliconazole®, Luzu®, Naftin®,

Onmel®, Tolsura ®, Vytone®, Xolegel®;

31. Certain antipsychotics: Abilify® Myci (only), Aristada®, Nuplazid®, Rexulti®;

32. Certain cholesterol/triglyceride-lowering agents: Lovaza®, Niaspan®, niacin ER, niacor; Flolipid®; all

Fenofibrates (e.g. Antara®, Lipofen®, Fenoglide®, Tricor®, etc.);

33. Certain COPD medications: Daliresp®, Lonhala Magn®, Trelegy®, Yupelri®;

34. Certain gastrointestinal agents: Mytesi®, Relistor®, Symproic®, Viberzi®, Xermelo®;

35. Certain gout agents: Duzallo®, Zurampic®;

36. Certain ophthalmic agents: Inveltys®, Rhopressa®, Vyzulta®;

37. Certain topical steroids: Enstilar®, Trianex®, Triderm®; Impoyz®; all brands with generics available; all

gels, aerosols, sprays, shampoos, tapes and lotions;

38. Most convenience kits and paks such as but not limited to: Flanax Pain Kit Relief, Morgidox Kit,

Naproxen Comfort Kit, Nutridox Kit, etc.;

39. Miscellaneous exclusions: See below for a list of the medications.

Miscellaneous Exclusions

This is not a complete list of medications excluded by the plan. This list is subject to change as new drugs are

added to the market. The absence of a medication from this list does not guarantee payment by the plan. The

exclusion applies to both the brand and generic (if available) versions of medications listed below as well as all

doses and dosage forms unless specifically noted otherwise. .

ADDYI

ALEVAMAX CRE

ALPAWASH OIN

ALZAIR NASAL SPR

ARAKODA

ATOPADERM CRE

ATOPICLAIR CRE

AUVI-Q

BALCOLTRA

BEAU RX GEL

CAROSPIR

CELACYN GEL

CERACADE EMU

COPASIL GEL

DERMACINRX PAK

DPN PAK

DERMACINRX PAK

INFLAMMA

DERMACINRX PAK

THERAZOL

DERMACINRX SOL

BASE

DERMASORB XM KIT

DEXAMETHASON

TAB 10-DAY

DEXAMETHASON

TAB 13-DAY

DEXAMETHASON

TAB 6-DAY

DEXERYL CRE

DEXPAK PAK 10 DAY

DEXPAK PAK 13 DAY

DEXPAK PAK 6 DAY

DILATRATE SR CAP

40MG

DOXEPIN HCL

CREAM

DURLAZA

ELETONE CRE

ELETONE CRE

TWINPACK

EMULSION SB EMU

EMVERM CHW

MTMP Guide 2018-2019 33

ENDOMETRIN SUP

100MG

ENTTY EMU SPRAY

EPICERAM EMU

EPIPEN 2-PAK

EPIPEN-JR

EPISIL LIQ

EVZIO INJ

FLEXIPAK PAK

GOCOVRI

GONITRO POW

GUANFACINE ER

HIDEX 6-DAY PAK

1.5MG

HPR PLUS CRE

HYLATOPIC CRE

PLUS

IMIQUIMOD CRE

PMP

INFLAMMACIN MIS

INTUNIV

ISORDIL TAB 40MG

ISORDIL TAB 5MG

ISOSORB DIN TAB

40MG ER

ISOSORB DIN TAB

40MG SA

KAMDOY EMU

KELARX GEL

LOCORT PAK 11-DAY

LOKELMA PAK

LOYON SOL

LUCEMYRA

MACRILEN PAK

60MG

MEMANT TITRA PAK

5-10MG

MEMANTINE HC ER

MEMANTINE HC SOL

MEMANTINE SOL

METOPIC CRE 41%

MIMYX CRE

NAMENDA TAB 5-

10MG

NAMENDA XR

NAMENDA XR CAP

TITRATION

NASCOBAL SPR

500MCG

NEOCERA CRE

NEOSALUS CP CRE

NEOSALUS CRE

NIVATOPIC CRE

PLUS

NOCDURNA SUB

NOCDURNA SUB

55.3MCG

NOCTIVA EMU

NOCTIVA SPR

NORITATE CRE

NUDICLO PAK

NUVAIL SOL

ORAFATE PST

OSMOLEX ER

PEG BASE OIN

PENLEN EMU SPRAY

PERTZYE

PHLAG SPR

POLYPEG OIN BASE

PREVIDOLRX PAK

PLUS

PREVYMIS

PROTHELIAL PST

PRUCLAIR CRE

PRUDOXIN CRE

PRUMYX CRE

QBREXZA PAD

RECEDO GEL

REMIGEN CREA CRE

RESTIZAN GEL

SCAR MANAGE GEL

SCARCIN GEL

SCARSILK GEL

SOLOSEC GRA 2GM

SUVICORT EMU

SYNERDERM EMU

TAPERDEX PAK 12-

DAY

TAPERDEX PAK 6

DAY

TAPERDEX PAK 7-

DAY

TDM SOLUTION SOL

TETRIX CRE

TIGLUTIK SUS

TOLAK CRE

UREA CRE 41%

UTOPIC CRE 41%

VALCHLOR GEL

XENAFLAMM PAK

XERALUX CRE

ZONACORT PAK 11

DAY

ZONALON CRE

ZOSTAVAX INJ

ZYCLARA

MTMP Guide 2018-2019 34

Qualified High Deductible Health Savings Account Benefit Plans Wellness Drug List

In addition to a healthy lifestyle, preventive medications can help people avoid many illnesses and conditions.

Preventive medications are defined as those prescribed to prevent the occurrence of a chronic disease or condition

for those individuals with risk factors, or to prevent the recurrence of a disease or condition. Some examples of

the medications listed are for high blood pressure, high cholesterol, diabetes, asthma, osteoporosis, and heart

disease.

This list provides examples of your preventive medications by drug category/therapeutic classification.

Medications may be added to or removed from the list, depending on different factors, including the intended

purpose of the medication and new medications.

To help you tell generic and brand drugs apart, all generics start with a lowercase letter.

SP Oral and self-injectable Specialty medications may be subject to limitations based on plan benefit design.

+ Products excluded from the Select Premium Formulary

‡ Where differences are noted between this Formulary and your benefit plan documents, the benefit plan

documents will rule.

This list is intended as a reference and may not be all-inclusive. Brand or generic availability may not be current

due to changes in the market. Use of generics may be required depending upon plan design.

Antipsychotics

ABILIFY

ADASUVE

aripiprazole

ARISTADA

chlorpromazine

clozapine

CLOZARIL

EQUETRO

FANAPT

FAZACLO

fluphenazine

GEODON

haloperidol

INVEGA

LATUDA

loxapine

molindone

NUPLAZID

olanzapine

olanzapine / fluoxetine

paliperidone ER

perphenazine

prochlorperazine

quetiapine

REXULTI

RISPERDAL

risperidone

SAPHRIS

SEROQUEL

SEROQUEL XR

SYMBYAX

thioridazine

thiothixene

trifluoperazine

VRAYLAR

VERSACLOZ

ziprasidone

ZYPREXA

Asthma and COPD

ACCOLATE

ADVAIR DISKUS

ADVAIR HFA

AEROSPAN

AIRDUO +

albuterol neb / syp / tab

albuterol ER

ALVESCO +

ANORO ELLIPTA

ARCAPTA

ARMONAIR +

ARNUITY ELPT

ASMANEX +

ASMANEX HFA +

ATROVENT HFA

BEVESPI +

BREO ELLIPTA

BROVANA

budesonide suspension

COMBIVENT RESPIMAT

cromolyn nebulizer solution

DALIRESP

DULERA +

ELIXOPHYLLIN

FLOVENT DISKUS

FLOVENT HFA

FLUTICASONE INH SALMETER

FORADIL

INCRUSE ELPT

ipratropium inhalation solution

MTMP Guide 2018-2019 35

ipratropium / albuterol

isoproterenol

LEVALBUTEROL AER +

levalbuterol neb

LONHALA MAGNAIR

metaproterenol

montelukast

PERFOROMIST NEB

PROAIR HFA

PROAIR RESPICLICK

PROVENTIL HFA +

PULMICORT +

PULMICORT FLEXHALER

QVAR +

SEEBRI NEOHALER +

SEREVENT DISKUS

SINGULAIR +

SPIRIVA

STIOLTO RESPIMAT

STRIVERDI RESPIMAT

SYMBICORT

terbutaline

THEO-24 CR / ER

theochron CR

theophylline

theophylline CR / ER

TRELEGY ELLIPTA

TUDORZA PRES +

UTIBRON NEOHALER +

VENTOLIN HFA

VOSPIRE ER

XOPENEX HFA +

XOPENEX SOLUTION

zafirlukast

zileuton ER

ZYFLO

ZYFLO CR

Cancer

anastrozole

ARIMIDEX

AROMASIN SP

EVISTA

exemestane SP

FARESTON

FEMARA SP

letrozole SP

raloxifene

SOLTAMOX

tamoxifen

Cardiovascular/Heart Disease

Anti-Anginal Agents

DILATRATE SR

GONITRO

ISORDIL

isosorb dinitrate

isosorbide dinitrate ER

isosorbide mononitrate

isosorbide mononitrate ER

minitran

NITRO-BID

NITRO-DUR

nitroglycerin

NITROLINGUAL SPR

NITROMIST

NITROSTAT +

nitro-time

petn

RANEXA

Anticoagulants

AGGRENOX

ARIXTRA SP

ASA / dipyridamole

BEVYXXA

BRILINTA

cilostazol

clopidogrel

COUMADIN

dipyridamole

DURLAZA

EFFIENT

ELIQUIS

enoxaparin SP

fondaparinux SP

FRAGMIN SP

heparin

jantoven

LOVENOX SP

PERSANTINE

PLAVIX

PLETAL

PRADAXA

prasugrel

SAVAYSA

ticlopidine

warfarin

XARELTO

YOSPRALA

ZONTIVITY

Cardiac Glycosides

digitek

digox

digoxin

LANOXIN

High Blood Pressure

ACCUPRIL

ACCURETIC

acebutolol

ACEON

ADALAT CC

afeditab CR

ALDACTAZIDE

ALDACTONE

ALTACE

amiloride

amiloride / hctz

amlodipine

amlodipine / atorvastatin

amlodipine / benazepril

amlodipine / olmesartan

amlodipine / valsartan

ATACAND

ATACAND HCT

atenol / chlorthalidone

atenolol

AVALIDE

AVAPRO

AZOR +

benazepril

benazepril / hctz

BENICAR +

BENICAR HCT +

BETAPACE

BETAPACE AF

betaxolol

BIDIL

bisoprolol

bisoprolol / hctz

bumetanide

BUMEX

BYSTOLIC

BYVALSON

CADUET

CALAN

CALAN SR

candesartan

candesartan / hctz

captopril

captopril / hctz

CARDIZEM

CARDIZEM CD

CARDIZEM LA

CARDURA

cartia XT

carvedilol

CATAPRES

CATAPRES TTS

chlorothiazide

chlorthalidone

clonidine

CLORPRES

COREG

COREG CR

CORGARD

CORZIDE

COZAAR

DEMADEX

DEMSER

DIBENZYLINE

dilt-XR

diltiazem

diltiazem CD

diltiazem ER

MTMP Guide 2018-2019 36

DIOVAN +

DIOVAN HCT +

DIURIL

doxazosin

DUTOPROL

DYAZIDE

DYRENIUM

EDARBI

EDARBYCLOR

EDECRIN

enalapril

enalapril / hctz

EPANED

eplerenone

eprosartan

ethacrynic acid

EXFORGE

EXFORGE HCT

ezide

felodipine ER

fosinopril

fosinopril / hctz

furosemide

guanfacine

HEMANGEOL

hydralazine

hydrochlorothiazide

HYZAAR

indapamide

INDERAL LA

INDERAL XL

INNOPRAN XL

INSPRA

irbesartan

irbesartan / hctz

isradipine

labetalol

LASIX

lisinopril

lisinopril / hctz

LOPRESSOR

LOPRESSOR HCT

losartan

losartan / hctz

LOTENSIN

LOTENSIN HCT

LOTREL

matzim LA

MAVIK

MAXZIDE

MAXZIDE-25

methyclothiazide

methyldopa

methyldopa / hctz

metolazone

METOPRO / HCTZ

metoprolol

metoprolol ER

metoprolol / hctz

MICARDIS

MICARDIS HCT

MICROZIDE

MINIPRESS

minoxidil

moexipril

moexipril / hctz

nadolol

nadolol / bendroflumethiazide

nicardipine

nifedical XL

nifedipine

nifedipine ER

nimodipine

nisoldipine

nisoldipine ER

NORVASC +

NYMALIZE

olmesartan

olmesartan / amlo / hctz

olmesartan / hctz

perindopril

phenoxybenzamine

pindolol

prazosin hcl

PRESTALIA

PRINIVIL

PROCARDIA

PROCARDIA XL

propranolol

propranolol ER

propranolol / hctz

QBRELIS

quinapril

quinapril / hctz

ramipril

SECTRAL

sotalol

sotalol AF

SOTYLIZE

spironolactone

spironolactone / hctz

SULAR

TARKA

taztia XT

TEKTURNA

TEKTURNA HCT

telmisartan

telmisartan / amlodipine

telmisartan / hctz

TENEX

TENORETIC

TENORMIN

terazosin

TIAZAC

timolol (tablet)

TOPROL XL +

torsemide

trandolapril

trandolapril / verapamil

triamterene / hctz

TRIBENZOR +

TWYNSTA

valsartan

valsartan / hctz

VASERETIC

VASOTEC

VECAMYL

verapamil

verapamil ER / SR

VERELAN

VERELAN PM

ZEBETA

ZESTORETIC

ZESTRIL

ZIAC

High Cholesterol

ALTOPREV

ANTARA

atorvastatin

cholestyramine

cholestyramine lite

COLESTID

colestipol

CRESTOR +

ezetimibe

ezetim / simva

fenofibrate

fenofibric

fenofibric DR

FENOGLIDE

FIBRICOR

FLOLIPID

fluvastatin

gemfibrozil

JUXTAPID SP

KYNAMRO SP

LESCOL XL

LIPITOR +

LIPOFEN

LIVALO

LOFIBRA

LOPID

lovastatin

LOVAZA +

MEVACOR

niacin ER (Rx)

niacor

NIASPAN ER

omega-3-acid (Rx)

PRALUENT SP

PRAVACHOL

pravastatin

prevalite

QUESTRAN

QUESTRAN LITE

REPATHA SP

MTMP Guide 2018-2019 37

rosuvastatin

simvastatin

TRICOR

TRIGLIDE

triklo

TRILIPIX

VASCEPA

VYTORIN +

WELCHOL

ZETIA +

ZOCOR

ZYPITAMAG

Contraceptives ‡

This section lists contraceptive categories.

Please note that brands and generics are

eligible.

CONTRACEPTIVE PATCH

CONTRACEPTIVE RING (NUVARING)

EMERGENCY CONTRACEPTIVES

IMPLANT CONTRACEPTIVE

INJECTABLE CONTRACEPTIVE

IUDs

ORAL CONTRACEPTIVES

Diabetes

Insulin

ADMELOG +

AFREZZA

APIDRA +

BASAGLAR +

FIASP +

HUMALOG

HUMALOG KWIKPEN

HUMALOG MIX

HUMULIN

LANTUS

LANTUS SOLOSTAR

LEVEMIR +

NOVOLIN +

NOVOLIN RELION +

NOVOLOG +

NOVOLOG MIX +

TOUJEO

TRESIBA FLEX +

Non-Insulin

acarbose

ACTOPLUS MET

ACTOPLUS MET XR

ACTOS

ADLYXIN +

ALOGLIPTIN +

ALOGLIPTIN / METFORMIN +

ALOGLIPTIN / PIOGLITAZONE +

AMARYL

BYDUREON

BYETTA

chlorpropamide

CYCLOSET

DIABETA

DUETACT

FARXIGA +

FORTAMET +

glimepiride

glipizide

glipizide / metformin

glipizide ER

glipizide XL

GLUCOPHAGE

GLUCOPHAGE XR

GLUCOTROL

GLUCOTROL XL

GLUCOVANCE

GLUMETZA +

glyburide

glyburide / metformin

glyburide micronized

GLYNASE

GLYSET

GLYXAMBI

INVOKAMET

INVOKAMET XR

INVOKANA

JANUMET

JANUMET XR

JANUVIA

JARDIANCE

JENTADUETO

JENTADUETO XR

KAZANO +

KOMBIGLYZE XR +

metformin

metformin ER

miglitol

nateglinide

NESINA +

ONGLYZA +

OSENI +

OZEMPIC

pioglitazone

pioglitazone / glimepride

pioglitazone / metformin

PRANDIN

PRECOSE

QTERN +

repaglinide

RIOMET

SOLIQUA

SEGLUROMET

STEGLATRO

STEGLUJAN

STARLIX

SYMLIN

SYNJARDY

SYNJARDY XR

TANZEUM +

tolazamide

tolbutamide

TRADJENTA

TRULICITY

VICTOZA

XIGDUO XR +

XULTOPHY

Estrogens

ACTIVELLA

ALORA

amabelz

ANGELIQ

CLIMARA

CLIMARA PRO

COMBIPATCH

covaryx

covaryx HS

DIVIGEL

DUAVEE

eemt

eemt HS

ELESTRIN

est estrogen mtest

est estrogen mtest HS

estra / noreth

ESTRACE (ORAL TAB)

estrad val

estradiol (oral tabs, patch)

estrog / mtest

ESTROGEL

estropipate

EVAMIST

FEMHRT

fyavolv

jevantique

jinteli

lopreeza

MENEST

MENOSTAR

mimvey

mimvey lo

MINIVELLE

noreth / ethin

PREFEST

PREMPHASE

PREMARIN (ORAL TAB)

PREMPRO

VIVELLE-DOT +

Gastrointestinal-Ulcer Drugs‡

ACIPHEX +

AXID

CARAFATE +

cimetidine

CYTOTEC

DEXILANT

Esomeprazole +

MTMP Guide 2018-2019 38

ESOMEPRAZOLE 24.65MG AND

49.3MG +

famotidine

lanso / amox / clarith

lansoprazole

misoprostol

NEXIUM +

nizatidine

OMECLAMOX

omeppi

omepra / bicar +

omeprazole

pantoprazole

PEPCID

PREVACID +

PREVPAC

PRILOSEC

PROTONIX

PYLERA

rabeprazole

ranitidine

sucralfate

ZANTAC

ZEGERID +

HIV/AIDS

abacavir / lamivudine SP

abacavir SP

abacavir / lamivudine / zidovudine SP

APTIVUS SP

atazanavir SP

ATRIPLA SP

BIKTARVY SP

COMBIVIR SP

COMPLERA SP

CIMDUO SP

CRIXIVAN SP

DESCOVY SP

didanosine SP

EDURANT SP

efavirenz SP

EMTRIVA SP

EPIVIR SP

EPZICOM SP

EVOTAZ SP

fosamprenavir SP

FUZEON SP

GENVOYA SP

INTELENCE SP

INVIRASE SP

ISENTRESS SP

JULUCA SP

KALETRA SP

lamivudine SP

lamivudine / zidovudine SP

LEXIVA SP

lopinavir / ritonavir sol SP

nevirapine SP

nevirapine ER SP

NORVIR SP

ODEFSEY SP

PREZCOBIX SP

PREZISTA SP

RESCRIPTOR SP

RETROVIR SP

REYATAZ SP

ritonavir SP

SELZENTRY SP

stavudine SP

STRIBILD SP

SUSTIVA SP

SYMFI LO SP

tenofovir SP

TIVICAY SP

TRIUMEQ SP

TRIZIVIR SP

TRUVADA SP

TYBOST SP

VIDEX SP

VIDEX EC SP

VIRACEPT SP

VIRAMUNE SP

VIRAMUNE XR SP

VIREAD SP

VITEKTA SP

ZERIT SP

ZIAGEN SP

zidovudine SP

Osteoporosis

ACTONEL

alendronate

ATELVIA

BINOSTO

BONIVA

calcitonin spray

etidronate

EVISTA

FORTEO SP

FOSAMAX

FOSAMAX + D

ibandronate

MIACALCIN SPRAY

raloxifene

risedronate

Smoking Deterrents ‡

bupropion

CHANTIX

NICODERM CQ

NICORETTE

nicotine gum / lozenge / patch

NICOTROL INH / NS

ZYBAN

Transplant

ASTAGRAF XL SP

AZASAN

azathioprine

CELLCEPT SP

cyclosporine SP

cyclosporine modified SP

ENVARSUS XR SP

gengraf SP

IMURAN

mycophenolate SP

mycophenolic DR SP

MYFORTIC SP

NEORAL SP

PROGRAF SP

RAPAMUNE SP

SANDIMMUNE SP

sirolimus SP

tacrolimus cap SP

ZORTRESS SP

Vitamins & Electrolytes

Pediatric vitamins with fluoride

(for example; POLY-VI-FLOR, tri-vit / fl)

generic products

BRAND NAME PRODUCTS

Prenatal multivitamins with iron and

folic acid

(for example; OB COMPLETE, prenatabs

RX)

generic products

BRAND NAME PRODUCTS

MTMP Guide 2018-2019 39

Political Subdivision Choice Select Formulary

The most up to date formulary may be located at https://tmlhealthbenefits.org/.

The most effective way to control costs is through the use of generic drugs and a drug formulary.

Drug Tier Includes

Tier 1:

Preferred Network Tier

* The OptumRx Preferred Network of Pharmacies includes HEB and Walmart (not Sam’s

Club). Use Tier 1 drugs for the lowest out-of-pocket costs.

Tier 2:

Value Tiered

Not all medications for diabetes, hypertension, and high cholesterol qualify (e.g., Cost Share

prescription exclusions). Copays are applicable. Use Tier 2 drugs, instead of Tier 3, to

help reduce your out-of-pocket costs.

Tier 3 Most commonly used generic drugs. Some low-cost brands may be included. Many Tier 3

drugs have lower cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Tier 4:

Mid-range Cost

Many common brand-name drugs, called preferred brands. Lower cost alternative drugs are

listed in the Cost Share prescriptions section of this booklet.

Tier 5:

High Cost Mostly higher cost brand drugs, also known as non-preferred brands.

Tier 6:

Highest Cost

High cost brand and generic drugs that have very similar or equivalent low cost alternative

drugs.

Tier 7:

Biotech/Biosimilar

Specialty Prescriptions

Biotech drugs differ from pharmaceutical drugs in that they use biotechnology as a means for

manufacturing, which involves the manipulation of microorganisms, such as bacteria, or

biological substances, like enzymes, to perform a specific process. Biosimilar prescriptions

are biologic medical products which are almost identical to the original product.

Tier E

Excluded

May be excluded from coverage or subject to prior authorization. Lower-cost options are

available and covered.

Tier i-P Preferred specialty injectables

Check your benefit plan documents to find out your specific prescription plan costs.

Tier i-NP Non-preferred specialty injectables

Check your benefit plan documents to find out your specific prescription plan costs.

* Drugs may transition from tier to tier within benefit plan year impacting your out of pocket expense.

https://tmlhealthbenefits.org/

MTMP Guide 2018-2019 40

Some of the medications on this list may NOT be covered by your plan or have additional restrictions. Their

presence on this list does NOT guarantee coverage.

SP = Specialty Medication – Medication is designated as specialty. 3P = Tier 3 preferred

DRUG NAME DRUG

TIER NOTES

ANALGESICS - DRUGS FOR PAIN

acetaminophen-codeine #2 1



acetaminophen-codeine oral tablet 1

butalbital-apap-caffeine oral capsule 1

butalbital-apap-caffeine oral tablet 50-

325-40 mg

1

EMBEDA E

fentanyl 1

hydrocodone-acetaminophen oral tablet

10-300 mg, 10-325 mg, 2.5-325 mg, 5-

300 mg, 5-325 mg, 7.5-300 mg, 7.5-325

mg

1

hydromorphone hcl oral tablet 1

HYSINGLA ER E

methadone hcl oral tablet 1

morphine sulfate er oral tablet extended

release

1

oxycodone hcl oral tablet 1

oxycodone-acetaminophen oral tablet

10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-

325 mg

1

OXYCONTIN ORAL TABLET ER 12

HOUR ABUSE-DETERRENT

2

tramadol hcl ir 1

tramadol-acetaminophen 1

ZOHYDRO ER ORAL CAPSULE ER

12 HOUR ABUSE-DETERRENT

E

ANALGESICS - DRUGS FOR PAIN AND INFLAMMATION

celecoxib oral 4

diclofenac potassium 1

diclofenac sodium oral 1

diclofenac sodium transdermal gel 1 % E

etodolac oral tablet 1

FLECTOR E

ibuprofen oral tablet 400 mg, 600 mg,

800 mg

1

indomethacin oral 1

ketorolac tromethamine oral 1

meloxicam oral tablet 1

nabumetone oral 1

naproxen oral tablet 1

naproxen sodium oral tablet 275 mg, 550

mg

1

sulindac oral 1

DRUG NAME DRUG

TIER NOTES

ANESTHETICS

lidocaine external ointment E

lidocaine external patch 5 % 1 PA

ANTI-ADDICTION / SUBSTANCE ABUSE TREATMENT AGENTS

BUNAVAIL E

buprenorphine hcl sublingual 1

buprenorphine hcl-naloxone hcl 1

CHANTIX STARTING MONTH PAK 3

naltrexone hcl oral 1

NARCAN 2

SUBOXONE SUBLINGUAL FILM 2

ZUBSOLV 2

ANTIBACTERIALS

amoxicillin oral capsule 1

amoxicillin oral suspension reconstituted 1

amoxicillin oral tablet 1

amoxicillin-potassium clavulanate oral

suspension reconstituted 200-28.5

mg/5ml, 250-62.5 mg/5ml, 400-57

mg/5ml, 600-42.9 mg/5ml

1


tablet 250-125 mg, 500-125 mg, 875-

125 mg

1

azithromycin oral suspension

reconstituted

1

azithromycin oral tablet 250 mg, 500

mg, 600 mg

1

BETHKIS 2 SP

cefdinir 1

cefuroxime axetil oral tablet 1

cephalexin oral capsule 1

cephalexin oral suspension reconstituted 1

ciprofloxacin hcl oral 1

clarithromycin oral tablet 1

clindamycin hcl oral 1

clindamycin phosphate external gel 1

clindamycin phosphate external lotion 1

clindamycin phosphate external solution 1

CLINDESSE 3

DORYX MPC 4

doxycycline hyclate oral capsule 1

doxycycline hyclate oral tablet 100 mg,

150 mg, 20 mg, 75 mg

4

doxycycline monohydrate oral capsule 1

doxycycline monohydrate oral tablet 1

levofloxacin oral tablet 1

MTMP Guide 2018-2019 41

DRUG NAME DRUG

TIER NOTES

metronidazole oral tablet 1

metronidazole vaginal 1

minocycline hcl oral capsule 1

mupirocin external 1

nitrofurantoin macrocrystal oral 1

nitrofurantoin monohydrate

macrocrystals

1

penicillin v potassium oral tablet 1

SOLODYN ORAL TABLET

EXTENDED RELEASE 24 HOUR 105

MG, 115 MG, 55 MG, 65 MG, 80 MG

4

sulfamethoxazole-trimethoprim oral

suspension 200-40 mg/5ml

1

sulfamethoxazole-trimethoprim oral

tablet

1

ANTICOAGULANTS

ELIQUIS 2

enoxaparin sodium i-NP SP

PRADAXA 2

SAVAYSA 3

warfarin sodium oral 1

XARELTO 2

XARELTO STARTER PACK 2

ANTICONVULSANTS - DRUGS FOR SEIZURES

carbamazepine oral tablet 1

divalproex sodium er oral tablet

extended release 24 hour

1

divalproex sodium oral tablet delayed

release

1

gabapentin oral capsule 1

gabapentin oral tablet 1

lamotrigine oral tablet 1

levetiracetam oral tablet 1

oxcarbazepine oral tablet 1

phenytoin sodium extended 1

topiramate oral tablet 1

VIMPAT 3

zonisamide oral 1

ANTIDEMENTIA AGENTS - DRUGS FOR ALZHEIMER'S DISEASE

AND DEMENTIA

donepezil hcl oral tablet 1

memantine hcl oral tablet 10 mg, 5 mg 1

NAMZARIC ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 14-

10 MG, 28-10 MG

2

ANTIDEPRESSANTS

amitriptyline hcl oral 1

bupropion hcl er (sr) 1

bupropion hcl er (xl) 1

bupropion hcl oral 1

citalopram hydrobromide oral tablet 1

DRUG NAME DRUG

TIER NOTES

desvenlafaxine succinate er 1

doxepin hcl oral capsule 1

duloxetine hcl oral capsule delayed

release particles 20 mg, 30 mg, 60 mg

1

DULOXETINE HCL ORAL CAPSULE

DELAYED RELEASE PARTICLES 40

MG

3

escitalopram oxalate oral tablet 1

fluoxetine hcl oral capsule 1

fluoxetine hcl oral tablet 1

FORFIVO XL 2

mirtazapine oral tablet 1

nortriptyline hcl oral capsule 1

paroxetine hcl er 1

paroxetine hcl oral tablet 1

sertraline hcl oral tablet 1

trazodone hcl oral 1

TRINTELLIX 3

venlafaxine hcl 1

venlafaxine hcl er 1

VIIBRYD ORAL TABLET 3

VIIBRYD STARTER PACK 3

ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING

meclizine hcl oral tablet 25 mg 1

metoclopramide hcl oral tablet 1

ondansetron hcl oral tablet 1

ondansetron odt 1

prochlorperazine maleate oral 1

VARUBI ORAL E

ANTIFUNGALS

fluconazole oral tablet 1

GYNAZOLE-1 3

JUBLIA E

KERYDIN E

ketoconazole external cream 1

ketoconazole external shampoo 1

nystatin external cream 1

nystatin mouth/throat 1

terbinafine hcl oral 1

terconazole vaginal cream 1

ANTIGOUT AGENTS

allopurinol oral 1

COLCHICINE ORAL TABLET 3

COLCRYS 2

ULORIC 2 PA

ZURAMPIC E

ANTIMIGRAINE AGENTS

MIGRANAL 3

ONZETRA XSAIL 4

rizatriptan benzoate 1

MTMP Guide 2018-2019 42

DRUG NAME DRUG

TIER NOTES

sumatriptan succinate oral 1

SUMAVEL DOSEPRO

SUBCUTANEOUS SOLUTION JET-

INJECTOR

4

ANTINEOPLASTICS - DRUGS FOR CANCER

anastrozole oral 1

CABOMETYX 2 SP

capecitabine 1 SP

IBRANCE 3 SP

letrozole oral 1

mercaptopurine oral 1 SP

REVLIMID 3 SP

SPRYCEL 2 SP

tamoxifen citrate oral 1

XTANDI 3 SP

ZYTIGA 3 SP

ANTIPARASITICS

EMVERM E

hydroxychloroquine sulfate oral 1

permethrin external cream 1

SOOLANTRA 2

ANTIPARKINSON AGENTS

benztropine mesylate oral 1

carbidopa-levodopa oral tablet 1

pramipexole dihydrochloride 1

ropinirole hcl 1

ZELAPAR 3

ANTIPLATELETS

BRILINTA 2

cilostazol 1

clopidogrel bisulfate oral 1

ANTIPSYCHOTICS - DRUGS FOR MOOD DISORDERS

aripiprazole oral tablet 1

ARISTADA INTRAMUSCULAR

PREFILLED SYRINGE 441

MG/1.6ML, 662 MG/2.4ML, 882

MG/3.2ML

3

haloperidol oral 1

INVEGA SUSTENNA 3

INVEGA TRINZA 3

LATUDA 3

olanzapine oral tablet 1

quetiapine fumarate 1

REXULTI E

risperidone oral tablet 1

SAPHRIS 2

ziprasidone hcl 1

DRUG NAME DRUG

TIER NOTES

ANTIVIRALS

abacavir sulfate-lamivudine 1 SP

acyclovir oral capsule 1

acyclovir oral tablet 1

ATRIPLA 2 SP

COMPLERA 2 SP

DESCOVY 3 SP

entecavir 1 SP

EPCLUSA 2 SP

GENVOYA 2 SP

HARVONI 2 SP

INTELENCE 2 SP

ISENTRESS ORAL TABLET 2 SP

MAVYRET 2 SP

NORVIR ORAL TABLET 2 SP

ODEFSEY 2 SP

oseltamivir phosphate oral capsule 1

PREZCOBIX 2 SP

PREZISTA ORAL TABLET 150 MG,

600 MG, 75 MG, 800 MG

2 SP

REYATAZ ORAL CAPSULE 150 MG,

200 MG, 300 MG

3 SP

STRIBILD 2 SP

TIVICAY 2 SP

TRIUMEQ 2 SP

TRUVADA 2 SP

valacyclovir hcl oral 1

VIREAD ORAL TABLET 150 MG, 200

MG, 250 MG

2 SP

VIREAD ORAL TABLET 300 MG 3 SP

VOSEVI 2 SP

ZOVIRAX EXTERNAL CREAM 2

ZOVIRAX EXTERNAL OINTMENT 3

ANXIOLYTICS - DRUGS FOR ANXIETY

alprazolam oral tablet 1

buspirone hcl oral 1

clonazepam oral tablet 1

diazepam oral tablet 1

hydroxyzine hcl oral tablet 1

hydroxyzine pamoate oral 1

lorazepam oral tablet 1

triazolam 1

BIPOLAR AGENTS - DRUGS FOR MOOD DISORDERS

lithium carbonate er 1

lithium carbonate oral capsule 1

MTMP Guide 2018-2019 43

DRUG NAME DRUG

TIER NOTES

BLOOD PRODUCTS / MODIFIERS / VOLUME EXPANDERS - DRUGS

FOR BLEEDING DISORDERS

AFSTYLA i-P SP

ARANESP (ALBUMIN FREE)

INJECTION SOLUTION 100

MCG/ML, 200 MCG/ML, 25 MCG/ML,

300 MCG/ML, 40 MCG/ML, 60

MCG/ML

i-P SP


INJECTION SOLUTION PREFILLED

SYRINGE

i-P SP

GRANIX i-P SP

NEUPOGEN INJECTION SOLUTION

300 MCG/ML, 480 MCG/1.6ML

i-P SP


PREFILLED SYRINGE

i-P SP

NUWIQ i-P SP

PROCRIT i-P SP

ZARXIO i-P SP

CARDIOVASCULAR AGENTS - DRUGS FOR HEART AND

CIRCULATION CONDITIONS

amiodarone hcl oral 1

amlodipine besylate oral 1

amlodipine besylate-benazepril hcl 1

amlodipine besylate-valsartan 1

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral 1

benazepril hcl oral 1

benazepril-hydrochlorothiazide 1

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide 1

bumetanide oral 1

BYSTOLIC 2

BYVALSON 2

cartia xt 1

carvedilol 1

chlorthalidone oral tablet 25 mg, 50 mg 1

choline fenofibrate 1

clonidine hcl oral 1

CRESTOR 4

digox 1

digoxin oral tablet 1

diltiazem hcl er beads 1

diltiazem hcl er coated beads oral

capsule extended release 24 hour

1

diltiazem hcl oral 1

doxazosin mesylate 1

EDARBI 4

EDARBYCLOR 4

enalapril maleate oral 1

ezetimibe 1

ezetimibe-simvastatin 1

DRUG NAME DRUG

TIER NOTES

fenofibrate micronized oral capsule 134

mg, 200 mg, 67 mg

E

fenofibrate oral tablet E

fenofibric acid oral capsule delayed

release

E

flecainide acetate 1

furosemide oral tablet 1

gemfibrozil oral 1

guanfacine hcl oral 1

hydralazine hcl oral 1

hydrochlorothiazide oral 1

irbesartan 1

irbesartan-hydrochlorothiazide 1

isosorbide mononitrate er 1

labetalol hcl oral 1

LIPOFEN E

lisinopril oral 1

lisinopril-hydrochlorothiazide 1

LIVALO 4

losartan potassium 1

losartan potassium-hctz 1

lovastatin 1

metoprolol succinate er 1

metoprolol tartrate oral 1

MULTAQ 3

nadolol oral tablet 20 mg, 40 mg, 80 mg 1

niacin er (antihyperlipidemic) E

nifedipine er 1

nifedipine er osmotic release 1

nitroglycerin sublingual 1

olmesartan medoxomil oral 4

olmesartan medoxomil-hctz 4

omega-3-acid ethyl esters E

pentoxifylline er 1

PRALUENT SUBCUTANEOUS

SOLUTION PEN-INJECTOR

E SP

pravastatin sodium 1

prazosin hcl oral 1

propranolol hcl er 1

propranolol hcl oral tablet 1

quinapril hcl 1

ramipril 1

RANEXA 2

REPATHA E SP

REPATHA PUSHTRONEX SYSTEM E SP

REPATHA SURECLICK E SP

rosuvastatin calcium 1

simvastatin oral 1

sotalol hcl oral 1

spironolactone oral 1

TEKTURNA 4

TEKTURNA HCT 4

telmisartan 4

torsemide oral 1

MTMP Guide 2018-2019 44

DRUG NAME DRUG

TIER NOTES

triamterene-hctz 1

valsartan 1

valsartan-hydrochlorothiazide 1

VASCEPA E

verapamil hcl er oral tablet extended

release 120 mg, 180 mg, 240 mg

1

verapamil hcl oral 1

WELCHOL 2

CENTRAL NERVOUS SYSTEM AGENTS - DRUGS FOR ATTENTION

DEFICIT DISORDER

ADDERALL XR 3

amphetamine-dextroamphetamine 1

amphetamine-dextroamphetamine er 1

atomoxetine hcl 1

CONTEMPLA XR-ODT 3

dexmethylphenidate hcl 1

dexmethylphenidate hcl er 1

guanfacine hcl er E

methylphenidate hcl er 1

methylphenidate hcl er oral tablet 1

methylphenidate hcl oral tablet 1

VYVANSE 2

CENTRAL NERVOUS SYSTEM AGENTS - DRUGS FOR MULTIPLE

SCLEROSIS

AMPYRA 2 SP

AUBAGIO 3 SP

AVONEX PEN INTRAMUSCULAR

AUTO-INJECTOR KIT

i-P SP

AVONEX PREFILLED

INTRAMUSCULAR PREFILLED

SYRINGE KIT

i-P SP

AVONEX VIAL INTRAMUSCULAR

KIT

i-P SP

BETASERON SUBCUTANEOUS KIT i-P SP

COPAXONE SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE

i-P SP

GILENYA 3 3P; SP

TECFIDERA 2 SP

CENTRAL NERVOUS SYSTEM AGENTS - MISCELLANEOUS

CONTRAVE E

GRALISE 4

GRALISE STARTER 4

LYRICA ORAL CAPSULE 4

phentermine hcl oral tablet E

DENTAL AND ORAL AGENTS - DRUGS FOR MOUTH AND THROAT

CONDITIONS

chlorhexidine gluconate mouth/throat 1

lidocaine viscous 1

DERMATOLOGICAL AGENTS - DRUGS FOR SKIN CONDITIONS

ABSORICA E

DRUG NAME DRUG

TIER NOTES

ACZONE 2

adapalene external gel 1

ATRALIN 3

claravis 1

clindamycin phosphate-benzoyl peroxide

external gel 1-5 %

1

clotrimazole-betamethasone external

cream

1

COSENTYX 150 MG/ML i-P 3P; SP

COSENTYX 300 DOSE i-P 3P; SP

COSENTYX SENSOREADY 300

DOSE

i-P 3P; SP

COSENTYX SENSOREADY PEN

SUBCUTANEOUS SOLUTION

AUTO-INJECTOR 150 MG/ML

i-P 3P; SP

DIFFERIN EXTERNAL GEL 0.3 % 3

DIFFERIN EXTERNAL LOTION 3

DUPIXENT i-P SP

ELIDEL 2

ENSTILAR E

EPIDUO 3

EPIDUO FORTE 3

EUCRISA 2

FLUOROPLEX 3

METROGEL EXTERNAL GEL 3

metronidazole external gel 1

MIRVASO 2

ONEXTON 3

ORACEA 4

OXSORALEN ULTRA 2

RETIN-A MICRO GEL 0.04 %, 0.1 % E

RETIN-A MICRO PUMP EXTERNAL

GEL 0.04 %, 0.1 %

E

RETIN-A MICRO PUMP EXTERNAL

GEL 0.06 %, 0.08 %

E

STELARA SUBCUTANEOUS


i-P SP

TACLONEX E

TAZORAC 3

tretinoin external cream 1

VECTICAL 3

ZYCLARA 3

ZYCLARA PUMP 3

DIABETES - ANTIDIABETIC AGENTS

BYDUREON BCISE AUTOINJECTOR 2

BYDUREON PEN 2

BYDUREON VIAL 2

BYETTA 10 MCG PEN 2

BYETTA 5 MCG PEN 2

FARXIGA 3

glimepiride 1

glipizide er 1

glipizide ir 1

glipizide xl 1

MTMP Guide 2018-2019 45

DRUG NAME DRUG

TIER NOTES

glyburide oral 1

glyburide-metformin 1

INVOKAMET E

INVOKAMET XR E

INVOKANA E

JANUMET 2

JANUMET XR 2

JANUVIA 2

JARDIANCE 2

JENTADUETO 2

JENTADUETO XR 2

KOMBIGLYZE XR ?

metformin hcl er 1

metformin hcl er (mod) E

metformin hcl er (osm) oral tablet

extended release 24 hour 1000 mg, 500

mg

E

metformin hcl ir 1

ONGLYZA 3

pioglitazone hcl 1

SOLIQUA 2

SYNJARDY 2

SYNJARDY XR 2

TRADJENTA 2

TRULICITY 2

VICTOZA 2

DIABETES - GLUCOSE MONITORING

ACCU-CHEK AVIVA CONNECT KIT

W/DEVICE

2

ACCU-CHEK AVIVA PLUS 2

ACCU-CHEK COMPACT PLUS

CARE KIT

2

ACCU-CHEK COMPACT PLUS TEST

STRIPS

2

ACCU-CHEK FASTCLIX LANCET

KIT

2

ACCU-CHEK FASTCLIX LANCETS 2

ACCU-CHEK GUIDE 2

ACCU-CHEK MULTICLIX LANCET

DEVICE KIT

2

ACCU-CHEK MULTICLIX LANCETS 2

ACCU-CHEK NANO SMARTVIEW

KIT W/DEVICE

2

ACCU-CHEK SMARTVIEW TEST

STRIPS

2

ACCU-CHEK SOFT TOUCH

LANCETS

2

ACCU-CHEK SOFTCLIX LANCET

DEVICE KIT KIT

2

ACCU-CHEK SOFTCLIX LANCETS 2

DEXCOM G4 PLATINUM

PEDIATRIC RECEIVER DEVICE

3

DRUG NAME DRUG

TIER NOTES

DEXCOM G4 PLATINUM

RECEIVER, SENSOR,

TRANSMITTER DEVICE

3

DEXCOM G5 SENSOR,

TRANSMITTER, MOBILE RECEIVER

3

ONETOUCH ULTRA 2 KIT

W/DEVICE

2

ONETOUCH ULTRA BLUE TEST

STRIPS

2

ONETOUCH ULTRA MINI KIT

W/DEVICE

2

ONETOUCH VERIO 2

ONETOUCH VERIO FLEX SYSTEM

KIT W/DEVICE

2

ONETOUCH VERIO TEST STRIPS 2

ONETOUCH VERIO IQ SYSTEM KIT

W/DEVICE

2

ONETOUCH VERIO SYNC SYSTEM

KIT W/DEVICE

2

DIABETES - INSULINS

HUMALOG U-100 AND U-200

KWIKPEN

2

HUMALOG MIX 50/50 KWIKPEN 2

HUMALOG MIX 50/50 VIAL 2



HUMALOG U-100 JUNIOR

KWIKPEN

2

HUMALOG U-100 VIAL AND

CARTRIDGE

2

HUMULIN 70/30 KWIKPEN 2

HUMULIN 70/30 VIAL 2

HUMULIN N KWIKPEN 2

HUMULIN N VIAL 2

HUMULIN R U-500 KWIKPEN 2

HUMULIN R U-500 VIAL

(CONCENTRATED)

2

HUMULIN R VIAL 2

LANTUS U-100 SOLOSTAR 2

LANTUS U-100 VIAL 2

LEVEMIR U-100 FLEXTOUCH 2

LEVEMIR U-100 VIAL 2

NOVOFINE AUTOCOVER PEN

NEEDLE

2

NOVOFINE PEN NEEDLE 2

NOVOFINE PLUS PEN NEEDLE 2

NOVOLIN 70/30 VIAL 2

NOVOLIN N VIAL 2

NOVOLIN R VIAL 2

NOVOLOG U-100 FLEXPEN 2

NOVOLOG MIX 70/30 FLEXPEN 2

NOVOLOG MIX 70/30 VIAL 2

NOVOLOG U-100 PENFILL 2

NOVOLOG U-100 VIAL 2

MTMP Guide 2018-2019 46

DRUG NAME DRUG

TIER NOTES

NOVOTWIST PEN NEEDLE 32G X 5

MM

2

TOUJEO SOLOSTAR 2

TRESIBA FLEXTOUCH 2

ELECTROLYTES / MINERALS / METALS / VITAMINS

cyanocobalamin injection 1

folic acid oral tablet 1 mg 1

klor-con m20 1

ludent 1

potassium chloride crys er 1

potassium chloride er 1

potassium citrate er 1

VELTASSA 3

vitamin d (ergocalciferol) 1

GASTROINTESTINAL AGENTS - DRUGS FOR ACID REFLUX AND

ULCER

DEXILANT E

esomeprazole magnesium E

famotidine oral tablet 20 mg, 40 mg 1

lansoprazole oral capsule delayed release E

omeprazole oral capsule delayed release E

pantoprazole sodium oral E

rabeprazole sodium E

ranitidine hcl oral capsule 1

ranitidine hcl oral syrup 1

ranitidine hcl oral tablet 150 mg, 300 mg 1

sucralfate oral tablet 1

GASTROINTESTINAL AGENTS - DRUGS FOR BOWEL, INTESTINE

AND STOMACH CONDITIONS

AMITIZA 3

dicyclomine hcl oral capsule 1

dicyclomine hcl oral tablet 1

diphenoxylate-atropine oral tablet 1

gavilyte-g 1

LINZESS 2

MOVIPREP 3

OMECLAMOX-PAK E

polyethylene glycol 3350 oral powder 1

PREPOPIK 3

PYLERA E

RELISTOR SUBCUTANEOUS

SOLUTION 12 MG/0.6ML

E

SUPREP BOWEL PREP KIT 3

VIBERZI 3

GENETIC OR ENZYME DISORDER: DRUGS FOR REPLACEMENT,

MODIFIERS, TREATMENT

CERDELGA 3 SP

CREON 2

ZENPEP ORAL CAPSULE DELAYED

RELEASE PARTICLES 10000 UNIT,

15000 UNIT, 20000-63000 UNIT,

2

DRUG NAME DRUG

TIER NOTES

25000 UNIT, 3000-10000 UNIT, 5000

UNIT

GENITOURINARY AGENTS - DRUGS FOR BLADDER, GENITAL

AND KIDNEY CONDITIONS

CIALIS E

DEPEN TITRATABS 2 SP

MYRBETRIQ 4

oxybutynin chloride er 4

oxybutynin chloride oral tablet 1

phenazopyridine hcl oral tablet 100 mg,

200 mg

1

RENVELA ORAL TABLET 3

tolterodine tartrate er 4

TOVIAZ 4

VELPHORO 3

VESICARE 4

VIAGRA E

GENITOURINARY AGENTS - DRUGS FOR PROSTATECONDITIONS

alfuzosin hcl er 1

finasteride oral tablet 5 mg 1

RAPAFLO 2

tamsulosin hcl 1

terazosin hcl oral 1

HORMONAL AGENTS - ADRENAL

betamethasone valerate external cream 1

clobetasol propionate external cream 1

clobetasol propionate external ointment 1

clobetasol propionate external solution 1

CLOBEX SPRAY E

dexamethasone oral tablet 1

fluocinonide external cream 1

hydrocortisone external cream 2.5 % 1

hydrocortisone external ointment 2.5 % 1

hydrocortisone oral 1

methylprednisolone oral 1

mometasone furoate external cream 1

prednisolone oral solution 1

prednisolone oral syrup 15 mg/5ml 1

prednisolone sodium phosphate oral

solution 10 mg/5ml, 15 mg/5ml, 20

mg/5ml, 25 mg/5ml, 6.7 (5 base)

mg/5ml

1

prednisone oral tablet 1

prednisone oral tablet therapy pack 1

triamcinolone acetonide external cream 1

triamcinolone acetonide external

ointment

1

HORMONAL AGENTS - MEN'S HEALTH

ANDRODERM TRANSDERMAL

PATCH 24 HOUR

E

MTMP Guide 2018-2019 47

DRUG NAME DRUG

TIER NOTES

ANDROGEL PUMP TRANSDERMAL

GEL 20.25 MG/ACT (1.62%)

E

ANDROGEL TRANSDERMAL GEL

20.25 MG/1.25GM (1.62%), 40.5

MG/2.5GM (1.62%)

E

testosterone cypionate intramuscular

solution 100 mg/ml, 200 mg/ml

1

HORMONAL AGENTS - OSTEOPOROSIS

OSPHENA 3

raloxifene hcl 1

HORMONAL AGENTS - PITUITARY

CETROTIDE SUBCUTANEOUS KIT

0.25 MG

i-P SP

GONAL-F i-P SP

GONAL-F RFF i-P SP

GONAL-F RFF REDIJECT i-P SP

HP ACTHAR E SP

LUPRON DEPOT (1-MONTH)

INTRAMUSCULAR KIT 7.5 MG

i-P SP



i-P SP


INTRAMUSCULAR KIT 30MG

i-P SP



i-P SP

NORDITROPIN FLEXPRO i-P SP

NUTROPIN AQ NUSPIN 10 i-P SP



OMNITROPE i-P SP

OVIDREL i-P SP

HORMONAL AGENTS - SEX HORMONES AND BIRTH CONTROL

apri 1

aviane 1

blisovi 24 fe 1

blisovi fe 1.5/30 1

blisovi fe 1/20 1

CLIMARA PRO 2

cryselle-28 1

DIVIGEL 3

drospirenone-ethinyl estradiol 1

DUAVEE 2

ELESTRIN 3

ENDOMETRIN E

enskyce 1

ESTRACE VAGINAL 3

estradiol oral 1

estradiol transdermal 1

jolivette 1

junel 1/20 1

junel fe 1.5/30 1

junel fe 1/20 1

DRUG NAME DRUG

TIER NOTES

levonorgestrel-ethinyl estrad oral tablet

0.1-20 mg-mcg, 0.15-30 mg-mcg

1

LO LOESTRIN FE 3

loryna 1

low-ogestrel 1

MAKENA INTRAMUSCULAR i-P SP

medroxyprogesterone acetate

intramuscular

1

medroxyprogesterone acetate oral 1

microgestin 1.5/30 1

microgestin 1/20 1

microgestin fe 1.5/30 1

microgestin fe 1/20 1

MINIVELLE 3

mono-linyah 1

mononessa 1

NATAZIA 2

nikki 1

norethindrone acet-ethinyl est oral tablet 1

norethindrone oral 1

norgestimate-ethinyl estradiol triphasic 1

nortrel 1/35 (21) 1

nortrel 1/35 (28) 1

NUVARING 2

ocella 1

portia-28 1

PREMARIN ORAL 2

PREMARIN VAGINAL 2

PREMPHASE 2

PREMPRO 2

progesterone micronized oral 1

SAFYRAL 3

sprintec 28 1

tri-estarylla 1

tri-linyah 1

tri-lo-marzia 1

tri-lo-sprintec 1

trinessa (28) 1

trinessa lo 1

tri-sprintec 1

vienva 1

viorele 1

xulane 1

yuvafem 1

HORMONAL AGENTS - THYROID

ARMOUR THYROID 3

levo-t 1

levothyroxine sodium oral 1

levoxyl 1

liothyronine sodium oral 1

methimazole oral 1

NATURE-THROID ORAL TABLET

113.75 MG, 130 MG, 146.25 MG, 16.25

MG, 195 MG, 260 MG, 32.5 MG, 325

3

MTMP Guide 2018-2019 48

DRUG NAME DRUG

TIER NOTES

MG, 48.75 MG, 65 MG, 81.25 MG, 97.5

MG

SYNTHROID 3

TIROSINT 3

IMMUNOLOGICAL AGENTS - DRUGS FOR IMMUNE SYSTEM

STIMULATION OR SUPPRESSION

azathioprine oral 1

CIMZIA PREFILLED KIT i-P SP

CIMZIA STARTER KIT i-P SP

CIMZIA VIAL KIT i-P SP

cyclosporine modified oral capsule 1 SP

ENBREL SUBCUTANEOUS


i-NP SP

ENBREL SURECLICK


AUTO-INJECTOR

i-NP SP

HAEGARDA i-P SP

HUMIRA PEDIATRIC CROHNS

START SUBCUTANEOUS

PREFILLED SYRINGE KIT 40

MG/0.8ML

i-P SP

HUMIRA PEN SUBCUTANEOUS

PEN-INJECTOR KIT

i-P SP

HUMIRA PEN-CROHNS STARTER

SUBCUTANEOUS PEN-INJECTOR

KIT

i-P SP

HUMIRA PEN-PSORIASIS STARTER

SUBCUTANEOUS PEN-INJECTOR

KIT

i-P SP

HUMIRA SUBCUTANEOUS

PREFILLED SYRINGE KIT

i-P SP

methotrexate oral 1

methotrexate sodium oral 1

mycophenolate mofetil oral capsule 1 SP

mycophenolate mofetil oral tablet 1 SP

mycophenolate sodium 1 SP

ORENCIA SUBCUTANEOUS


i-NP SP

OTEZLA ORAL TABLET 2 SP

OTEZLA ORAL TABLET THERAPY

PACK

2 SP

PROGRAF ORAL 3 SP

RASUVO SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 10

MG/0.2ML, 12.5 MG/0.25ML, 15

MG/0.3ML, 17.5 MG/0.35ML, 20

MG/0.4ML, 22.5 MG/0.45ML, 25

MG/0.5ML, 30 MG/0.6ML, 7.5

MG/0.15ML

2

REMICADE i-P SP

SIMPONI ARIA i-P SP

SIMPONI SUBCUTANEOUS

SOLUTION AUTO-INJECTOR

i-P SP



i-P SP

DRUG NAME DRUG

TIER NOTES

STELARA INTRAVENOUS i-P SP

tacrolimus oral 1 SP

TREMFYA i-P SP

XELJANZ XR 3 SP

IMMUNOLOGICAL AGENTS - DRUGS FOR VACCINATION

AFLURIA PRESERVATIVE FREE

INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE

3

BOOSTRIX INTRAMUSCULAR

SUSPENSION 5-2.5-18.5

3

FLUARIX QUADRIVALENT


PREFILLED SYRINGE

3

FLUCELVAX QUADRIVALENT


PREFILLED SYRINGE

3

FLUVIRIN INTRAMUSCULAR

SUSPENSION

3


SUSPENSION PREFILLED SYRINGE

3

FLUZONE HIGH-DOSE


PREFILLED SYRINGE

3

FLUZONE QUADRIVALENT


3



PREFILLED SYRINGE

3

ZOSTAVAX SUBCUTANEOUS

SUSPENSION RECONSTITUTED

E

INFLAMMATORY BOWEL DISEASE AGENTS

APRISO 2

CANASA 2

DELZICOL 3

DIPENTUM 3

mesalamine oral tablet delayed release

1.2 gm

1

MESALAMINE ORAL TABLET

DELAYED RELEASE 800 MG

3

PENTASA 3

PROCTOFOAM HC 2

sulfasalazine oral tablet 1

UCERIS RECTAL 3

METABOLIC BONE DISEASE AGENTS - DRUGS FOR

OSTEOPOROSIS

alendronate sodium oral tablet 1

BINOSTO 4

calcitriol oral capsule 1

FORTEO SUBCUTANEOUS

SOLUTION 600 MCG/2.4ML

i-P SP

ibandronate sodium oral 4

TYMLOS i-P SP

MTMP Guide 2018-2019 49

DRUG NAME DRUG

TIER NOTES

MISCELLANEOUS THERAPEUTIC AGENTS

BOTOX i-NP Non-

Cosmetic;

SP

CETYLEV 3

EUFLEXXA INTRA-ARTICULAR


i-P SP

SYNVISC INTRA-ARTICULAR


i-P SP

SYNVISC ONE INTRA-ARTICULAR


i-P SP

OPHTHALMIC AGENTS - DRUGS FOR EYE ALLERGY, INFECTION

AND INFLAMMATION

AZASITE 3

BESIVANCE 3

ciprofloxacin hcl ophthalmic 1

erythromycin ophthalmic 1

gentamicin sulfate ophthalmic solution 1

ketorolac tromethamine ophthalmic 1

MOXEZA 2

moxifloxacin hcl ophthalmic 1

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic 1

PAZEO 2

prednisolone acetate ophthalmic 1

PROLENSA 2

tobramycin ophthalmic 1

OPHTHALMIC AGENTS - DRUGS FOR GLAUCOMA

ALPHAGAN P 2

AZOPT 2

BETIMOL 3

brimonidine tartrate ophthalmic 1

COMBIGAN 2

COSOPT PF 3

dorzolamide hcl-timolol mal 1

latanoprost ophthalmic 1

LUMIGAN OPHTHALMIC

SOLUTION 0.01 %

2

SIMBRINZA 2

timolol maleate ophthalmic solution 1

TRAVATAN Z 2

ZIOPTAN 3

OPHTHALMIC AGENTS - DRUGS FOR MISCELLANEOUS EYE

CONDITIONS

LASTACAFT 3

neomycin-polymyxin-dexameth

ophthalmic suspension 3.5-10000-0.1

1

polymyxin b-trimethoprim 1

RESTASIS 2

RESTASIS MULTIDOSE 2

tobramycin-dexamethasone 1

DRUG NAME DRUG

TIER NOTES

XIIDRA 2

OTIC AGENTS - DRUGS FOR EAR CONDITIONS

CIPRODEX 2

neomycin-polymyxin-hc otic solution

1 %

1

neomycin-polymyxin-hc otic suspension 1

ofloxacin otic 1

RESPIRATORY TRACT / PULMONARY AGENTS - DRUGS FOR

ALLERGIES, COUGH, COLD

ASTEPRO NASAL SOLUTION 0.15 % 3

azelastine hcl nasal 1

benzonatate 1

cetirizine hcl oral solution E

cetirizine hcl oral syrup 1 mg/ml E

DYMISTA E

fluticasone propionate nasal E

hydrocodone polst-cpm polst er oral

suspension extended release 10-8

mg/5ml

1

ipratropium bromide nasal 1

levocetirizine dihydrochloride oral tablet E

mometasone furoate nasal E

OMNARIS E

promethazine hcl oral tablet 1

promethazine-codeine 1

promethazine-dm 1

pseudoephedrine-bromphen-dm oral

syrup 30-2-10 mg/5ml

1

QNASL E

QNASL CHILDRENS E

TUZISTRA XR ORAL SUSPENSION

EXTENDED RELEASE

3

XOLAIR i-NP SP

ZETONNA E

ZUTRIPRO 3


ASTHMA AND OTHER LUNG CONDITIONS

ADVAIR DISKUS 2

ADVAIR HFA 2

AEROSPAN 3

albuterol sulfate inhalation 1

ANORO ELLIPTA 2

ARNUITY ELLIPTA 2

BREO ELLIPTA 2

budesonide inhalation 1

COMBIVENT RESPIMAT 2

DULERA 3

EPINEPHRINE INJECTION

SOLUTION AUTO-INJECTOR 0.15

MG/0.15ML

3 Made by

Impax

MTMP Guide 2018-2019 50

DRUG NAME DRUG

TIER NOTES



MG/0.3ML

2 Made by

Mylan

EPINEPHRINE SOLUTION AUTO-

INJECTOR 0.3 MG/0.3ML INJECTION

2 Made by

Mylan


INJECTOR 0.3 MG/0.3ML INJECTION

3 Made by

Impax

FLOVENT DISKUS 2

FLOVENT HFA 2

INCRUSE ELLIPTA 2

ipratropium bromide inhalation 1

ipratropium-albuterol 1

montelukast sodium oral tablet 1

montelukast sodium oral tablet chewable 1

PERFOROMIST 3

PROAIR HFA 2

PROAIR RESPICLICK 2

PROVENTIL HFA 3

PULMICORT FLEXHALER 2

QVAR INHALATION AEROSOL

SOLUTION

2

SEREVENT DISKUS 2

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT 2

STIOLTO RESPIMAT 2

SYMBICORT 2

VENTOLIN HFA 2

DRUG NAME DRUG

TIER NOTES


PULMONARY HYPERTENSION

ADCIRCA 3 SP

ADEMPAS 2 SP

LETAIRIS 2 SP

OPSUMIT 2 SP

ORENITRAM 3 SP

sildenafil citrate oral tablet 20 mg 1 SP

TRACLEER 2 SP

SKELETAL MUSCLE RELAXANTS - DRUGS FOR MUSCLE

TENSION AND SPASM

baclofen oral 1

carisoprodol oral 1

cyclobenzaprine hcl oral 1

LORZONE 4

metaxalone 1

methocarbamol oral 1

orphenadrine citrate er 1

tizanidine hcl oral tablet 1

SLEEP DISORDER AGENTS

eszopiclone 1

modafinil 1

SILENOR 4

temazepam 1

zolpidem tartrate er 4

zolpidem tartrate oral 1

MTMP Guide 2018-2019 51

Political Subdivision Select Premium Formulary

The most up to date formulary may be located at https://tmlhealthbenefits.org/.

The most effective way to control costs is through the use of generic drugs and a drug formulary.

Drug Tier Includes

Tier 1:

Preferred Network Tier

Lower-cost generics and some brand-name. Use Tier 1 drugs for the lowest out-of-pocket

costs.

Tier 2:

Value Tiered

Mid-range cost preferred brand-name. Use Tier 2 drugs, instead of Tier 3, to help reduce

your out-of-pocket costs.

Tier 3 Highest-cost non-preferred. Many Tier 3 drugs have lower cost options in Tier 1 or 2. Ask

your doctor if they could work for you.

Tier E

Excluded

May be excluded from coverage or subject to prior authorization. Lower-cost options are

available and covered.

* Drugs may transition from tier to tier within benefit plan year impacting your out of pocket expense.

Some medications are noted with letters next to them to help you see which ones may have coverage requirements

or limits. Your benefit plan determines how these medications may be covered for you.

Some of the medications on this list may NOT be covered by your plan or have additional restrictions. Their

presence on this list does NOT guarantee coverage.

M = Authorized generic or co-branded product SP = Specialty Medication – Medication is designated as specialty.

3P = Tier 3 preferred

DRUG NAME DRUG TIER

NOTES

ANALGESICS - DRUGS FOR PAIN

ABSTRAL E




acetaminophen-codeine oral tablet 1

ARYMO ER E

butalbital-apap-caffeine oral capsule 1

butalbital-apap-caffeine oral tablet 50-

325-40 mg

1 generic Fioricet

excluded

DURAGESIC-100 E

DURAGESIC-12 E

DURAGESIC-25 E

DURAGESIC-50 E

DURAGESIC-75 E

EMBEDA 2

DRUG NAME DRUG TIER

NOTES

fentanyl 1

FENTORA BUCCAL TABLET 100

MCG, 200, MCG, 400 MCG, 600

MCG, 800 MCG

E

hydrocodone- acetaminophen oral tablet

10-300 mg, 10-325 mg, 2.5-325 mg, 5-

300 mg, 5-325 mg, 7.5-300 mg, 7.5-325

mg

1

hydromorphone hcl oral tablet 1

HYSINGLA ER 2

KADIAN ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 10

MG, 100 MG, 20 MG, 200 MG, 30 MG,

40 MG, 50 MG, 60 MG, 80 MG

E

LAZANDA E

methadone hcl oral tablet 1

morphine sulfate er oral tablet extended 1

https://tmlhealthbenefits.org/

MTMP Guide 2018-2019 52

DRUG NAME DRUG TIER

NOTES

release

NORCO E

NUCYNTA E

NUCYNTA ER E

OPANA ER ORAL TABLET ER 12

HOUR ABUSE-DETERRENT

E

oxycodone hcl oral tablet 1

oxycodone- acetaminophen oral tablet

10-325 mg, 2.5-325 mg, 5-25 mg, 7.5-

325 mg

1

OXYCONTIN ORAL TABLET ER 12

HOUR ABUSE-DETERRENT 2

PERCOCET ORAL TABLET 10-325

MG, 2.5-325 MG, 5-325 MG, 7.5-325

MG

E

SUBSYS E

tramadol hcl ir 1

tramadol-acetaminophen 1

XTAMPZA ER E

ZOHYDRO ER ORAL CAPSULE ER

12 HOUR ABUSE-DETERRENT

E

ANALGESICS - DRUGS FOR PAIN AND INFLAMMATION

CAMBIA E

CELEBREX E

celecoxib oral E

diclofenac potassium 1

diclofenac sodium oral 1

diclofenac sodium transdermal gel 1 % E

DUEXIS E

etodolac oral tablet 1

FLECTOR E

ibuprofen oral tablet 400 mg, 600 mg,

800 mg

1

indomethacin oral 1

ketorolac tromethamine oral 1

meloxicam oral tablet 1

nabumetone oral 1

naproxen oral tablet 1

naproxen sodium oral tablet 275 mg,

550 mg

1

PENNSAID TRANSDERMAL

SOLUTION 2 %

E

sulindac oral 1

VIMOVO E

VOLTAREN GEL 1% E

ZORVOLEX E

ANESTHETICS

lidocaine external ointment E

lidocaine external patch 5 % 1

LIDODERM E

DRUG NAME DRUG TIER

NOTES

ANTI-ADDICTION / SUBSTANCE ABUSE TREATMENT AGENTS

BUNAVAIL 3

buprenorphine hcl sublingual 1

buprenorphine hcl- naloxone hcl 1

CHANTIX STARTING MONTH PAK 3

naltrexone hcl oral 1

NARCAN 2

SUBOXONE SUBLINGUAL FILM 2

ZUBSOLV 2

ANTIBACTERIALS

ACTICLATE E

amoxicillin oral capsule 1

amoxicillin oral suspension

reconstituted

1

amoxicillin oral tablet 1


suspension reconstituted 200-28.5

mg/5ml, 250-62.5 mg/5ml, 400-57

mg/5ml, 600-42.9 mg/5ml

1

amoxicillin-potassium clavulanate

oral tablet 250-125 mg, 500-125

mg, 875-125 mg

1

azithromycin oral suspension

reconstituted

1

azithromycin oral tablet 250 mg, 500

mg, 600 mg

1

BETHKIS 2 SP

cefdinir 1

cefuroxime axetil oral tablet 1

cephalexin oral capsule 1

cephalexin oral suspension

reconstituted

1

ciprofloxacin hcl oral 1

clarithromycin oral tablet 1

clindamycin hcl oral 1

clindamycin phosphate external gel 1

clindamycin phosphate external lotion 1

clindamycin phosphate external

solution

1

CLINDESSE 3

DORYX MPC E

doxycycline hyclate oral capsule E

doxycycline hyclate oral tablet 100 mg,

150 mg, 20 mg, 75 mg

E

doxycycline monohydrate oral capsule 1 50 and

100mg only

doxycycline monohydrate oral tablet 1 50, 75, and

100 only

KITABIS PAK E SP

levofloxacin oral tablet 1

metronidazole oral tablet 1

metronidazole vaginal 1

MTMP Guide 2018-2019 53

DRUG NAME DRUG TIER

NOTES

minocycline hcl oral capsule 1

mupirocin external 1

nitrofurantoin macrocrystal oral 1

nitrofurantoin

monohydrate

macrocrystals

1

penicillin v potassium oral tablet 1

SOLODYN ORAL TABLET

EXTENDED RELEASE 24 HOUR

105 MG, 115 MG, 55 MG, 65 MG, 80

MG

E

sulfamethoxazole- trimethoprim oral

suspension 200-40 mg/5ml

1

sulfamethoxazole- trimethoprim oral

tablet

1

TOBI NEBULIZER E SP

TOBI PODHALER E SP

tobramycin nebulization solution 300

mg/5ml inhalation

1 SP

TOBRAMYCIN NEBULIZATION

SOLUTION 300 MG/5ML

INHALATION

E M; SP

ANTICOAGULANTS

ELIQUIS 2

enoxaparin sodium 1 SP

PRADAXA 2

SAVAYSA 3

warfarin sodium oral 1

XARELTO 2

XARELTO STARTER PACK 2

ANTICONVULSANTS - DRUGS FOR SEIZURES

carbamazepine oral tablet 1

DILANTIN INFATABS E

DILANTIN ORAL CAPSULE 100 MG E

DILANTIN ORAL SUSPENSION E

divalproex sodium er oral tablet


1

divalproex sodium oral tablet delayed

release

1

gabapentin oral capsule 1

gabapentin oral tablet 1

lamotrigine oral tablet 1

levetiracetam oral tablet 1

oxcarbazepine oral tablet 1

phenytoin sodium extended 1

topiramate oral tablet 1

TROKENDI XR E

VIMPAT 3

zonisamide oral 1

DRUG NAME DRUG TIER

NOTES

ANTIDEMENTIA AGENTS - DRUGS FOR ALZHEIMER'S DISEASE AND

DEMENTIA

donepezil hcl oral tablet 1

memantine hcl oral tablet 10 mg, 5 mg 1

NAMZARIC ORAL CAPSULE

EXTENDED RELEASE 24 HOUR

14-10 MG, 28-10 MG

2

ANTIDEPRESSANTS

amitriptyline hcl oral 1

bupropion hcl er (sr) 1

bupropion hcl er (xl) 1

bupropion hcl oral 1

citalopram hydrobromide oral tablet 1

CYMBALTA E

desvenlafaxine succinate er E

doxepin hcl oral capsule 1

duloxetine hcl oral capsule delayed

release particles 20 mg, 30 mg, 60 mg

E

DULOXETINE HCL ORAL

CAPSULE DELAYED RELEASE

PARTICLES 40 MG

E

EFFEXOR XR E

escitalopram oxalate oral tablet 1

fluoxetine hcl oral capsule 1

fluoxetine hcl oral tablet 1

FORFIVO XL 2

LEXAPRO ORAL TABLET E

mirtazapine oral tablet 1

nortriptyline hcl oral capsule 1

paroxetine hcl er 1

paroxetine hcl oral tablet 1

PRISTIQ E

PROZAC ORAL CAPSULE E

sertraline hcl oral tablet 1

trazodone hcl oral 1

TRINTELLIX 3

venlafaxine hcl 1

venlafaxine hcl er 1 capsules only

VIIBRYD ORAL TABLET E

VIIBRYD STARTER PACK E

WELLBUTRIN SR E

WELLBUTRIN XL E

ZOLOFT E

ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING

meclizine hcl oral tablet 25 mg 1

metoclopramide hcl oral tablet 1

ondansetron hcl oral tablet 1

ondansetron odt 1

prochlorperazine maleate oral 1

VARUBI ORAL E

MTMP Guide 2018-2019 54

DRUG NAME DRUG TIER

NOTES

ANTIFUNGALS

fluconazole oral tablet 1

GYNAZOLE-1 3

JUBLIA E

KERYDIN E

ketoconazole external cream 1

ketoconazole external shampoo 1

nystatin external cream 1

nystatin mouth/throat 1

terbinafine hcl oral 1

terconazole vaginal cream 1

ANTIGOUT AGENTS

allopurinol oral 1

COLCHICINE ORAL TABLET 3

COLCRYS 2

ULORIC 2

ZURAMPIC E

ANTIMIGRAINE AGENTS

MIGRANAL 3

ONZETRA XSAIL E

rizatriptan benzoate 1

sumatriptan succinate oral 1

SUMAVEL DOSEPRO

SUBCUTANEOUS SOLUTION JET-

INJECTOR

E

ZOMIG ORAL E

ZOMIG ZMT E

ANTINEOPLASTICS - DRUGS FOR CANCER

anastrozole oral 1

CABOMETYX 2 SP

capecitabine 1 SP

IBRANCE 3 SP

letrozole oral 1

mercaptopurine oral 1 SP

REVLIMID 3 SP

SPRYCEL 2 SP

tamoxifen citrate oral 1

XTANDI 3 SP

ZYTIGA 3 SP

ANTIPARASITICS

EMVERM 2

hydroxychloroquine sulfate oral 1

permethrin external cream 1

SOOLANTRA 2

ANTIPARKINSON AGENTS

benztropine mesylate oral 1

carbidopa-levodopa oral tablet 1

pramipexole dihydrochloride 1

DRUG NAME DRUG TIER

NOTES

ropinirole hcl 1

ZELAPAR 3

ANTIPLATELETS

BRILINTA 2

cilostazol 1

clopidogrel bisulfate oral 1

ANTIPSYCHOTICS - DRUGS FOR MOOD DISORDERS

aripiprazole oral tablet 1

ARISTADA INTRAMUSCULAR

PREFILLED SYRINGE 441

MG/1.6ML, 662 MG/2.4ML, 882

MG/3.2ML

3

haloperidol oral 1

INVEGA SUSTENNA 3

INVEGA TRINZA 3

LATUDA 3

olanzapine oral tablet 1

quetiapine fumarate 1

REXULTI E

risperidone oral tablet E

SAPHRIS 2

ziprasidone hcl 1

ANTIVIRALS

abacavir sulfate- lamivudine 1 SP

acyclovir oral capsule 1

acyclovir oral tablet 1

ATRIPLA E SP

COMPLERA 2 SP

DESCOVY 3 SP

entecavir 1 SP

EPCLUSA 2 SP

GENVOYA 3 SP

HARVONI 2 SP

INTELENCE 2 SP

ISENTRESS ORAL TABLET 2 SP

MAVYRET 2 SP

NORVIR ORAL TABLET 2 SP

ODEFSEY 3 SP

oseltamivir phosphate oral capsule 1

PREZCOBIX 2 SP

PREZISTA ORAL TABLET 150

MG, 600 MG, 75 MG, 800 MG

2 SP

REYATAZ ORAL CAPSULE 150

MG, 200 MG, 300 MG

3 SP

STRIBILD 3 SP

TAMIFLU ORAL CAPSULE E

TAMIFLU ORAL SUSPENSION

RECONSTITUTED 6 MG/ML

2

TIVICAY 2 SP

TRIUMEQ 2 SP

TRUVADA 2 SP

valacyclovir hcl oral 1

MTMP Guide 2018-2019 55

DRUG NAME DRUG TIER

NOTES

VIREAD ORAL TABLET 150 MG,

200 MG, 250 MG

2 SP

VIREAD ORAL TABLET 300 MG 3 SP

VOSEVI 2 SP

ZOVIRAX EXTERNAL CREAM 2

ZOVIRAX EXTERNAL OINTMENT E

ZOVIRAX ORAL E

ANXIOLYTICS - DRUGS FOR ANXIETY

alprazolam oral tablet 1

buspirone hcl oral 1

clonazepam oral tablet 1

diazepam oral tablet 1

hydroxyzine hcl oral tablet 1

hydroxyzine pamoate oral 1

lorazepam oral tablet 1

triazolam 1

VALIUM E

XANAX E

XANAX XR E

BIPOLAR AGENTS - DRUGS FOR MOOD DISORDERS

lithium carbonate er 1

lithium carbonate oral capsule 1

BLOOD PRODUCTS / MODIFIERS / VOLUME EXPANDERS - DRUGS

FOR BLEEDING DISORDERS

AFSTYLA 3 SP


INJECTION SOLUTION 100

MCG/ML, 200 MCG/ML, 25

MCG/ML, 300 MCG/ML, 40

MCG/ML, 60 MCG/ML

E SP


INJECTION SOLUTION PREFILLED

SYRINGE

E SP

EPOGEN INJECTION SOLUTION

10000 UNIT/ML, 2000 UNIT/ML,

20000 UNIT/ML, 3000 UNIT/ML,

4000 UNIT/ML

E SP

GRANIX 2 SP


300 MCG/ML, 480 MCG/1.6ML

2 SP


PREFILLED SYRINGE

2 SP

NUWIQ 3 SP

PROCRIT 2 SP

ZARXIO 2 SP

CARDIOVASCULAR AGENTS - DRUGS FOR HEART AND

CIRCULATION CONDITIONS

amiodarone hcl oral 1

amlodipine besylate oral 1

amlodipine besylate- benazepril hcl 1

amlodipine besylate- valsartan 1

DRUG NAME DRUG TIER

NOTES

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral 1

AZOR E

benazepril hcl oral 1

benazepril- hydrochlorothiazide 1

BENICAR E

BENICAR HCT E

bisoprolol fumarate 1

bisoprolol- hydrochlorothiazide 1

bumetanide oral 1

BYSTOLIC 2

BYVALSON 2

cartia xt 1

carvedilol 1

chlorthalidone oral tablet 25 mg, 50 mg 1

choline fenofibrate 1

clonidine hcl oral 1

CRESTOR E

digox 1

digoxin oral tablet 1

diltiazem hcl er beads 1

diltiazem hcl er coated beads oral

capsule extended release 24 hour

1

diltiazem hcl oral 1

DIOVAN E

DIOVAN HCT E

doxazosin mesylate 1

EDARBI E

EDARBYCLOR E

enalapril maleate oral 1

ezetimibe 1

ezetimibe-simvastatin 1

fenofibrate micronized oral capsule

134 mg, 200 mg, 67 mg

E

fenofibrate oral tablet E

fenofibric acid oral capsule delayed

release

E

flecainide acetate 1

furosemide oral tablet 1

gemfibrozil oral 1

guanfacine hcl oral 1

hydralazine hcl oral 1

hydrochlorothiazide oral 1

irbesartan 1

irbesartan- hydrochlorothiazide 1

isosorbide mononitrate er 1

labetalol hcl oral 1

LIPITOR E

LIPOFEN E

lisinopril oral 1

lisinopril- hydrochlorothiazide 1

LIVALO E

losartan potassium 1

losartan potassium-hctz 1

MTMP Guide 2018-2019 56

DRUG NAME DRUG TIER

NOTES

lovastatin 1

LOVAZA E

metoprolol succinate er 1

metoprolol tartrate oral 1

MULTAQ 3

nadolol oral tablet 20 mg, 40 mg, 80 mg 1

niacin er (antihyperlipidemic) E

nifedipine er 1

nifedipine er osmotic release 1

nitroglycerin sublingual 1

NITROSTAT E

NORVASC E

olmesartan medoxomil oral E

olmesartan medoxomil- hctz E

omega-3-acid ethyl esters E

pentoxifylline er 1

PRALUENT SUBCUTANEOUS

SOLUTION PEN- INJECTOR

2 SP

pravastatin sodium 1

prazosin hcl oral 1

propranolol hcl er 1

propranolol hcl oral tablet 1

quinapril hcl 1

ramipril 1

RANEXA 2

REPATHA 2 SP

REPATHA PUSHTRONEX SYSTEM 2 SP

REPATHA SURECLICK 2 SP

rosuvastatin calcium 1

simvastatin oral 1

sotalol hcl oral 1

spironolactone oral 1

TEKTURNA 2

TEKTURNA HCT 2

telmisartan E

TOPROL XL E

torsemide oral 1

triamterene-hctz oral capsule 37.5-25

mg

1

triamterene-hctz oral tablet 1

TRIBENZOR E

valsartan 1

valsartan- hydrochlorothiazide 1

VASCEPA 2

verapamil hcl er oral tablet extended

release 120 mg, 180 mg, 240 mg

1

verapamil hcl oral 1

VYTORIN E

WELCHOL 2

ZETIA E

CENTRAL NERVOUS SYSTEM AGENTS - DRUGS FOR ATTENTION

DEFICIT DISORDER

ADDERALL XR E

amphetamine- dextroamphetamine 1

DRUG NAME DRUG TIER

NOTES

amphetamine- dextroamphetamine er E

atomoxetine hcl 1

CONCERTA E

dexmethylphenidate hcl 1

dexmethylphenidate hcl er E

guanfacine hcl er E

methylphenidate hcl er oral tablet

extended release 10 mg, 18 mg, 20 mg,

27 mg, 36 mg, 54 mg

E

methylphenidate hcl er oral tablet


E

methylphenidate hcl oral tablet 1

VYVANSE 2

CENTRAL NERVOUS SYSTEM AGENTS - DRUGS FOR MULTIPLE

SCLEROSIS

AMPYRA 2 SP

AUBAGIO 3 SP

AVONEX PEN

INTRAMUSCULAR AUTO-

INJECTOR KIT

2 SP

AVONEX PREFILLED

INTRAMUSCULAR PREFILLED

SYRINGE KIT

2 SP

AVONEX VIAL INTRAMUSCULAR

KIT

2 SP

BETASERON SUBCUTANEOUS KIT 2 SP

COPAXONE SUBCUTANEOUS


2 SP

EXTAVIA SUBCUTANEOUS KIT E SP

GILENYA 3 3P; SP

PLEGRIDY E SP

PLEGRIDY STARTER PACK E SP

REBIF REBIDOSE SUBCUTANEOUS

SOLUTION AUTO- INJECTOR

3 SP

REBIF REBIDOSE TITRATION

PACK SUBCUTANEOUS SOLUTION

AUTO- INJECTOR

3 SP

REBIF SUBCUTANEOUS


3 SP

REBIF TITRATION PACK


PREFILLED SYRINGE

3 SP

TECFIDERA 2 SP

CENTRAL NERVOUS SYSTEM AGENTS - MISCELLANEOUS

CONTRAVE E

GRALISE E

GRALISE STARTER E

LYRICA ORAL CAPSULE 2

phentermine hcl oral tablet E

MTMP Guide 2018-2019 57

DRUG NAME DRUG TIER

NOTES

DENTAL AND ORAL AGENTS - DRUGS FOR MOUTH AND THROAT

CONDITIONS

chlorhexidine gluconate mouth/throat 1

lidocaine viscous 1

DERMATOLOGICAL AGENTS - DRUGS FOR SKIN CONDITIONS

ABSORICA E

ACANYA E

ACZONE 2

adapalene external gel 1

AKTIPAK E

ATRALIN 3

BENZACLIN E

BENZACLIN WITH PUMP E

BENZAMYCIN E

claravis 1

clindamycin phosphate- benzoyl

peroxide external gel 1-5 %

1

clotrimazole- betamethasone external

cream

1

COSENTYX 150 MG/ML 3 3P; SP

COSENTYX 300 DOSE 3 3P; SP

COSENTYX SENSOREADY 300

DOSE

3 3P; SP

COSENTYX SENSOREADY PEN


AUTO- INJECTOR 150 MG/ML

3 3P; SP

DIFFERIN EXTERNAL GEL 0.3 % 3

DIFFERIN EXTERNAL LOTION 3

DUAC E

DUPIXENT 2 SP

ELIDEL 2

ENSTILAR E

EPIDUO 3

EPIDUO FORTE 3

EUCRISA 2

FLUOROPLEX 3

METROGEL EXTERNAL GEL 3

metronidazole external gel 1

MIRVASO E

ONEXTON 3

ORACEA E

OXSORALEN ULTRA 2

RETIN-A MICRO GEL 0.04 %,

0.1 %

E

RETIN-A MICRO PUMP

EXTERNAL GEL 0.04 %, 0.1 %

E

RETIN-A MICRO PUMP

EXTERNAL GEL 0.06 %, 0.08 %

2

STELARA SUBCUTANEOUS


2 SP

TACLONEX EXTERNAL

OINTMENT

E

TACLONEX EXTERNAL 3

DRUG NAME DRUG TIER

NOTES

SUSPENSION

TALTZ E SP

TAZORAC 3

tretinoin external cream 1

VECTICAL 3

VELTIN E

ZIANA E

ZYCLARA 3

ZYCLARA PUMP 3

DIABETES - ANTIDIABETIC AGENTS

ADLYXIN E

ADLYXIN STARTER PACK E

ALOGLIPTIN BENZOATE E M

ALOGLIPTIN- METFORMIN HCL E M

ALOGLIPTIN- PIOGLITAZONE E M

BYDUREON BCISE

AUTOINJECTOR

2

BYDUREON PEN 2

BYDUREON VIAL 2

BYETTA 10 MCG PEN 2

BYETTA 5 MCG PEN 2

FARXIGA E

glimepiride 1

glipizide er 1

glipizide ir 1

glipizide xl 1

GLUMETZA E

glyburide oral 1

glyburide-metformin 1

INVOKAMET 2

INVOKAMET XR 2

INVOKANA 2

JANUMET 2

JANUMET XR 2

JANUVIA 2

JARDIANCE 2

JENTADUETO 2

JENTADUETO XR 2

KAZANO E

KOMBIGLYZE XR E

metformin hcl er 1

metformin hcl er (mod) E

metformin hcl er (osm) oral tablet

extended release 24 hour 1000 mg, 500

mg

E

metformin hcl ir 1

NESINA E

ONGLYZA E

OSENI E

pioglitazone hcl 1

SOLIQUA 2

SYNJARDY 2

SYNJARDY XR 2

TANZEUM E

MTMP Guide 2018-2019 58

DRUG NAME DRUG TIER

NOTES

TRADJENTA 2

TRULICITY 2

VICTOZA 2

XIGDUO XR E

DIABETES - GLUCOSE MONITORING

ACCU-CHEK AVIVA DEVICE E

ACCU-CHEK AVIVA CONNECT

KIT W/DEVICE

E

ACCU-CHEK AVIVA PLUS E


CARE KIT

E


TEST STRIPS

E

ACCU-CHEK FASTCLIX LANCET

KIT

2

ACCU-CHEK FASTCLIX LANCETS 2

ACCU-CHEK GUIDE E

ACCU-CHEK MULTICLIX

LANCET DEVICE KIT

2

ACCU-CHEK MULTICLIX

LANCETS

2

ACCU-CHEK NANO SMARTVIEW

KIT W/DEVICE

E

ACCU-CHEK SMARTVIEW TEST

STRIPS

E

ACCU-CHEK SOFT TOUCH

LANCETS

2

ACCU-CHEK SOFTCLIX LANCET

DEVICE KIT KIT

2

ACCU-CHEK SOFTCLIX LANCETS 2

DEXCOM G4 PLATINUM

PEDIATRIC RECEIVER DEVICE

3

DEXCOM G4 PLATINUM

RECEIVER, SENSOR,

TRANSMITTER DEVICE

3

DEXCOM G5 SENSOR,

TRANSMITTER, MOBILE

RECEIVER

3

ONETOUCH ULTRA 2 KIT

W/DEVICE

2

ONETOUCH ULTRA BLUE TEST

STRIPS

2

ONETOUCH ULTRA MINI KIT

W/DEVICE

2

ONETOUCH VERIO 2

ONETOUCH VERIO FLEX

SYSTEM KIT W/DEVICE

2

ONETOUCH VERIO TEST STRIPS 2

ONETOUCH VERIO IQ SYSTEM

KIT W/DEVICE

2

ONETOUCH VERIO SYNC

SYSTEM KIT W/DEVICE

2

DRUG NAME DRUG TIER

NOTES

DIABETES - INSULINS

APIDRA SOLOSTAR E

APIDRA VIAL E

BASAGLAR KWIKPEN E

FIASP E

FIASP FLEXTOUCH E

HUMALOG U-100 AND U-200

KWIKPEN

2





HUMALOG U-100 JUNIOR

KWIKPEN

2

HUMALOG U-100 VIAL AND

CARTRIDGE

2

HUMULIN 70/30 KWIKPEN 2

HUMULIN 70/30 VIAL 2

HUMULIN N KWIKPEN 2

HUMULIN N VIAL 2

HUMULIN R U-500 KWIKPEN 2

HUMULIN R U-500 VIAL

(CONCENTRATED)

2

HUMULIN R VIAL 2

LANTUS U-100 SOLOSTAR 2

LANTUS U-100 VIAL 2

LEVEMIR U-100 FLEXTOUCH E

LEVEMIR U-100 VIAL E

NOVOFINE AUTOCOVER PEN

NEEDLE

2

NOVOFINE PEN NEEDLE 2

NOVOFINE PLUS PEN NEEDLE 2

NOVOLIN 70/30 RELION E

NOVOLIN 70/30 VIAL E

NOVOLIN N RELION E

NOVOLIN N VIAL E

NOVOLIN R RELION E

NOVOLIN R VIAL E

NOVOLOG U-100 FLEXPEN E

NOVOLOG MIX 70/30 FLEXPEN E

NOVOLOG MIX 70/30 VIAL E

NOVOLOG U-100 PENFILL E

NOVOLOG U-100 VIAL E

NOVOTWIST PEN NEEDLE 32G X 5

MM

2

TOUJEO SOLOSTAR 2

TRESIBA FLEXTOUCH 2

ELECTROLYTES / MINERALS / METALS / VITAMINS

cyanocobalamin injection 1

folic acid oral tablet 1 mg 1

klor-con m20 1

ludent 1

potassium chloride crys er 1

MTMP Guide 2018-2019 59

DRUG NAME DRUG TIER

NOTES

potassium chloride er 1

potassium citrate er 1

VELTASSA 3

VITAFOL ORAL TABLET E

vitamin d (ergocalciferol) 1

GASTROINTESTINAL AGENTS - DRUGS FOR ACID REFLUX AND

ULCER

ACIPHEX E

CARAFATE ORAL TABLET E

DEXILANT 2

esomeprazole magnesium E

famotidine oral tablet 20 mg, 40 mg 1

lansoprazole oral capsule delayed

release

E

NEXIUM ORAL CAPSULE

DELAYED RELEASE

E

omeprazole oral capsule delayed release E

pantoprazole sodium oral E

PREVACID E

rabeprazole sodium E

ranitidine hcl oral capsule 1

ranitidine hcl oral syrup 1

ranitidine hcl oral tablet 150 mg, 300

mg

1

sucralfate oral tablet 1

ZEGERID E

GASTROINTESTINAL AGENTS - DRUGS FOR BOWEL, INTESTINE

AND STOMACH CONDITIONS

AMITIZA E

dicyclomine hcl oral capsule 1

dicyclomine hcl oral tablet 1

diphenoxylate-atropine oral tablet 1

gavilyte-g 1

LINZESS 2

MOTOFEN E

MOVANTIK 2

MOVIPREP 3

OMECLAMOX-PAK 2

polyethylene glycol 3350 oral powder 1

PREPOPIK 3

PYLERA 2

RELISTOR SUBCUTANEOUS

SOLUTION 12 MG/0.6ML

E

SUPREP BOWEL PREP KIT 3

VIBERZI E

GENETIC OR ENZYME DISORDER: DRUGS FOR REPLACEMENT,

MODIFIERS, TREATMENT

CERDELGA 3 SP

CREON 2

PANCREAZE E

PERTZYE E

VIOKACE E

DRUG NAME DRUG TIER

NOTES

ZENPEP ORAL CAPSULE

DELAYED RELEASE PARTICLES

10000 UNIT, 15000 UNIT, 20000-

63000 UNIT, 25000 UNIT, 3000-

10000 UNIT, 5000 UNIT

2

GENITOURINARY AGENTS - DRUGS FOR BLADDER, GENITAL AND

KIDNEY CONDITIONS

CIALIS 2

DEPEN TITRATABS 2 SP

LEVITRA E

MYRBETRIQ 2

oxybutynin chloride er E

oxybutynin chloride oral tablet 1

phenazopyridine hcl oral tablet 100 mg,

200 mg

1

RENVELA ORAL TABLET 3

STAXYN E

STENDRA E

tolterodine tartrate er E

TOVIAZ E

VELPHORO 3

VESICARE E

VIAGRA E

GENITOURINARY AGENTS - DRUGS FOR PROSTATE CONDITIONS

alfuzosin hcl er 1

finasteride oral tablet 5 mg 1

RAPAFLO 2

tamsulosin hcl 1

terazosin hcl oral 1

HORMONAL AGENTS - ADRENAL

betamethasone valerate external cream 1

clobetasol propionate external cream 1

clobetasol propionate external ointment 1

clobetasol propionate external solution 1

CLOBEX SPRAY E

dexamethasone oral tablet 1

fluocinonide external cream 1

hydrocortisone external cream 2.5 % 1

hydrocortisone external ointment 2.5 % 1

hydrocortisone oral 1

methylprednisolone oral 1

mometasone furoate external cream 1

prednisolone oral solution 1

prednisolone oral syrup 15 mg/5ml 1

prednisolone sodium phosphate oral

solution 10 mg/5ml, 15 mg/5ml, 20

mg/5ml, 25 mg/5ml, 6.7 (5 base)

mg/5ml

1

prednisone oral tablet 1

prednisone oral tablet therapy pack 1

triamcinolone acetonide external cream 1

triamcinolone acetonide external 1

MTMP Guide 2018-2019 60

DRUG NAME DRUG TIER

NOTES

ointment

HORMONAL AGENTS - MEN'S HEALTH

ANDRODERM TRANSDERMAL

PATCH 24 HOUR

2

ANDROGEL PUMP

TRANSDERMAL GEL 20.25

MG/ACT (1.62%)

2


20.25 MG/1.25GM (1.62%), 40.5

MG/2.5GM (1.62%)

2


25 MG/2.5GM (1%), 50 MG/5GM

(1%)

E

DEPO-TESTOSTERONE

INTRAMUSCULAR SOLUTION

E

FORTESTA E

TESTIM E

testosterone cypionate intramuscular

solution 100 mg/ml, 200 mg/ml

1

TESTOSTERONE TRANSDERMAL

GEL 10 MG/ACT (2%)

E M

VOGELXO PUMP E

VOGELXO TRANSDERMAL GEL 50

MG/5GM (1%)

E

HORMONAL AGENTS - OSTEOPOROSIS

OSPHENA 3

raloxifene hcl 1

HORMONAL AGENTS - PITUITARY

BRAVELLE E SP

CETROTIDE SUBCUTANEOUS KIT

0.25 MG

2 SP

FOLLISTIM AQ SUBCUTANEOUS E SP

GENOTROPIN E SP

GENOTROPIN MINIQUICK E SP

GONAL-F 2 SP

GONAL-F RFF 2 SP

GONAL-F RFF REDIJECT 2 SP

HP ACTHAR 2 SP

HUMATROPE E SP

LUPRON DEPOT (1- MONTH)


2 SP



2 SP



2 SP



2 SP

NORDITROPIN FLEXPRO 2 SP

NUTROPIN AQ NUSPIN 10 2 SP



OMNITROPE 2 SP

DRUG NAME DRUG TIER

NOTES

OVIDREL 3 SP

SAIZEN E SP

SAIZEN CLICK.EASY E SP

SAIZENPREP E SP

ZOMACTON E SP

HORMONAL AGENTS - SEX HORMONES AND BIRTH CONTROL

apri 1

aviane 1

BEYAZ E

blisovi 24 fe 1

blisovi fe 1.5/30 1

blisovi fe 1/20 1

CLIMARA PRO 2

cryselle-28 1

DIVIGEL 3

drospirenone-ethinyl estradiol 1

DUAVEE 2

ELESTRIN 3

ENDOMETRIN 2

enskyce 1

ESTRACE VAGINAL 3

estradiol oral 1

estradiol transdermal 1

jolivette 1

junel 1/20 1

junel fe 1.5/30 1

junel fe 1/20 1

levonorgestrel-ethinyl estrad oral

tablet 0.1-20 mg-mcg, 0.15-30 mg-

mcg

1

LO LOESTRIN FE 3

loryna 1

low-ogestrel 1

MAKENA INTRAMUSCULAR 2 SP

medroxyprogesterone acetate

intramuscular

1

medroxyprogesterone acetate oral 1

microgestin 1.5/30 1

microgestin 1/20 1

microgestin fe 1.5/30 1

microgestin fe 1/20 1

MINASTRIN 24 FE E

MINIVELLE 3

mono-linyah 1

mononessa 1

NATAZIA 2

nikki 1

norethindrone acet- ethinyl est oral

tablet

1

norethindrone oral 1

norgestimate-ethinyl estradiol triphasic 1

nortrel 1/35 (21) 1

nortrel 1/35 (28) 1

NUVARING 2

MTMP Guide 2018-2019 61

DRUG NAME DRUG TIER

NOTES

ocella 1

ORTHO TRI-CYCLEN (28) E

ORTHO TRI-CYCLEN LO E

portia-28 1

PREMARIN ORAL 2

PREMARIN VAGINAL 2

PREMPHASE 2

PREMPRO 2

progesterone micronized oral 1

SAFYRAL 3

sprintec 28 1

tri-estarylla 1

tri-linyah 1

tri-lo-marzia 1

tri-lo-sprintec 1

trinessa (28) 1

trinessa lo 1

tri-sprintec 1

VAGIFEM VAGINAL TABLET 10

MCG

E

vienva 1

viorele 1

VIVELLE-DOT E

xulane 1

YAZ E

yuvafem 1

HORMONAL AGENTS - THYROID

ARMOUR THYROID 3

CYTOMEL E

levo-t 1

levothyroxine sodium oral 1

levoxyl 1

liothyronine sodium oral 1

methimazole oral 1

NATURE-THROID ORAL TABLET

113.75 MG, 130 MG, 146.25 MG,

16.25 MG, 195 MG, 260 MG, 32.5

MG, 325 MG, 48.75 MG, 65 MG,

81.25 MG, 97.5 MG

3

SYNTHROID 3

TIROSINT 3

IMMUNOLOGICAL AGENTS - DRUGS FOR IMMUNE SYSTEM

STIMULATION OR SUPPRESSION

azathioprine oral 1

CIMZIA PREFILLED KIT 2 SP

CIMZIA STARTER KIT 2 SP

CIMZIA VIAL KIT 2 SP

cyclosporine modified oral capsule 1 SP

ENBREL SUBCUTANEOUS


3 SP

ENBREL SURECLICK


AUTO- INJECTOR

3 SP

DRUG NAME DRUG TIER

NOTES

HAEGARDA 3 SP

HUMIRA PEDIATRIC CROHNS

START SUBCUTANEOUS

PREFILLED SYRINGE KIT 40

MG/0.8ML

2 SP

HUMIRA PEN SUBCUTANEOUS

PEN- INJECTOR KIT

2 SP

HUMIRA PEN-CROHNS STARTER

SUBCUTANEOUS PEN- INJECTOR

KIT

2 SP

HUMIRA PEN- PSORIASIS

STARTER SUBCUTANEOUS PEN-

INJECTOR KIT

2 SP

HUMIRA SUBCUTANEOUS

PREFILLED SYRINGE KIT

2 SP

INFLECTRA E SP

methotrexate oral 1

methotrexate sodium oral 1

mycophenolate mofetil oral capsule 1 SP

mycophenolate mofetil oral tablet 1 SP

mycophenolate sodium 1 SP

ORENCIA SUBCUTANEOUS


3 SP

OTEZLA ORAL TABLET 2 SP

OTEZLA ORAL TABLET THERAPY

PACK

2 SP

PROGRAF ORAL 3 SP

RASUVO SUBCUTANEOUS

SOLUTION AUTO- INJECTOR 10

MG/0.2ML, 12.5 MG/0.25ML, 15

MG/0.3ML, 17.5 MG/0.35ML, 20

MG/0.4ML, 22.5 MG/0.45ML, 25

MG/0.5ML, 30 MG/0.6ML, 7.5

MG/0.15ML

2

REMICADE 2 SP

SIMPONI ARIA 2 SP


SOLUTION AUTO- INJECTOR

2 SP



2 SP

STELARA INTRAVENOUS 2 SP

tacrolimus oral 1 SP

TREMFYA 2 SP

XELJANZ XR 3 SP

IMMUNOLOGICAL AGENTS - DRUGS FOR VACCINATION

AFLURIA PRESERVATIVE FREE


PREFILLED SYRINGE

3

BOOSTRIX INTRAMUSCULAR

SUSPENSION 5-2.5-18.5

3

FLUARIX QUADRIVALENT


PREFILLED SYRINGE

3

MTMP Guide 2018-2019 62

DRUG NAME DRUG TIER

NOTES

FLUCELVAX QUADRIVALENT


PREFILLED SYRINGE

3


SUSPENSION

3


SUSPENSION PREFILLED

SYRINGE

3

FLUZONE HIGH-DOSE


PREFILLED SYRINGE

3



3



PREFILLED SYRINGE

3

ZOSTAVAX SUBCUTANEOUS

SUSPENSION RECONSTITUTED

E

INFLAMMATORY BOWEL DISEASE AGENTS

APRISO 2

ASACOL HD E

CANASA 2

DELZICOL E

DIPENTUM E

LIALDA E

mesalamine oral tablet delayed release

1.2 gm

1

MESALAMINE ORAL TABLET

DELAYED RELEASE 800 MG

E M

PENTASA 3

PROCTOFOAM HC 2

sulfasalazine oral tablet 1

UCERIS RECTAL 3

METABOLIC BONE DISEASE AGENTS - DRUGS FOR OSTEOPOROSIS

alendronate sodium oral tablet 1

BINOSTO E

calcitriol oral capsule 1

FORTEO SUBCUTANEOUS

SOLUTION 600 MCG/2.4ML

2 SP

ibandronate sodium oral E

TYMLOS 2 SP

MISCELLANEOUS THERAPEUTIC AGENTS

BOTOX 2 Non-

Cosmetic;

SP

CETYLEV 3

EUFLEXXA INTRA- ARTICULAR


2 SP

SYNVISC INTRA- ARTICULAR


2 SP

SYNVISC ONE INTRA-

ARTICULAR SOLUTION

2 SP

DRUG NAME DRUG TIER

NOTES

PREFILLED SYRINGE

OPHTHALMIC AGENTS - DRUGS FOR EYE ALLERGY, INFECTION

AND INFLAMMATION

AZASITE 3

BESIVANCE 3

ciprofloxacin hcl ophthalmic 1

erythromycin ophthalmic 1

gentamicin sulfate ophthalmic solution 1

ketorolac tromethamine ophthalmic 1

MOXEZA 2

moxifloxacin hcl ophthalmic 1

ofloxacin ophthalmic 1

olopatadine hcl ophthalmic 1

PAZEO 2

prednisolone acetate ophthalmic 1

PROLENSA 2

tobramycin ophthalmic 1

OPHTHALMIC AGENTS - DRUGS FOR GLAUCOMA

ALPHAGAN P OPHTHALMIC

SOLUTION 0.1 %

2

ALPHAGAN P OPHTHALMIC

SOLUTION 0.15 %

E

AZOPT 2

BETIMOL 3

brimonidine tartrate ophthalmic 1

COMBIGAN 2

COSOPT PF 3

dorzolamide hcl-timolol mal 1

latanoprost ophthalmic 1

LUMIGAN OPHTHALMIC

SOLUTION 0.01 %

2

RESCULA E

SIMBRINZA 2

timolol maleate ophthalmic solution 1

TRAVATAN Z 2

ZIOPTAN E

OPHTHALMIC AGENTS - DRUGS FOR MISCELLANEOUS EYE

CONDITIONS

LASTACAFT 3

neomycin-polymyxin- dexameth

ophthalmic suspension 3.5-10000-0.1

1

polymyxin b-trimethoprim 1

RESTASIS 2

RESTASIS MULTIDOSE 2

TOBRADEX OPHTHALMIC

SUSPENSION

E

tobramycin- dexamethasone 1

XIIDRA 2

MTMP Guide 2018-2019 63

DRUG NAME DRUG TIER

NOTES

OTIC AGENTS - DRUGS FOR EAR CONDITIONS

CIPRODEX 2

neomycin-polymyxin-hc otic solution

1 %

1

neomycin-polymyxin-hc otic

suspension

1

ofloxacin otic 1


ALLERGIES, COUGH, COLD

ASTEPRO NASAL SOLUTION

0.15 %

3

azelastine hcl nasal 1

benzonatate 1

cetirizine hcl oral solution E

cetirizine hcl oral syrup 1 mg/ml E

DYMISTA 2

fluticasone propionate nasal E

hydrocodone polst-cpm polst er oral

suspension extended release 10-8

mg/5ml

1

ipratropium bromide nasal 1

levocetirizine dihydrochloride oral

tablet

E

mometasone furoate nasal E

NASONEX E

OMNARIS E

promethazine hcl oral tablet 1

promethazine-codeine 1

promethazine-dm 1

pseudoephedrine- bromphen-dm oral

syrup 30-2-10 mg/5ml

1

QNASL E

QNASL CHILDRENS E

TUZISTRA XR ORAL SUSPENSION

EXTENDED RELEASE

3

XOLAIR 2 SP

ZETONNA E

ZUTRIPRO 3


ASTHMA AND OTHER LUNG CONDITIONS

ADVAIR DISKUS 2

ADVAIR HFA 2

AIRDUO RESPICLICK 113/14 E



albuterol sulfate inhalation 1

ALVESCO E

ANORO ELLIPTA 2

ARNUITY ELLIPTA 2

ASMANEX 120 METERED DOSES E

ASMANEX 14 METERED

DOSES

E

DRUG NAME DRUG TIER

NOTES

ASMANEX 30 METERED

DOSES

E

ASMANEX 60 METERED

DOSES

E

ASMANEX 7 METERED DOSES E

ASMANEX HFA E

AUVI-Q INJECTION SOLUTION

AUTO- INJECTOR

E

BREO ELLIPTA 2

budesonide inhalation 1

COMBIVENT RESPIMAT 2

DULERA E



MG/0.15ML

E Made by

Impax; M



MG/0.3ML

2 Made by

Mylan


INJECTOR 0.3 MG/0.3ML

INJECTION

2 Made by

Mylan


INJECTOR 0.3 MG/0.3ML

INJECTION

E Made by

Impax; M

EPIPEN 2-PAK INJECTION


E

EPIPEN JR 2-PAK INJECTION


E

FLOVENT DISKUS 2

FLOVENT HFA 2

INCRUSE ELLIPTA 2

ipratropium bromide inhalation 1

ipratropium-albuterol 1

LEVALBUTEROL HFA

INHALATION AEROSOL 45

MCG/ACT

E M

montelukast sodium oral tablet 1

montelukast sodium oral tablet

chewable

1

PERFOROMIST 3

PROAIR HFA 2

PROAIR RESPICLICK 2

PROVENTIL HFA E

PULMICORT FLEXHALER 2

PULMICORT SUSPENSION E

QVAR INHALATION AEROSOL

SOLUTION

E

QVAR REDIHALER E

SEREVENT DISKUS 2

SINGULAIR E

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT 2

STIOLTO RESPIMAT 2

SYMBICORT 2

MTMP Guide 2018-2019 64

DRUG NAME DRUG TIER

NOTES

TUDORZA PRESSAIR

INHALATION AEROSOL POWDER

BREATH ACTIVATED

E

VENTOLIN HFA 2

XOPENEX HFA E


PULMONARY HYPERTENSION

ADCIRCA 3 SP

ADEMPAS 2 SP

LETAIRIS 2 SP

OPSUMIT 2 SP

ORENITRAM 3 SP

sildenafil citrate oral tablet 20 mg 1 SP

TRACLEER 2 SP

SKELETAL MUSCLE RELAXANTS - DRUGS FOR MUSCLE TENSION

AND SPASM

AMRIX E

baclofen oral 1

DRUG NAME DRUG TIER

NOTES

carisoprodol oral 1

cyclobenzaprine hcl oral 1

LORZONE E

metaxalone 1

methocarbamol oral 1

orphenadrine citrate er 1

tizanidine hcl oral tablet 1

SLEEP DISORDER AGENTS

AMBIEN E

AMBIEN CR E

eszopiclone 1

LUNESTA E

modafinil 1

NUVIGIL E

SILENOR E

temazepam 1

zolpidem tartrate er E

zolpidem tartrate oral 1

MTMP Guide 2018-2019 65

OptumRx Pharmacy Resources

Mobile Application

The convenient app makes the online pharmacy experience as simple as possible.

From your mobile phone, you can:

View all medications in a clear and concise format using the "Medicine Cabinet" feature

Refill and renew home delivery prescriptions

Transfer a retail prescription to home delivery

Find drug prices and lower cost options

View your prescription claims history or order status

Locate a pharmacy: Enjoy the convenience of our pharmacy locator to locate an in-network retail location at

any time.

Set up refill reminders: Set text message reminders for refills or taking a medication

Track your order

When you receive your physician's order, visit optumrx.com, register, and follow the simple step-by-step

instructions. You can manage your medication(s) online.

Mobile Friendly Website

Access your Account Anytime, Anywhere.

Manage your prescription drug benefits on your smartphone, iPad, Android tablet, or other handheld device.

OptumRx Mobile makes it easy to:

Refill mail service pharmacy prescriptions

Check the status of and track orders

Locate a pharmacy by ZIP code

View your prescription history

Set up text message medication reminders

Search your formulary by generic or brand-name drug, status, or class

How do I find the mobile site?

Open your smartphone browser and type in m.optumrx.com. You also can type in our full address, optumrx.com,

and you will automatically be directed to the mobile version of our site. Once the site is loaded on your phone,

you can bookmark it.


http://www.m.optumrx.com/


MTMP Guide 2018-2019 66

Can I use the mobile site on any smartphone?

Yes. Just enter m.optumrx.com into the web browser of your smartphone.

Can I use both the full site and the mobile site?

Yes. If you make a change to your account or manage your prescriptions on one site, that information will be

updated on the other site as well.

How to refill prescriptions

1. On the home page, click "My Prescriptions". Click "Refill Prescriptions". (If you are not logged in, you will

be prompted to log in first.)

2. Select the prescription(s) you would like refilled by checking the box(es).

3. Click "Add to Cart" to proceed to the shopping cart page.

4. Review your selections. You can remove items from your cart, keep shopping, or check out. When you are

finished, click "Check Out".

5. Review your shipping information and your order summary. You may change your shipping address or add

a new one.

6. Review your order summary. To make changes to your order, click "Back". If your order is complete, click

"Submit".

How to set up text message medication reminders

1. On the home page, click "My Prescriptions". Click "Medication Reminders". (If you are not logged in, you

will be prompted to log in first.)

2. Enter the mobile phone number where you want the text message reminder(s) to be sent.

3. Select your time zone.

4. Select your mobile carrier.

5. Choose the type of reminder you would like to receive. You can get reminders when mail order prescriptions

are ready for refill and renewal, when prescriptions are eligible for transfer to mail service, and when orders

have been shipped. You can also set reminders for specific times of day and for specific medications.

6. When you are done, click "Save".

http://www.m.optumrx.com/

MTMP Guide 2018-2019 67

Consumer Portal

The OptumRx® consumer portal empowers you to become an informed advocate of your own health by allowing

you to easily manage and gain deeper insight into your prescription benefits.

Simple: The responsive design makes it easy for you to access your complete profile to manage your

prescription benefits on any device.

Smart: With accurate drug pricing, proactive messaging on cost savings, and detailed order status

information, all of your real time benefits information is readily available.

Seamless: You can enroll in text message reminders for taking your medications as well as when you need to

refill or renew prescriptions, and when orders have shipped.

Register or sign in to optumrx.com to take advantage of these features.

My Medicine Cabinet

Upon login, you will see your My Medicine Cabinet dashboard. This makes it easy for you to view your real time

benefits and access the many tools and features to help you manage your medications and health from a single

page.

Once registered on the website, you can access:

1. Household prescriptions

Ability to manage prescriptions on behalf of

family members

2. Order status

You are able to track where your home

delivery order is within the process and view

order hold information if applicable

3. Proactive savings messaging

Advocates for you by providing proactive

ways to save such as transferring retail

prescriptions to home delivery

4. Member tools

Provides easy access to the most commonly

used member tools throughout the site

5. Medicine cards

Provides visibility to the most relevant information for medications


MTMP Guide 2018-2019 68

Single Sign-On Access

Re-registration is required.

The first time you click on the new SSO link from tmlhealthbenefits.org, you will be taken to OptumRx's

Portal to register. Registration will create a unique identifier that will recognize your access between websites

from that point forward.

The next time you click on the SSO link, you will be taken directly into the OptumRx Portal.

Mail Order Service

OptumRx state-of-the-art mail service pharmacy sends refrigerated injectable medications via express delivery to

your location of choice, or to your provider to administer to you in the office. Our goal is to meet and exceed your

needs when it comes to how, when, and where you receive your medications.

How do I use OptumRx mail service pharmacy for new prescriptions?

Ordering a new medication is easy with our website. Just log on to optumrx.com. From there go to "My Account"

then click on "Manage My Mail Service" to fill a new prescription through our easy-to-use online tools. Or, if

you prefer to speak to someone on the phone, call (800) 788-7871 (TTY 711) to order through home delivery

anytime.

How will I order refills from OptumRx mail service pharmacy?

Once you place your first order with OptumRx, you can choose from three different ways to order refills:

Online: Order refills by logging into optumrx.com, selecting "Manage my Prescriptions" and viewing your

refills.

Mail: Complete the reorder form included with each medication shipment and then mail it to us for processing.

Phone: Call customer service at (800) 788-7871 (TTY 711). You can choose to use our automated system or

speak with a representative.

Also, if you register at optumrx.com, you will receive e-mail reminders when it is time to refill your prescription.

How long will it take to receive my mail service prescription orders?

New prescription orders should arrive in about 10 business days after we receive complete order information,

while refills should arrive in about 7 business days.





Medication Therapy Management Guide - Portland, TX

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