Your Pharmacy Benefits

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A well-balanced pharmacy network offers you convenient access and competitive discounts for brand and generic medications. Our national retail pharmacy network includes more than 64,000 chain and independent retail pharmacies, so you’re sure to find one close to home or work.

Using your ID card

When you fill a prescription through a participating pharmacy, show the pharmacy your ID card so they can submit a claim for coverage by your pharmacy benefit plan. When you pick up your prescription, the pharmacy then collects your applicable member contribution as defined by your plan.

If you do not present your ID card or you fill a prescription at a non-participating pharmacy, you pay the full retail price for your medication. If the prescription is eligible for coverage under your pharmacy benefit plan, you may submit a claim to request reimbursement (forms are available at optumrx.com or by calling customer service).

When you submit a claim using the reimbursement form, OptumRx first determines if your plan covers the medication. If it is covered, the amount you receive is based on contracted pharmacy rates less your plan’s out-of-pocket member contribution. All prescription claims are subject to your pharmacy benefit plan’s rules and restrictions.

Retail pharmacy network

OptumRx | optumrx.com

Retail pharmacy network

Finding a network pharmacy

You can choose from three easy ways to find participating pharmacies near you:

1. Review the partial list included on the following pages.

2. Go to our website and use the LOCATE A PHARMACY tool.

3. Contact customer service using the number on the back of your benefit plan member ID card.

AA S Medication Solutions

AADP

Accesshealth

Accesshealth Plus

Albertsons

American Drug Stores

American Pharmacy Network Solutions

Amerita

Aurora Pharmacy

BBalls Four B Corp

Bi Lo

Bimart Corporation

Biorx

Brookshire Bros

Brookshire Grocery Company

CCardinal Health Managed Care Servic

Carrs Quality Center

Central Dakota Pharmacys

Cigna Medical Group Pharmacy

City Market

Complete Claims Processing

Costco Pharmacies

Curators Of The University Of Mo

CVS Pharmacy

DDallas Metrocare Services

Dillon Stores

Discount Drug Mart

Doctors Choice Pharmacies

EE Medrx Solutions

Eaton Apothecary

Epic Pharmacy Network

FF & F Pharmacies

Fairview Health Services

Fairview Pharmacy Services

Family Care Pharmacy Network

Ff Acquisition

Food City-K-Va-T Food Stores

Food Lion

Fred Meyer

Freds Pharmacy

Freds Stores Of Tennessee

Fruth Pharmacy

Frys Food And Drug Stores

GGerimed Network

Giant Eagle

Global

Good Neighbor Phcy Provider

HHannaford Bros Co

Harris Teeter

Harvard Vanguard Medical Associates

Heb Grocery Company

Horton And Converse Pharmacy

Humana Pharmacy Inc Pharmacy

Hy-Vee

IIHC Health Services

Ingles Markets Pharmacy

Innovatix Network

Innovatix Specialty Network

Inserra Supermarkets

Insty Meds

KK Mart Pharmacy

King Soopers Pharmacy Co

Kinney Drugs

Kleins Family Markets

Klingensmiths Drug Store

Kohlls Pharmacy And Homecare

KS Management Services

LLeader Drug Stores

Leader Puerto Rico

LML Enterprises

Longs Drug Stores California

MM K Stores

Major Value Third Party Network

Marianos Pharmacies

Marshfield Clinic Pharmacy

Maxor National Phcy Srvs Corp

Mayo Clinic Pharmacy

Mds Rx

Medicap Pharmacies

Medicine Shoppe International

Meijer

Mha Long Term Care Network

Myrx

NNai Saturn Eastern

Navarro Discount Pharmacies

NCPRX

Neighborcare Pharmacy Services

Northeast Phcy Svce Corp

Northwest Health Ventures

OOmnicare Inc Ncs Healthcare

Oncology Pharmacy Services

PPacmed Clinics

Patient First Corporation

Pharmerica

Physicians Pharmaceutical Corp

Physicians Pharmaceutical Corp

Planned Parenthood Of The Pacific S

Poc Network Technologies

Ppok Rxselect Phcy Network

Price Chopper House Calls Pharma

Procare Pharmacy

Progressive Pharmacies

Provider Services Of America

Publix Super Markets

QQCP Networx

Quality Food Centers

Quick Chek Corporation

RRaleys Drug Center

Ralphs Pharmacy

Randalls Food And Drug

Recept Healthcare Services

Red Cross Pharmacy

Redners Markets

Rite Aid Corporation

Ronetco Supermarkets

Roundys Pharmacies

SS R S

Safeway

Saker Shoprites

Sav Mor Drug Stores

Save Mart Supermarkets

Schnuck Markets

Seip Drug

Shaws Supermarket

Shopko Stores Operating Co

Shoprite Financial Services

Shoprite Supermarkets

Smiths Food And Drug Center

Stop And Shop Pharmacy

Supervalu Pharmacies

Swift Rx Llc

TTarget Corporation

Tempest Med

The Bartell Drug Company

The Kroger Co

Third Party Station

Third Party Station Cp

Third Party Station Pr

Thrifty Drug Stores

Tom Thumb Pharmacies

Tops Markets

UUcsd Medical Center Phcy

United Drugs

United Drugs Rural Network

United Pharmacy Tx

University Of Utah Pharmacies

VValley Wholesale Drug Co

Vantage Rx Dispensing Services

Village Supermarkets

Vons Companies

WWalgreens Drug Store

Walmart Stores

Wegman Food Market

Weis Pharmacies

Welgo

Winn Dixie Pharmacy

ZZallie Supermarkets

2300 Main Street, Irvine, CA 92614

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.

All Optum® trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

© 2017 Optum, Inc. All rights reserved. ORX0779-UMR_170728

optumrx.com

Your 2020 Formulary

For the most current list of covered medications or if you have questions:

Call the number on your member ID card.

Visit your plan’s website on your member ID card to:

• Find a participating retail pharmacy by ZIP code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

Innoviant Premium

Effective July 1, 2020

2

Understanding your formulary

What is a formulary?A formulary is a list of prescribed medications or other pharmacy care products, services or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription medications.

To create the list, OptumRx® is guided by the Pharmacy and Therapeutics Committee. This group of doctors, nurses, and pharmacists reviews which medications will be covered, how well the drugs work and overall value. They also make sure there are safe and covered options.

About this formulary Where differences between this formulary and your benefit plan exist, the benefit plan documents rule. This may not be a complete list of medications that are covered by your plan. Please review your benefit plan for full details.

How do I use my formulary?You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. If your medication is not listed here, please visit your plan’s member website or call the number on your member ID card.

What are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or plan sponsor. This is how much you will pay when you fill a prescription.

When does the formulary change?• Medications may move to a lower tier at any time.

• Medications may move to a higher tier when a generic equal becomes available.

• Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year.

When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage?A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication?You or your authorized representative and your doctor can ask for a coverage request by calling the number on your member ID card.

3

Medication tips

What is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent for a brand-name medication ends, the FDA can approve a generic version with the same active ingredients.

What if my doctor writes a brand-name prescription?If your doctor gives you a prescription for a brand-name medication, ask if a generic or lower-cost option could be right for you. Generic medications are usually your lowest-cost option.

Over-the-counter medicationsAn over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options. Even though OTC medications may not be covered by your pharmacy benefit, they may cost less than a prescription medication.

What if I am taking a specialty medication?Specialty medications are for rare or complex conditions and are usually higher-cost medications. Please note, not all specialty medications are listed in the formulary. Our specialty pharmacy can provide most of your specialty medications along with helpful programs and services. Call 1-855-427-4682 and have your prescriptions delivered right to your home or doctor’s office.

4

Reading your formulary

The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX). Generic medications are shown in lowercase (for example, clobetasol).

Tier informationUsing lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you meet your deductible.

Drug Tier Includes Helpful Tips

Tier 1 $ Lower-cost generics and some brand name

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

Tier 2 $$ 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 not be covered or need prior authorization. Lower-cost options are available and covered.

Drug list informationIn this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.

M Authorized generic or cobranded product

PA Prior Authorization – Your doctor is required to give OptumRx more information to determine coverage.

QL Quantity Limit – Medication may be limited to a certain quantity.

SP Specialty Medication – Medication is designated as specialty.

ST Step Therapy – Trial of lower-cost medication(s) is required before a higher-cost medication can be covered.

3P Tier 3 preferred

++ Benefit Design Options – Coverage is determined by your prescription medication benefit plan.

Table of Contents

Analgesics - Drugs for Pain.................................................................................................................................7Analgesics - Drugs for Pain and Inflammation.................................................................................................... 8Anesthetics..........................................................................................................................................................8Anti-Addiction / Substance Abuse Treatment Agents......................................................................................... 8Antibacterials.......................................................................................................................................................8Anticoagulants.....................................................................................................................................................9Anticonvulsants - Drugs for Seizures................................................................................................................ 10Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 10Antidepressants.................................................................................................................................................10Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 11Antifungals.........................................................................................................................................................11Antigout Agents................................................................................................................................................. 12Antimigraine Agents.......................................................................................................................................... 12Antineoplastics - Drugs for Cancer....................................................................................................................12Antiparasitics..................................................................................................................................................... 13Antiparkinson Agents........................................................................................................................................ 13Antiplatelets.......................................................................................................................................................13Antipsychotics - Drugs for Mood Disorders....................................................................................................... 13Antivirals............................................................................................................................................................13Anxiolytics - Drugs for Anxiety...........................................................................................................................14Bipolar Agents - Drugs for Mood Disorders.......................................................................................................14Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders..............................................14Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 15Central Nervous System Agents - Drugs for Attention Deficit Disorder........................................................... 17Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 17Central Nervous System Agents - Miscellaneous............................................................................................. 18Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................18Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 18Diabetes - Antidiabetic Agents.......................................................................................................................... 20Diabetes - Glucose Monitoring.......................................................................................................................... 21Diabetes - Glycemic Agents.............................................................................................................................. 22Diabetes - Insulins.............................................................................................................................................22Electrolytes / Minerals / Metals / Vitamins.........................................................................................................23Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................24Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................25Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 25Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................25Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 26Hormonal Agents - Adrenal............................................................................................................................... 26Hormonal Agents - Men's Health.......................................................................................................................26Hormonal Agents - Osteoporosis...................................................................................................................... 26Hormonal Agents - Pituitary.............................................................................................................................. 26Hormonal Agents - Sex Hormones and Birth Control........................................................................................27Hormonal Agents - Thyroid............................................................................................................................... 29Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 29Inflammatory Bowel Disease Agents.................................................................................................................30Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 30Metabolic Bone Disease Agents - Other........................................................................................................... 30Miscellaneous Therapeutic Agents................................................................................................................... 30Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................31Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................31

5

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 32Otic Agents - Drugs for Ear Conditions............................................................................................................. 32Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................32Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 32Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 34Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 34Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 34Sleep Disorder Agents...................................................................................................................................... 34

6

Drug Name Drug Tier Notes

Analgesics - Drugs for Pain

ABSTRAL E

acetaminophen-codeine #2

1 QL


1 QL


1 QL

acetaminophen-codeine oral tablet

1 QL

APADAZ E

apap-caff-dihydrocodeine oral capsule

1 QL

ARYMO ER E

BELBUCA 2 PA; QL

BENZHYDROCODONE-ACETAMINOPHEN

E

butalbital-apap-caffeine 1

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR

E

CONZIP E

DILAUDID ORAL E

DURAGESIC-100 E

DURAGESIC-12 E

DURAGESIC-25 E

DURAGESIC-50 E

DURAGESIC-75 E

fentanyl 1 PA; QL

FENTANYL CITRATE BUCCAL TABLET

E M

FENTORA E

FIORICET E

FIORICET/CODEINE E


hydrocodone-acetaminophen oral tablet

1 QL

hydromorphone hcl oral tablet

1 QL

HYSINGLA ER 2 PA; QL

KADIAN E

LAZANDA E

morphine sulfate er oral tablet extended release

1 PA; QL

MS CONTIN E

NORCO E

NUCYNTA E

NUCYNTA ER E

OXYCODONE HCL E

OXYCODONE HCL ER E M

oxycodone hcl oral tablet

1 QL

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1 QL

OXYCONTIN 2 PA; QL

PERCOCET E

ROXICODONE E

SUBSYS E

TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG

E M

tramadol hcl oral tablet 50 mg

1 QL

TREZIX 3 QL

TYLENOL WITH CODEINE #3

E

TYLENOL WITH CODEINE #4 ORAL TABLET 300-60 MG

E

For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.

7


ULTRACET E

ULTRAM E

XTAMPZA ER E

ZOHYDRO ER E

Analgesics - Drugs for Pain and Inflammation

ARTHROTEC E

CAMBIA E

CELEBREX E

celecoxib oral 1 QL

diclofenac sodium oral 1

diclofenac sodium transdermal gel 1 %

1 QL

DUEXIS E

etodolac oral tablet 1

FLECTOR E

ibuprofen oral tablet 200 mg

E

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

indomethacin oral capsule 25 mg, 50 mg

1

KETOROLAC TROMETHAMINE NASAL SOLUTION 15.75 MG/SPRAY

E M

ketorolac tromethamine oral

1 QL

meloxicam oral 1

MOBIC E

nabumetone oral 1

NALFON E

NAPRELAN 3

naproxen oral tablet 1

naproxen sodium oral tablet 220 mg

E


naproxen sodium oral tablet 275 mg, 550 mg

1

PENNSAID E

QMIIZ ODT E

SPRIX E

VIMOVO E

VOLTAREN E

ZIPSOR E

ZORVOLEX E

Anesthetics

lidocaine external ointment

1

lidocaine external patch 5 %

1

lidocaine-prilocaine external cream

1

LIDODERM E

ZTLIDO E

Anti-Addiction / Substance Abuse Treatment Agents

BUNAVAIL 3 QL

buprenorphine hcl sublingual

1 QL

buprenorphine hcl-naloxone hcl

1 QL

CHANTIX 3 ++; QL

CHANTIX CONTINUING MONTH PAK

3 ++; QL

CHANTIX STARTING MONTH PAK

3 ++; QL

naltrexone hcl oral 1

NARCAN 2

SUBOXONE E

ZUBSOLV 2 QL

Antibacterials

ACTICLATE E

amoxicillin oral capsule 1


8


amoxicillin oral suspension reconstituted

1

amoxicillin oral tablet 1

amoxicillin-potassium clavulanate oral suspension reconstituted

1

amoxicillin-potassium clavulanate oral tablet

1

azithromycin oral suspension reconstituted

1

azithromycin oral tablet 1

cefdinir 1

cefuroxime axetil 1

cephalexin oral capsule 1

cephalexin oral suspension reconstituted

1

ciprofloxacin hcl oral tablet 250 mg, 500 mg

1

clarithromycin oral tablet

1

clindamycin hcl oral 1

CLINDESSE 3

DIFICID 3

DORYX E

DORYX MPC E

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet

1

doxycycline monohydrate oral capsule

1

doxycycline monohydrate oral tablet

1

levofloxacin oral tablet 1


metronidazole oral tablet

1

metronidazole vaginal 1

minocycline hcl oral capsule

1

MINOLIRA E

mupirocin external 1

nitrofurantoin macrocrystal oral

1

nitrofurantoin monohydrate macrocrystals

1

NUZYRA ORAL 3

penicillin v potassium oral tablet

1

SEYSARA 3 ST

SILVADENE E

SOLODYN E

SOLOSEC 3

sulfamethoxazole-trimethoprim oral

1

TARGADOX E

XENLETA INTRAVENOUS

E

XENLETA ORAL 3

XEPI 3

XIMINO 3

Anticoagulants

BEVYXXA 3 QL

ELIQUIS 2 QL

ELIQUIS DVT/PE STARTER PACK

2 QL

enoxaparin sodium 1 SP; QL

PRADAXA 2 QL

warfarin sodium oral 1

XARELTO 2 QL

XARELTO STARTER PACK

2 QL


9


Anticonvulsants - Drugs for Seizures

carbamazepine oral tablet

1

CARBATROL E

DEPAKOTE E

DEPAKOTE ER E

DEPAKOTE SPRINKLES

E

DILANTIN INFATABS E

DILANTIN ORAL CAPSULE 100 MG

E

DILANTIN ORAL SUSPENSION

E

divalproex sodium er 1

divalproex sodium oral tablet delayed release

1

EPIDIOLEX 3 PA; SP

gabapentin oral capsule

1

gabapentin oral tablet 1

KEPPRA ORAL E

KEPPRA XR E

LAMICTAL E

LAMICTAL ODT E

LAMICTAL STARTER E

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR

E

lamotrigine er 1

lamotrigine oral tablet 1

levetiracetam oral tablet

1

NEURONTIN E

ONFI E

oxcarbazepine oral tablet

1

OXTELLAR XR E

QUDEXY XR E


SABRIL E SP

SYMPAZAN 3 PA

TEGRETOL E

TEGRETOL-XR E

TOPAMAX E

TOPAMAX SPRINKLE E

topiramate oral tablet 1

TRILEPTAL E

TROKENDI XR E

VIMPAT INTRAVENOUS

E

VIMPAT ORAL 3

ZONEGRAN E

zonisamide oral 1

Antidementia Agents - Drugs for Alzheimer's Disease and Dementia

donepezil hcl oral tablet 10 mg, 23 mg

1

memantine hcl oral tablet 10 mg, 5 mg

1

NAMZARIC 2 QL

Antidepressants

amitriptyline hcl oral 1

BRISDELLE E

bupropion hcl er (sr) 1 QL

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

1 QL

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

2 QL

bupropion hcl oral 1

CELEXA E


10


citalopram hydrobromide oral tablet

1

CYMBALTA E

desvenlafaxine succinate er

1 QL

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 50 mg, 75 mg

1

duloxetine hcl oral 1 QL

EFFEXOR XR E

escitalopram oxalate oral tablet

1

fluoxetine hcl oral capsule

1

fluoxetine hcl oral tablet 1

fluvoxamine maleate 1

FORFIVO XL 3 QL

LEXAPRO E

mirtazapine oral tablet 1

nortriptyline hcl oral capsule

1

paroxetine hcl 1

PAXIL CR E

PAXIL ORAL TABLET E

PRISTIQ E

PROZAC E

sertraline hcl oral tablet 1

trazodone hcl oral 1

TRINTELLIX 3 ST; QL

venlafaxine hcl 1

venlafaxine hcl er 1

VIIBRYD 3 QL

VIIBRYD STARTER PACK

3 QL

WELLBUTRIN SR E

WELLBUTRIN XL E


ZOLOFT E

Antiemetics - Drugs for Nausea and Vomiting

meclizine hcl oral tablet 1 ++

metoclopramide hcl oral tablet 10 mg

1

ondansetron hcl oral tablet 4 mg, 8 mg

1

ondansetron odt 1

prochlorperazine maleate oral

1

SANCUSO E

scopolamine 1

VARUBI ORAL TABLET 90 MG

3 QL

Antifungals

ciclopirox external solution

E ++

clotrimazole external cream

1

clotrimazole-betamethasone external cream

1

CRESEMBA ORAL 3

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 QL

terconazole vaginal cream

1

TOLSURA E


11


Antigout Agents

allopurinol oral 1

COLCHICINE ORAL CAPSULE

E

colchicine tablet 0.6 mg oral

1 Made by Mylan


E Made by Par


EMade by Prasco

COLCRYS 2

MITIGARE E

Antimigraine Agents

AIMOVIG 2 PA; QL

AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

E

eletriptan hydrobromide 1 QL

EMGALITY 2 PA; QL

EMGALITY (300 MG DOSE)

2 PA; QL

IMITREX E

IMITREX STATDOSE REFILL

E

IMITREX STATDOSE SYSTEM

E

MAXALT E

MAXALT-MLT E

ONZETRA XSAIL E

RELPAX E

rizatriptan benzoate 1 QL

sumatriptan succinate oral

1 QL

TOSYMRA E

TREXIMET E

ZEMBRACE SYMTOUCH

E

ZOMIG ORAL E


ZOMIG ZMT E

Antineoplastics - Drugs for Cancer

AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG

E SP

anastrozole oral 1

ARIMIDEX E

BELRAPZO E SP

BENDAMUSTINE HCL E SP

CABOMETYX 2 PA; SP

capecitabine 1 PA; SP

ERLEADA E SP

GLEEVEC E SP

IBRANCE ORAL CAPSULE

3 PA; SP

IDHIFA 3 PA; SP; QL

imatinib mesylate 1 PA; SP

IMBRUVICA ORAL TABLET

3 PA; SP

KANJINTI 2 PA; SP

letrozole oral 1

LYNPARZA 2 PA; SP

MVASI 2 PA; SP

NUBEQA 3 PA; SP

OGIVRI E SP

REVLIMID 2 PA; SP

RUBRACA 2 PA; SP

RUXIENCE 2 PA; SP

SPRYCEL 2 PA; SP

tamoxifen citrate oral 1

TARGRETIN ORAL E SP

temozolomide 1 PA; SP

TRAZIMERA 2 PA; SP

TREANDA E SP

TRUXIMA E SP


12


XPOVIO (100 MG ONCE WEEKLY)

3 PA; SP


3 PA; SP


3 PA; SP

XPOVIO (80 MG TWICE WEEKLY)

3 PA; SP

XTANDI 3 PA; SP

YONSA E SP

ZEJULA 2 PA; SP

ZIRABEV 2 PA; SP

ZYTIGA E SP

Antiparasitics

ARAKODA 3

EMVERM 2

hydroxychloroquine sulfate oral

1

NATROBA E

permethrin external 1

PLAQUENIL E

Antiparkinson Agents

benztropine mesylate oral

1

carbidopa-levodopa oral tablet

1

GOCOVRI E

INBRIJA 3 PA; SP

OSMOLEX ER E

pramipexole dihydrochloride

1

ropinirole hcl 1

RYTARY 3 ST

Antiplatelets

ASPIRIN-OMEPRAZOLE

E M

BRILINTA 2


clopidogrel bisulfate oral

1

PLAVIX E

prasugrel hcl 1

YOSPRALA E

Antipsychotics - Drugs for Mood Disorders

ABILIFY E

ABILIFY MAINTENA E

aripiprazole oral tablet 1 QL

ARISTADA E

ARISTADA INITIO E

INVEGA SUSTENNA E

INVEGA TRINZA E

LATUDA 3 QL

olanzapine oral tablet 1 QL

PERSERIS E

quetiapine fumarate 1 QL

quetiapine fumarate er 1 QL

REXULTI 3 QL

RISPERDAL E

risperidone oral tablet 1 QL

SAPHRIS 2 QL

SEROQUEL E

SEROQUEL XR E

VRAYLAR 3 ST; QL

ziprasidone hcl 1 QL

ZYPREXA E

Antivirals

acyclovir oral tablet 1

ATRIPLA E

BARACLUDE ORAL TABLET

E SP

BIKTARVY 3

CIMDUO 2

DESCOVY 3 PA


13


DOVATO 2

entecavir 1 SP; QL

EPCLUSA 2 PA; SP; QL

GENVOYA 3

HARVONI 2 PA; SP; QL

JULUCA 2

LEDIPASVIR-SOFOSBUVIR

E M; SP

MAVYRET 2 PA; SP; QL

ODEFSEY 3

oseltamivir phosphate oral

1 QL

PREZCOBIX 2

SOFOSBUVIR-VELPATASVIR

E M; SP

SYMFI 2

SYMFI LO 2

TAMIFLU E

TEMIXYS E

TIVICAY 2

TRIUMEQ 2

TRUVADA 2

valacyclovir hcl oral 1 QL

VALTREX E

VEMLIDY 3 SP

VOSEVI 2 PA; SP; QL

XOFLUZA (40 MG DOSE)

3 QL

XOFLUZA (80 MG DOSE)

3 QL

ZOVIRAX E

Anxiolytics - Drugs for Anxiety

alprazolam oral tablet 1 QL

ATIVAN ORAL E

buspirone hcl oral 1

clonazepam oral tablet 1 QL


diazepam oral tablet 1

hydroxyzine hcl oral tablet

1

hydroxyzine pamoate oral

1

KLONOPIN E

lorazepam oral tablet 1 QL

triazolam 1 QL

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

ADYNOVATE 3 SP

AFSTYLA 3 SP

ARANESP (ALBUMIN FREE)

2 PA; SP

ELOCTATE 3 SP

EPOGEN E SP

FULPHILA E SP

GRANIX E SP

JIVI 3 SP

MULPLETA 2 PA; SP

NEULASTA 3 PA; SP

NEULASTA ONPRO 3 PA; SP

NEUPOGEN E SP

NIVESTYM 2 PA; SP

NOVOEIGHT 3 SP

NUWIQ 3 SP

PROCRIT E SP


14


RETACRIT 2 PA; SP

UDENYCA 3 PA; SP

ULTOMIRIS 3 PA; SP

ZARXIO 2 PA; SP

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ALTACE E

amiodarone hcl oral 1

amlodipine besylate oral

1

amlodipine besylate-benazepril hcl

1

amlodipine besylate-valsartan

1

amlodipine-olmesartan 1

ATACAND E

atenolol oral 1

atenolol-chlorthalidone 1

atorvastatin calcium oral

1

AVAPRO E

AZOR E

benazepril hcl oral 1

BENICAR E

BENICAR HCT E

bisoprolol fumarate 1

bisoprolol-hydrochlorothiazide

1

bumetanide oral 1

BYSTOLIC 2

candesartan cilexetil 1

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

E

cartia xt 1


carvedilol 1

CATAPRES-TTS-1 E

CATAPRES-TTS-2 E

CATAPRES-TTS-3 E

chlorthalidone 1

clonidine hcl oral 1

COLESTID E

COLESTID FLAVORED

E

COREG E

COREG CR E

CORLANOR ORAL TABLET

3 PA; QL

COZAAR E

CRESTOR E

digoxin oral tablet 1

diltiazem hcl er coated beads oral capsule extended release 24 hour

1

dilt-xr 1

DIOVAN E

DIOVAN HCT E

doxazosin mesylate oral

1

DYAZIDE E

EDARBI 3 ST

EDARBYCLOR 3 ST

enalapril maleate oral 1

ENTRESTO 2 QL

EXFORGE E

EXFORGE HCT E

ezetimibe 1

ezetimibe-simvastatin 1

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

1

fenofibrate oral tablet 1


15


fenofibric acid oral capsule delayed release

1

flecainide acetate 1

furosemide oral tablet 1

gemfibrozil oral 1

guanfacine hcl 1

HEMANGEOL 3

hydralazine hcl oral 1

hydrochlorothiazide oral

1

HYZAAR E

INDERAL LA E

INDERAL XL E

INNOPRAN XL E

irbesartan 1

irbesartan-hydrochlorothiazide

1

isosorbide mononitrate er

1

KAPSPARGO SPRINKLE

E

KATERZIA E

labetalol hcl oral 1

LASIX E

LESCOL XL E

LIPITOR E

lisinopril oral 1

lisinopril-hydrochlorothiazide

1

LIVALO 3 ST

losartan potassium 1

losartan potassium-hctz 1

LOTREL E

lovastatin 1

LOVAZA E

metoprolol succinate er 1

metoprolol tartrate oral 1


MICARDIS E

MICARDIS HCT E

MULTAQ 3

nadolol oral 1

NIASPAN E

nifedipine er 1

nifedipine er osmotic release

1

nitroglycerin sublingual 1

NITROSTAT E

NORVASC E

olmesartan medoxomil oral

1

olmesartan medoxomil-hctz

1

olmesartan-amlodipine-hctz

1

omega-3-acid ethyl esters

1 PA

PRALUENT 2 PA; QL

PRAVACHOL E

pravastatin sodium 1

prazosin hcl oral 1

PRINIVIL E

propranolol hcl er 1

propranolol hcl oral tablet

1

QUESTRAN E

QUESTRAN LIGHT E

quinapril hcl 1

ramipril 1

RANEXA E

ranolazine er 1

REPATHA 2 PA; QL

REPATHA PUSHTRONEX SYSTEM

2 PA; QL


16


REPATHA SURECLICK

2 PA; QL

rosuvastatin calcium 1

simvastatin oral tablet 1

sotalol hcl oral 1

spironolactone oral 1

TEKTURNA 2

TEKTURNA HCT 2 ST

telmisartan 1

telmisartan-hctz 1

TENORMIN E

TIKOSYN E

TOPROL XL E

torsemide 1

triamterene-hctz 1

TRIBENZOR E

TRICOR E

valsartan 1

valsartan-hydrochlorothiazide

1

VASCEPA 3 PA

verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg

1

verapamil hcl er oral tablet extended release

1

VYTORIN E

WELCHOL E

ZESTRIL E

ZETIA E

ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG

E

ZYPITAMAG E


Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL E

ADDERALL XR E

ADHANSIA XR E

amphetamine-dextroamphetamine

1 PA; QL

amphetamine-dextroamphetamine er

1 PA; QL

atomoxetine hcl 1 QL

CONCERTA E

dexmethylphenidate hcl er

1 PA; QL

dexmethylphenidate hcl oral tablet 10 mg, 5 mg

1 PA; QL

EVEKEO E

FOCALIN E

FOCALIN XR E

guanfacine hcl er 1 PA

INTUNIV E

JORNAY PM 3 PA; ST; QL

methylphenidate hcl er 1 PA; QL

methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 40 mg

1 PA; QL

methylphenidate hcl oral tablet

1 PA; QL

RITALIN E

RITALIN LA E

STRATTERA E

VYVANSE 2 PA; QL

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA 3 PA; SP; QL


17


AUBAGIO 3 PA; SP; QL

AVONEX PEN 2 PA; SP; QL

AVONEX PREFILLED 2 PA; SP; QL

BETASERON 2 PA; SP; QL

COPAXONE 2 PA; SP; QL

EXTAVIA E SP

GILENYA 3PA; 3P; SP; QL

glatiramer acetate 1 PA; SP; QL

MAVENCLAD (10 TABS)

3 PA; 3P; SP

MAVENCLAD (4 TABS)

3 PA; 3P; SP

MAVENCLAD (5 TABS)

3 PA; 3P; SP

MAVENCLAD (6 TABS)

3 PA; 3P; SP

MAVENCLAD (7 TABS)

3 PA; 3P; SP

MAVENCLAD (8 TABS)

3 PA; 3P; SP

MAVENCLAD (9 TABS)

3 PA; 3P; SP

MAYZENT 3PA; 3P; SP; QL

MAYZENT STARTER PACK

3PA; 3P; SP; QL

PLEGRIDY E SP

PLEGRIDY STARTER PACK

E SP

REBIF 3 PA; SP; QL

REBIF REBIDOSE 3 PA; SP; QL

REBIF REBIDOSE TITRATION PACK

3 PA; SP; QL

REBIF TITRATION PACK

3 PA; SP; QL

TECFIDERA 2 PA; SP; QL


Central Nervous System Agents - Miscellaneous

ADDYI 3 ++; QL

ADIPEX-P E ++

AUSTEDO 3 PA; SP; QL

CONTRAVE 2 ++

GRALISE 3 ST; QL

GRALISE STARTER 3 ST; QL

HORIZANT 3 PA; QL

LYRICA E

phentermine hcl oral capsule 30 mg

1 ++

phentermine hcl oral tablet

1 ++

pregabalin oral capsule 1 QL

SAXENDA 3 ++

TEGSEDI 3 PA; SP

TIGLUTIK 3 PA; SP; QL

VYLEESI 3 ++; QL

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

chlorhexidine gluconate mouth/throat

1

lidocaine viscous hcl 1

Dermatological Agents - Drugs for Skin Conditions

ABSORICA 3 PA

ABSORICA LD 3 PA

ACANYA E

ACZONE EXTERNAL GEL 5 %

E

ACZONE EXTERNAL GEL 7.5 %

2

ALA SCALP E

APEXICON E E


18


BENZACLIN E

BENZACLIN WITH PUMP

E

BENZAMYCIN E

betamethasone dipropionate external cream

1

BRYHALI 3

CALCIPOTRIENE EXTERNAL FOAM

E M

CAPEX E

claravis 1 PA

CLINDAGEL E

clindamycin phosphate-benzoyl peroxide external gel 1-5 %

1

clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL

E M

clindamycin phosphate gel 1 % external

1

clobetasol propionate external cream

1

clobetasol propionate external ointment

1

clobetasol propionate external solution

1

CLOBEX E

CLOBEX SPRAY E

CLODERM E

CORDRAN EXTERNAL TAPE

E

DESONATE E


DIFFERIN EXTERNAL CREAM

E ++

DIFFERIN EXTERNAL GEL 0.3 %

E ++

DIFFERIN EXTERNAL LOTION

E ++

DUOBRII E

DUPIXENT 2 PA; SP; QL

ELIDEL E

ENSTILAR 3 QL

EPIDUO E

EPIDUO FORTE 3

EUCRISA 2 ST

FINACEA EXTERNAL GEL

E

fluocinonide external cream

1

FLUOROPLEX 3

FLUOROURACIL EXTERNAL CREAM 0.5 %

2

fluorouracil external cream 5 %

1

HALOBETASOL PROPIONATE EXTERNAL FOAM

E M

HALOG E

hydrocortisone external cream 0.5 %

E

hydrocortisone external cream 1 %, 2.5 %

1

hydrocortisone external ointment 0.5 %

E

hydrocortisone external ointment 1 %, 2.5 %

1

imiquimod external 1

IMIQUIMOD PUMP E M

IMPOYZ E

KENALOG EXTERNAL E


19


LEXETTE E

METROGEL E

metronidazole external cream

1

metronidazole external gel

1

MICORT-HC EXTERNAL CREAM 2.5 %

E

MIRVASO 2

mometasone furoate external cream

1

NORITATE E

ONEXTON 3

ORACEA E

PANDEL E

PROPECIA E

PSORCON E

QBREXZA 3 QL

RETIN-A E ++

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 PA; ++

SERNIVO 3

SOOLANTRA 2

SORILUX E

TACLONEX EXTERNAL OINTMENT

E

TACLONEX EXTERNAL SUSPENSION

3 QL

tacrolimus external ointment

1


TAZORAC EXTERNAL CREAM 0.1 %

E

TOPICORT SPRAY E

tretinoin external cream 1 PA; ++

triamcinolone acetonide external cream

1

triamcinolone acetonide external ointment

1

ULTRAVATE E

VECTICAL E

VELTIN E

VERDESO E

ZIANA E

ZYCLARA E

ZYCLARA PUMP E

Diabetes - Antidiabetic Agents

ADLYXIN E

ADLYXIN STARTER PACK

E

ALOGLIPTIN BENZOATE

E M

ALOGLIPTIN-METFORMIN HCL

E M

ALOGLIPTIN-PIOGLITAZONE

E M

BYDUREON 2 ST; QL

BYDUREON BCISE AUTOINJECTOR

2 ST; QL

BYETTA 10 MCG PEN 2 ST; QL

BYETTA 5 MCG PEN 2 ST; QL

FARXIGA 2 ST

FORTAMET E

glimepiride 1

glipizide er 1

glipizide ir 1

GLUCOPHAGE ORAL TABLET 1000 MG, 500 MG, 850 MG

E


20


GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG

E

GLUMETZA E

glyburide oral 1

GLYXAMBI 2 ST

INVOKAMET E

INVOKAMET XR E

INVOKANA E

JANUMET 2 ST

JANUMET XR 2 ST

JANUVIA 2 ST

JARDIANCE 2 ST

JENTADUETO 2 ST

JENTADUETO XR 2 ST

KAZANO E

KOMBIGLYZE XR E

metformin hcl er 1

metformin hcl er (mod) E

metformin hcl er (osm) E

metformin hcl oral tablet

1

NESINA E

ONGLYZA E

OSENI E

OZEMPIC 2 ST; QL

pioglitazone hcl 1

QTERN E

RYBELSUS 2 ST; QL

SEGLUROMET E

SOLIQUA 2 ST; QL

STEGLATRO E

STEGLUJAN E

SYMLINPEN 60 3 PA

SYNJARDY 2 ST


SYNJARDY XR 2 ST

TRADJENTA 2 ST

TRULICITY 2 ST; QL

VICTOZA 2 ST; QL

XIGDUO XR 2 ST

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA DEVICE

E ++

ACCU-CHEK AVIVA CONNECT KIT W/DEVICE

E ++

ACCU-CHEK AVIVA PLUS KIT W/DEVICE

E ++

ACCU-CHEK COMPACT PLUS CARE KIT

E ++

ACCU-CHEK COMPACT PLUS CONTROL

E ++

ACCU-CHEK COMPACT PLUS TEST STRIPS

E ++

ACCU-CHEK FASTCLIX LANCET KIT

2 ++

ACCU-CHEK GUIDE KIT W/DEVICE

E ++

ACCU-CHEK GUIDE CONTROL

E ++

ACCU-CHEK MULTICLIX LANCET DEVICE KIT

2 ++

ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE

E ++

ACCU-CHEK SMARTVIEW CONTROL

E ++

ACCU-CHEK SMARTVIEW TEST STRIPS

E ++


21


ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

2 ++

DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)

2 ++

DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC) DEVICE

2 ++

FREESTYLE LIBRE 14 DAY READER

E ++

FREESTYLE LIBRE 14 DAY SENSOR

E ++

FREESTYLE LIBRE READER

E ++

FREESTYLE LIBRE SENSOR SYSTEM

E ++

LANCETS 2 ++

ONETOUCH ULTRA 2 KIT W/DEVICE

2 ++

ONETOUCH ULTRA BLUE TEST STRIPS

2 ++; QL

ONETOUCH ULTRA MINI KIT W/DEVICE

2 ++

ONETOUCH VERIO KIT W/DEVICE

2 ++

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE

2 ++

ONETOUCH VERIO TEST STRIPS

2 ++; QL

ONETOUCH VERIO IQ SYSTEM

2 ++


ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE

2 ++

V-GO 20 2 ++

V-GO 30 2 ++

V-GO 40 2 ++

Diabetes - Glycemic Agents

BAQSIMI ONE PACK 2 ++

BAQSIMI TWO PACK 2 ++

GLUCAGON EMERGENCY KIT

2Made by Lilly; ++

GLUCAGON EMERGENCY KIT

2Made by Fresenius; ++

GVOKE PFS 2 ++

Diabetes - Insulins

ADMELOG E ++

ADMELOG SOLOSTAR

E ++

APIDRA SOLOSTAR E ++

APIDRA VIAL E ++

BASAGLAR KWIKPEN E ++

BD AUTOSHIELD DUO PEN NEEDLES

2 ++

BD ULTRA-FINE INSULIN SYRINGES

2 ++

BD ULTRA-FINE PEN NEEDLES

2 ++

FIASP E ++

FIASP FLEXTOUCH E ++

FIASP PENFILL E ++

HUMALOG 2 ++

HUMALOG KWIKPEN 2 ++

HUMALOG MIX 50/50 KWIKPEN

2 ++

HUMALOG MIX 50/50 VIAL

2 ++

HUMALOG MIX 75/25 KWIKPEN

2 ++


22


HUMALOG MIX 75/25 VIAL

2 ++

HUMALOG U-100 JUNIOR KWIKPEN

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 ++

INSULIN ASP PROT & ASP FLEXPEN

E M; ++

INSULIN ASPART E M; ++

INSULIN ASPART FLEXPEN

E M; ++

INSULIN ASPART PENFILL

E M; ++

INSULIN ASPART PROT & ASPART

E M; ++

INSULIN LISPRO E M; ++

INSULIN LISPRO (1 UNIT DIAL)

E M; ++

LANTUS 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 FLEXPEN

E ++

NOVOLIN 70/30 FLEXPEN RELION

E ++

NOVOLIN 70/30 RELION

E ++

NOVOLIN 70/30 VIAL E ++

NOVOLIN N FLEXPEN E ++

NOVOLIN N FLEXPEN RELION

E ++

NOVOLIN N RELION E ++

NOVOLIN N VIAL E ++

NOVOLIN R FLEXPEN E ++

NOVOLIN R FLEXPEN RELION

E ++

NOVOLIN R RELION E ++

NOVOLIN R VIAL E ++

NOVOLOG FLEXPEN E ++

NOVOLOG MIX 70/30 FLEXPEN

E ++

NOVOLOG MIX 70/30 VIAL

E ++

NOVOLOG PENFILL E ++

NOVOLOG U-100 VIAL E ++

NOVOTWIST PEN NEEDLE

2 ++

TOUJEO MAX SOLOSTAR

2 ++

TOUJEO SOLOSTAR 2 ++

TRESIBA E ++

TRESIBA FLEXTOUCH

E ++

Electrolytes / Minerals / Metals / Vitamins

AZESCO E ++

CARNITOR ORAL E

CARNITOR SF E


23


cyanocobalamin injection solution 1000 mcg/ml

1 ++

ergocalciferol oral capsule

1 ++

folic acid oral tablet 1 mg

1 ++

folic acid oral tablet 800 mcg

E

K-TAB E

LOKELMA 3

multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg

E ++

NASCOBAL 3 ++

potassium chloride crys er

1

potassium chloride er 1

potassium citrate er 1

PREGENNA E ++

PRENATE E ++

PRENATE DHA E ++

PRENATE ELITE E ++

PRENATE ENHANCE E ++

PRENATE ESSENTIAL E ++

PRENATE MINI E ++

PRENATE PIXIE E ++

PRENATE RESTORE E ++

sodium fluoride oral tablet chewable

E ++

TRINAZ E ++

VELTASSA 3

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1 ++

ZALVIT E ++


Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

ACIPHEX E ++

CARAFATE ORAL TABLET

E

esomeprazole magnesium oral capsule delayed release

E ++

famotidine oral tablet E ++

gnp lansoprazole E ++

lansoprazole capsule delayed release 15 mg oral (otc)

E ++

misoprostol oral 1

NEXIUM ORAL CAPSULE DELAYED RELEASE

E ++

omeprazole oral capsule delayed release

1 QL

omeprazole-sodium bicarbonate

E ++

pantoprazole sodium oral

1 QL

PREVACID E ++

PREVACID SOLUTAB ORAL TABLET DELAYED RELEASE DISPERSIBLE 15 MG

E ++

PROTONIX ORAL TABLET DELAYED RELEASE

E ++

RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE

E M; ++

ranitidine hcl oral capsule

E ++

ranitidine hcl oral syrup 1 ++

ranitidine hcl oral tablet E ++


24


sucralfate oral tablet 1

ZEGERID E ++

Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions

AMITIZA E

CLENPIQ 3

dicyclomine hcl oral capsule

1

dicyclomine hcl oral tablet

1

diphenoxylate-atropine oral tablet

1

gavilyte-g 1

glycopyrrolate oral tablet 1 mg, 2 mg

1

GLYCOPYRROLATE ORAL TABLET 1.5 MG

3

GOLYTELY E

lactulose oral solution 1

LINZESS 2 ST; QL

MOTEGRITY 3 ST; QL

MOTOFEN E

MOVANTIK E

MOVIPREP E

NULYTELY WITH FLAVOR PACKS

E

OMECLAMOX-PAK 2

peg 3350-kcl-na bicarb-nacl

1

PLENVU 3

PREPOPIK 3

PYLERA 2

RELISTOR E

SUPREP BOWEL PREP KIT

3

SYMPROIC 2 ST; QL

TRULANCE E


VIBERZI 3 PA; QL

ZELNORM 3 PA; QL

Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment

CERDELGA 3 PA; SP

CREON 2

NITYR 3 PA; SP

PANCREAZE E

PERTZYE E

STRENSIQ 2 PA; SP

VIOKACE E

ZENPEP 2

Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions

AURYXIA 3

CIALIS E ++

DEPEN TITRATABS 2 SP

INTRAROSA 3

LEVITRA E ++

MYRBETRIQ 2

oxybutynin chloride er 1

oxybutynin chloride oral tablet

1

phenazopyridine hcl oral tablet 100 mg, 200 mg

1

RENAGEL E

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg

1 ++; QL

solifenacin succinate 1

STAXYN E ++

STENDRA E ++

tadalafil oral 1 ++; QL


25


tolterodine tartrate er 1

TOVIAZ 3

VELPHORO 3

VESICARE E

VIAGRA E ++

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er 1

AVODART E

dutasteride oral 1

finasteride oral tablet 5 mg

1

FLOMAX E

tamsulosin hcl 1

terazosin hcl oral capsule 1 mg, 10 mg, 5 mg

1

Hormonal Agents - Adrenal

CORTEF E

dexamethasone oral tablet

1

hydrocortisone oral 1

KENALOG INJECTION SUSPENSION 40 MG/ML

E

methylprednisolone oral

1

prednisolone oral solution

1

prednisolone sodium phosphate oral solution

1

prednisone oral tablet 1

prednisone oral tablet therapy pack

1

RAYOS E

TAPERDEX 12-DAY 3

TAPERDEX 6-DAY 3


TAPERDEX 7-DAY 3

Hormonal Agents - Men's Health

ANDRODERM 2 PA

ANDROGEL E

ANDROGEL PUMP E

DEPO-TESTOSTERONE

E

FORTESTA E

TESTIM E

testosterone cypionate intramuscular

1 PA

testosterone transdermal gel 1.62 %, 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)

1 PA

VOGELXO E

VOGELXO PUMP E

XYOSTED 3 PA

Hormonal Agents - Osteoporosis

OSPHENA 3

raloxifene hcl 1

Hormonal Agents - Pituitary

ACTHAR 2 PA; SP

cabergoline 1

CETROTIDE E ++; SP

FOLLISTIM AQ 2 PA; ++; SP

ganirelix acetate 1PA; Made by Organon/Merck; ++; SP

GENOTROPIN E ++; SP

GENOTROPIN MINIQUICK

E ++; SP


26


GONAL-F E ++; SP

GONAL-F RFF E ++; SP

GONAL-F RFF REDIJECT

E ++; SP

HUMATROPE E ++; SP

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG

2 PA; SP

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG

2 PA; SP

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

2 PA; SP

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

2 PA; SP

MENOPUR 3 PA; ++; SP

NOCDURNA 3

NOCTIVA E

NORDITROPIN FLEXPRO

2 PA; ++; SP

NUTROPIN AQ NUSPIN 10

2 PA; ++; SP


2 PA; ++; SP


2 PA; ++; SP

OMNITROPE E ++; SP

ORILISSA 2 PA; QL

OVIDREL 3 PA; ++; SP

SAIZEN E ++; SP

SAIZENPREP E ++; SP

SANDOSTATIN E SP

ZOMACTON E ++; SP


Hormonal Agents - Sex Hormones and Birth Control

ANNOVERA E ++

apri 1 ++

aviane 1 ++

BEYAZ E ++

BIJUVA 3

blisovi 24 fe 1 ++

blisovi fe 1.5/30 1 ++

blisovi fe 1/20 1 ++

CLIMARA E

CLIMARA PRO 2

cryselle-28 1 ++

DELESTROGEN INTRAMUSCULAR OIL 20 MG/ML, 40 MG/ML

E

DIVIGEL 3

drospirenone-ethinyl estradiol

1 ++

DUAVEE 2

ELESTRIN 3

ENDOMETRIN 2 ++

enskyce 1 ++

errin 1 ++

estarylla 1 ++

ESTRACE E

estradiol oral 1

estradiol transdermal 1

estradiol vaginal 1

EVAMIST 3

femynor 1 ++

GENERESS FE E ++

gianvi 1 ++

IMVEXXY MAINTENANCE PACK

3

IMVEXXY STARTER PACK

3


27


isibloom 1 ++

junel 1.5/30 1 ++

junel 1/20 1 ++

junel fe 1.5/30 1 ++

junel fe 1/20 1 ++

junel fe 24 1 ++

kariva 1 ++

kurvelo 1 ++

larin fe 1/20 1 ++

larissia 1 ++

lessina 1 ++

levonorgest-eth est & eth est

1 ++; QL

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg, 0.15-0.03 mg

1 ++; QL

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

1 ++

LO LOESTRIN FE E ++

LOESTRIN 1.5/30 (21) E ++

LOESTRIN 1/20 (21) E ++

LOESTRIN FE 1.5/30 E ++

LOESTRIN FE 1/20 E ++

low-ogestrel 1 ++

MAKENA 2 PA; SP

medroxyprogesterone acetate intramuscular

1 ++; QL

medroxyprogesterone acetate oral

1

MINASTRIN 24 FE E ++

MINIVELLE 3

MIRENA (52 MG) E ++

mono-linyah 1 ++

NATAZIA 2 ++

nikki 1 ++


norethindrone acetate oral

1

norethindrone acet-ethinyl est

1 ++

norethindrone oral 1 ++

norgestimate-ethinyl estradiol triphasic

1 ++

nortrel 1/35 (21) 1 ++

nortrel 1/35 (28) 1 ++

NUVARING 3 ++

ORTHO MICRONOR E ++

ORTHO TRI-CYCLEN LO

E ++

ORTHO-NOVUM 1/35 (28)

E ++

ORTHO-NOVUM 7/7/7 (28)

E ++

PREMARIN ORAL 2

PREMARIN VAGINAL 2

PREMPHASE 2

PREMPRO 2

progesterone micronized oral

1

PROMETRIUM E

SAFYRAL E ++

SEASONIQUE E ++

SLYND E ++

sprintec 28 1 ++

syeda 1 ++

TAYTULLA 3 ++

tri femynor 1 ++

tri-linyah 1 ++

tri-lo-marzia 1 ++

tri-lo-sprintec 1 ++

tri-sprintec 1 ++

VAGIFEM E

vienva 1 ++

viorele 1 ++


28


VIVELLE-DOT E

xulane 1 ++

YASMIN 28 E ++

YAZ E ++

Hormonal Agents - Thyroid

ARMOUR THYROID 3 ST

CYTOMEL E

euthyrox 1

levothyroxine sodium oral

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 ST

np thyroid oral tablet 60 mg

1

SYNTHROID E

TIROSINT E

TIROSINT-SOL E

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA ACTPEN 3 PA; 3P; SP

ACTEMRA SUBCUTANEOUS

3 PA; 3P; SP

azathioprine oral 1

CIMZIA 2 PA; SP

CIMZIA PREFILLED KIT

2 PA; SP

CIMZIA STARTER KIT 2 PA; SP


COSENTYX (300 MG DOSE)

E SP

COSENTYX 150 MG/ML

E SP

COSENTYX SENSOREADY (300 MG)

E SP

COSENTYX SENSOREADY PEN

E SP

CUTAQUIG E SP

cyclosporine modified oral capsule

1 SP

ENBREL MINI 3 PA; SP

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

ENBREL SURECLICK 3 PA; SP

FIRAZYR 3 PA; SP

HAEGARDA 3 PA; SP

HUMIRA 2 PA; SP

HUMIRA PEDIATRIC CROHNS START

2 PA; SP

HUMIRA PEN 2 PA; SP

HUMIRA PEN-CD/UC/HS STARTER

2 PA; SP

HUMIRA PEN-PS/UV/ADOL HS START

2 PA; SP

INFLECTRA 2 PA; SP

leflunomide oral 1

methotrexate oral 1

methotrexate sodium oral

1

mycophenolate mofetil oral capsule

1 SP

mycophenolate mofetil oral tablet

1 SP

mycophenolate sodium 1 SP

OLUMIANT E SP


29


ORENCIA 3 PA; 3P; SP

ORENCIA CLICKJECT 3 PA; 3P; SP

OTEZLA 2 PA; SP

PANZYGA E SP

PROGRAF ORAL CAPSULE

3 SP

RASUVO 2 PA; QL

REMICADE E SP

RENFLEXIS 2 PA; SP

RINVOQ 2 PA; SP

RUCONEST 3 PA; SP

SIMPONI 2 PA; SP

SIMPONI ARIA 2 PA; SP

sirolimus oral tablet 1 SP

SKYRIZI (150 MG DOSE)

2 PA; SP

STELARA 2 PA; SP

tacrolimus oral 1 SP

TAKHZYRO 3 PA; SP

TALTZ 3 PA; 3P; SP

TREMFYA 2 PA; SP

XELJANZ 2 PA; SP

XELJANZ XR 2 PA; SP

Inflammatory Bowel Disease Agents

APRISO 2

ASACOL HD E

CANASA E

DELZICOL E

DIPENTUM E

LIALDA E

mesalamine oral tablet delayed release

1

PENTASA 3

PROCTOFOAM HC RECTAL FOAM 1-1 %

2

sulfasalazine oral tablet 1


UCERIS ORAL E

UCERIS RECTAL 3

Metabolic Bone Disease Agents - Drugs for Osteoporosis

alendronate sodium oral tablet 10 mg, 5 mg

1

alendronate sodium oral tablet 35 mg, 70 mg

1 QL

BINOSTO 3 QL

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML

2 PA; SP

ibandronate sodium oral

1 QL

PROLIA 2 PA; SP; QL

RAYALDEE 3

TYMLOS 2 PA; SP

Metabolic Bone Disease Agents - Other

calcitriol oral capsule 1

SENSIPAR E

Miscellaneous Therapeutic Agents

BOTOX 2PA; Non-Cosmetic; SP

DUROLANE 2 PA; SP

EUFLEXXA 2 PA; SP

FIRDAPSE E SP

GEL-ONE E

GELSYN-3 2 PA; SP

GENVISC 850 E

HYALGAN E SP

HYMOVIS E SP

MONOVISC E SP


30


ORTHOVISC E SP

SODIUM HYALURONATE INTRA-ARTICULAR

E SP

SUPARTZ FX E SP

SYNVISC E SP

SYNVISC ONE E SP

TRIVISC E

VISCO-3 E

Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation

AZASITE 3

BESIVANCE 3

BROMSITE E

ciprofloxacin hcl ophthalmic

1

erythromycin ophthalmic

1

gentamicin sulfate ophthalmic

1

ILEVRO E

INVELTYS 3

ketorolac tromethamine ophthalmic

1

LOTEMAX OPHTHALMIC GEL

3 QL

LOTEMAX OPHTHALMIC OINTMENT

3 QL

LOTEMAX OPHTHALMIC SUSPENSION

E

LOTEMAX SM 3

MOXEZA 2

moxifloxacin hcl ophthalmic

1

NEVANAC E

ofloxacin ophthalmic 1


olopatadine hcl ophthalmic

1

PATADAY OPHTHALMIC SOLUTION 0.2 %

E

PATANOL OPHTHALMIC SOLUTION 0.1 %

E

PAZEO E

PRED FORTE E

prednisolone acetate ophthalmic

1

PROLENSA 2 QL

VIGAMOX E

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 E

dorzolamide hcl-timolol mal

1

dorzolamide hcl-timolol mal pf

1

latanoprost ophthalmic 1

LUMIGAN 2 QL

RHOPRESSA 2

ROCKLATAN 2 QL

SIMBRINZA 2

timolol maleate ophthalmic solution

1

TIMOPTIC E


31


TIMOPTIC OCUDOSE E

TIMOPTIC-XE E

TRAVATAN Z 3 QL

VYZULTA E

XALATAN E

ZIOPTAN E

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

LATISSE E

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

polymyxin b-trimethoprim

1

RESTASIS 2 PA

RESTASIS MULTIDOSE

2 PA

TOBRADEX OPHTHALMIC SUSPENSION

E

tobramycin-dexamethasone

1

XIIDRA 2 PA

Otic Agents - Drugs for Ear Conditions

CIPRODEX 2

neomycin-polymyxin-hc otic suspension

1

ofloxacin otic 1

OTOVEL 3

Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold

azelastine hcl nasal 1 QL

benzonatate 1

CLARINEX E ++


CLARINEX-D 12 HOUR

E

cyproheptadine hcl oral tablet

1

DYMISTA 2 QL

FASENRA 2 PA; SP

FASENRA PEN 2 PA; SP

ipratropium bromide nasal

1

NASONEX E ++

NUCALA 2 PA; SP; QL

promethazine hcl oral tablet

1

promethazine-codeine 1 PA; QL

promethazine-dm 1

pseudoephedrine-bromphen-dm

1

XHANCE E ++

XOLAIR 2 PA; SP

Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ADVAIR DISKUS 2 QL

ADVAIR HFA 2 QL

AIRDUO RESPICLICK 113/14

E


E


E

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

1Made by Perrigo; QL

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

1Made by Teva; QL


32


ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

EMade by Par; M

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION

EMade by Prasco; M

albuterol sulfate inhalation

1 QL

ALVESCO E

ANORO ELLIPTA 2 QL

ARNUITY ELLIPTA 2 QL

ASMANEX (120 METERED DOSES)

E


E


E


E


E

ASMANEX HFA E

ATROVENT HFA 3 QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML, 0.3 MG/0.3ML

E

BEVESPI AEROSPHERE

E

BREO ELLIPTA 2 QL

budesonide inhalation 1 QL

BUDESONIDE-FORMOTEROL FUMARATE

E M


COMBIVENT RESPIMAT

2 QL

DULERA E

epinephrine injection solution auto-injector

1

EPIPEN 2-PAK 3 ST

EPIPEN JR 2-PAK E

FLOVENT DISKUS 2 QL

FLOVENT HFA 2 QL

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose

1 QL

INCRUSE ELLIPTA 2 QL

ipratropium-albuterol 1 QL

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT

E M

LONHALA MAGNAIR REFILL KIT

3 QL

LONHALA MAGNAIR STARTER KIT

3 QL

montelukast sodium oral tablet

1

montelukast sodium oral tablet chewable

1

PERFOROMIST 3 QL

PROAIR DIGIHALER E

PROAIR HFA E

PROAIR RESPICLICK E

PROVENTIL HFA E

PULMICORT FLEXHALER

2 QL

PULMICORT SUSPENSION

E

QVAR REDIHALER E


33


SEEBRI NEOHALER E

SEREVENT DISKUS 2 QL

SINGULAIR E

SPIRIVA HANDIHALER

2 QL

SPIRIVA RESPIMAT 2 QL

STIOLTO RESPIMAT 2 QL

SYMBICORT 2 QL

SYMJEPI 3

TRELEGY ELLIPTA 2 QL

TUDORZA PRESSAIR E

UTIBRON NEOHALER E

VENTOLIN HFA 2 QL

wixela inhub 1 QL

XOPENEX HFA E

YUPELRI E

Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS 2 SP

KITABIS PAK E SP

PULMOZYME 2 PA; SP

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

Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA E SP

ADEMPAS 2 PA; SP; QL

LETAIRIS E SP


OPSUMIT 2 PA; SP; QL

ORENITRAM 3 PA; SP

REMODULIN E SP

sildenafil citrate oral tablet 20 mg

1 PA; SP; QL

TRACLEER 62.5 MG, 125 MG

E SP

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

AMRIX E

baclofen oral 1

carisoprodol oral 1

cyclobenzaprine hcl oral

1

LORZONE 3

metaxalone 1

methocarbamol oral 1

NORGESIC FORTE E

ORPHENGESIC FORTE

E M

SKELAXIN E

SOMA E

tizanidine hcl oral 1

ZANAFLEX E

Sleep Disorder Agents

AMBIEN E

AMBIEN CR E

armodafinil 1 PA; QL

eszopiclone 1 QL

LUNESTA E

modafinil 1 PA; QL

NUVIGIL E

PROVIGIL E

RESTORIL E

SILENOR 3 QL


34


SUNOSI 2 PA; QL

temazepam 1 QL

WAKIX 3 PA; SP; QL

XYREM 3 PA; SP; QL

zolpidem tartrate er 1 QL

zolpidem tartrate oral 1 QL


35


36

Index of Drugs

ABILIFY.....................................13ABILIFY MAINTENA................. 13ABSORICA............................... 18ABSORICA LD..........................18ABSTRAL....................................7ACANYA................................... 18ACCU-CHEK AVIVA CONNECT KIT W/DEVICE.......21ACCU-CHEK AVIVA DEVICE...21ACCU-CHEK AVIVA PLUS KIT W/DEVICE..........................21ACCU-CHEK COMPACT PLUS CARE KIT....................... 21ACCU-CHEK COMPACT PLUS CONTROL...................... 21ACCU-CHEK COMPACT PLUS TEST STRIPS................ 21ACCU-CHEK FASTCLIX LANCET KIT............................. 21ACCU-CHEK GUIDE CONTROL................................ 21ACCU-CHEK GUIDE KIT W/DEVICE................................ 21ACCU-CHEK MULTICLIX LANCET DEVICE KIT...............21ACCU-CHEK NANO SMARTVIEW KIT W/DEVICE...21ACCU-CHEK SMARTVIEW CONTROL................................ 21ACCU-CHEK SMARTVIEW TEST STRIPS...........................21ACCU-CHEK SOFTCLIX LANCET DEVICE KIT...............22acetaminophen-codeine..............7acetaminophen-codeine #2.........7acetaminophen-codeine #3.........7acetaminophen-codeine #4.........7ACIPHEX.................................. 24ACTEMRA................................ 29ACTEMRA ACTPEN.................29ACTHAR................................... 26ACTICLATE................................ 8acyclovir.................................... 13ACZONE................................... 18ADCIRCA..................................34ADDERALL............................... 17ADDERALL XR......................... 17ADDYI....................................... 18ADEMPAS................................ 34ADHANSIA XR..........................17ADIPEX-P................................. 18ADLYXIN...................................20ADLYXIN STARTER PACK...... 20

ADMELOG................................ 22ADMELOG SOLOSTAR........... 22ADVAIR DISKUS...................... 32ADVAIR HFA............................ 32ADYNOVATE............................14AFINITOR................................. 12AFSTYLA.................................. 14AIMOVIG...................................12AIRDUO RESPICLICK 113/14..32AIRDUO RESPICLICK 232/14..32AIRDUO RESPICLICK 55/14....32AJOVY...................................... 12ALA SCALP.............................. 18albuterol sulfate.........................33albuterol sulfate hfa...................32ALBUTEROL SULFATE HFA... 33alendronate sodium.................. 30alfuzosin hcl er.......................... 26allopurinol..................................12ALOGLIPTIN BENZOATE........ 20ALOGLIPTIN-METFORMIN HCL...........................................20ALOGLIPTIN-PIOGLITAZONE. 20ALPHAGAN P........................... 31alprazolam................................ 14ALTACE.................................... 15ALVESCO................................. 33AMBIEN.................................... 34AMBIEN CR.............................. 34amiodarone hcl......................... 15AMITIZA....................................25amitriptyline hcl......................... 10amlodipine besylate.................. 15amlodipine besylate-benazepril hcl............................................. 15amlodipine besylate-valsartan.. 15amlodipine-olmesartan..............15amoxicillin............................... 8, 9amoxicillin-potassium clavulanate..................................9amphetamine-dextroamphetamine.................. 17amphetamine-dextroamphetamine er.............. 17AMPYRA...................................17AMRIX.......................................34anastrozole............................... 12ANDRODERM.......................... 26ANDROGEL..............................26ANDROGEL PUMP.................. 26ANNOVERA..............................27ANORO ELLIPTA..................... 33APADAZ......................................7

apap-caff-dihydrocodeine........... 7APEXICON E............................ 18APIDRA SOLOSTAR................ 22APIDRA VIAL............................22apri............................................ 27APRISO.................................... 30ARAKODA................................ 13ARANESP (ALBUMIN FREE)...14ARIMIDEX.................................12aripiprazole............................... 13ARISTADA................................ 13ARISTADA INITIO.................... 13armodafinil ................................ 34ARMOUR THYROID.................29ARNUITY ELLIPTA...................33ARTHROTEC..............................8ARYMO ER.................................7ASACOL HD............................. 30ASMANEX (120 METERED DOSES).................................... 33ASMANEX (14 METERED DOSES).................................... 33ASMANEX (30 METERED DOSES).................................... 33ASMANEX (60 METERED DOSES).................................... 33ASMANEX (7 METERED DOSES).................................... 33ASMANEX HFA........................ 33ASPIRIN-OMEPRAZOLE......... 13ATACAND.................................15atenolol..................................... 15atenolol-chlorthalidone..............15ATIVAN..................................... 14atomoxetine hcl.........................17atorvastatin calcium.................. 15ATRIPLA................................... 13ATROVENT HFA...................... 33AUBAGIO..................................18AURYXIA.................................. 25AUSTEDO.................................18AUVI-Q......................................33AVAPRO................................... 15aviane....................................... 27AVODART.................................26AVONEX PEN...........................18AVONEX PREFILLED.............. 18AZASITE................................... 31azathioprine.............................. 29azelastine hcl............................ 32AZESCO................................... 23azithromycin................................9AZOPT...................................... 31

37

AZOR........................................ 15baclofen.................................... 34BAQSIMI ONE PACK............... 22BAQSIMI TWO PACK...............22BARACLUDE............................ 13BASAGLAR KWIKPEN............. 22BD AUTOSHIELD DUO PEN NEEDLES................................. 22BD ULTRA-FINE INSULIN SYRINGES............................... 22BD ULTRA-FINE PEN NEEDLES................................. 22BELBUCA................................... 7BELRAPZO...............................12benazepril hcl............................15BENDAMUSTINE HCL............. 12BENICAR.................................. 15BENICAR HCT..........................15BENZACLIN..............................19BENZACLIN WITH PUMP........ 19BENZAMYCIN.......................... 19BENZHYDROCODONE-ACETAMINOPHEN.....................7benzonatate.............................. 32benztropine mesylate................13BESIVANCE............................. 31betamethasone dipropionate.... 19BETASERON............................18BETHKIS...................................34BETIMOL.................................. 31BEVESPI AEROSPHERE.........33BEVYXXA................................... 9BEYAZ...................................... 27BIJUVA..................................... 27BIKTARVY................................ 13BINOSTO..................................30bisoprolol fumarate................... 15bisoprolol-hydrochlorothiazide.. 15blisovi 24 fe............................... 27blisovi fe 1.5/30......................... 27blisovi fe 1/20............................ 27BOTOX..................................... 30BREO ELLIPTA........................ 33BRILINTA..................................13brimonidine tartrate................... 31BRISDELLE.............................. 10BROMSITE............................... 31BRYHALI...................................19budesonide............................... 33BUDESONIDE-FORMOTEROL FUMARATE....33bumetanide............................... 15BUNAVAIL.................................. 8

buprenorphine hcl....................... 8buprenorphine hcl-naloxone hcl............................................... 8bupropion hcl............................ 10bupropion hcl er (sr)..................10bupropion hcl er (xl).................. 10BUPROPION HCL ER (XL)...... 10buspirone hcl.............................14butalbital-apap-caffeine...............7BUTRANS...................................7BYDUREON..............................20BYDUREON BCISE AUTOINJECTOR...................... 20BYETTA 10 MCG PEN............. 20BYETTA 5 MCG PEN............... 20BYSTOLIC................................ 15cabergoline............................... 26CABOMETYX........................... 12CALCIPOTRIENE..................... 19calcitriol ..................................... 30CAMBIA...................................... 8CANASA................................... 30candesartan cilexetil ................. 15capecitabine..............................12CAPEX......................................19CARAFATE...............................24carbamazepine......................... 10CARBATROL............................ 10carbidopa-levodopa.................. 13CARDIZEM LA..........................15carisoprodol.............................. 34CARNITOR............................... 23CARNITOR SF..........................23cartia xt..................................... 15carvedilol...................................15CATAPRES-TTS-1................... 15CATAPRES-TTS-2................... 15CATAPRES-TTS-3................... 15cefdinir........................................ 9cefuroxime axetil ......................... 9CELEBREX.................................8celecoxib..................................... 8CELEXA....................................10cephalexin...................................9CERDELGA.............................. 25CETROTIDE............................. 26CHANTIX.................................... 8CHANTIX CONTINUING MONTH PAK...............................8CHANTIX STARTING MONTH PAK.............................................8chlorhexidine gluconate............ 18chlorthalidone............................15

CIALIS.......................................25ciclopirox................................... 11CIMDUO................................... 13CIMZIA......................................29CIMZIA PREFILLED KIT...........29CIMZIA STARTER KIT............. 29CIPRODEX............................... 32ciprofloxacin hcl.................... 9, 31citalopram hydrobromide.......... 11claravis......................................19CLARINEX................................ 32CLARINEX-D 12 HOUR............32clarithromycin..............................9CLENPIQ.................................. 25CLIMARA.................................. 27CLIMARA PRO......................... 27CLINDAGEL..............................19clindamycin hcl............................9clindamycin phosphate............. 19CLINDAMYCIN PHOSPHATE.. 19clindamycin phosphate-benzoyl peroxide.......................19CLINDESSE................................9clobetasol propionate................19CLOBEX................................... 19CLOBEX SPRAY...................... 19CLODERM................................ 19clonazepam...............................14clonidine hcl.............................. 15clopidogrel bisulfate.................. 13clotrimazole...............................11clotrimazole-betamethasone.....11COLCHICINE............................12colchicine.................................. 12COLCRYS.................................12COLESTID................................ 15COLESTID FLAVORED............15COMBIGAN.............................. 31COMBIVENT RESPIMAT......... 33CONCERTA..............................17CONTRAVE.............................. 18CONZIP...................................... 7COPAXONE..............................18CORDRAN................................19COREG.....................................15COREG CR...............................15CORLANOR..............................15CORTEF................................... 26COSENTYX (300 MG DOSE)...29COSENTYX 150 MG/ML.......... 29COSENTYX SENSOREADY (300 MG)...................................29

38

COSENTYX SENSOREADY PEN...........................................29COSOPT...................................31COZAAR................................... 15CREON..................................... 25CRESEMBA..............................11CRESTOR................................ 15cryselle-28.................................27CUTAQUIG............................... 29cyanocobalamin........................ 24cyclobenzaprine hcl.................. 34cyclosporine modified............... 29CYMBALTA...............................11cyproheptadine hcl....................32CYTOMEL.................................29DELESTROGEN.......................27DELZICOL................................ 30DEPAKOTE.............................. 10DEPAKOTE ER........................ 10DEPAKOTE SPRINKLES......... 10DEPEN TITRATABS.................25DEPO-TESTOSTERONE......... 26DESCOVY................................ 13DESONATE.............................. 19desvenlafaxine succinate er......11dexamethasone........................ 26DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)..............................22dexmethylphenidate hcl............ 17dexmethylphenidate hcl er........ 17diazepam.................................. 14diclofenac sodium....................... 8dicyclomine hcl..........................25DIFFERIN................................. 19DIFICID....................................... 9digoxin.......................................15DILANTIN..................................10DILANTIN INFATABS............... 10DILAUDID................................... 7diltiazem hcl er coated beads... 15dilt-xr......................................... 15DIOVAN.................................... 15DIOVAN HCT............................15DIPENTUM............................... 30diphenoxylate-atropine..............25divalproex sodium..................... 10divalproex sodium er.................10DIVIGEL....................................27donepezil hcl............................. 10DORYX....................................... 9

DORYX MPC.............................. 9dorzolamide hcl-timolol mal...... 31dorzolamide hcl-timolol mal pf.. 31DOVATO...................................14doxazosin mesylate.................. 15doxepin hcl................................11doxycycline hyclate..................... 9doxycycline monohydrate........... 9drospirenone-ethinyl estradiol...27DUAVEE................................... 27DUEXIS.......................................8DULERA................................... 33duloxetine hcl............................ 11DUOBRII................................... 19DUPIXENT................................19DURAGESIC-100....................... 7DURAGESIC-12......................... 7DURAGESIC-25......................... 7DURAGESIC-50......................... 7DURAGESIC-75......................... 7DUROLANE.............................. 30dutasteride................................ 26DYAZIDE.................................. 15DYMISTA.................................. 32EDARBI.....................................15EDARBYCLOR......................... 15EFFEXOR XR........................... 11ELESTRIN................................ 27eletriptan hydrobromide............ 12ELIDEL......................................19ELIQUIS......................................9ELIQUIS DVT/PE STARTER PACK.......................................... 9ELOCTATE............................... 14EMGALITY................................12EMGALITY (300 MG DOSE).... 12EMVERM.................................. 13enalapril maleate.......................15ENBREL....................................29ENBREL MINI........................... 29ENBREL SURECLICK.............. 29ENDOMETRIN..........................27enoxaparin sodium......................9enskyce.....................................27ENSTILAR................................ 19entecavir................................... 14ENTRESTO.............................. 15EPCLUSA................................. 14EPIDIOLEX............................... 10EPIDUO.................................... 19EPIDUO FORTE....................... 19epinephrine............................... 33EPIPEN 2-PAK......................... 33

EPIPEN JR 2-PAK.................... 33EPOGEN...................................14ergocalciferol.............................24ERLEADA................................. 12errin...........................................27erythromycin............................. 31escitalopram oxalate................. 11esomeprazole magnesium........24estarylla.....................................27ESTRACE................................. 27estradiol.................................... 27eszopiclone............................... 34etodolac...................................... 8EUCRISA.................................. 19EUFLEXXA............................... 30euthyrox.................................... 29EVAMIST.................................. 27EVEKEO................................... 17EXFORGE................................ 15EXFORGE HCT........................ 15EXTAVIA...................................18ezetimibe...................................15ezetimibe-simvastatin............... 15famotidine................................. 24FARXIGA.................................. 20FASENRA................................. 32FASENRA PEN.........................32femynor..................................... 27fenofibrate................................. 15fenofibrate micronized...............15fenofibric acid............................16fentanyl....................................... 7FENTANYL CITRATE.................7FENTORA...................................7FIASP........................................22FIASP FLEXTOUCH.................22FIASP PENFILL........................ 22FINACEA.................................. 19finasteride................................. 26FIORICET................................... 7FIORICET/CODEINE..................7FIRAZYR...................................29FIRDAPSE................................ 30flecainide acetate...................... 16FLECTOR................................... 8FLOMAX................................... 26FLOVENT DISKUS................... 33FLOVENT HFA......................... 33fluconazole................................11fluocinonide...............................19FLUOROPLEX..........................19FLUOROURACIL......................19fluorouracil ................................ 19

39

fluoxetine hcl............................. 11fluticasone-salmeterol............... 33fluvoxamine maleate................. 11FOCALIN.................................. 17FOCALIN XR............................ 17folic acid.................................... 24FOLLISTIM AQ......................... 26FORFIVO XL.............................11FORTAMET.............................. 20FORTEO................................... 30FORTESTA...............................26FREESTYLE LIBRE 14 DAY READER................................... 22FREESTYLE LIBRE 14 DAY SENSOR...................................22FREESTYLE LIBRE READER..22FREESTYLE LIBRE SENSOR SYSTEM................................... 22FULPHILA.................................14furosemide................................ 16gabapentin................................ 10ganirelix acetate........................26gavilyte-g...................................25GEL-ONE..................................30GELSYN-3................................ 30gemfibrozil .................................16GENERESS FE........................ 27GENOTROPIN..........................26GENOTROPIN MINIQUICK......26gentamicin sulfate..................... 31GENVISC 850...........................30GENVOYA................................ 14gianvi.........................................27GILENYA.................................. 18glatiramer acetate..................... 18GLEEVEC................................. 12glimepiride.................................20glipizide er.................................20glipizide ir.................................. 20GLUCAGON EMERGENCY KIT............................................ 22GLUCOPHAGE.........................20GLUCOPHAGE XR...................21GLUMETZA.............................. 21glyburide................................... 21glycopyrrolate............................25GLYCOPYRROLATE................25GLYXAMBI................................21gnp lansoprazole.......................24GOCOVRI................................. 13GOLYTELY............................... 25GONAL-F.................................. 27GONAL-F RFF.......................... 27

GONAL-F RFF REDIJECT....... 27GRALISE.................................. 18GRALISE STARTER.................18GRANIX.................................... 14guanfacine hcl...........................16guanfacine hcl er.......................17GVOKE PFS............................. 22GYNAZOLE-1........................... 11HAEGARDA..............................29HALOBETASOL PROPIONATE.......................... 19HALOG..................................... 19HARVONI..................................14HEMANGEOL........................... 16HORIZANT................................18HUMALOG................................22HUMALOG KWIKPEN.............. 22HUMALOG MIX 50/50 KWIKPEN................................. 22HUMALOG MIX 50/50 VIAL......22HUMALOG MIX 75/25 KWIKPEN................................. 22HUMALOG MIX 75/25 VIAL......23HUMALOG U-100 JUNIOR KWIKPEN................................. 23HUMATROPE........................... 27HUMIRA....................................29HUMIRA PEDIATRIC CROHNS START......................29HUMIRA PEN........................... 29HUMIRA PEN-CD/UC/HS STARTER................................. 29HUMIRA PEN-PS/UV/ADOL HS START................................ 29HUMULIN 70/30 KWIKPEN...... 23HUMULIN 70/30 VIAL...............23HUMULIN N KWIKPEN............ 23HUMULIN N VIAL..................... 23HUMULIN R U-500 KWIKPEN..23HUMULIN R U-500 VIAL (CONCENTRATED)..................23HUMULIN R VIAL..................... 23HYALGAN.................................30hydralazine hcl.......................... 16hydrochlorothiazide...................16hydrocodone-acetaminophen..... 7hydrocortisone.................... 19, 26hydromorphone hcl..................... 7hydroxychloroquine sulfate....... 13hydroxyzine hcl......................... 14hydroxyzine pamoate................14HYMOVIS................................. 30HYSINGLA ER............................7

HYZAAR................................... 16ibandronate sodium.................. 30IBRANCE.................................. 12ibuprofen..................................... 8IDHIFA...................................... 12ILEVRO.....................................31imatinib mesylate...................... 12IMBRUVICA.............................. 12imiquimod..................................19IMIQUIMOD PUMP...................19IMITREX................................... 12IMITREX STATDOSE REFILL..12IMITREX STATDOSE SYSTEM................................... 12IMPOYZ.................................... 19IMVEXXY MAINTENANCE PACK........................................ 27IMVEXXY STARTER PACK..... 27INBRIJA.................................... 13INCRUSE ELLIPTA.................. 33INDERAL LA............................. 16INDERAL XL............................. 16indomethacin...............................8INFLECTRA.............................. 29INNOPRAN XL..........................16INSULIN ASP PROT & ASP FLEXPEN..................................23INSULIN ASPART.................... 23INSULIN ASPART FLEXPEN... 23INSULIN ASPART PENFILL.....23INSULIN ASPART PROT & ASPART....................................23INSULIN LISPRO......................23INSULIN LISPRO (1 UNIT DIAL).........................................23INTRAROSA............................. 25INTUNIV....................................17INVEGA SUSTENNA................13INVEGA TRINZA...................... 13INVELTYS.................................31INVOKAMET.............................21INVOKAMET XR.......................21INVOKANA............................... 21ipratropium bromide.................. 32ipratropium-albuterol................. 33irbesartan.................................. 16irbesartan-hydrochlorothiazide..16isibloom.....................................28isosorbide mononitrate er......... 16JANUMET................................. 21JANUMET XR........................... 21JANUVIA...................................21JARDIANCE..............................21

40

JENTADUETO.......................... 21JENTADUETO XR.................... 21JIVI............................................14JORNAY PM............................. 17JUBLIA......................................11JULUCA.................................... 14junel 1.5/30............................... 28junel 1/20.................................. 28junel fe 1.5/30........................... 28junel fe 1/20.............................. 28junel fe 24................................. 28KADIAN.......................................7KANJINTI.................................. 12KAPSPARGO SPRINKLE.........16kariva........................................ 28KATERZIA................................ 16KAZANO................................... 21KENALOG...........................19, 26KEPPRA................................... 10KEPPRA XR............................. 10KERYDIN.................................. 11ketoconazole.............................11KETOROLAC TROMETHAMINE.......................8ketorolac tromethamine........ 8, 31KITABIS PAK............................ 34KLONOPIN............................... 14KOMBIGLYZE XR.....................21K-TAB....................................... 24kurvelo...................................... 28labetalol hcl............................... 16lactulose....................................25LAMICTAL................................ 10LAMICTAL ODT........................10LAMICTAL STARTER...............10LAMICTAL XR.......................... 10lamotrigine................................ 10lamotrigine er............................ 10LANCETS................................. 22lansoprazole..............................24LANTUS SOLOSTAR............... 23LANTUS U-100 VIAL................ 23larin fe 1/20............................... 28larissia.......................................28LASIX........................................16latanoprost................................ 31LATISSE................................... 32LATUDA....................................13LAZANDA................................... 7LEDIPASVIR-SOFOSBUVIR.... 14leflunomide................................29LESCOL XL.............................. 16lessina.......................................28

LETAIRIS.................................. 34letrozole.................................... 12LEVALBUTEROL HFA..............33LEVEMIR U-100 FLEXTOUCH.23LEVEMIR U-100 VIAL...............23levetiracetam.............................10LEVITRA................................... 25levofloxacin................................. 9levonorgest-eth est & eth est.... 28levonorgest-eth estrad 91-day.. 28levonorgestrel-ethinyl estrad.....28levothyroxine sodium................ 29LEXAPRO................................. 11LEXETTE.................................. 20LIALDA......................................30lidocaine......................................8lidocaine viscous hcl................. 18lidocaine-prilocaine..................... 8LIDODERM................................. 8LINZESS................................... 25liothyronine sodium................... 29LIPITOR.................................... 16lisinopril ..................................... 16lisinopril-hydrochlorothiazide.....16lithium carbonate.......................14lithium carbonate er.................. 14LIVALO..................................... 16LO LOESTRIN FE.....................28LOESTRIN 1.5/30 (21)..............28LOESTRIN 1/20 (21).................28LOESTRIN FE 1.5/30............... 28LOESTRIN FE 1/20.................. 28LOKELMA................................. 24LONHALA MAGNAIR REFILL KIT............................................ 33LONHALA MAGNAIR STARTER KIT...........................33lorazepam................................. 14LORZONE.................................34losartan potassium....................16losartan potassium-hctz............ 16LOTEMAX.................................31LOTEMAX SM.......................... 31LOTREL.................................... 16lovastatin...................................16LOVAZA....................................16low-ogestrel...............................28LUMIGAN..................................31LUNESTA................................. 34LUPRON DEPOT (1-MONTH)..27LUPRON DEPOT (3-MONTH)..27LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG..27

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG..27LYNPARZA............................... 12LYRICA..................................... 18MAKENA...................................28MAVENCLAD (10 TABS)..........18MAVENCLAD (4 TABS)............18MAVENCLAD (5 TABS)............18MAVENCLAD (6 TABS)............18MAVENCLAD (7 TABS)............18MAVENCLAD (8 TABS)............18MAVENCLAD (9 TABS)............18MAVYRET.................................14MAXALT....................................12MAXALT-MLT........................... 12MAYZENT.................................18MAYZENT STARTER PACK.... 18meclizine hcl............................. 11medroxyprogesterone acetate.. 28meloxicam...................................8memantine hcl...........................10MENOPUR................................27mesalamine...............................30metaxalone............................... 34metformin hcl er........................ 21metformin hcl er (mod)..............21metformin hcl er (osm).............. 21metformin hcl ir ......................... 21methimazole..............................29methocarbamol......................... 34methotrexate............................. 29methotrexate sodium................ 29methylphenidate hcl.................. 17methylphenidate hcl er..............17methylphenidate hcl er (la)........17methylprednisolone...................26metoclopramide hcl...................11metoprolol succinate er.............16metoprolol tartrate.....................16METROGEL..............................20metronidazole....................... 9, 20MICARDIS................................ 16MICARDIS HCT........................ 16MICORT-HC............................. 20MINASTRIN 24 FE....................28MINIVELLE............................... 28minocycline hcl............................9MINOLIRA...................................9MIRENA (52 MG)......................28mirtazapine............................... 11MIRVASO................................. 20misoprostol................................24MITIGARE.................................12

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MOBIC........................................ 8modafinil ....................................34mometasone furoate................. 20mono-linyah.............................. 28MONOVISC.............................. 30montelukast sodium.................. 33morphine sulfate er..................... 7MOTEGRITY.............................25MOTOFEN................................ 25MOVANTIK............................... 25MOVIPREP............................... 25MOXEZA...................................31moxifloxacin hcl.........................31MS CONTIN................................7MULPLETA............................... 14MULTAQ................................... 16multivitamin/fluoride.................. 24mupirocin.................................... 9MVASI.......................................12mycophenolate mofetil .............. 29mycophenolate sodium............. 29MYRBETRIQ.............................25nabumetone................................ 8nadolol...................................... 16NALFON..................................... 8naltrexone hcl..............................8NAMZARIC............................... 10NAPRELAN.................................8naproxen..................................... 8naproxen sodium........................ 8NARCAN.....................................8NASCOBAL.............................. 24NASONEX................................ 32NATAZIA...................................28NATROBA.................................13NATURE-THROID.................... 29neomycin-polymyxin-dexameth 32neomycin-polymyxin-hc............ 32NESINA.....................................21NEULASTA............................... 14NEULASTA ONPRO.................14NEUPOGEN............................. 14NEURONTIN.............................10NEVANAC.................................31NEXIUM.................................... 24NIASPAN.................................. 16nifedipine er.............................. 16nifedipine er osmotic release.... 16nikki...........................................28nitrofurantoin macrocrystal..........9nitrofurantoin monohydrate macrocrystals..............................9nitroglycerin...............................16

NITROSTAT..............................16NITYR....................................... 25NIVESTYM................................14NOCDURNA............................. 27NOCTIVA.................................. 27NORCO.......................................7NORDITROPIN FLEXPRO....... 27norethindrone............................28norethindrone acetate............... 28norethindrone acet-ethinyl est...28NORGESIC FORTE..................34norgestimate-ethinyl estradiol triphasic.....................................28NORITATE................................20nortrel 1/35 (21)........................ 28nortrel 1/35 (28)........................ 28nortriptyline hcl..........................11NORVASC................................ 16NOVOEIGHT............................ 14NOVOFINE AUTOCOVER PEN NEEDLE........................... 23NOVOFINE PEN NEEDLE....... 23NOVOFINE PLUS PEN NEEDLE....................................23NOVOLIN 70/30 FLEXPEN...... 23NOVOLIN 70/30 FLEXPEN RELION.....................................23NOVOLIN 70/30 RELION......... 23NOVOLIN 70/30 VIAL............... 23NOVOLIN N FLEXPEN.............23NOVOLIN N FLEXPEN RELION.....................................23NOVOLIN N RELION................23NOVOLIN N VIAL..................... 23NOVOLIN R FLEXPEN.............23NOVOLIN R FLEXPEN RELION.....................................23NOVOLIN R RELION................23NOVOLIN R VIAL..................... 23NOVOLOG FLEXPEN.............. 23NOVOLOG MIX 70/30 FLEXPEN..................................23NOVOLOG MIX 70/30 VIAL......23NOVOLOG PENFILL................ 23NOVOLOG U-100 VIAL............ 23NOVOTWIST PEN NEEDLE.... 23np thyroid.................................. 29NUBEQA...................................12NUCALA................................... 32NUCYNTA...................................7NUCYNTA ER.............................7NULYTELY WITH FLAVOR PACKS......................................25

NUTROPIN AQ NUSPIN 10..... 27NUTROPIN AQ NUSPIN 20..... 27NUTROPIN AQ NUSPIN 5....... 27NUVARING............................... 28NUVIGIL....................................34NUWIQ......................................14NUZYRA..................................... 9nystatin......................................11ODEFSEY.................................14ofloxacin..............................31, 32OGIVRI..................................... 12olanzapine.................................13olmesartan medoxomil..............16olmesartan medoxomil-hctz...... 16olmesartan-amlodipine-hctz......16olopatadine hcl..........................31OLUMIANT............................... 29OMECLAMOX-PAK.................. 25omega-3-acid ethyl esters.........16omeprazole............................... 24omeprazole-sodium bicarbonate............................... 24OMNITROPE............................ 27ondansetron hcl........................ 11ondansetron odt........................ 11ONETOUCH ULTRA 2 KIT W/DEVICE................................ 22ONETOUCH ULTRA BLUE TEST STRIPS...........................22ONETOUCH ULTRA MINI KIT W/DEVICE................................ 22ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE..........22ONETOUCH VERIO IQ SYSTEM................................... 22ONETOUCH VERIO KIT W/DEVICE................................ 22ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE..........22ONEXTON................................ 20ONFI......................................... 10ONGLYZA.................................21ONZETRA XSAIL......................12OPSUMIT..................................34ORACEA...................................20ORENCIA..................................30ORENCIA CLICKJECT............. 30ORENITRAM............................ 34ORILISSA................................. 27ORPHENGESIC FORTE.......... 34ORTHO MICRONOR................ 28ORTHO TRI-CYCLEN LO.........28ORTHO-NOVUM 1/35 (28)....... 28

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ORTHO-NOVUM 7/7/7 (28)...... 28ORTHOVISC.............................31oseltamivir phosphate............... 14OSENI.......................................21OSMOLEX ER.......................... 13OSPHENA................................ 26OTEZLA.................................... 30OTOVEL................................... 32OVIDREL.................................. 27oxcarbazepine...........................10OXTELLAR XR......................... 10oxybutynin chloride................... 25oxybutynin chloride er............... 25OXYCODONE HCL.................... 7oxycodone hcl............................. 7OXYCODONE HCL ER.............. 7oxycodone-acetaminophen.........7OXYCONTIN...............................7OZEMPIC..................................21PANCREAZE............................ 25PANDEL....................................20pantoprazole sodium.................24PANZYGA.................................30paroxetine hcl............................11PATADAY................................. 31PATANOL................................. 31PAXIL........................................11PAXIL CR..................................11PAZEO......................................31peg 3350-kcl-na bicarb-nacl......25penicillin v potassium.................. 9PENNSAID..................................8PENTASA................................. 30PERCOCET................................ 7PERFOROMIST........................33permethrin.................................13PERSERIS................................13PERTZYE................................. 25phenazopyridine hcl.................. 25phentermine hcl........................ 18pioglitazone hcl......................... 21PLAQUENIL..............................13PLAVIX..................................... 13PLEGRIDY................................18PLEGRIDY STARTER PACK... 18PLENVU....................................25polymyxin b-trimethoprim..........32potassium chloride crys er........ 24potassium chloride er................24potassium citrate er...................24PRADAXA...................................9PRALUENT...............................16pramipexole dihydrochloride..... 13

prasugrel hcl............................. 13PRAVACHOL............................16pravastatin sodium....................16prazosin hcl...............................16PRED FORTE...........................31prednisolone............................. 26prednisolone acetate.................31prednisolone sodium phosphate................................. 26prednisone................................ 26pregabalin................................. 18PREGENNA..............................24PREMARIN............................... 28PREMPHASE........................... 28PREMPRO................................28PRENATE................................. 24PRENATE DHA........................ 24PRENATE ELITE...................... 24PRENATE ENHANCE.............. 24PRENATE ESSENTIAL............ 24PRENATE MINI........................ 24PRENATE PIXIE.......................24PRENATE RESTORE...............24PREPOPIK................................25PREVACID................................24PREVACID SOLUTAB..............24PREZCOBIX............................. 14PRINIVIL................................... 16PRISTIQ....................................11PROAIR DIGIHALER................33PROAIR HFA............................ 33PROAIR RESPICLICK..............33prochlorperazine maleate......... 11PROCRIT..................................14PROCTOFOAM HC.................. 30progesterone micronized.......... 28PROGRAF................................ 30PROLENSA.............................. 31PROLIA.....................................30promethazine hcl.......................32promethazine-codeine.............. 32promethazine-dm...................... 32PROMETRIUM......................... 28PROPECIA............................... 20propranolol hcl.......................... 16propranolol hcl er...................... 16PROTONIX............................... 24PROVENTIL HFA..................... 33PROVIGIL................................. 34PROZAC................................... 11pseudoephedrine-bromphen-dm............................................. 32PSORCON................................20

PULMICORT FLEXHALER.......33PULMICORT SUSPENSION.... 33PULMOZYME........................... 34PYLERA....................................25QBREXZA.................................20QMIIZ ODT................................. 8QTERN..................................... 21QUDEXY XR.............................10QUESTRAN.............................. 16QUESTRAN LIGHT.................. 16quetiapine fumarate.................. 13quetiapine fumarate er.............. 13quinapril hcl...............................16QVAR REDIHALER.................. 33RABEPRAZOLE SODIUM........ 24raloxifene hcl.............................26ramipril ...................................... 16RANEXA................................... 16ranitidine hcl..............................24ranolazine er............................. 16RASUVO...................................30RAYALDEE...............................30RAYOS..................................... 26REBIF....................................... 18REBIF REBIDOSE....................18REBIF REBIDOSE TITRATION PACK.................... 18REBIF TITRATION PACK.........18RELISTOR................................ 25RELPAX....................................12REMICADE............................... 30REMODULIN............................ 34RENAGEL.................................25RENFLEXIS.............................. 30REPATHA................................. 16REPATHA PUSHTRONEX SYSTEM................................... 16REPATHA SURECLICK........... 17RESTASIS................................ 32RESTASIS MULTIDOSE.......... 32RESTORIL................................ 34RETACRIT................................ 15RETIN-A....................................20RETIN-A MICRO GEL 0.04 %, 0.1 %.........................................20RETIN-A MICRO PUMP........... 20REVLIMID................................. 12REXULTI...................................13RHOPRESSA........................... 31RINVOQ....................................30RISPERDAL..............................13risperidone................................ 13RITALIN.................................... 17

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RITALIN LA...............................17rizatriptan benzoate.................. 12ROCKLATAN............................ 31ropinirole hcl..............................13rosuvastatin calcium................. 17ROXICODONE........................... 7RUBRACA................................ 12RUCONEST..............................30RUXIENCE............................... 12RYBELSUS...............................21RYTARY................................... 13SABRIL..................................... 10SAFYRAL..................................28SAIZEN..................................... 27SAIZENPREP........................... 27SANCUSO................................ 11SANDOSTATIN........................ 27SAPHRIS.................................. 13SAXENDA.................................18scopolamine..............................11SEASONIQUE.......................... 28SEEBRI NEOHALER................ 34SEGLUROMET.........................21SENSIPAR................................30SEREVENT DISKUS................ 34SERNIVO..................................20SEROQUEL.............................. 13SEROQUEL XR........................ 13sertraline hcl..............................11SEYSARA................................... 9sildenafil citrate................... 25, 34SILENOR.................................. 34SILVADENE................................9SIMBRINZA.............................. 31SIMPONI...................................30SIMPONI ARIA......................... 30simvastatin................................ 17SINGULAIR...............................34sirolimus....................................30SKELAXIN................................ 34SKYRIZI (150 MG DOSE).........30SLYND...................................... 28sodium fluoride..........................24SODIUM HYALURONATE........31SOFOSBUVIR-VELPATASVIR.14solifenacin succinate.................25SOLIQUA.................................. 21SOLODYN.................................. 9SOLOSEC...................................9SOMA....................................... 34SOOLANTRA............................20SORILUX.................................. 20sotalol hcl.................................. 17

SPIRIVA HANDIHALER............34SPIRIVA RESPIMAT................ 34spironolactone...........................17sprintec 28................................ 28SPRIX......................................... 8SPRYCEL................................. 12STAXYN....................................25STEGLATRO............................ 21STEGLUJAN.............................21STELARA..................................30STENDRA.................................25STIOLTO RESPIMAT............... 34STRATTERA.............................17STRENSIQ................................25SUBOXONE................................8SUBSYS..................................... 7sucralfate.................................. 25sulfamethoxazole-trimethoprim...9sulfasalazine............................. 30sumatriptan succinate............... 12SUNOSI.................................... 35SUPARTZ FX............................31SUPREP BOWEL PREP KIT....25syeda........................................ 28SYMBICORT.............................34SYMFI....................................... 14SYMFI LO................................. 14SYMJEPI...................................34SYMLINPEN 60........................ 21SYMPAZAN.............................. 10SYMPROIC...............................25SYNJARDY...............................21SYNJARDY XR.........................21SYNTHROID.............................29SYNVISC.................................. 31SYNVISC ONE......................... 31TACLONEX...............................20tacrolimus............................20, 30tadalafil ......................................25TAKHZYRO.............................. 30TALTZ....................................... 30TAMIFLU...................................14tamoxifen citrate........................12tamsulosin hcl........................... 26TAPERDEX 12-DAY................. 26TAPERDEX 6-DAY................... 26TAPERDEX 7-DAY................... 26TARGADOX................................9TARGRETIN............................. 12TAYTULLA................................28TAZORAC.................................20TECFIDERA..............................18TEGRETOL...............................10

TEGRETOL-XR........................ 10TEGSEDI.................................. 18TEKTURNA...............................17TEKTURNA HCT...................... 17telmisartan................................ 17telmisartan-hctz.........................17temazepam............................... 35TEMIXYS.................................. 14temozolomide............................12TENORMIN...............................17terazosin hcl..............................26terbinafine hcl............................11terconazole............................... 11TESTIM.....................................26testosterone.............................. 26testosterone cypionate..............26TIGLUTIK..................................18TIKOSYN.................................. 17timolol maleate..........................31TIMOPTIC.................................31TIMOPTIC OCUDOSE..............32TIMOPTIC-XE...........................32TIROSINT................................. 29TIROSINT-SOL.........................29TIVICAY.................................... 14tizanidine hcl............................. 34TOBI NEBULIZER.................... 34TOBI PODHALER.....................34TOBRADEX.............................. 32tobramycin................................ 34TOBRAMYCIN.......................... 34tobramycin-dexamethasone......32TOLSURA................................. 11tolterodine tartrate er.................26TOPAMAX................................ 10TOPAMAX SPRINKLE..............10TOPICORT SPRAY.................. 20topiramate................................. 10TOPROL XL..............................17torsemide.................................. 17TOSYMRA................................ 12TOUJEO MAX SOLOSTAR...... 23TOUJEO SOLOSTAR...............23TOVIAZ..................................... 26TRACLEER...............................34TRADJENTA.............................21TRAMADOL HCL ER..................7tramadol hcl ir ............................. 7TRAVATAN Z............................32TRAZIMERA............................. 12trazodone hcl............................ 11TREANDA.................................12TRELEGY ELLIPTA..................34

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TREMFYA.................................30TRESIBA...................................23TRESIBA FLEXTOUCH............23tretinoin..................................... 20TREXIMET................................12TREZIX....................................... 7tri femynor................................. 28triamcinolone acetonide............ 20triamterene-hctz........................ 17triazolam................................... 14TRIBENZOR............................. 17TRICOR.................................... 17TRILEPTAL...............................10tri-linyah.................................... 28tri-lo-marzia............................... 28tri-lo-sprintec............................. 28TRINAZ..................................... 24TRINTELLIX..............................11tri-sprintec................................. 28TRIUMEQ................................. 14TRIVISC....................................31TROKENDI XR......................... 10TRULANCE...............................25TRULICITY............................... 21TRUVADA.................................14TRUXIMA..................................12TUDORZA PRESSAIR............. 34TYLENOL WITH CODEINE #3... 7TYLENOL WITH CODEINE #4... 7TYMLOS................................... 30UCERIS.................................... 30UDENYCA................................ 15ULTOMIRIS.............................. 15ULTRACET................................. 8ULTRAM..................................... 8ULTRAVATE.............................20UTIBRON NEOHALER............. 34VAGIFEM..................................28valacyclovir hcl..........................14VALIUM.....................................14valsartan................................... 17valsartan-hydrochlorothiazide... 17VALTREX..................................14VARUBI.....................................11VASCEPA................................. 17VECTICAL................................ 20VELPHORO.............................. 26VELTASSA............................... 24VELTIN..................................... 20VEMLIDY.................................. 14venlafaxine hcl.......................... 11venlafaxine hcl er...................... 11VENTOLIN HFA........................34

verapamil hcl er.........................17VERDESO................................ 20VESICARE................................26V-GO 20....................................22V-GO 30....................................22V-GO 40....................................22VIAGRA.................................... 26VIBERZI.................................... 25VICTOZA.................................. 21vienva........................................28VIGAMOX................................. 31VIIBRYD....................................11VIIBRYD STARTER PACK....... 11VIMOVO......................................8VIMPAT.....................................10VIOKACE.................................. 25viorele....................................... 28VISCO-3....................................31vitamin d (ergocalciferol)...........24VIVELLE-DOT...........................29VOGELXO................................ 26VOGELXO PUMP..................... 26VOLTAREN.................................8VOSEVI.....................................14VRAYLAR................................. 13VYLEESI................................... 18VYTORIN.................................. 17VYVANSE................................. 17VYZULTA..................................32WAKIX...................................... 35warfarin sodium...........................9WELCHOL................................ 17WELLBUTRIN SR.....................11WELLBUTRIN XL..................... 11wixela inhub.............................. 34XALATAN..................................32XANAX......................................14XANAX XR................................14XARELTO................................... 9XARELTO STARTER PACK.......9XELJANZ.................................. 30XELJANZ XR............................ 30XENLETA....................................9XEPI............................................9XHANCE................................... 32XIGDUO XR..............................21XIIDRA...................................... 32XIMINO....................................... 9XOFLUZA (40 MG DOSE)........ 14XOFLUZA (80 MG DOSE)........ 14XOLAIR.....................................32XOPENEX HFA........................ 34

XPOVIO (100 MG ONCE WEEKLY)..................................13XPOVIO (60 MG ONCE WEEKLY)..................................13XPOVIO (80 MG ONCE WEEKLY)..................................13XPOVIO (80 MG TWICE WEEKLY)..................................13XTAMPZA ER............................. 8XTANDI.....................................13xulane....................................... 29XYOSTED.................................26XYREM..................................... 35YASMIN 28............................... 29YAZ........................................... 29YONSA..................................... 13YOSPRALA...............................13YUPELRI...................................34ZALVIT......................................24ZANAFLEX............................... 34ZARXIO.....................................15ZEGERID.................................. 25ZEJULA.....................................13ZELNORM................................ 25ZEMBRACE SYMTOUCH........ 12ZENPEP....................................25ZESTRIL................................... 17ZETIA........................................17ZIANA....................................... 20ZIOPTAN.................................. 32ziprasidone hcl.......................... 13ZIPSOR.......................................8ZIRABEV...................................13ZOCOR..................................... 17ZOHYDRO ER............................ 8ZOLOFT....................................11zolpidem tartrate....................... 35zolpidem tartrate er................... 35ZOMACTON............................. 27ZOMIG...................................... 12ZOMIG ZMT..............................12ZONEGRAN..............................10zonisamide................................10ZORVOLEX................................ 8ZOVIRAX.................................. 14ZTLIDO....................................... 8ZUBSOLV................................... 8ZYCLARA................................. 20ZYCLARA PUMP...................... 20ZYPITAMAG............................. 17ZYPREXA................................. 13ZYTIGA..................................... 13

45

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OptumRx and its family of affiliated Optum companies does not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities.

We provide assistance free of charge to people with disabilities or whose primary language is not English. To request a document in another format such as large print or to get language assistance such as a qualified interpreter, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week.

If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can send a complaint to:

OptumRx Civil Rights Coordinator 11000 Optum Circle Eden Prairie, MN 55344

Phone: 1-800-562-6223, TTY 711 Fax: 855-351-5495 Email: [email protected]

If you need help filing a complaint, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week. You can also file a complaint directly with the U.S. Dept. of Health and Human services online, by phone, or by mail:

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

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Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

This information is available in other formats like large print. To ask for another format, please call the telephone number listed on your health plan ID card.

Multi-language interpreter servicesATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card.

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OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.

optumrx.com

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com/optumrx.All Optum trademarks and logos are owned by Optum, Inc. in the U.S. and other jurisdictions. All other trademarks are the property of their respective owners.© 2020 Optum, Inc. All rights reserved.WF1984874_ORX_Innoviant Premium Booklet_070120 68275F-012020 Innoviant Premium

Therapeutic Category Excluded Medications Preferred Alternatives

ALLERGIC REACTIONS

Anaphylaxis Treatment Auvi-Q (0.15mg, 0.3mg), Epi-Pen JR 0.15mg epinephrine injection, Epi-Pen 0.3mg

ANALGESICS

Non-Steroidal Anti-Inflammatory Agents

Oral Cambia, Zipsor, Zorvolex

celecoxib, diflunisal, etodolac, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin

Qmiiz ODT meloxicam

Topical Flector diclofenac patch

Pennsaid diclofenac solution

Other Ketorolac Nasal Spray (M), Sprix Nasal Spray

diclofenac, ibuprofen, meloxicam

Pain

Opioid combinations

Apadaz, Benzhydrocodone/acetaminophen

hydrocodone/acetaminophen, oxycodone/acetaminophen

Oral Long-Acting Opioid Analgesics

Arymo ER, Kadian ER 200 mg, Nucynta ER, Oxycodone Powder, Oxycodone ER (M), Xtampza ER

hydromorphone HCl ER, morphine sulfate ER, oxymorphone HCl ER, Embeda, Hysingla ER, OxyContin

Conzip, Tramadol ER 100mg, 200mg, 300mg (M) tramadol

Oral Short-Acting Opioid Analgesics

Nucynta

codeine sulfate, hydromorphone HCl, morphine sulfate, oxycodone HCl, oxymorphone HCl

Transmucosal Fentanyl Analgesics

Abstral, Fentora, Fentanyl Citrate Buccal Tab (M), Lazanda, Subsys

fentanyl citrate lozenge

July 1, 2020 Premium Formulary Exclusions & Preferred Specialty Prior Authorization Requirements

(M) Co-branded product 1 Existing utilizers of these medications will be allowed to continue on therapy. Grandfathering will not be provided for any other excluded drugs.


ANALGESICS

Skeletal Muscle Relaxant Combinations Norgesic Forte, Orphengesic Forte (M) orphenadrine tab, aspirin

ANTIBACTERIALS, ORAL

Oral Antibiotics Doryx MPC, Doxycycline Hyclate delayed release 80mg, Minolira doxycycline, minocycline

ANTICONVULSANTS

Seizure Disorders

Trokendi XR1 topiramate ER

Oxtellar XR1 oxcarbazepine IR

Lamictal ODT Kit lamotrigine ODT, lamotrigine XR

ANTIFUNGALS, ORAL

Oral Antifungals Tolsura Itraconazole cap

ANTIMIGRAINES

CGRP Antagonists Ajovy

amitriptyline, atenolol, divalproex sodium, nadolol, propranolol, timolol, topiramate, venlafaxine, Aimovig, Emgality

Serotonin Receptor Agonists Onzetra Xsail, Tosymra, Zembrace Symtouch rizatriptan ODT, sumatriptan injection, sumatriptan nasal spray, zolmitriptan ODT

ANTIPARKINSON AGENTS

Parkinson's Disease Gocovri, Osmolex ER amantadine

ANTIVIRALS

Hepatitis-C drugs Ledipasvir-Sofosbuvir (M), Sofosbuvir-Velpatasvir (M)

Epclusa, Harvoni, Mavyret, Vosevi

HIV drugs Atripla1, Temixys1 Please talk with your doctor about clinically appropriate options.

AUTONOMIC & CENTRAL NERVOUS SYSTEM

Attention Deficit Disorder Adhansia XR Vyvanse

Interferon Beta Medications for Multiple Sclerosis Extavia1, Plegridy1 Avonex, Betaseron

CARDIOVASCULAR

Cholesterol-Lowering Agents Zypitamag

atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, Livalo



CARDIOVASCULAR

Hypertension

Inderal XL , Innopran XL propranolol ER

Kapspargo metoprolol ER

Katerzia amlodipine

CHEMOTHERPY AGENTS

Alkylating Agents Belrapzo, Bendamustine, Treanda

Please talk to your doctor about clinically appropriate options.

Antiandrogens Erleada1, Yonsa1, Zytiga1

Molecular Target Inhibitors Afinitor oral tab 2.5mg, 5mg, 7.5mg

Monoclonal Antibodies Ogivri, Truxima

CONTRACEPTIVES

Oral

Lo Loestrin junel FE, larin FE, microgestin FE, tarina FE

Slynd Camila, Incassia, Nora-Be, norethindrone, Norlyda, Norlyroc

Vaginal ring Annovera etonogestrel-ethinyl estradiol vaginal ring

CORTICOSTEROIDS

Oral Steroids Rayos prednisone

DERMATOLOGICAL AGENTS

Topical Acne Treatment

Aktipak, Clindagel, Clindamycin phosphate 1% gel(M), Veltin

adapalene, adapalene/benzoyl peroxide, clindamycin gel/lotion/solution, clindamycin/benzoyl peroxide, erythromycin/benzoyl peroxide, tretinoin cream, Epiduo Forte, Onexton

Adapalene lotion (M), Differin lotion adapalene

Topical anesthetics ZTlido lidocaine patch

Topical Antifungals Jublia terbinafine, Kerydin

Topical Antiinfectives Noritate cream metronidazole cream/gel/lotion, Soolantra



DERMATOLOGICAL AGENTS

Topical Corticosteroids

ALA Scalp lotion, Micort-HC cream hydrocortisone

Apexicon E cream fluocinonide, betamethasone

Capex shampoo Derma-Smoothe/FS, flucinolone acetonide scalp oil

Cordran tape flurandrenolide

Desonate gel, Pandel cream flurandrenolide, hydrocortisone valerate, triamcinolone acetonide

Halobetasol foam(M), Lexette betamethasone, clobetasol, halobetasol cream/ointment

Halog ointment fluticasone, halobetasol, triamcinolone

Impoyz cream clobetasol

Psorcon cream, Verdeso foam betamethasone, fluocinolone

Ultravate lotion clobetasol proprionate, fluocinonide, halobetasol proprionate

Topical Immune Response Modifier

Imiquimod cream pump 3.75% (M), Zyclara, Zyclara Pump imiquimod 5% cream

Topical Plaque Psoriasis Duobrii Lotion clobetasol, fluocinonide,

halobetasol, tazorotene, Enstilar

Calcipotriene Foam 0.005% (M), Sorilux calcipotriene

DIABETES

Blood Glucose Meters, Test Strips and Control Solutions

Examples: Abbott (FreeStyle, Precision), Arkray(Glucocard), Bayer (Breeze, Contour), Nipro (TRUEtest, TRUEtrack), Roche (Accu-Chek)

Lifescan (One Touch products)

Continuous Glucose Monitoring (CGM) Freestyle Libre Dexcom

Blood Sugar Regulators Miscellaneous

metformin HCl 24hr ER osmotic release, metformin HCl 24hr ER modified release

metformin ER (generic GLUCOPHAGE XR )

Dipeptidyl Peptidase-4 (DPP4) Inhibitors & Combinations

Alogliptin(M), Alogliptin with metformin(M), Alogliptin with pioglitazone(M), Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni

Janumet, Janumet XR, Januvia, Jentadueto, Jentadueto XR, Tradjenta

Basal insulins Basaglar, Levemir, Tresiba Lantus, Toujeo

Glucagon-Like Peptide-1(GLP1) Agonists Adlyxin

Bydureon, Bydureon BCise, Byetta, Ozempic, Rybelsus, Trulicity, Victoza

Insulins Novolin Humulin



DIABETES

Rapid-acting insulins Admelog, Apidra, Fiasp, Insulin Aspart (M), Insulin Lispro (M), Novolog Humalog

Sodium-glucose co-transporter (SGLT2) Inhibitors - Single agent

Invokana, Steglatro Farxiga, Jardiance

Sodium-glucose co-transporter (SGLT2) inhibitors - Combination agents

Invokamet, Invokamet XR, Segluromet Synjardy, Synjardy XR, Xigduo XR

SGLT2 and DPP4 Combinations QTERN, Steglujan Glyxambi

ENDOCRINE (OTHER)

Growth Hormones Genotropin, Humatrope, Omnitrope, Saizen, Zomacton Norditropin, Nutropin

Infertility Bravelle, Gonal-F, Gonal-F RFF Follistim AQ

Cetrotide ganirelix (made by Organon/Merck)

Nocturia Noctiva desmopressin, Nocdurna

GASTROINTESTINAL

Anti-Diarrheal Agents Motofen diphenoxylate/atropine, loperamide

Antiemetics Sancuso patch granisetron solution/tablet, ondansetron ODT

Anti-Inflammatory, Anti-Ulcer Agents Duexis esomeprazole-naproxen tab,

famotidine with ibuprofen

Irritable Bowel Syndrome with Constipation/ Chronic Idiopathic Constipation (IBS-C/CIC)

Amitiza, Trulance Linzess

Opioid-Induced Constipation (OIC) Amitiza, Movantik, Relistor Symproic

Inflammatory Bowel Disease Dipentum balsalazide, mesalamine, Apriso

Laxatives Golytely packets Gavilyte-C, Gavilyte-H, PEG 3350

Moviprep Clenpiq, Plenvu, Prepopik, Suprep

Pancreatic Enzymes Pancreaze, Pertzye, Viokace Creon, Zenpep

Proton pump inhibitors omeppi, omeprazole with sodium bicarbonate (cap, powder pak), Rabeprazole sprinkle cap (M)

lansoprazole, omeprazole, pantoprazole, Aciphex Sprinkle caps, Dexilant



HEMATOLOGICAL

Erythropoiesis-Stimulating Agents Epogen, Procrit Aranesp, Retacrit

Immune globulin, intravenous (IVIG) Panzyga1


Immune globulin, subcutaneous (SCIG) Cutaquig1


Long-Acting Granulocyte-Colony Stimulating Factor (G-CSFs)

Fulphila Neulasta, Udenyca

Short-Acting Granulocyte-Colony Stimulating Factor (G-CSFs)

Granix, Neupogen Nivestym, Zarxio

IMMUNOMODULATORS Interleukin-17 (IL-17) Inhibitor Cosentyx 1 Taltz

JAK Inhibitor Olumiant1 Rinvoq, Xeljanz, Xeljanz XR

TNF inhibitor Remicade Inflectra, Renflexis

OPHTHALMIC

Antiglaucoma Drugs

Vyzulta, Zioptan latanoprost ophthalmic solution, travoprost ophthalmic solution, Lumigan

Timoptic Ocudose timolol ophthalmic solution

Mast cell stabilizers Pazeo azelastine ophthalmic solution, olopatadine ophthalmic solution

Non-steroidal Anti-Inflammatory Agents Bromsite, Ilevro, Nevanac

bromfenac ophthalmic solution, diclofenac ophthalmic solution, flurbiprofen sodium ophthalmic solution, ketorolac tromethamine ophthalmic solution, Prolensa

OTHER

Antigout Agents Colchicine capsule, Colchicine tablet (made by Par), Colchicine tablet (made by Prasco), Mitigare

Colcrys, colchicine tablet (made by Mylan)

Antihistamines and combinations

Clarinex Syrup desloratadine

Clarinex-D desloratadine with pseudoephedrine

Corticosteroid nasal sprays Xhance mometasone furoate, Beconase AQ



OTHER

Lambert-Eaton Myasthenic Syndrome (LEMS) Firdapse Ruzurgi

Osteoarthritis/Hyaluronic acid injections

Gel-One, Genvisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Sodium Hyaluronate, Supartz FX, Synvisc, Synvisc-One, Trivisc, Visco-3

Durolane, Euflexxa, Gelsyn-3

Platelet-Modifying Agent Aspirin/Omeprazole (M), Yosprala aspirin with omeprazole

Prenatal vitamins Examples: Azesco, Pregenna, Prenate, Trinaz, Zalvit Any preferred prenatal vitamin

Thyroid Agents Tirosint caps, solution levothyroxine

RESPIRATORY

COPD: Inhaled Anticholinergics

Seebri, Tudorza Incruse Ellipta, Spiriva

Yupelri Lonhala Magnair

COPD: Long-Acting Beta Agonist/Long-Acting Muscarinic Agonist Combination inhalers

Bevespi, Utibron Anoro Ellipta, Stiolto Respimat

Cystic Fibrosis (inhaled tobramycin) Kitabis Pak, TOBI Podhaler, Tobramycin Neb(M) Bethkis

Pulmonary Anti-Inflammatory Inhalers

Alvesco, Asmanex, Asmanex HFA, QVAR Redihaler

Arnuity Ellipta, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler

Pulmonary Anti-Inflammatory , Long-Acting Beta Agonist Combination Inhalers

AirDuo, Budesonide/Formoterol (M), Dulera

fluticasone/salmeterol inhaler, Wixela Inhub, Advair Diskus, Advair HFA, Breo Ellipta, Symbicort

Pulmonary Anti-Hypertensives Tracleer 62.5mg, 125mg tab bosentan tab

Short-Acting Beta-2 Adrenergic Inhalers

Albuterol HFA Inhaler(M), Levalbuterol Inhaler(M), Proair Digihaler, ProAir HFA, ProAir Respiclick, Proventil HFA, Xopenex HFA

albuterol HFA (generic for PROAIR HFA made by Perrigo), albuterol HFA (generic for PROAIR HFA made by Teva), Ventolin HFA

UROLOGICAL

Erectile Dysfunction Oral Agents Stendra sildenafil


Excluded brand-name medications with generic equivalents

The brand-name medications below are excluded on the formulary. These brand-name medications have been identified as having available generic equivalents covered at Tier 1 on the formulary. Speak with your pharmacist to have your excluded brand-name medication substituted with its generic equivalent. A generic medication contains the same active ingredient(s) as a brand-name medication. An active ingredient is what makes the medication work. For example, Lipitor® and its generic both contain atorvastatin, which reduces the amount of bad cholesterol in the blood. Brand-name medications are often protected by a patent. When the patent ends, drug companies can apply to the U.S. Food and Drug Administration (FDA) to begin making generic versions of the medication.

Abilify Acanya Aciphex tablet Acticlate Aczone 5% Adcirca Adderall Adderall XR Adipex-P Alphagan P 0.15% Altace Ambien Ambien CR Amrix Androgel Arimidex Arthrotec Asacol HD Atacand Ativan Avapro Avodart Azor Baraclude Benicar Benicar HCT Benzaclin Benzamycin Beyaz Brisdelle Butrans Canasa Carafate Carbatrol Cardizem LA 180,240,300, 360, 420mg Carnitor solution, tablet Catapres-TTS patch Celebrex Celexa Cialis Clarinex 5mg tab Climara patch Clobex Cloderm Colestid Concerta Coreg Coreg CR Cortef Cosopt solution Cosopt PF solution

Cozaar Crestor Cymbalta Cytomel Delestrogen injection 20mg/ml, 40mg/ml Delzicol Depakote Depakote ER Depakote sprinkle cap Depo-testosterone injection Differin cream, gel Dilantin cap 100mg Dilantin chewable Dilantin suspension Dilaudid Diovan Diovan HCT Doryx tab Duac Duragesic Dyazide Effexor XR Elidel Epiduo gel Estrace Evekeo Exalgo Exforge Exforge HCT Finacea gel Fioricet Fioricet w/ codeine Flomax Focalin Focalin XR Fortamet Fortesta Generess FE chewable Gleevec Glucophage Glucophage XR Glumetza Golytely solution Halog cream Hyzaar Imitrex Inderal LA Intuniv Kadian 10,20,30,40,50,60, 80,100mg

Kenalog spray Kenalog-40 injection Keppra Keppra XR Klonopin K-tab Lamictal chewable Lamictal starter kit Lamictal ODT Lamictal tab Lamictal XR Lasix Latisse Lescol XL Letairis Levitra Lexapro Lialda Lidoderm Lipitor Loestrin 21 Loestrin FE Lotemax suspension Lotrel Lovaza Lunesta Lyrica Maxalt Maxalt-MLT Metrogel Micardis Micardis HCT Minastrin Mobic MS Contin Nalfon Nasonex Natroba Neurontin Nexium capsule Niaspan ER Nitrostat Norco Norvasc Nulytely Nuvigil Onfi Oracea Ortho Micron Ortho Tri-Cyclen Ortho-Tri-Cyclen Lo Ortho-Cyclen Ortho-Novum

Pataday Patanol Paxil Paxil CR Percocet Plavix Pravachol Pred Forte Prevacid Prinivil Pristiq Prometrium Propecia Protonix tab Provigil Prozac Pulmicort inhalation suspension Qudexy XR Questran Ranexa Relpax Remodulin injection Renagel Restoril Retin-A Retin-A micro gel 0.04%, 0.1% Risperdal solution, tablet Ritalin Ritalin LA Roxicodone Sabril Safyral Sandostatin injection Seasonique Sensipar Seroquel Seroquel XR Silvadene Singulair Skelaxin Solodyn Soma Staxyn Strattera Suboxone Synthroid Taclonex ointment Tamiflu Targadox Targretin Tazorac cream 0.1%

Tegretol Tegretol-XR Tenormin Testim gel Tikosyn Timoptic Timoptic-XE TOBI nebulizer solution Tobradex suspension Topamax Topamax sprinkle cap Topicort spray Toprol XL Treximet Tribenzor Tricor Trileptal Tylenol/cod tab Uceris tab Ultracet Ultram Vagifem Valium Valtrex Vectical Vesicare Viagra Vigamox Vimovo Vivelle-Dot Volgelxo Voltaren gel Vytorin Welchol Wellbutrin Xalatan Xanax Xanax XR Yasmin 28 Yaz Zanaflex Zegerid Zestril Zetia Ziana Zocor Zohydro ER Zoloft Zomig tab Zomig ZMT Zonegran Zovirax Zyprexa

Required Prior Authorization +

Therapeutic Class

Non-Preferred Medications

Preferred Medications

Hepatitis C All other brands non-preferred with prior authorization Epclusa, Harvoni, Mavyret, Vosevi

Multiple Sclerosis All other brands non-preferred with prior authorization

Avonex, Betaseron, Copaxone, Tecfidera

Immunomodulators All other brands non-preferred with prior authorization

Cimzia, Humira, Inflectra, Otezla, Renflexis, Rinvoq, Simponi, Simponi Aria, Skyrizi, Stelara, Tremfya, Xeljanz, Xeljanz XR

+ All of the products listed above are currently subject to prior authorization. Preferred medications are required prior to new requests for non-preferred medication(s). Existing utilizers of non-preferred medication(s) within the therapeutic categories of Hepatitis C, Immunomodulators and Multiple Sclerosis will be eligible to remain on current therapy if compliance and efficacy of therapy are demonstrated. Exceptions will be granted for specific indications where the preferred agents do not have FDA-approval for use. (M) Co-branded product

About this document: Where differences exist between this formulary and your benefit plan documents, the benefit plan documents rule. This may not be a complete list of medications, and not all medications listed may be covered by your plan. Please look at the benefit plan documents provided by your employer or plan sponsor for full details. © 2020 Optum, Inc. All rights reserved. OR100-7555 All Optum® trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

1

Utilization management updates - July 1, 2020

Prior authorization — Premium

There are some medications that have to be authorized by a doctor before you can get them, because the medications are approved or effective only for some conditions.

Reviewing medications

A group of doctors and pharmacists meets often to review medications under pharmacy benefit plans. They also recommend prior authorization guidelines.

Safe and effective

When making recommendations, the review committee focuses on medication safety, effectiveness and cost, including:

• U.S. Food and Drug Administration (FDA) approved uses

• Medication instruction labels

• Accepted or published clinical recommendations

Getting a short-term supply

If you must take a medication that requires prior authorization right away, there are two options that may work for you. First, ask your doctor if a sample is available. Or, check with your pharmacy to request a short-term supply of 5 days or less. Keep in mind, you will be responsible for the full cost at that time. If the prior authorization request is approved, then your pharmacist can fill the rest of your prescription.

Requesting a prior authorization

You, your pharmacist or your doctor can start the prior authorization process by contacting us. We will work with your doctor to get the information needed for the review. Once we receive a completed prior authorization form from your doctor, we will conduct a review within a few days and send you and your doctor a letter regarding the decision.

In this drug list, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

Premium Formulary

2

Premium Non-Specialty Prior Authorization List

These medications may require prior authorization based on your benefit plan. For more information, contact customer service at the phone number on your member ID card.

THERAPY CLASS MEDICATION NAME QUANTITY LIMITAnti-infectivesAnthelmintics ALBENZA (albendazole) NoneAntibiotics AEMCOLO (rifamycin) None

XIFAXAN (rifaximin) NoneAntifungals CICLODAN KIT (ciclopirox) None

CICLOPIROX KIT (ciclopirox) NoneCNL8 NAIL KIT (ciclopirox) NoneKERYDIN (tavaborole) NoneONMEL (itraconazole) NonePEDIPROX-4 (ciclopirox) nail kit NoneSPORANOX (itraconazole) Soln NoneSPORANOX (itraconazole) None

Antimalarial QUALAQUIN (quinine) NoneAntiretrovirals, HIV DESCOVY (emtricitabine/tenofovir) None

SELZENTRY (maraviroc) NoneTROGARZO (ibalizumab-uiyk) None

CardiologyAntilipemic omega-3-acid 1 gm None

PRALUENT (alirocumab) 2 syringes/28 daysREPATHA (evolocumab) 3 syringes/28 daysREPATHA PUSH (evolocumab) 1 cartridge/28 daysVASCEPA (icosapent ethyl) None

Heart Failure CORLANOR (ivabradine) 2 tabs/dayCORLANOR (ivabradine) Soln 15 mL/day

Central Nervous SystemADHD Agents (PA age 19+ only)

ADZENYS ER (amphetamine) 15 mL/dayADZENYS XR-ODT (amphetamine) 1 tab/dayamphetamine 6 tabs/dayamphetamine/dextroamphetamine 30 mg tab

2 tabs/day

amphetamine/dextroamphetamine 3 tabs/dayamphetamine/detroamphetamine ER 1 cap/dayAPTENSIO XR (methylphenidate) 1 cap/dayCOTEMPLA XR-ODT (methylphenidate) 8.6 mg

6 tabs/day

COTEMPLA XR-ODT (methylphenidate) 17.3 mg

3 tabs/day

COTEMPLA XR-ODT (methylphenidate) 25.9 mg

2 tabs/day

3

THERAPY CLASS MEDICATION NAME QUANTITY LIMITDAYTRANA (methylphenidate transdermal)

1 patch/day

DESOXYN (methamphetamine) 5 tabs/dayDEXEDRINE (dextroamphetamine) 10 mg

6 caps/day

DEXEDRINE (dextroamphetamine) 5 mg

3 caps/day

DEXEDRINE (dextroamphetamine) 15 mg

4 caps/day

dexmethylphenidate 2 tabs/daydexmethylphenidate ER 1 cap/dayDYANAVEL XR (amphetamine) 8 mL/dayEVEKEO ODT (amphetamine) 5 mg, 10 mg

3 tabs/day

EVEKEO ODT (amphetamine) 15 mg, 20 mg

2 tabs/day

JORNAY PM (methylphenidate) 1 cap/dayMETADATE CD (methylphenidate) 1 cap/dayMETADATE ER (methylphenidate) 20 mg

3 tabs/day

METHYLIN (methylphenidate) 3 tabs/dayMETHYLIN (methylphenidate) Soln 10 mg/5 mL

30 mL/day

METHYLIN (methylphenidate) Soln 5 mg/5 mL

60 mL/day

METHYLIN CHEW TAB (methylphenidate)

3 tabs/day

METHYLIN CHEW TAB (methylphenidate) 10 mg

6 tabs/day

METHYLIN ER (methylphenidate) 20 mg

3 tabs/day

methylphenidate 3 tabs/dayMETHYLPHENIDATE ER (methylphenidate) 10 mg

2 tabs/day

methylphenidate ER tab osmotic release 36 mg

2 tabs/day

methylphenidate ER tab osmotic release

1 tab/day

MYDAYIS (amphetamine/dextroamphetamine)

1 cap/day

PROCENTRA (dextroamphetamine) Sol

60 mL/day

QUILLICHEW ER (methylphenidate) 30 mg

2 tabs/day

4

THERAPY CLASS MEDICATION NAME QUANTITY LIMITQUILLICHEW ER (methylphenidate) 1 tab/dayQUILLIVANT XR (methylphenidate) 12 mL/dayRELEXXII (methylphenidate) 72 mg 1 tab/dayRITALIN LA (methylphenidate) 1 cap/dayRITALIN SR (methylphenidate) 20 mg 3 tabs/dayVYVANSE (lisdexamfetamine) 1 cap/dayVYVANSE CHEW TAB (lisdexamfetamine)

1 tab/day

ZENZEDI (dextroamphetamine) 30 mg 2 tabs/dayZENZEDI (dextroamphetamine) 3 tabs/dayZENZEDI (dextroamphetamine) 10 mg 6 tabs/day

Analgesics (non-opioid)

diclofenac solution 1.5% Nonenaproxen-esomeprazole 2 tabs/dayQUTENZA (capsaicin) 4 patches/3 months

Analgesics (opioid) acetaminophen/codeine soln 120-12 mg/5 mL

136 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 166.5 mL/day, 2 fills/60 days for treatment experienced

acetaminophen/codeine tab 300-15 13 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 13 tabs/day, 2 fills/60 days for treatment experienced



ACTIQ (fentanyl citrate) 4 lozenges/dayAVINZA (morphine ext-release) 1 cap/dayAVINZA (morphine ext-release) 120 mg 2 caps/dayBELBUCA (buprenorphine) film 2 films/daybutorphanol nasal spray 10 mg/mL 1 bottle/fill, 2 fills/60 daysBUTRANS (buprenorphine) 4 patches/28 days

5

THERAPY CLASS MEDICATION NAME QUANTITY LIMITcodeine tab 15 mg 21 tabs/day, 7 day supply (age 20 and

older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 40 tabs/day, 2 fills/60 days for treatment experienced

codeine tab 30 mg 10 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 20 tabs/day, 2 fills/60 days for treatment experienced

codeine tab 60 mg 5 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 10 tabs/day, 2 fills/60 days for treatment experienced

DEMEROL (meperidine) tab 100 mg 4 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 9 tabs/day, 2 fills/60 days for treatment experienced

DEMEROL (meperidine) tab 50 mg 9 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 18 tabs/day, 2 fills/60 days for treatment experienced

DOLOPHINE (methadone) NoneEMBEDA (morphine/naltrexone) 2 caps/dayfentanyl transdermal patch 15 patches/30 daysfentanyl transdermal patch 75 mcg/hr, 100 mcg/hr

30 patches/30 days

hydrocodone/acetaminophen sol 7.5-325 mg/15 mL

98 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naive; 180 mL/day, 2 fills/60 days for treatment experienced

hydrocodone/acetaminophen sol 10-325 mg/15 mL

73.5 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 135 mL/day, 2 fills/60 days for treatment experienced

hydrocodone/acetaminophen tab 10-325 mg

4 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 9 tabs/day, 2 fills/60 days for treatment experienced

6

THERAPY CLASS MEDICATION NAME QUANTITY LIMIThydrocodone/acetaminophen tab 5-300 mg


hydrocodone/acetaminophen tab 5-325 mg


hydrocodone/acetaminophen tab 7.5-300 mg


hydrocodone/acetaminophen tab 7.5-325 mg


hydrocodone/ibuprofen tab 7.5-200 mg


hydromorphone liq 1 mg/mL 12.25 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naive; 22.5 mL/day, 2 fills/60 days for treatment experienced

hydromorphone supp 3 mg 4 supps/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 7 supps/day, 2 fills/60 days for treatment experienced

hydromorphone tab 2 mg 6 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 11 tabs/day, 2 fills/60 days for treatment experienced

hydromorphone tab 4 mg 3 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 5 tabs/day, 2 fills/60 days for treatment experienced

7

THERAPY CLASS MEDICATION NAME QUANTITY LIMIThydromorphone tab 8 mg 1 tabs/day, 7 day supply (age 20 and


hydromorphone tab ER 2 tabs/dayHYSINGLA ER (hydrocodone bitartrate)

1 tab/day

levorphanol tab 2 mg 2 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 4 tabs/day, 2 fills/60 days for treatment experienced

levorphanol tab 3 mg 1 tab/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 2 tabs/day, 2 fills/60 days for treatment experienced

LORTAB (hydrocodone/acetaminophen) elx 10-300 mg/15 mL


meperidine/promethazine cap 50-25 mg

9 caps/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 18 caps/day, 2 fills/60 days for treatment experienced

mepridine sol 50 mg/5 mL 49 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 90 mL/day, 2 fills/60 days for treatment experienced

MORPHABOND ER (morphine ext-release)

2 tabs/day

morphine sol 10 mg/5 mL 24.5 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 45 mL/day, 2 fills/60 days for treatment experienced

morphine sol 20 mg/5 mL 12.25 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 22.5 mL/day, 2 fills/60 days for treatment experienced

8

THERAPY CLASS MEDICATION NAME QUANTITY LIMITmorphine sol 20 mg/mL 2.4 mL/day, 7 day supply (age 20 and

older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 4.5 mL/day, 2 fills/60 days for treatment experienced

morphine supp 10 mg 4 supps/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 9 supps/day, 2 fills/60 days for treatment experienced




morphine tab 15 mg 3 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 6 tabs/day, 2 fills/60 days for treatment experienced

morphine tab 30 mg 1 tab/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 3 tabs/day, 2 fills/60 days for treatment experienced

morphine sulfate ER cap 2 caps/daymorphine sulfate ER tab 3 tabs/dayNALOCET (oxycodone/acetaminophen)


OPANA (oxymorphone) tab 10 mg 1 tab/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 3 tabs/day, 2 fills/60 days for treatment experienced

9

THERAPY CLASS MEDICATION NAME QUANTITY LIMITOPANA (oxymorphone) tab 5 mg 3 tabs/day, 7 day supply (age 20 and


OXAYDO (oxycodone) tab 5 mg 6 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 12 tabs/day, 2 fills/60 days for treatment experienced

OXAYDO (oxycodone) tab 7.5 mg 4 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 8 tabs/day, 2 fills/60 days for treatment experienced

oxycodone/aspirin tab 6 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 12 tabs/day, 2 fills/60 days for treatment experienced

oxycodone/ibuprofen tab 5-400 mg 6 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 8 tabs/day, 2 fills/60 days for treatment experienced

oxycodone cap 5 mg 6 caps/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 12 caps/day, 2 fills/60 days for treatment experienced

oxycodone conc 20 mg/mL 1.6 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 3 mL/day, 2 fills/60 days for treatment experienced

oxycodone sol 5 mg/5 mL 32.6 mL/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 60 mL/day, 2 fills/60 days for treatment experienced

oxycodone tab 5 mg 6 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 12 tabs/day, 2 fills/60 days for treatment experienced

10

THERAPY CLASS MEDICATION NAME QUANTITY LIMIToxycodone tab 10 mg 3 tabs/day, 7 day supply (age 20 and


oxycodone tab 15 mg 2 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 4 tabs/day, 2 fills/60 days for treatment experienced

oxycodone tab 20 mg 1 tab/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 3 tabs/day, 2 fills/60 days for treatment experienced

oxycodone tab 30 mg 1 tab/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 2 tabs/day, 2 fills/60 days for treatment experienced

oxycodone/acetaminophen sol 5-325 mg/5 mL


oxycodone/acetaminophen tab 10-325 mg


oxycodone/acetaminophen tab 2.5-325 mg


oxycodone/acetaminophen tab 5-325 mg


oxycodone/acetaminophen tab 7.5-325 mg


OXYCONTIN (oxycodone ext-release) 4 tabs/dayoxymorphone ER 4 tabs/day

11

THERAPY CLASS MEDICATION NAME QUANTITY LIMITpentazocine/naloxone tab 50-0.5 mg


PRIMLEV (oxycodone/acetaminophen) tab 10-300 mg


PRIMLEV (oxycodone/acetaminophen) tab 5-300 mg


PRIMLEV (oxycodone/acetaminophen) tab 7.5-300 mg


SYNALGOS-DC (aspirin/caffeine/dihydrocodeine) cap


tramadol tab 50 mg 8 tabs/day, 7 day supply (age 20 and older), 3 day supply (age less than 20), 2 fills/60 days for treatment naïve; 8 tabs/day, 2 fills/60 days for treatment experienced

tramadol/acetaminophen tab 37.5-325 mg


tramadol cap ER 1 cap/daytramadol tab ER 1 tab/dayTREZIX (acetaminophen/caffeine/dihydrocodeine) cap


12

THERAPY CLASS MEDICATION NAME QUANTITY LIMITVICODIN HP (hydrocodone/acetaminophen) tab 10-300 mg


hydrocodone cap ER 2 caps/dayhydrocodone cap ER 50 mg 4 caps/day

Anticonvulsants BANZEL (rufinamide) Noneclobazam NoneHORIZANT (gabapentin enacarbil) 2 tabs/daySYMPAZAN (clobazam) None

Antipsychotics ADASUVE (loxapine) NoneAntitussives (PA age <18)

CAPCOF (phenylephrine/chlorpheniramine/codeine)

240 mL/fill, 2 fills/60 days

CHERATUSSIN (guaifenesin/codeine) 240 mL/fill, 2 fills/60 daysCODAR AR (chlorpheniramine/codeine)


CODAR D (pseudoephedrine/codeine)


CODAR GF (guaifenesin/codeine) 240 mL/fill, 2 fills/60 daysCODITUSSIN (guaifenesin/codeine) 240 mL/fill, 2 fills/60 daysCODITUSSIN AC (guaifenesin/codeine)


FLOWTUSS (hydrocodone/guaifenesin)


guaifenesin/codeine 240 mL/fill, 2 fills/60 daysHISTEX-AC (phenylephrine/triprolidine/codeine)


hydrocodone/chlorpheniramine 240 mL/fill, 2 fills/60 daysHYDROMET (hydrocodone/homatropine)


LEXUSS 210 (chlorpheniramine/codeine)


MAR-COF BP (pseudoephedrine/brompheniramine/codeine)


MAR-COF CG (guaifenesin/codeine) 240 mL/fill, 2 fills/60 daysM-CLEAR WC (guaifenesin/codeine) 240 mL/fill, 2 fills/60 daysM-END MAX D (pseudoephedrine/chlorpheniramine/codeine)


M-END PE (phenylephrine/brompheniramine/codeine)


M-END WC (pseudoephedrine/brompheniramine/codeine)


NINJACOF-XG (guaifenesin/codeine) 240 mL/fill, 2 fills/60 days

13

THERAPY CLASS MEDICATION NAME QUANTITY LIMITOBREDON (hydrocodone/guaifenesin)


PHENHIST DH (pseudoephedrine/brompheniramine/codeine)


POLY-TUSSIN (phenylephrine/brompheniramine/codeine)


PRO-CLEAR AC (codeine/pyrilamine) 240 mL/fill, 2 fills/60 dayspromethazine/phenylephrine/codeine


promethazine/codeine 240 mL/fill, 2 fills/60 dayspseudoephedrine/chlorpheniramine/hydrocodone


PRO-RED AC (phenylephrine/dexchlorpheniramine/codeine)


RELCOF C (guaifenesin/codeine) 240 mL/fill, 2 fills/60 daysREZIRA (pseudoephedrine/hydrocodone)


RYDEX (pseudoephedrine/brompheniramine/codeine)


TRICODE AR (pseudoephedrine/chlorpheniramine/codeine)


TRYMINE CG (guaifenesin/codeine) 240 mL/fill, 2 fills/60 daysTUSNEL C (pseudoephedrine w/ cod-gg)


TUSSICAPS (hydrocodone/chlorpheniramine) 10-8 mg

2 caps/day, 7 day supply, 2 fills/60 days

TUSSICAPS (hydrocodone/chlorpheniramine) 5-4 mg

4 caps/day, 7 day supply, 2 fills/60 days

TUSSIGON (hydrocodone/homatropine)

6 tabs/day, 7 day supply, 2 fills/60 days

TUSSIONEX (hydrocodone/chlorpheniramine)


TUXARIN ER (codeine/chlorpheniramine)

2 tabs/day, 7 day supply, 2 fills/60 days

TUZISTRA XR (codeine/chlorpheniramine)


VIRTUSSIN (pseudoephedrine w/ cod-gg)


VITUZ (hydrocodone/chlorpheniramine)


Z-TUSS AC (chlorpheniramine/codeine)


ZUTRIPRO (pseudoephedrine/chlorpheniramine/hydrocodone)


14

THERAPY CLASS MEDICATION NAME QUANTITY LIMITHypoactive Sexual Desire Disorder

ADDYI (flibanserin) 1 tab/day

Migraine AIMOVIG (erenumab) 2 syringes/30 daysAIMOVIG (erenumab) 140 mg/mL 1 syringe/30 daysEMGALITY (galcanezumab-gnlm) 1 syringe/auto-injector/30 daysEMGALITY (galcanezumab-gnlm) 100 mg

3 syringes/auto-injectors/30 days

Miscellaneous NUEDEXTA (dextromethorphan/quinidine)

None

RILUTEK (riluzole) 2 tabs/dayTIGLUTIK (riluzole) 20 mL/day

Parkinson’s DUOPA (carbidopa-levodopa) Susp NoneNUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (flurazepam) 1 cap/dayStimulants armodafinil 1 tab/day

armodafinil 50 mg 2 tabs/daymodafinil 1 tab/day

Weight Loss BONTRIL (phendimetrazine) NoneCONTRAVE (naltrexone-bupropion) NoneDIDREX (benzphetamine) NoneLOMAIRA (phentermine) Nonephentermine NoneQSYMIA (phentermine/topiramate) NoneREGIMEX (benzphetamine) NoneSAXENDA (liraglutide) NoneSUPRENZA (phentermine) NoneTENUATE (diethylpropion) NoneXENICAL (orlistat) None

DermatologyAcne (Oral) ABSORICA (isotretinoin) None

ABSORICA LD (isotretinoin) NoneAMNESTEEM (isotretinoin) NoneCLARAVIS (isotretinoin) NoneMYORISAN (isotretinoin) NoneZENATANE (isotretinoin) None

Acne (PA age >25 only)

adapalene NoneALTRENO (tretinoin) NoneATRALIN (tretinoin) NoneAVITA (tretinoin) NonePLIXDA (adapalene) Nonetretinoin cream Nonetretinoin microsphere gel None

15

THERAPY CLASS MEDICATION NAME QUANTITY LIMITTRETIN-X (tretinoin) None

Endocrinology & Metabolism Androgens, Testosterone (Oral)

ANADROL-50 (oxymetholone) NoneANDROID (methyltestosterone) NoneANDROXY (fluoxymesterone) NoneMETHITEST (methyltestosterone) NoneOXANDRIN (oxandrolone) 2.5 mg 8 tabs/dayOXANDRIN (oxandrolone) 10 mg 2 tabs/dayTESTRED (methyltestosterone) None

Androgens, Testosterone (Injectable)

AVEED (testosterone undecanoate) NoneDELATESTRYL (testosterone enanthate)

None

TESTOPEL (testosterone pellet) None

testosterone cypionate NoneXYOSTED (testosterone enanthate) None

Androgens, Testosterone (Topical)

ANDRODERM (testosterone) NoneNATESTO (testosterone nasal) NoneSTRIANT (testosterone) Nonetestosterone gel 1.62% None

Antidiabetic Agents

AFREZZA (insulin regular) NoneSYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabs/day

CESAMET (nabilone) 20 caps/fill or 3 max days supplyDICLEGIS (doxylamine-pyridoxine) 4 tabs/dayMARINOL (dronabinol) 2 caps/daySYNDROS (dronabinol) 120 mL/30 days

Irritable Bowel Syndrome

LOTRONEX (alosetron) NoneVIBERZI (eluxadoline) 2 tabs/day

ImmunologyAllergen Extracts GRASTEK (timothy grass pollen) 1 tab/day

ODACTRA (house dust mite) 1 tab/dayORALAIR (mixed grass pollens allergen) 300 IR

1 tab/day

ORALAIR ADULT SAMPLE KIT (mixed grass pollens allergen) Kit

1 kit/year

ORALAIR ADULT STARTER PACK (mixed grass pollens allergen)

1 pack/year

ORALAIR CHILDREN/ADOLESCENTS (mixed grass pollens allergen) Starter Pack

2 packs/year

16

THERAPY CLASS MEDICATION NAME QUANTITY LIMITORALAIR CHILDREN/ADOLESCENTS (mixed grass pollens allergen) Sample Kit

2 kits/year;

RAGWITEK (short ragweed pollen allergen)

1 tab/day

Immunizations VARIZIG (varicella-zoster immune globulin)

None

MiscellaneousAntimetabolites SIKLOS (hydroxyurea) 100 mg NoneCalcium Modifier cinacalcet NoneMethotrexate Auto-Injectors

OTREXUP (methotrexate) 4 auto-injectors/28 daysRASUVO (methotrexate) 4 auto-injectors/28 days

Toxicology EXJADE (deferasirox) NoneFERRIPROX (deferiprone), None

JADENU (deferasirox), None

JADENU SPRINKLE (deferasirox), None

Wound Care REGRANEX (becaplermin) NoneOncology Miscellaneous PROVENGE (sipuleucel-T) NoneOphthalmologyMiscellaneous RESTASIS (cyclosporine) None

XIIDRA (lifitegrast) NoneRespiratoryAsthma/COPD DALIRESP (roflumilast) None

PLEASE NOTE: This drug list may have regular updates and may not include all medications. Drugs in this list include brand and generic and include all dosage types unless noted. If a new drug is approved and falls into one of the targeted PA categories, the new drug may be automatically added to this list.

17

Premium Specialty Prior Authorization List

These medications may require prior authorization as defined by your benefit plan. For more information, contact customer service at the member phone number on your ID card.

THERAPY CLASS MEDICATION NAME QUANTITY LIMITAnti-infectivesAntiprotozoals DARAPRIM (pyrimethamine) NoneAntithrombotic Agentsvon Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

CardiologyAntilipemic JUXTAPID (lomitapide) 1 tab/day

KYNAMRO (mipomersen) 4 syringes/28 daysPulmonary Arterial Hypertension

ADEMPAS (riociguat) 3 tabs/dayALYQ (tadalafil) 2 tabs/dayambrisentan 1 tab/daybosentan tab 2 tabs/dayFLOLAN (epoprostenol) NoneOPSUMIT (macitentan) 1 tab/dayORENITRAM (treprostinil diolamine) NoneREVATIO (sildenafil) Soln NoneREVATIO (sildenafil) Susp 2 bottles/30 daysREVATIO (sildenafil) Tabs 3 tabs/daytadalafil 2 tabs/dayTRACLEER (bosentan) Tabs for Susp 4 tabs/daytreprostinil NoneTYVASO (treprostinil) 1 ampule/dayUPTRAVI (selexipag) 2 tabs/dayUPTRAVI (selexipag) Pack 2 packs/yearVELETRI (epoprostenol) NoneVENTAVIS (iloprost) 9 ampules/day

Transthyretin Stabilizers

VYNDAMAX (tafamidis) 1 cap/dayVYNDAQEL (tafamidis meglumine) 4 caps/day

Vasopressors NORTHERA (droxidopa) NoneCentral Nervous SystemAnticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln Nonevigabatrin tabs None

Antidepressants SPRAVATO (esketamine) NoneZULRESSO (brexanolone) None

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)/30 daysMiscellaneous RADICAVA (edaravone) Soln None

18

THERAPY CLASS MEDICATION NAME QUANTITY LIMITMuscular Dystrophy

EMFLAZA (deflazacort) NoneEXONDYS 51 (eteplirsen) None

Musculoskeletal Agents

FIRDAPSE (amifampridine phosphate) NoneRUZURGI (amifanpridine) None

Neurological Agents

ONPATTRO (patisiran sodium) NoneTEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) NoneBOTOX COSMETIC (onabotulinumtoxinA)

None

DYSPORT (abobotulinumtoxinA) NoneMYOBLOC (rimabotulinumtoxinB) NoneXEOMIN (incobotulinumtoxinA) None

Parkinson’s APOKYN (apomorphine) 30 cartridges/30 daysINBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 cap/daySUNOSI (solriamfetol) 1 cap/dayWAKIX (pitolisant) 2 tabs/day

DermatologyAlkylating Agents VALCHLOR (mechlorethamine) Gel NoneAtopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes/28 days Electrolyte & Renal AgentsDiuretics KEVEYIS (dichlorphenamide) 4 tabs/dayEndocrinology & MetabolismGonadotropins ELIGARD (leuprolide) 22.5 mg

(3-month)1 injection/84 days

ELIGARD (leuprolide) 30 mg (4-month)

1 injection/112 days

ELIGARD (leuprolide) 45 mg (6-month)


ELIGARD (leuprolide) 7.5 mg (1-month)

1 injection/28 days

FIRMAGON (degarelix) 120 mg 2 vials/yearFIRMAGON (degarelix) 80 mg 1 vial/28 daysLUPANETA PACK (leuprolide) 11.25 mg (3 mon)

1 pack/84 days

LUPANETA PACK (leuprolide) 3.75 mg (1 mon)

1 pack/28 days

LUPRON (leuprolide) 1 mg/0.2 mL NoneLUPRON DEPOT (leuprolide) 3.75 mg & 7.5 mg (1-month)

None

LUPRON DEPOT-PED (leuprolide) NoneORILISSA (elagolix) 150 mg 1 tab/dayORILISSA (elagolix) 200 mg 2 tabs/day

19

THERAPY CLASS MEDICATION NAME QUANTITY LIMITSUPPRELIN LA (histrelin acetate) 1 kit/365 daysTRELSTAR (triptorelin) 22.5 mg (6-month)


TRELSTAR DEPOT (triptorelin) 3.75 mg (1-month)

1 injection/28 days

TRELSTAR LA (triptorelin) 11.25 mg (3-month)

1 injection/84 days

TRIPTODUR (triptorelin) 1 injection/84 daysVANTAS (histrelin) 1 implant/year

Growth Hormones and Related Therapy

EGRIFTA (tesamorelin) 2 vials (1 mg each)/dayEGRIFTA SV (tesamorelin) 1 vial (2 mg each)/dayNORDITROPIN (somatropin) NoneNUTROPIN (somatropin) NoneNUTROPIN AQ (somatropin) NoneSEROSTIM (somatropin) NoneZORBTIVE (somatropin) None

Growth Hormones and Related Therapy (Acromegaly)

INCRELEX (mecasermin) NoneSOMAVERT (pegvisomant) None

Hormone Modifiers MYALEPT (metreleptin) NoneNATPARA (parathyroid hormone) 2 cartridges/28 days

Miscellaneous ACTHAR (corticotropin) NoneKORLYM (mifepristone) 4 tabs/day

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (2.34 mL) per 28 daysFORTEO (teriparatide) NonePROLIA (denosumab) 2 syringes/yearTYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampules/daySIGNIFOR LAR (pasireotide) 1 vial/28 daysSOMATULINE DEPOT (lanreotide) None

Enzyme-RelatedAlpha-1 proteinase inhibitor

ARALAST (alpha-1 proteinase inhibitor)

None

GLASSIA (alpha-1 proteinase inhibitor)

None

PROLASTIN (alpha-1 proteinase inhibitor)

None

PROLASTIN-C (alpha-1 proteinase inhibitor)

None

ZEMAIRA (alpha-1 proteinase inhibitor)

None

20

THERAPY CLASS MEDICATION NAME QUANTITY LIMITCystine-depleting Agents

CYSTARAN (cysteamine) 4 bottles/28 daysPROCYSBI (cysteamine bitartrate) None

Enzyme Replacement

ALDURAZYME (laronidase) NoneBRINEURA (cerliponase) Soln NoneCERDELGA (eliglustat) NoneCEREZYME (imiglucerase) NoneELAPRASE (idursulfase) NoneELELYSO (taliglucerase) NoneFABRAZYME (agalsidase beta) None

GALAFOLD (migalastat hcl) cap 14 caps/28 daysKANUMA (sebelipase alfa) NoneLUMIZYME (alglucosidase alfa) NoneMEPSEVII (vestronidase alfa) NoneNAGLAZYME (galsulfase) NoneRAVICTI (glycerol phenylbutyrate) NoneREVCOVI (elapegademase-lvlr) NoneSTRENSIQ (asfotase alfa) NoneVIMIZIM (elosulfase) NoneVPRIV (velaglucerase) NoneXURIDEN (uridine triacetate) 4 packets/dayZAVESCA (miglustat) None

Enzyme, Gout KRYSTEXXA (pegloticase) NoneMetabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) NonePhenylketonuria Treatment Agents

KUVAN (sapropterin) NonePALYNZIQ (pegvaliase-pqpz) 10 mg/0.5 mL

1 syringe/day

PALYNZIQ (pegvaliase-pqpz) 2.5 mg/0.5 mL

8 syringes/28 days

PALYNZIQ (pegvaliase-pqpz) 20 mg/mL 2 syringes/dayGastroenterologyBile Acid Agents CHENODAL (chenodiol) None

CHOLBAM (cholic acid) NoneDiarrhea XERMELO (telotristat ethyl) 3 tabs/dayHepatic Agents OCALIVA (obeticholic acid) 1 tab/dayShort Bowel Syndrome

GATTEX (teduglutide) None

ImmunologyHematopoietic Agents

ARANESP (darbepoetin alfa) NoneDOPTELET (avatrombopag) NoneLEUKINE (sargramostim) None

21

THERAPY CLASS MEDICATION NAME QUANTITY LIMITMIRCERA (methoxy polyethylene glycol-epoetin)

None

MOZOBIL (plerixafor) 8 vials (9.6 mL) per transplantMULPLETA (lusutrombopag) NoneNEULASTA (pegfilgrastim) NoneNIVESTYM (filgrastim-aafi) NoneNPLATE (romiplostim) NonePROMACTA (eltrombopag) NoneREBLOZYL (luspatercept) NoneRETACRIT (epoetin alfa-epbx) NoneSOLIRIS (eculizumab) NoneTAVALISSE (fostamatinib) NoneUDENYCA (pegfilgrastim-cbqv) NoneULTOMIRIS (ravulizumab-cwvz) NoneZARXIO (filgrastim) None

Hemostatic Agent BERINERT (c1 esterase) NoneCINRYZE (c1 esterase) NoneFIRAZYR (icatibant) Soln NoneHAEGARDA (c1 esterase) NoneKALBITOR (ecallantide) Soln NoneRUCONEST (c1 esterase) Solr NoneTAKHZYRO (lanadelumab-flyo) None

Hepatitis C Agents DAKLINZA (daclatasvir dihydrochloride)

1 tab/day

EPCLUSA (sofosbuvir-velpatasvir) 1 tab/dayHARVONI (ledipasvir-sofosbuvir) 90-400 mg

1 tab/day

HARVONI (ledipasvir-sofosbuvir) 45-200 mg

2 tab/day

MAVYRET (glecaprevir-pibrentasvir) 3 tabs/dayPEGASYS (peginterferon alfa-2a) NonePEG-INTRON (peginterferon alfa-2b) NoneSOVALDI (sofosbuvir) 400 mg 1 tab/daySOVALDI (sofosbuvir) 200 mg 2 tab/dayVIEKIRA PAK (dasabuvir-ombitasvir-paritaprevir-ritonavir)

4 tabs/day

VIEKIRA XR (dasabuvir-ombitasvir-paritaprevir-ritonavir)

3 tabs/day

VOSEVI (sofosbuvir-velpatasivir) 1 tab/dayZEPATIER (elbasvir-grazoprevir) 1 tab/day

Immune Globulins BIVIGAM (immune globulin) NoneCARIMUNE (immune globulin) None

22

THERAPY CLASS MEDICATION NAME QUANTITY LIMITCUVITRU (immune globulin) NoneCYTOGAM (cytomegalovirus immune globulin)

None

FLEBOGAMMA (immune globulin) NoneFLEBOGAMMA DIF (immune globulin)

None

GAMASTAN (immune globulin) NoneGAMMAGARD (immune globulin) NoneGAMMAKED (immune globulin) NoneGAMMAPLEX (immune globulin) NoneGAMUNEX (immune globulin) NoneGAMUNEX-C (immune globulin) NoneHIZENTRA (immune globulin) NoneHYQVIA (hyaluron immune globulin) NoneOCTAGAM (immune globulin) NonePRIVIGEN (immune globulin) None

Immunomodulators ACTEMRA (tocilizumab) Sosy NoneCIMZIA (certolizumab) NoneENBREL (etanercept) NoneENTYVIO (vedolizumab) NoneHUMIRA (adalimumab) NoneILUMYA (tildrakizumab-asmn) NoneINFLECTRA (infliximab) NoneKEVZARA (sarilumab) NoneKINERET (anakinra) NoneORENCIA (abatacept) NoneOTEZLA (apremilast) NoneRENFLEXIS (infliximab) NoneRINVOQ (upadacitinib) NoneSILIQ (brodalumab) Sosy NoneSIMPONI (golimumab) NoneSIMPONI ARIA (golimumab) NoneSKYRIZI (risankizumab-rzaa) NoneSTELARA (ustekinumab) NoneTALTZ (ixekizumab) NoneTREMFYA (guselkumab) NoneXELJANZ (tofacitinib) NoneXELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) NoneILARIS (canakinumab) 2 vials/4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) NoneBENLYSTA (belimumab) None

23

THERAPY CLASS MEDICATION NAME QUANTITY LIMITCRYSVITA (burosumab-twza) None

Monoclonal Antibody

GAMIFANT (emapalumab-lzsg) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabs/dayAUBAGIO (teriflunomide) 1 tab/dayAVONEX (interferon beta-1a) 1 kit (4 syringes)/28 daysBETASERON (interferon beta-1b) 1 package/28 daysCOPAXONE (glatiramer) SOSY 20 mg/ml

30 syringes/30 days

COPAXONE (glatiramer) SOSY 40 mg/ml

12 syringes/28 days

GILENYA (fingolimod) 1 cap/dayGLATOPA (glatiramer) SOSY 20 mg/ml

30 syringes/30 days

LEMTRADA (alemtuzumab) NoneMAVENCLAD (cladribine) NoneMAYZENT (siponimod fumarate) 0.25 mg

4 tabs/day

MAYZENT (siponimod fumarate) 2 mg

1 tab/day

MAYZENT (siponimod fumarate) starter pack

2 starter packs (24 tabs)/365 days

NOVANTRONE (mitoxantrone) NoneOCREVUS (ocrelizumab) Soln 40 mL/365 daysREBIF (interferon beta-1a) 12 syringes/28 daysREBIF (interferon beta-1a) Starter Pack

1 starter pack/year

TECFIDERA (dimethyl fumarate) 2 caps/dayTECFIDERA (dimethyl fumarate) Starter Pack

1 starter pack/year

TYSABRI (natalizumab) 1 injection /28 daysTransplant NULOJIX (belatacept) None

ZORTRESS (everolimus) NoneMiscellaneousAmino Acid ENDARI (glutamine) NoneCollagenase XIAFLEX (collagenase clostridium

histolyticum)None

Diagnostic THYROGEN (thyrotropin alfa) NoneMovement Disorder Agents

AUSTEDO (deutetrabenazine) 4 tabs/dayINGREZZA (valbenazine tosylate) 1 cap/dayINGREZZA (valbenazine tosylate) pack 56 caps (2 packs) per 365 daysXENAZINE (tetrabenazine) None

24

THERAPY CLASS MEDICATION NAME QUANTITY LIMITMusculoskeletal Agents

SPINRAZA (nusinersen) Soln NoneZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) NoneSYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) NoneEUFLEXXA (sodium hyaluronate) NoneGELSYN-3 (sodium hyaluronate) None

Obstetrics & GynecologyFertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) Noneganirelix acetate NoneMENOPUR (menotropins) NoneNOVAREL (chorionic gonadotropin) NoneOVIDREL (chorionic gonadotropin) NonePREGNYL (chorionic gonadotropin) NoneREPRONEX (menotropins) None

Hormone Replacement

hydroxyprogesterone caproate NoneMAKENA (hydroxyprogesterone caproate)

None

Oncology (Injectable)Alkylating Agents BENDEKA (bendamustine) NoneAntifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln NoneAntimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) NoneCAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) NoneInterferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) NoneInterleukins ELZONRIS (tagraxofusp-erzs) NoneKinase and Molecular Target Inhibitors

ALIQOPA (copanlisib) NoneKYPROLIS (carfilzomib) NoneVELCADE (bortezomib) None

Miscellaneous BELEODAQ (belinostat) NoneDACOGEN (decitabine) NoneISTODAX (romidepsin) NoneSYNRIBO (omacetaxine) NoneVYXEOS (daunorubicin-cytarabine) NoneZALTRAP (ziv-aflibercept) None

Monoclonal Antibody

ADCETRIS (brentuximab) NoneARZERRA (ofatumumab) NoneAVASTIN (bevacizumab) None

25

THERAPY CLASS MEDICATION NAME QUANTITY LIMITBAVENCIO (avelumab) Soln NoneBESPONSA (inotuzumab) NoneBLINCYTO (blinatumomab) NoneCYRAMZA (ramucirumab) NoneDARZALEX (daratumumab) Soln NoneEMPLICITI (elotuzumab) Solr NoneERBITUX (cetuximab) Soln NoneGAZYVA (obinutuzumab) NoneHERCEPTIN (trastuzumab) NoneHERCEPTIN HYLECTA (trastuzumab and hyaluronidase-oysk)

None

IMFINZI (durvalumab) Soln NoneKADCYLA (ado-trastuzumab emtansine)

None

KANJINTI (trastuzumab-anns) NoneKEYTRUDA (pembrolizumab) NoneLARTRUVO (olaratumab) NoneLIBTAYO (cemiplimab-rwlc) NoneLUMOXITI (moxetumomab pasudotox-tdfk)

None

MVASI (bevacizumab-awwb) NoneMYLOTARG (gemtuzumab) NoneOPDIVO (nivolumab) NonePERJETA (pertuzumab) NonePOLIVY (polatuzumab vedotin-piiqPORTRAZZA (necitumumab) Soln NonePOTELIGEO (mogamulizumab-kpkc) NoneRITUXAN HYCELA (rituximab-hyaluronidase)

None

RUXIENCE (rituximab) NoneSYLVANT (siltuximab) NoneUNITUXIN (dinutuximab) NoneXGEVA (denosumab) NoneYERVOY (ipilimumab) NoneZIRABEV (bevacizumab) None

Oncology (Oral)Alkylating Agents TEMODAR (temozolomide) NoneAntiandrogen INREBIC (fedratinib) None

NUBEQA (darolutamide) NoneROZLYTREK (entrectinib) NoneXTANDI (enzalutamide ) None

26

THERAPY CLASS MEDICATION NAME QUANTITY LIMITKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) NoneALECENSA (alectinib) NoneALUNBRIG (brigatinib) 30 mg 4 tabs/dayALUNBRIG (brigatinib) 90 mg, 180 mg 1 tab/dayALUNBRIG (brigatinib) Pack 1 pack/yearBALVERSA (erdafitinib) NoneBOSULIF (bosutinib) NoneBRAFTOVI (encorafenib) NoneCABOMETYX (cabozantinib s-malate) NoneCAPRELSA (vandetanib) 100 mg 2 tabs/dayCALQUENCE (acalabrutinib) NoneCAPRELSA (vandetanib) NoneCOMETRIQ (carbozantinib) NoneCOPIKTRA (duvelisib) NoneCOTELLIC (cobimetnib) NoneDAURISMO (glasdegib) NoneERIVEDGE (vismodegib) Noneeverolimus 1 tab/dayFARYDAK (panobinostat) NoneGILOTRIF (afatinib) 1 tab/dayGLEEVEC (imatinib) NoneIBRANCE (palbociclib) NoneICLUSIG (ponatinib) 15 mg 2 tabs/dayICLUSIG (ponatinib) 45 mg NoneIDHIFA (enasidenib) 1 tab/dayIMBRUVICA (ibrutinib) NoneINLYTA (axitinib) NoneIRESSA (gefitinib) NoneJAKAFI (ruxolitinib) NoneJAKAFI (ruxolitinib) 10 mg 2 tabs/dayLENVIMA (lenvatinib) NoneLORBRENA (lorlatinib) NoneLYNPARZA (olaparib) NoneMEKINIST (trametinib) NoneMEKTOVI (binimetinib) NoneNERLYNX (neratinib) 6 tabs/dayNEXAVAR (sorafenib) NoneNINLARO (ixazomib) NoneODOMZO (sonidegib) NoneRYDAPT (midostaurin) NoneSPRYCEL (dasatinib) None

27

THERAPY CLASS MEDICATION NAME QUANTITY LIMITSTIVARGA (regorafenib) NoneSUTENT (sunitinib) NoneTAFINLAR (dabrafenib) NoneTAGRISSO (osimertinib) NoneTAGRISSO (osimertinib) 40 mg 1 tab/dayTARCEVA (erlotinib) 100 mg, 150 mg NoneTARCEVA (erlotinib) 25 mg 3 tabs/dayTASIGNA (nilotinib) NoneTIBSOVO (ivosidenib) NoneTYKERB (lapatinib) NoneVENCLEXTA (venetoclax) NoneVERZENIO (abemaciclib) NoneVITRAKVI (larotrectinib) NoneVIZIMPRO (dacomitinib) NoneVOTRIENT (pazopanib) NoneXALKORI (crizotinib) NoneXOSPATA (gilteritinib) NoneZEJULA (niraparib tosylate) NoneZELBORAF (vemurafenib) NoneZYDELIG (idelalisib) NoneZYKADIA (ceritinib) None

Miscellaneous bexarotene caps NoneKISQALI (ribociclib) NoneKISQALI FEMARA DOSE (ribociclib succinate-letrozole) Pack

None

LONSURF (trifluridine-tipiracil) 15-6.14 mg

None

LONSURF (trifluridine-tipiracil) 20-8.19 mg

None

RUBRACA (rucaparib camsylate) NoneXELODA (capecitabine) NoneXPOVIO (selinexor) NoneZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) NoneThalidomide-related Agents

POMALYST (pomalidomide) NoneREVLIMID (lenalidomide) NoneTHALOMID (thalidomide) None

OphthalmologyMiscellaneous LUXTURNA (voretigene neparvovec-

rzyl)None

OXERVATE (cenegermin-bkbj) 2 mL (2 vials)/day

28

THERAPY CLASS MEDICATION NAME QUANTITY LIMITRespiratoryAsthma/COPD CINQAIR (reslizumab) Soln None

DUPIXENT (dupilumab) Sosy 4 syringes/28 daysFASENRA (benralizumab) NoneNUCALA (mepolizumab) 3 vials/28 daysXOLAIR (omalizumab) None

Cystic fibrosis CAYSTON (aztreonam) NoneKALYDECO (ivacaftor) NoneORKAMBI (lumacaftor-ivacaftor) 4 tabs/dayORKAMBI (lumacaftor-ivacaftor) packets

2 packets/day

PULMOZYME (dornase alfa) NoneSYMDEKO (tezacaftor-ivacaftor) 2 tabs/dayTRIKAFTA (elexacaftor-tezacaftor-ivacaftor)

3 tabs/day

Pulmonary Fibrosis ESBRIET (pirfenidone) NoneOFEV (nintedanib) None

Respiratory Syncytial Virus Agents

SYNAGIS (palivizumab) None

PLEASE NOTE: This drug list may have regular updates and may not include all medications. Drugs in this list include brand and generic and all dosage types unless noted. If a new drug is approved and falls into one of the targeted PA categories, the new drug may be automatically added to this list.

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1


Quantity limits — Premium

Your pharmacy benefit plan has a quantity limits program that can help you get the best results from your medication therapy. With safe doses, quantity limits can also keep prescription drug costs lower for you.

Determining quantity limits

Quantity limits are meant to lower the risk of overuse. Quantity limit rules are based on:

• Food and Drug Administration (FDA) approved uses

• Medication instruction labels

• Accepted or published clinical recommendations

Establishing guidelines for use

A group of doctors and pharmacists meets often to review medications under pharmacy benefit plans. They also recommend quantity limit guidelines.

In this drug list, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

Premium Formulary

2

Premium non-specialty quantity limit

THERAPY CLASS MEDICATION NAME LIMITAnti-infectivesAntibiotics SIVEXTRO (tedizolid) Soln 6 vials/30 daysAntibiotics SIVEXTRO (tedizolid) Tabs 6 tabs/30 daysAntibiotics ZYVOX (linezolid) 28 tabs/30 daysAntibiotics ZYVOX (linezolid) Suspension 6 bottles (900 mL)/28 daysAntifungals LAMISIL (terbinafine) 250 mg 84 days supply/180 daysAntivirals, Herpetic SITAVIG (acyclovir) 50 mg 2 tabs/30 daysAntivirals, Herpetic VALTREX (valacyclovir) 4 tabs/dayAntivirals, Influenza oseltamivir 30 mg 40 caps/365 daysAntivirals, Influenza oseltamivir 45 mg, 75 mg 20 caps/365 days

Antivirals, Influenza oseltamivir Suspension 360 mL/365 daysAntivirals, Influenza RELENZA (zanamivir) 40 inh/365 daysAntivirals, Influenza XOFLUZA (baloxavir marboxil) 4 tabs/365 daysCardiologyAnticoagulants BEVYXXA (betrixaban) 43 tabs/180 daysAnticoagulants ELIQUIS (apixiban) 2 tabs/dayAnticoagulants ELIQUIS (apixiban) 5 mg 3 tabs/dayAnticoagulants PRADAXA (dabigatran) 2 caps/dayAnticoagulants SAVAYSA (edoxaban) 1 tab/dayAnticoagulants XARELTO (rivaroxaban) 1 tab/dayAnticoagulants XARELTO (rivaroxaban) 2.5 mg, 15 mg 2 tabs/dayAnticoagulants XARELTO (rivaroxaban) Starter Pack 2 packs/365 daysAntilipemic PRALUENT (alirocumab) 2 syringes/28 daysAntilipemic REPATHA (evolocumab) 3 syringes/28 daysAntilipemic REPATHA PUSH (evolocumab) 1 cartridge/28 daysHeart Failure CORLANOR (ivabradine) 2 tabs/dayHeart Failure CORLANOR (ivabradine) Suspension 15 mL/dayHeart Failure ENTRESTO (sacubitril/valsartan) 2 tabs/dayCentral Nervous SystemADHD Agents ADZENYS ER (amphetamine) 15 mL/dayADHD Agents ADZENYS XR-ODT (amphetamine) 1 tab/dayADHD Agents amphetamine 6 tabs/dayADHD Agents amphetamine/dextroamphetamine

30 mg tab2 tabs/day

ADHD Agents amphetamine/dextroamphetamine 3 tabs/dayADHD Agents amphetamine/detroamphetamine ER 1 cap/dayADHD Agents APTENSIO XR (methylphenidate) 1 cap/dayADHD Agents COTEMPLA XR-ODT (methylphenidate)

8.6 mg6 tabs/day

ADHD Agents COTEMPLA XR-ODT (methylphenidate) 17.3 mg

3 tabs/day

3

THERAPY CLASS MEDICATION NAME LIMITADHD Agents COTEMPLA XR-ODT (methylphenidate)

25.9 mg2 tabs/day

ADHD Agents DAYTRANA (methylphenidate transdermal)

1 patch/day

ADHD Agents DESOXYN (methamphetamine) 5 tabs/dayADHD Agents DEXEDRINE (dextroamphetamine) 5 mg 3 caps/dayADHD Agents DEXEDRINE (dextroamphetamine) 15 mg 4 caps/dayADHD Agents DEXEDRINE (dextroamphetamine) 10 mg 6 caps/dayADHD Agents dexmethylphenidate 2 tabs/dayADHD Agents dexmethylphenidate ER 1 cap/dayADHD Agents DYANAVEL XR (amphetamine) 8 mL/dayADHD Agents EVEKEO ODT (amphetamine) 5 mg,

10 mg3 tabs/day

ADHD Agents EVEKEO ODT (amphetamine) 15 mg, 20 mg

2 tabs/day

ADHD Agents JORNAY PM (methylphenidate) 1 cap/dayADHD Agents METADATE CD (methylphenidate) 1 cap/dayADHD Agents METADATE ER (methylphenidate) 20 mg 3 tabs/dayADHD Agents METHYLIN (methylphenidate) 3 tabs/dayADHD Agents METHYLIN 10 mg/5 mL

(methylphenidate) Soln30 mL/day

ADHD Agents METHYLIN 5 mg/5 mL (methylphenidate) Soln

60 mL/day

ADHD Agents METHYLIN CHEW TAB (methylphenidate) 3 tabs/dayADHD Agents METHYLIN CHEW TAB (methylphenidate)

10 mg6 tabs/day

ADHD Agents METHYLIN ER (methylphenidate) 20 mg 3 tabs/dayADHD Agents methylphenidate 3 tabs/dayADHD Agents METHYLPHENIDATE ER (methylphenidate)

10 mg2 tabs/day

ADHD Agents methylphenidate ER tab osmotic release 36 mg

2 tabs/day

ADHD Agents methylphenidate ER tab osmotic release 1 tab/dayADHD Agents MYDAYIS (amphetamine/

dextroamphetamine)1 cap/day

ADHD Agents PROCENTRA (dextroamphetamine) Sol 60 mL/dayADHD Agents QUILLICHEW ER (methylphenidate)

30 mg2 tabs/day

ADHD Agents QUILLICHEW ER (methylphenidate) 1 tab/dayADHD Agents QUILLIVANT XR (methylphenidate) 12 mL/dayADHD Agents RELEXXII (methylphenidate) 72 mg 1 tab/dayADHD Agents RITALIN LA (methylphenidate) 1 cap/dayADHD Agents RITALIN SR (methylphenidate) 20 mg 3 tabs/day

4

THERAPY CLASS MEDICATION NAME LIMITADHD Agents STRATTERA (atomoxetine) 1 cap/dayADHD Agents STRATTERA (atomoxetine) 10 mg, 40 mg 2 caps/dayADHD Agents VYVANSE (lisdexamfetamine) 1 cap/dayADHD Agents VYVANSE CHEW TAB (lisdexamfetamine) 1 tab/dayADHD Agents ZENZEDI (dextroamphetamine) 10 mg 6 tabs/dayADHD Agents ZENZEDI (dextroamphetamine) 3 tabs/dayADHD Agents ZENZEDI (dextroamphetamine) 30 mg 2 tabs/dayAlzheimers Agents NAMENDA XR (memantine hcl) caps 1 cap/dayAlzheimers Agents NAMENDA XR TITRATION PACK

(memantine hcl) caps2 packs/365 days

Alzheimers Agents NAMZARIC (memantine hcl) caps 1 cap/ dayAlzheimers Agents NAMZARIC TITRATION PACK

(memantine hcl)2 packs/365 days

Analgesics (non-opioid) celecoxib 2 caps/dayAnalgesics (non-opioid) diclofenac gel 1% 10 tubes/monthAnalgesics (non-opioid) diclofenac patch 2 patches/day up to 15 daysAnalgesics (non-opioid) ketorolac 20 tabs or 5 days supply/

30 daysAnalgesics (non-opioid) naproxen-esomeprazole 2 tabs/dayAnalgesics (non-opioid) QUTENZA (capsaicin) 4 patches/3 monthsAnalgesics (opioid) ACTIQ (fentanyl citrate) 4 lozenges/dayAnalgesics (opioid) AVINZA (morphine ext-release) 1 cap/dayAnalgesics (opioid) AVINZA (morphine ext-release) 120 mg 2 caps/dayAnalgesics (opioid) BELBUCA (buprenorphine) film 2 films/dayAnalgesics (opioid) BUNAVAIL (buprenorphrine/naloxone)

2.1-0.3 mg6 films/day

Analgesics (opioid) BUNAVAIL (buprenorphrine/naloxone) 6.3-1 mg

2 films/day

Analgesics (opioid) BUNAVAIL (buprenorphrine/naloxone) 4.2-0.7 mg

3 films/day

Analgesics (opioid) buprenorphrine/naloxone 8-2 mg 3 tabs or films/dayAnalgesics (opioid) buprenorphrine/naloxone 12-3 mg 2 films/dayAnalgesics (opioid) buprenorphrine/naloxone 4-1 mg 6 films/dayAnalgesics (opioid) buprenorphrine/naloxone 2-0.5 mg 12 tabs or films/dayAnalgesics (opioid) BUTRANS (buprenorphine) 4 patches/28 daysAnalgesics (opioid) EMBEDA (morphine/naltrexone) 2 caps/dayAnalgesics (opioid) fentanyl transdermal patch 15 patches/30 daysAnalgesics (opioid) fentanyl transdermal patch 75 mcg/hr,

100 mcg/hr30 patches/30 days

Analgesics (opioid) hydrocodone cap ER 2 caps/dayAnalgesics (opioid) hydrocodone cap ER 50 mg 4 caps/dayAnalgesics (opioid) hydromorphone tab ER 2 tabs/day

5

THERAPY CLASS MEDICATION NAME LIMITAnalgesics (opioid) HYSINGLA ER (hydrocodone bitartrate) 1 tab/dayAnalgesics (opioid) MORPHABOND ER (morphine ext-release) 2 tabs/dayAnalgesics (opioid) morphine sulfate ER cap 2 caps/dayAnalgesics (opioid) morphine sulfate ER tab 3 tabs/dayAnalgesics (opioid) NUCYNTA ER (tapentadol) 2 tabs/dayAnalgesics (opioid) OXYCONTIN (oxycodone ext-release) 4 tabs/dayAnalgesics (opioid) oxymorphone ext-release 4 tabs/dayAnalgesics (opioid) SUBUTEX (buprenorphrine) 8 mg 3 tabs/dayAnalgesics (opioid) SUBUTEX (buprenorphrine) 2 mg 12 tabs/dayAnalgesics (opioid) tramadol cap ER 1 cap/dayAnalgesics (opioid) tramadol tab ER 1 tab/dayAnalgesics (opioid) ZUBSOLV (buprenorphine/naloxone) SL

Tab 0.7-0.18 MG3 tabs/day

Analgesics (opioid) ZUBSOLV (buprenorphine/naloxone) SL Tab 5.7-1.4 MG

3 tabs/day

Analgesics (opioid) ZUBSOLV (buprenorphine/naloxone) SL Tab 8.6/2.1 MG

2 tabs/day


1 tab/day


6 tabs/day

Analgesics (opioid) ZUBSOLV (buprenorphine/naloxone) SL Tab 1.4-0.36 MG

12 tabs/day

Anticonvulsants DIASTAT GEL (diazepam) 2 boxes/fillAnticonvulsants GRALISE (gabapentin) 300 mg 6 tabs/dayAnticonvulsants GRALISE (gabapentin) 600 mg 3 tabs/dayAnticonvulsants GRALISE (gabapentin) Pack 1 pack/fillAnticonvulsants HORIZANT (gabapentin enacarbil) 2 tabs/dayAnticonvulsants LYRICA CR (pregabalin) 3 tabs/dayAnticonvulsants LYRICA CR (pregabalin) 330mg 2 tabs/dayAnticonvulsants pregabalin cap 300 mg 2 caps/dayAnticonvulsants pregabalin caps 3 caps/dayAnticonvulsants pregabalin Soln 900 mL/30 daysAntidepressants APLENZIN (bupropion) 1 tab/dayAntidepressants bupropion SR 2 tabs/dayAntidepressants bupropion XL 1 tab/dayAntidepressants bupropion XL 150 mg 3 tabs/dayAntidepressants desvenlafaxine fumarate 1 tab/dayAntidepressants duloxetine 2 caps/dayAntidepressants duloxetine 30 mg 3 caps/dayAntidepressants EMSAM (selegiline) 1 patch/dayAntidepressants FETZIMA (levomilnacipran) 1 cap/day

6

THERAPY CLASS MEDICATION NAME LIMITAntidepressants FETZIMA (levomilnacipran) Pack 2 packs/365 daysAntidepressants FORFIVO XL (bupropion) 450 mg 1 tab/dayAntidepressants KHEDEZLA (desvenlafaxine ER) 1 tab/dayAntidepressants KHEDEZLA (desvenlafaxine ER) 100 mg 4 tabs/dayAntidepressants LUVOX CR (fluvoxamine) 2 caps/dayAntidepressants PEXEVA (paroxetine) 1 tab/dayAntidepressants PEXEVA (paroxetine) 30 mg 2 tabs/dayAntidepressants PRISTIQ (desvenlafaxine) 1 tab/dayAntidepressants PRISTIQ (desvenlafaxine) 100 mg 4 tabs/dayAntidepressants PROZAC WEEKLY (fluoxetine) 4 caps/28 daysAntidepressants TRINTELLIX (vortioxetine) 1 tab/dayAntidepressants VIIBRYD (vilazodone) 1 tab/dayAntidepressants VIIBRYD (vilazodone) Kit 1 kit (30 tabs)/ fillAntipsychotics aripiprazole tabs 1 tab/dayAntipsychotics aripiprazole ODT 2 tabs/dayAntipsychotics aripiprazole soln 25 mL/dayAntipsychotics CLOZARIL (clozapine) 100 mg 9 tabs/dayAntipsychotics CLOZARIL (clozapine) 200 mg 4 tabs/dayAntipsychotics CLOZARIL (clozapine) 25 mg 9 tabs/dayAntipsychotics CLOZARIL (clozapine) 50 mg 6 tabs/dayAntipsychotics FANAPT (iloperidone) 2 tabs/dayAntipsychotics FANAPT PAK (iloperidone) 1 pack/180 daysAntipsychotics FAZACLO (clozapine) 100 mg 9 tabs/dayAntipsychotics FAZACLO (clozapine) 12.5 mg 3 tabs/dayAntipsychotics FAZACLO (clozapine) 150 mg 6 tabs/dayAntipsychotics FAZACLO (clozapine) 200 mg 4 tabs/dayAntipsychotics FAZACLO (clozapine) 25 mg 9 tabs/dayAntipsychotics GEODON (ziprasidone) 2 caps/dayAntipsychotics INVEGA (paliperidone) 1 tab/dayAntipsychotics INVEGA (paliperidone) 6 mg 2 tabs/dayAntipsychotics LATUDA (lurasidone) 20 mg, 40 mg,

60mg, 120 mg1 tab/day

Antipsychotics LATUDA (lurasidone) 80 mg 2 tabs/dayAntipsychotics olanzapine tabs 1 tab/dayAntipsychotics quetiapine 300 mg, 400 mg 2 tabs/dayAntipsychotics quetiapine 25 mg, 50 mg, 100 mg,

200 mg3 tabs/day

Antipsychotics quetiapine ER 2 tabs/dayAntipsychotics quetiapine ER 200 mg 3 tabs/dayAntipsychotics REXULTI (brexpiprazole) 1 tab/dayAntipsychotics risperidone tabs 2 tabs/dayAntipsychotics risperidone soln 8 mL/day

7

THERAPY CLASS MEDICATION NAME LIMITAntipsychotics RISPERDAL M (risperidone) 2 tabs/dayAntipsychotics SAPHRIS (asenapine) 2 tabs/dayAntipsychotics SYMBYAX (olanzapine/fluoxetine) 1 cap/dayAntipsychotics SYMBYAX (olanzapine/fluoxetine)

3-25 mg3 caps/day

Antipsychotics SYMBYAX (olanzapine/fluoxetine) 6-25 mg

3 caps/day

Antipsychotics VERSACLOZ (clozapine) 18 mL/dayAntipsychotics VRAYLAR (cariprazine) 1 cap/dayAntipsychotics VRAYLAR (cariprazine) pack 2 packs/yearAntipsychotics ZYPREXA ZYDIS (olanzapine) 1 tab/dayBenzodiazepines alprazolam ER 1 tab/dayBenzodiazepines alprazolam ER 2 mg 5 tabs/dayBenzodiazepines alprazolam ER 3 mg 3 tabs/dayBenzodiazepines alprazolam ODT 4 tabs/dayBenzodiazepines alprazolam ODT 2 mg 5 tabs/dayBenzodiazepines alprazolam intensol 10 mL/dayBenzodiazepines alprazolam tabs 4 tabs/dayBenzodiazepines alprazolam tab 2 mg 5 tabs/dayBenzodiazepines chlordiazepoxide 10 mg 30 caps/dayBenzodiazepines chlordiazepoxide 25 mg 12 caps/dayBenzodiazepines chlordiazepoxide 5 mg 4 caps/dayBenzodiazepines clonazepam ODT 3 tabs/dayBenzodiazepines clonazepam ODT 2 mg 10 tabs/dayBenzodiazepines clonazepam tabs 3 tabs/dayBenzodiazepines clonazepam tab 2 mg 10 tabs/dayBenzodiazepines lorazepam intensol 5 mL/day

Benzodiazepines lorazepam tabs 3 tabs/dayBenzodiazepines lorazepam tab 2 mg 5 tabs/dayBenzodiazepines oxazepam 4 caps/dayBenzodiazepines TRANXENE T (clorazepate) 15 mg 6 tabs/dayBenzodiazepines TRANXENE T (clorazepate) 3.75 mg 24 tabs/dayBenzodiazepines TRANXENE T (clorazepate) 7.5 mg 12 tabs/dayFibromyalgia SAVELLA (milnacipran) 2 tabs/dayFibromyalgia SAVELLA (milnacipran) Pack 2 packs/365 daysHypoactive Sexual Desire Disorder

ADDYI (flibanserin) 1 tab/day

Migraine AMERGE (naratriptan) 9 tabs/30 daysMigraine AXERT (almotriptan) 12 tabs/30 daysMigraine eletriptan tabs 12 tabs/30 daysMigraine FROVA (frovatriptan) 12 tabs/30 daysMigraine MIGRANAL (dihydroergotamine) 1 package (8 vials)/30 daysMigraine rizatriptan tabs 18 tabs/30 days

8

THERAPY CLASS MEDICATION NAME LIMITMigraine rizatriptan ODT 18 tabs/30 daysMigraine sumatriptan injection 5 kits (10 units)/30 daysMigraine sumatriptan nasal 12 spray unit devices/30 daysMigraine sumatriptan tabs 9 tabs/30 daysMigraine sumatriptan-naproxen tabs 9 tabs/30 daysMigraine zolmitriptan ODT 12 tabs/30 daysMigraine zolmitriptan tabs 12 tabs/30 daysMigraine ZOMIG (zolmitriptan) Nasal 12 spray unit devices/30 daysMigraine MAXALT-MLT (rizatriptan) 18 tabs/30 daysMigraine MIGRANAL (dihydroergotamine) 1 package (8 vials)/30 daysMigraine RELPAX (eletriptan) 12 tabs/30 daysMigraine SUMAVEL DOSEPRO (sumatriptan) 12 prefilled syringes/30 days

TOSYMRA (sumatriptan) 12 spray unit devices/30 daysMigraine TREXIMET (sumatriptan/naproxen) 9 tabs/30 daysMigraine ZEMBRACE SYMTOUCH (sumatriptan) 4 cartons (16 doses)/30 daysMigraine ZOMIG (zolmitriptan) 12 tabs/30 daysMigraine ZOMIG (zolmitriptan) Nasal 2 packages (12 spray units)/

30 daysParkinson's XADAGO (safinamide) 1 tab/daySedative Hypnotics BELSOMRA (suvorexant) 1 tab/daySedative Hypnotics DORAL (quazepam) 1 tab/daySedative Hypnotics EDLUAR (zolpidem) 1 tab/daySedative Hypnotics estazolam tabs 1 tab/daySedative Hypnotics eszopiclone tabs 1 tab/daySedative Hypnotics flurazepam caps 1 cap/daySedative Hypnotics HALCION (triazolam) 2 tabs/daySedative Hypnotics INTERMEZZO (zolpidem) 1 tab/daySedative Hypnotics ROZEREM (ramelteon) 1 tab/daySedative Hypnotics SILENOR (doxepin) 1 tab/daySedative Hypnotics SONATA (zaleplon) 10 mg 2 cap/daySedative Hypnotics SONATA (zaleplon) 5 mg 1 cap/daySedative Hypnotics temazepam caps 1 cap/daySedative Hypnotics zolpidem tabs 1 tab/daySedative Hypnotics zolpidem ER 1 tab/daySedative Hypnotics ZOLPIMIST (zolpidem) 1 bottle (7.7 g)/30 daysStimulants armodafinil tabs 1 tab/dayStimulants armodafinil tab 50 mg 2 tabs/dayStimulants modafinil tabs 1 tab/dayToxicology LUCEMYRA (lofexidine) 16 tabs/day, 14 day supplyDermatologyAnticholinergic QBREXZA (glycopyrronium tosylate) 1 cloth/dayAnti-Inflammatory diclofenac gel 3% 300 gm/30 days

9

THERAPY CLASS MEDICATION NAME LIMITcalcipotriene/betamethasone ointment 400 g/30 days

Miscellaneous ENSTILAR (calcipotriene/betamethasone dipropionate)

420 g/28 days

Miscellaneous TACLONEX SCALP (calcipotriene/betamethasone)

120 g/30 days

Endocrinology and MetabolismAndrogens, Anabolic OXANDRIN (oxandrolone) 10 mg 2 tabs/daySteroids OXANDRIN (oxandrolone) 2.5 mg 8 tabs/dayAntidiabetic Agents BYDUREON, BYDUREON BCISE

(exenatide)4 vials/pen-inj/28 days

Antidiabetic Agents BYETTA (exenatide) 1 syringe/30 daysAntidiabetic Agents OZEMPIC (semaglutide) 1 pen/28 daysAntidiabetic Agents OZEMPIC (semaglutide) 1 mg 2 pens/28 days

RYBELSUS 3 MG (semaglutide) 2 boxes (60 tablets)/365 daysRYBELSUS (semaglutide) 1 tablet per daySOLIQUA (insulin glargine/lixisenatide) 5 pens (15 mL)/25 days

Antidiabetic Agents TRULICITY (dulaglutide) 4 pen-inj/28 daysAntidiabetic Agents VICTOZA (liraglutide) 3 pen-inj/ 30 daysAntidiabetic Agents XULTOPHY (insulin degludec/liraglutide) 5 pens (15 mL)/30 daysOsteoporosis ACTONEL (risedronate) tab 150 mg 1 tab/28 daysOsteoporosis ACTONEL (risedronate) tab 35 mg 4 tabs/28 daysOsteoporosis ATELVIA (risedronate) 4 tabs/28 daysOsteoporosis BINOSTO (alendronate) 4 tabs/28 daysOsteoporosis BONIVA (ibandronate) 1 tab/28 daysOsteoporosis BONIVA IV (ibandronate) 1 syringe/90 daysOsteoporosis FORTICAL (calcitonin) 1 bottle (3.7mL)/30 daysOsteoporosis FOSAMAX (alendronate) 35 mg & 70 mg 4 tabs/28 daysOsteoporosis FOSAMAX PLUS D (alendronate/

cholecalciferol)4 tabs/28 days

Osteoporosis MIACALCIN (calcitonin) 1 bottle (3.7mL)/30 daysGastroenterologyAntiemetics AKYNZEO (netupitant-palonosetron) 2 caps/30 daysAntiemetics ANZEMET (dolasetron) 2 tabs/30 daysAntiemetics BONJESTA (doxylamine-pyridoxine) 2 tabs/dayAntiemetics CESAMET (nabilone) 20 caps/fill or 3 max days

supplyAntiemetics DICLEGIS (doxylamine-pyridoxine) 4 tabs/dayAntiemetics EMEND (aprepitant) caps 125 mg 2 caps/30 daysAntiemetics EMEND (aprepitant) 125 mg/80 mg 2 packs (6 caps)/30 daysAntiemetics EMEND (aprepitant) 40 mg 1 cap/30 daysAntiemetics EMEND (aprepitant) 80 mg 4 caps/30 daysAntiemetics EMEND (aprepitant) Susp 125 mg 3 packets/30 days

10

THERAPY CLASS MEDICATION NAME LIMITAntiemetics KYTRIL (granisetron) 4 tabs/30 daysAntiemetics MARINOL (dronabinol) 2 caps/dayAntiemetics SUSTOL (ganisetron) 3 syringes/30 daysAntiemetics SYNDROS (dronabinol) 4 mL/dayAntiemetics VARUBI (rolapitant) 4 tabs/30 daysAntiemetics ZOFRAN (ondansetron) 120 mL/30 daysAntiemetics ZOFRAN (ondansetron) 24 mg 2 tabs/30 daysAntiemetics ZUPLENZ (ondansetron) 10 films/30 daysConstipation LINZESS (linaclotide) 1 cap/dayConstipation MOTEGRITY (prucalopride) 1 tablet per dayDiarrhea FULYZAQ (crofelemer) 2 tabs/dayDiarrhea MYTESI (crofelemer) 2 tabs/dayIrritable Bowel Syndrome VIBERZI (eluxadoline) 2 tabs/dayOpioid-induced Constipation

SYMPROIC (naldemedine) 1 tab/day

Proton Pump Inhibitors ACIPHEX SPRINKLE (rabeprazole) 1 cap/dayProton Pump Inhibitors DEXILANT (dexlansoprazole) 1 cap/dayProton Pump Inhibitors esomeprazole strontium 1 cap/dayProton Pump Inhibitors lansoprazole caps 1 cap/dayProton Pump Inhibitors lansoprazole tabs 1 tab/dayProton Pump Inhibitors NEXIUM (esomeprazole) caps 1 cap/dayProton Pump Inhibitors NEXIUM (esomeprazole) packets 1 packet/dayProton Pump Inhibitors omeprazole caps 1 cap/dayProton Pump Inhibitors pantoprazole tabs 1 tab/dayProton Pump Inhibitors PRILOSEC PACKETS (omeprazole) 2 packets/dayProton Pump Inhibitors PROTONIX (pantoprazole) packets 1 packet/dayProton Pump Inhibitors rabeprazole tabs 1 tab/dayMiscellaneousDiabetic Supplies GLUCOSE TEST STRIPS 300/30 daysMethotrexate Auto-Injectors

OTREXUP (methotrexate) 4 auto-injectors/28 daysRASUVO (methotrexate) 4 auto-injectors/28 days

Smoking Cessation Products

CHANTIX (varenicline) 180 days supply/yearCOMMIT (nicotine lozenges) 180 days supply/yearNICODERM (nicotine transdermal) 180 days supply/yearNICORETTE (nicotine gum) 180 days supply/yearNICOTROL Inhaler (nicotine) 180 days supply/yearNICOTROL NS (nicotine) 180 days supply/yearZYBAN (bupropion) 180 days supply/year

Obstetrics and GynecologyContraceptives AMETHIA (levonorg-eth est) 1/91 daysContraceptives AMETHIA LO (levonorg-eth est) 1/91 daysContraceptives ASHLYNA (levonorg-eth est) 1/91 days

11

THERAPY CLASS MEDICATION NAME LIMITContraceptives CAMRESE (levonorg-eth est) 1/91 daysContraceptives CAMRESE LO (levonorg-eth est) 1/91 daysContraceptives DAYSEE (levonorg-eth est) 1/91 daysContraceptives DEPO/DEPO-SUBQ PROVERA

(medroxyprogesterone)1/90 days

Contraceptives INTROVALE (levonorg-eth est) 1/91 daysContraceptives JOLESSA (levonorg-eth est) 1/91 daysContraceptives LOSEASONIQUE (ethinyl estradiol/

levonorgestrel)1/91 days

Contraceptives QUARTETTE (levonorg-eth est) 1/91 daysContraceptives QUASENSE (levonorg-eth est) 1/91 daysContraceptives SEASONIQUE (ethinyl estradiol/

levonorgestrel)1/91 days

Contraceptives SETLAKIN (levonorg-eth est) 1/91 daysHormone Replacement CRINONE (progesterone) 15 applicators/30 daysHormone Replacement ESTRING (estradiol) 1 package/90 daysHormone Replacement FEMRING (estradiol acetate) 1 package/90 daysMiscellaneous BRISDELLE (paroxetine) 1 cap/dayOphthalmologyAnti-inflammatory bromfenac 0.09% 4 bottles/yearAnti-inflammatory LOTEMAX (loteprednol) gel, oint 4 bottles/yearAnti-inflammatory PROLENSA (bromfenac sodium) 4 bottles/yearProstaglandins LUMIGAN (bimatoprost) 1 bottle (2.5 mL)/25 daysProstaglandins ROCKLATAN (netarsudil-latanoprost) 1 bottle (2.5 mL) per 25 daysProstaglandins TRAVATAN (travoprost) 1 bottle (2.5 mL)/25 daysProstaglandins TRAVATAN Z (travoprost) 1 bottle (2.5 mL)/25 daysProstaglandins XELPROS (latanoprost) 1 bottle (2.5 mL)/25 daysRespiratoryAllergy (intranasal) ASTELIN (azelastine) 2 bottles (60 mL)/30 daysAllergy (intranasal) ASTEPRO (azelastine) 2 bottles (60 mL)/30 daysAllergy (intranasal) BECONASE AQ (beclomethasone) 1 inhaler (25 g)/25 daysAllergy (intranasal) DYMISTA (fluticasone/azelastine) 1 inhaler (23 g)/30 daysAllergy (intranasal) flunisolide nasal 1 bottle (25 mL)/30 daysAllergy (intranasal) mometasone nasal 2 inhalers/30 daysAllergy (intranasal) OMNARIS (ciclesonide) 1 inhaler (12.5 g)/30 daysAllergy (intranasal) PATANASE (olopatadine) 1 bottle (30.5 g)/30 daysAllergy (intranasal) QNASL (beclomethasone) 1 inhaler/30 daysAllergy (intranasal) QNASL CHILDRENS (beclomethasone) 1 inhaler/30 daysAllergy (intranasal) RHINOCORT AQUA (budesonide) 2 bottles/30 daysAllergy (intranasal) VERAMYST (fluticasone furoate) 1 bottle (10 g)/30 daysAllergy (intranasal) ZETONNA (ciclesonide nasal) 1 inhaler (6.1 g)/30 days

12

THERAPY CLASS MEDICATION NAME LIMITAsthma/COPD (inhaled) ADVAIR DISKUS (fluticasone/salmeterol) 1 diskus (60 doses)/30 daysAsthma/COPD (inhaled) ADVAIR HFA (fluticasone/salmeterol) 1 inhaler/30 daysAsthma/COPD (inhaled) AEROSPAN (flunisolide) 2 inhalers (8.9 g each)/30 daysAsthma/COPD (inhaled) ANORO ELLIPTA (umeclidinium/vilanterol) 1 package (60 blisters)/30 daysAsthma/COPD (inhaled) ARNUITY ELLIPTA (fluticasone furoate) 1 inhaler/30 daysAsthma/COPD (inhaled) ATROVENT HFA (ipratropium) 2 inhalers (12.9 g each)/30 daysAsthma/COPD (inhaled) BREO ELLIPTA (fluticasone furoate/

vilanterol)1 package (60 blisters)/30 days

Asthma/COPD (inhaled) COMBIVENT RESPIMAT (ipratropium/albuterol)

2 inhalers (4 g each)/30 days

Asthma/COPD (inhaled) FLOVENT (fluticasone) 110 mcg, 220 mcg 2 inhalers (12 g each)/30 daysAsthma/COPD (inhaled) FLOVENT (fluticasone) 44 mcg 2 inhalers/30 daysAsthma/COPD (inhaled) FLOVENT DISKUS (fluticasone) 250 mcg 240 blisters/30 daysAsthma/COPD (inhaled) FLOVENT DISKUS (fluticasone) 50 mcg,

100 mcg60 blisters/30 days

Asthma/COPD (inhaled) FORADIL (formoterol) 1 package (60 doses)/30 daysAsthma/COPD (inhaled) INCRUSE ELLIPTA (umeclidnium) 1 inhaler/30 daysAsthma/COPD (inhaled) LONHALA MAGNAIR (glycopyrrolate) 60 vials/30 daysAsthma/COPD (inhaled) PROAIR HFA (albuterol) 2 inhalers/30 daysAsthma/COPD (inhaled) PROAIR RESPICLICK (albuterol) 2 inhalers/30 daysAsthma/COPD (inhaled) PULMICORT FLEXHALER (budesonide) 2 packages/30 daysAsthma/COPD (inhaled) SEREVENT DISKUS (salmeterol) 50 mcg 1 package (60 doses)/30 daysAsthma/COPD (inhaled) SPIRIVA HANDIHALER (tiotropium) 1 package (30 caps)/30 daysAsthma/COPD (inhaled) SPIRIVA RESPIMAT (tiotropium) 1 inhaler/30 daysAsthma/COPD (inhaled) STIOLTO RESPIMAT (tiotropium

br-olodaterol)1 inhaler/30 days

Asthma/COPD (inhaled) STRIVERDI RESPIMAT (olodaterol) 1 inhaler/30 daysAsthma/COPD (inhaled) SYMBICORT (budesonide/formoterol) 1 inhaler/30 daysAsthma/COPD (inhaled) TRELEGY ELLIPTA (fluticasone/

umeclidinium/vilanterol)60 blisters/30 days

Asthma/COPD (inhaled) VENTOLIN HFA (albuterol) 2 inhalers/30 daysAsthma/COPD (inhaled) WIXELA INHUB (fluticasone/salmeterol) 1 diskus (60 doses) per 30 daysAsthma/COPD (nebulized) ACCUNEB (albuterol) 5 packages (125 vials or 375

mL)/30 daysAsthma/COPD (nebulized) albuterol 2.5 mg/3 mL (0.083%) 180 vials (540 mL)/30 daysAsthma/COPD (nebulized) albuterol 5 mg/mL (0.5%) 150 mL/30 daysAsthma/COPD (nebulized) ATROVENT (ipratropium) 125 vials (312.5 mL)/30 daysAsthma/COPD (nebulized) BROVANA (arformoterol) 60 vials (120 mL)/30 daysAsthma/COPD (nebulized) budesonide respules 2 packages (120 mL)/30 daysAsthma/COPD (nebulized) DUONEB (ipratropium/albuterol) 180 vials (540 mL)/30 daysAsthma/COPD (nebulized) PERFOROMIST (formoterol) 60 vials (120 mL)/30 daysAsthma/COPD (nebulized) XOPENEX (levalbuterol) 180 vials (540 mL)/30 days

13

THERAPY CLASS MEDICATION NAME LIMITAsthma/COPD (nebulized) XOPENEX (levalbuterol) 1.25 mg/0.5 mL 90 vials (45 mL)/30 daysAsthma/COPD (nebulized) XOPENEX (levalbuterol) 1.25 mg/3 mL 90 vials (270 mL)/30 daysEpinephrine Auto-Injectors AUVI-Q (ephinephrine) 0.1 mg 2 auto-injectors/30 daysUrologyErectile Dysfunction CAVERJECT (alprostadil) 6 units/30 daysErectile Dysfunction EDEX (alprostadil) 6 units/30 daysErectile Dysfunction MUSE (alprostadil) 6 units/30 daysErectile Dysfunction sildenafil tabs 6 tabs/30 daysErectile Dysfunction tadalafil tab 10 mg 6 tabs/30 daysErectile Dysfunction tadalafil tab 2.5 mg 1 tab/dayErectile Dysfunction tadalafil tab 20 mg 6 tabs/30 daysErectile Dysfunction tadalafil tab 5 mg 1 tab/dayErectile Dysfunction vardenafil ODT 6 tabs/30 daysErectile Dysfunction vardenafil tabs 6 tabs/30 daysOveractive Bladder Antispasmodics

OXYTROL (oxybutynin) 8 patches/28 days

Premium specialty quantity limit

THERAPY CLASS MEDICATION NAME LIMITAnti-InfectivesAntiretrovirals, Hepatitis B BARACLUDE (entecavir) Soln 630 mL/30 daysAntiretrovirals, Hepatitis B entecavir tabs 1 tab/day

Antithrombotic Agentsvon Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

CardiologyAnticoagulants, LMWH ARIXTRA (fondaparinux) 35 days supply/180 daysAnticoagulants, LMWH FRAGMIN (dalteparin) 35 days supply/180 daysAnticoagulants, LMWH LOVENOX (enoxaparin) 35 days supply/180 daysAntilipemic JUXTAPID (lomitapide) 1 tab/dayAntilipemic KYNAMRO (mipomersen) 4 syringes/28 daysPulmonary Arterial Hypertension

ADEMPAS (riociguat) 3 tabs/dayALYQ (tadalafil) 2 tablets per dayambrisentan tabs 1 tab/daybosentan tabs 2 tabs/dayOPSUMIT (macitentan) 1 tab/dayREVATIO (sildenafil) Susp 2 bottles/30 daysREVATIO (sildenafil) Tabs 3 tabs/daytadalafil tabs 2 tabs/dayTRACLEER (bosentan) Tabs for Susp 4 tabs/dayTYVASO (treprostinil) 1 ampule/day

14

THERAPY CLASS MEDICATION NAME LIMITUPTRAVI (selexipag) 2 tabs/dayUPTRAVI (selexipag) Pack 2 packs/yearVENTAVIS (iloprost) 9 ampules/day

Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 cap/dayTransthyretin Stabilizers VYNDAQEL (tafamidis meglumine) 4 caps/dayCentral Nervous SystemDepressant XYREM (sodium oxybate) 3 bottles (540 mL)/30 daysParkinson's APOKYN (apomorphine) 30 cartridges/30 daysSleep Disorder HETLIOZ (tasimelteon) 1 cap/day

SUNOSI (solriamfetol) 1 cap/daySleep Disorder WAKIX (pitolisant) 2 tabs/dayDermatologyAtopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes/28 daysElectrolyte and Renal AgentsDiuretics KEVEYIS (dichlorphenamide) 4 tabs/dayEndocrinology and MetabolismGonadotropins ELIGARD (leuprolide) 22.5 mg (3-month) 1 injection/84 daysGonadotropins ELIGARD (leuprolide) 30 mg (4-month) 1 injection/112 days

Gonadotropins ELIGARD (leuprolide) 45 mg (6-month) 1 injection/168 daysGonadotropins ELIGARD (leuprolide) 7.5 mg (1-month) 1 injection/28 daysGonadotropins FIRMAGON (degarelix) 120 mg 2 vials/yearGonadotropins FIRMAGON (degarelix) 80 mg 1 vial/28 daysGonadotropins LUPANETA PACK (leuprolide) 11.25 mg

(3 mon)1 pack/84 days

Gonadotropins LUPANETA PACK (leuprolide) 3.75 mg (1 mon)

1 pack/28 days

Gonadotropins ORILISSA (elagolix) 150 mg 1 tab/dayGonadotropins ORILISSA (elagolix) 200 mg 2 tabs/dayGonadotropins SUPPRELIN LA (histrelin acetate) 1 kit/365 daysGonadotropins TRELSTAR (triptorelin) 22.5 mg (6-month) 1 injection/168 daysGonadotropins TRELSTAR DEPOT (triptorelin) 3.75 mg

(1-month)1 injection/28 days

Gonadotropins TRELSTAR LA (triptorelin) 11.25 mg (3-month)

1 injection/84 days

Gonadotropins TRIPTODUR (triptorelin) 1 injection/168 daysGonadotropins VANTAS (histrelin) 1 implant/yearGonadotropins ZOLADEX (goserelin) 10.8 mg 1 injection/84 daysGonadotropins ZOLADEX (goserelin) 3.6 mg 1 injection/28 daysGrowth Hormones and Related Therapy

EGRIFTA (tesamorelin) 2 vials (1 mg each)/dayEGRIFTA SV (tesamorelin) 1 vial (2 mg each)/day

Hormone Modifiers NATPARA (parathyroid hormone) 2 cartridges/28 daysMiscellaneous KORLYM (mifepristone) 4 tabs/day

15

THERAPY CLASS MEDICATION NAME LIMITOsteoporosis EVENITY (romosozumab-aqqg) 2 syringes (2.34 mL) per 28 days

PROLIA (denosumab) 2 syringes/yearSomatostatins SIGNIFOR (pasireotide) 2 ampules/daySomatostatins SIGNIFOR LAR (pasireotide) 1 vial/28 daysVasopressin Antagonist JYNARQUE (tolvaptan) 2 tabs/dayVasopressin Antagonist SAMSCA (tolvaptan) 2 tabs/dayEnzyme-RelatedCystine-depleting Agents CYSTARAN (cysteamine) 4 bottles/28 daysEnzyme Replacement GALAFOLD (migalastat hcl) cap 14 caps/28 daysEnzyme Replacement XURIDEN (uridine triacetate) 4 packets/dayPhenylketonuria Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 10 mg/0.5 mL

1 syringe/day

Phenylketonuria Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 2.5 mg/0.5 mL

8 syringes/28 days

Phenylketonuria Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 20 mg/mL

2 syringes/day

GastroenterologyDiarrhea XERMELO (telotristat ethyl) 3 tabs/dayHepatic Agents OCALIVA (obeticholic acid) 1 tab/dayImmunologyHematopoietic Agents MOZOBIL (plerixafor) 8 vials (9.6 mL)/transplant

Interleukins ILARIS (canakinumab) 2 vials/4 weeksMultiple Sclerosis AMPYRA (dalfampridine) 2 tabs/dayMultiple Sclerosis AUBAGIO (teriflunomide) 1 tab/dayMultiple Sclerosis AVONEX (interferon beta-1a) 1 kit (4 syringes)/28 daysMultiple Sclerosis BETASERON (interferon beta-1b) 1 package/28 daysMultiple Sclerosis COPAXONE (glatiramer) SOSY 20 mg/ml 30 syringes/30 daysMultiple Sclerosis COPAXONE (glatiramer) SOSY 40 mg/ml 12 syringes/28 daysMultiple Sclerosis GILENYA (fingolimod) 1 cap/dayMultiple Sclerosis GLATOPA (glatiramer) SOSY 20 mg/ml 30 syringes/30 daysMultiple Sclerosis MAYZENT (siponimod fumarate) 0.25 mg 4 tabs/dayMultiple Sclerosis MAYZENT (siponimod fumarate) 2 mg 1 tab/dayMultiple Sclerosis MAYZENT (siponimod fumarate) starter

pack2 starter packs (24 tabs)/365 days

Multiple Sclerosis OCREVUS (ocrelizumab) Soln 40mL (4 vials)/365 daysMultiple Sclerosis REBIF (interferon beta-1a) 12 syringes/28 daysMultiple Sclerosis REBIF (interferon beta-1a) Starter Pack 1 starter pack/yearMultiple Sclerosis TECFIDERA (dimethyl fumarate) 2 caps/dayMultiple Sclerosis TECFIDERA (dimethyl fumarate) Starter

Pack1 starter pack/year

Multiple Sclerosis TYSABRI (natalizumab) 1 injection/28 days

16

THERAPY CLASS MEDICATION NAME LIMITMovement Disorder Agents

AUSTEDO (deutetrabenazine) 4 tabs/dayINGREZZA (valbenazine tosylate) 1 cap/dayINGREZZA (valbenazine tosylate) pack 56 caps (2 packs) per 365 days

OncologyKinase and Molecular Target Inhibitors

ALUNBRIG (brigatinib) 30 mg 4 tabs/dayALUNBRIG (brigatinib) 90 mg 1 tab/dayALUNBRIG (brigatinib) 180 mg 1 tab/dayALUNBRIG (brigatinib) Starter Pack 1 pack/yearCAPRELSA (vandetanib) 100 mg 2 tabs/dayeverolimus tabs 1 tab/dayGILOTRIF (afatinib) 1 tab/dayICLUSIG (ponatinib) 15 mg 2 tabs/dayJAKAFI (ruxolitinib) 10 mg 2 tabs/dayTAGRISSO (osimertinib) 40mg 1 tab/dayTARCEVA (erlotinib) 25 mg 3 tabs/day

OphthalmologyMiscellaneous OXERVATE 2 mL (2 vials) per dayRespiratoryAsthma/COPD DUPIXENT (dupilumab) 4 syringes/28 daysAsthma/COPD NUCALA (mepolizumab) 3 vials/28 daysCystic Fibrosis ORKAMBI (lumacaftor/ivacaftor) 4 tabs/dayCystic Fibrosis ORKAMBI (lumacaftor/ivacaftor) packets 2 packets/dayCystic Fibrosis SYMDEKO (tezacaftor/ivacaftor) 2 tabs/dayCystic Fibrosis TOBI PODHALER (tobramycin) 1 package (224 tabs)/56 days

TRIKAFTA (elexacaf-tezacaf-ivacaf) 3 tabs/day

Quantity Limits effective as of July 1, 2020.

PLEASE NOTE: This drug list is subject to regular updates and may not be all inclusive. Drugs affected include both brand and generic and include all strengths unless noted. If a targeted drug has a new strength, it may be automatically added to the list.

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© 2020 Optum, Inc. All rights reserved. WF2183443-A_ORX_UM_Premium_QL_03092020 8513E-022020

1


Step therapy — Premium

Most medical conditions have many medication options. Although their clinical effectiveness may be the same, the cost can be very different. The Step Therapy program gives you the treatment you need, usually at a lower cost.

Here’s how it works:

With this program, you must try a Step 1 medication first, before a Step 2 medication may be covered. When you bring a prescription to your pharmacy, our system will check the medication for step therapy requirements. If your old pharmacy claims show you have tried a Step 1 medication in the recent past, the Step 2 medication may be filled. If not, the pharmacist will contact your doctor to explain next steps.

We encourage you to talk about your treatment and medication options with your doctor. If you have questions about the Step Therapy program, call the phone number on your member ID card.

Premium Formulary

2

Step therapy medications

If you have a prescription for any of the Step 2 medications below, you are required to first try a Step 1 medication(s) for benefit coverage.

Condition Step 1 Step 2Anti-infectives

Oral Brand Tetracyclines

Any one of the following generics: doxycycline, minocycline

ADOXA, MONODOX, VIBRAMYCIN

Oral Brand Tetracyclines

Both of the following generics: doxycycline AND minocycline

SEYSARA

Otic Agents ofloxacin CETRAXAL, ciprofloxacin

Cardiovascular

Renin-Angiotensin System Agents

Any one of the following generics: amlodipine-benazepril, amlodipine-olmesartan, benazepril, benazepril-HCTZ, candesartan, candesartan-HCTZ, captopril, captopril-HCTZ, enalapril, enalapril-HCTZ, fosinopril, fosinopril-HCTZ, irbesartan, irbesartan-HCTZ, lisinopril, lisinopril-HCTZ, losartan, losartan-HCTZ, moexipril, moexipril-HCTZ, olmesartan-HCTZ, olmesartan-amlodipine-HCTZ, perindopril, quinapril, quinapril-HCTZ, ramipril, telmisartan, telmisartan-HCTZ, trandolapril, trandolapril-verapamil

EDARBI, EDARBYCLOR, TEKTURNA HCT

Statins Any one of the following generics: atorvastatin, fluvastatin, fluvastatin ER, lovastatin, pravastatin, rosuvastatin, simvastatin

ALTOPREV, EZALLOR, FLOLIPID, SIMVASTATIN SUSP, LIVALO

Fibric Acid Derivatives

Any one of the following generics: fenofibric cap, fenofibrate tab, fenofibrate micronized cap, fenofibric acid tab AND LIPOFEN

FENOGLIDE, FIBRICOR, LOFIBRA, TRIGLIDE

3

Condition Step 1 Step 2Central Nervous System

ADHD Agents Any two of the following generics or preferred brands: amphetamine-dextroamphetamine IR or ER, dexmethylphenidate IR or ER, dextroamphetamine IR or SR, methylphenidate IR or ER VYVANSE

ADZENYS ER², ADZENYS XR ODT², APTENSIO XR², COTEMPLA XR-ODT², DAYTRANA², DESOXYN², DYANAVEL XR², JORNAY PM², KAPVAY, METADATE CD², METHYLIN² SOLUTION, METHYLIN CHEW², MYDAYIS², PROCENTRA², QUILLICHEW ER², QUILLIVANT², ZENZEDI²

Anticonvulsants3 Any one of the following generics: lamotrigine IR, levetiracetam IR or ER, oxcarbazepine IR, topiramate IR

BRIVIACT

Anticonvulsants3 topiramate IR topiramate ER

Antidepressants3 bupropion ER APLENZIN2

Antidepressants3 Any two of the following generics: desvenlafaxine succinate ER, duloxetine, venlafaxine, venlafaxine ER

FETZIMA2

Antidepressants3 Any two of the following generics: bupropion, citalopram, desvenlafaxine succinate ER, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, paroxetine ER, sertraline, venlafaxine, venlafaxine ER

DESVENLAFAXINE ER/KHEDEZLA2, PAXIL suspension, TRINTELLIX²

Antipsychotics3 Any one of the following generics or preferred brands: aripiprazole, olanzapine, quetiapine IR or ER, risperidone SAPHRIS

FANAPT2, VRAYLAR2

Insomnia Agents Any one of the following generics: eszopiclone, temazepam, zaleplon, zolpidem, zolpidem CR

BELSOMRA2

Insomnia Agents Any one of the following generics: zolpidem, zolpidem CR

EDLUAR2, ZOLPIMIST2

Migraine Agents Any one of the following generics: naratriptan, rizatriptan, sumatriptan, zolmitriptan

ZOMIG NASAL2

Neurologic Agents

gabapentin GRALISE2

Neurologic Agents

Any one of the following generics: amitriptyline, cyclobenzaprine, duloxetine, gabapentin, pregabalin

LYRICA CR2, SAVELLA2

4

Condition Step 1 Step 2Non-Narcotic Analgesics

Any two of the following generics: diclofenac, diclofenac CR, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, tolmetin

INDOCIN suppository, INDOCIN suspension, TIVORBEX, VIVLODEX

Opioid Antagonists

NARCAN EVZIO

Opioid Withdrawal

clonidine LUCEMYRA2

Parkinson’s Disease

Any one of the following generics: pramipexole IR or ER, ropinirole IR or ER

NEUPRO


Any one of the following generics: carbidopa-levodopa, carbidopa-levodopa CR

RYTARY


Both of the following generics: rasagiline, selegiline

XADAGO2

Dermatology

Rosacea Any one of the following generics or preferred brands: invermectin cream, SOOLANTRA

FINACEA FOAM

Rosacea MIRVASO RHOFADE

Skin Cancer Agents

Any one of the following generics: fluorouracil, imiquimod

diclofenac gel 3%2, PICATO

Topical Immuno-modulators

Any one of the following generics: alclometasone, amcinonide, betamethasone, clobetasol, clocortolone, desonide, desoximetasone, diflorasone, fluocinolone, fluocinonide, fluticasone, halobetasol, hydrocortisone, mometasone, prednicarbate, triamcinolone, pramoxine-HC, calcipotriene-betamethasone

EUCRISA

Endocrinology

Diabetic Agents Any one of the following generics: metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin

ACTOPLUS MET XR, AVANDIA, CYCLOSET, METFORMIN oral solution, RIOMET

Glucagon Any one of the following preferred brands: GLUCAGON, GVOKE, BAQSIMI

GLUCAGEN HYPOKIT

5

Condition Step 1 Step 2DPP4 Inhibitors Any one of the following generics:

metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin

JANUMET, JANUMET XR, JANUVIA, JENTADUETO, JENTADUETO XR, TRADJENTA

GLP-1 Agonists Any one of the following generics: metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin

BYDUREON², BYDUREON BCISE², BYETTA², OZEMPIC², RYBELSUS², TRULICITY², VICTOZA²

GLP-1 Agonist Combinations

Any one of the following preferred brands: BYDUREON¹, BYDUREON BCISE¹, BYETTA¹, OZEMPIC¹, TRULICITY¹, VICTOZA¹, LANTUS, OR TOUJEO

SOLIQUA2, XULTOPHY2

SGLT2 Inhibitors Any one of the following generics: metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin

FARXIGA, GLYXAMBI, JARDIANCE, SYNJARDY, SYNJARDY XR, XIGDUO XR

Gastroenterology

Constipation Agents

Any one of the following generics: lactulose, polyethylene glycol

LINZESS2, SYMPROIC2

Any one of the following generics: lactulose, polyethylene glycol AND LINZESS¹

MOTEGRITY²

Proton Pump Inhibitors

Any two of the following generics or preferred brands: esomeprazole, omeprazole, lansoprazole, pantoprazole, rabeprazole DEXILANT

ESOMEPRAZOLE STRONTIUM², FIRST-LANSOPRAZOLE, FIRST-OMEPRAZOLE, PRILOSEC²

Hormone Modifiers

Thyroid Replacement

levothyroxine ARMOUR THYROID, NATURE-THROID

Miscellaneous

Antigout Agents allopurinol DUZALLO, ULORIC, ZURAMPIC

Oncology

Chemotherapy Rescue Agents

levoleucovorin KHAPZORY

6

Condition Step 1 Step 2Ophthalmology

Antiglaucoma Agents

TRAVATAN Z or travoprost AND both of the following: latanoprost, LUMIGAN

XELPROS²

Ophthalmic Antihistamines

Both of the following generics: azelastine AND olopatadine

BEPREVE, LASTACAFT

Respiratory

Epinephrine Auto Injectors

Generic epinephrine EPIPEN

Leukotriene Modifiers

Any one of the following generics: montelukast, zafirlukast

zileuton ER, ZYFLO, ZYFLO CR

Long-Acting Bronchodilators

Any two of the following generics or preferred brands: fluticasone-salmeterol ADVAIR, BREO ELLIPTA, SEREVENT, SYMBICORT, WIXELA INHUB

ARCAPTA2, STRIVERDI RESPIMAT2

Urology

BPH Agents Any two of the following generics: alfuzosin, doxazosin, silodosin, tamsulosin, terazosin

CARDURA XL

Overactive Bladder Agents

Any one of the following generics: oxybutynin IR or ER, tolterodine IR, trospium IR

GELNIQUE, OXYTROL2

Step therapy requirements are effective as of July 1, 2020. The list of step therapy medications is subject to change without notice. Step therapy requirements may vary by benefit plan. Additional clinical programs for the medications above may affect your prescription drug coverage. These programs may include quantity limits and prior authorization.

1 These agents are also subject to additional step requirements as indicated in table.

2 Quantity limits may also apply. Please refer to the Premium Quantity Limits document.

3 Applies to new starts only

A generic equivalent is a generic version of a brand name medication. Generic equivalents have the same active ingredients, safety, quality and strength as their brand name counterparts, and they are proven to act the same way in the body. Generics also cost significantly less than brand name medications.

If you use a branded medication instead of its generic equivalent, you pay your plan’s applicable brand copayment plus a penalty. This penalty is the difference in cost between the brand and generic medications. Your out-of-pocket cost for the brand may be up to the entire cost of the medication. However, you will not be charged a penalty if your doctor tells the pharmacy to give you the brand instead of the generic.

Generics are typically the best value for you and your plan sponsor. Both of you usually pay less when you use generics.

About Generics

Generics are U.S. Food and Drug Administration (FDA) approved to be just as safe and effective as their brand name counterparts.

Generics are safe . . .• Meet the same quality standards as brand name medications• Tested for purity before reaching pharmacy shelves

. . . and effective• Strength, active ingredients and quality are equal to brand name medications• Proven to act the same way as brand name medications

. . . and usually cost less• You save money because your benefit plan’s generic copay is typically your lowest

out-of-pocket cost• Along with your own out-of-pocket savings, you take an active role in lowering your

benefit plan’s cost for providing your coverage when you use generic

Your Generics Program

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at www.optum.com.

All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

ORX0868_121121 ©2012 OptumRx, Inc.

www.optumrx.com

OptumRx offers specialty medication support through Optum® Specialty Pharmacy. Optum Specialty Pharmacy provides resources and personalized support to help you with your condition.

What is a specialty medication?

An injectable, infused, oral or inhaled medication is defined as a specialty medication if it:

• May require ongoing clinical oversight and extra education

• Has unique storage or shipping needs

• May not be available at retail pharmacies

• May require infusion or home nursing

What services does the specialty pharmacy provide?

Optum Specialty Pharmacy supports you with a team of pharmacists and nurses who specialize in your condition — at no extra cost to you. You also have:

• Access to your medications at your plan’s lowest cost

• 24/7 access to pharmacists

• Clinical and adherence programs

• Medication supplies at no extra cost

• Refill reminders

• Timely delivery in confidential packaging

Welcome to your specialty pharmacy.

Over

Specialty medication resources

Customer service Call 1-855-427-4682

Online at optumrx.com Price your medication, and find additional resources specific to your condition.


All Optum trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners.

© 2019 Optum, Inc. All rights reserved. ORX9551_182919 47594B-082019

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Guiding your health journeyWe understand the challenge of managing and living with a complex health condition. Optum Specialty Pharmacy is here to assist you every step of the way.

Getting started

Please call 1-855-427-4682 to enroll in the specialty pharmacy program.

24/7 access.

Pharmacists and patient care coordinators are available 24/7 to take care of everything, including:

• Transferring your prescription to Optum Specialty Pharmacy

• Helping you find affordable access to your medication

• Explaining how to use the specialty pharmacy

Personalized support.

We’re always available by phone to answer any questions you may have about your medication, side effects and more. But our personalized support doesn’t stop there.

Live video consults with clinicians who are experts in your condition. You can do the video consult from your home and even record the sessions.

Personalized videos help you feel more connected to others with the same condition. Patients with your condition share their treatment experiences through personalized videos. You’ll also see videos with advice from other experts, like pharmacists.

Working with your pharmacist or nurse

Continued conversations.

Tell your pharmacist or nurse about any changes or complications in your therapy, such as:

• Side effects

• Forgetting to take your medication

Monitor your health.

If you need help with any other health concerns, your pharmacist or nurse can help you find wellness management programs to help you stay on track.

Follow your care plan.

If you’re part of a clinical management program, follow your care plan and tell your pharmacist or nurse about any new medications you’re taking.

Staying on track

Quick and easy refills.

With a phone call reminder a few days before your next refill, it’s easy for you to fill your prescription. You can even sign up for text message reminders online or by phone.

Save time and money.

Optum Specialty Pharmacy can only fill specialty medications. Use your home delivery or retail pharmacy for your non-specialty prescriptions. If you’re looking to save money on your medications, finding lower-cost alternatives and filling your non-specialty prescriptions by mail can help.

Specialty medications are an important component to managing complex diseases and conditions, and sometimes it takes time for patients to find the right dose and comfort level before they’re able to follow their regimen.

The Smart Fill program from Optum® Specialty Pharmacy offers two strategies for dispensing specialty medications so that patients get the medications they need, adhere to their therapy, and reduce waste due to intolerance. Our split fill strategy enables twice-monthly prescription refills, while the 90-day fill program provides refills every three months.

Smart Fill program

Split fill 90-day fill

Eligible classes Oral oncology Multiple sclerosis, rheumatoid arthritis, transplant

Patient stability Unstable on medication Stable on medication

Clinical benefits Adjust to medication Adherence

Program outcome Avoid waste Patient convenience

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

Copays 1/2 copay 3x copay

Manage drug waste, adherence and costs

To see how Optum Specialty Pharmacy can help you better serve patients with specialty conditions, email us at [email protected] or visit us at optum.com/optumrx.

2300 Main Street, Irvine, CA 92614

OptumRx is a pharmacy care services company helping clients and more than 65 million members achieve better health outcomes and lower overall costs through innovative prescription drug benefit services.


© 2019 Optum, Inc. All rights reserved. ORX9673_191105

[email protected] | optum.com/optumrx

Split fill resultsWhen days’ supply was reduced for oral cancer medications for three months, 96% of patients benefited from our condition-specific approach and were able to stay on therapy. The 4% who were unable to tolerate their medications were supported through the discontinuation process, which resulted in a savings of $2,500 per patient with discontinued medication(s) per year.*

Split fill program strategy

Some specialty drugs can cause side effects that lead patients to stop taking and discard their medications. A recent OptumRx analysis found that almost half of patients on select oral oncology drugs discontinued their therapy within 90 days — an expensive loss for them and their plan sponsor alike.

Our split fill program helps avoid costs associated with early-discontinuation waste by filling half the prescription twice a month, rather than a full prescription once a month, when a patients starts a new regimen of oral oncology medications. Patients who tolerate the new drug for three months will be returned to standard days’ supply for duration of therapy. By increasing the frequency, this enables:

• More frequent conversations with the patient

• Early identification of adverse events

• Timely clinical intervention

• Adherence monitoring

90-day fill program strategy

Our 90-day program is a convenient option for patients taking medications for rheumatoid arthritis, multiple sclerosis or transplant. If patients demonstrate regimen stability and adherence, they have the option of receiving three months’ worth of medication per refill.

Instead of 12 refills and 12 copays per year, patients who take advantage of the 90-day fill program get four refills, with three copays per refill. The program is voluntary and enables:

• Enhanced member convenience

• Adherence monitoring

• Improved patient satisfaction

* OptumRx internal data. January 2016–June 2018.

Headline

OptumRx | optumrx.com

Optum® Specialty Pharmacy provides specialty medication support through your pharmacy benefits with OptumRx®. Optum Specialty Pharmacy provides comprehensive support services, including access to pharmacists around the clock, for high-cost oral and injectable medications used to treat rare and complex conditions.In addition, your medications will be shipped to you at no extra cost.

Specialty pharmacy drug list

July 1, 2020

Characteristics of specialty medications

Specialty medications are used to give care for rare and complex conditions. They are often drugs you take by mouth or inject. For a medication to be filled through Optum Specialty Pharmacy, it must be at least one of the following:

High-priced• Can cost more than $1,000/30 day supply.

Complex• Drug imitates compounds found in the body.

• Part of a specialty drug class.

High-touch• Special shipping or handling like refrigeration.

• Needs a doctor or pharmacist to measure how well it works for you.

• Special steps to follow as you take.



Adult incontinence

Solesta

Ammonia detoxicants

Ravicti PA

Anemia

Aranesp PA Epogen PA Mircera PA Omontys PA Procrit PA

Reblozyl PA Retacrit PA

Antibacterials

Arikayce

Anticoagulation

Arixtra Fragmin Innohep Lovenox

Anticovulsants

Diacomit PA

Epidiolex PA

Anti-Gout agent

Krystexxa PA

Antihyperlipidemic

Juxtapid PA

Kynamro PA Anti-infective

Daraprim PA

Prevymis

Asthma

Cinqair PA

Fasenra PA

Nucala PA

Xolair PA

Cardiovascular

Northera PA

Vyndamax PA

Vyndaqel PA

Central nervous system agents

Austedo PA

Brineura PA

Firdapse PA/ST

Hetlioz PA

Ingrezza PA

Radicava PA

Ruzurgi PA

Sabril PA

Tiglutik PA

Xenazine PA

Chemotherapy protectant

Elitek

Cystic fibrosis

BethkisCayston PA

Kalydeco PA

Kitabis pak

Orkambi PA

Pulmozyme PA

Symdeko PA Tobi ST

Tobi Podhalr ST

Tobramycin Trikafta PA

Dermatologic

Scenesse PA

Diagnostic

Acthrel

Duchenne muscular dystrophy

Emflaza PA

Endocrine

Bynfezia Pen ChenodalCrysvita PA

Cuprimine PA

CystadaneDepen TitraD-PenamineEgrifta PA

Firmagon PA

IsturisaJynarqueKorlym PA

Kuvan PA

Lupaneta PA

Makena PA

Myalept PA

Natpara PA

Nityr PA

Parsabiv

Procysbi PA

SamscaSandostatin PA

Signifor PA

Somatuline PA

Somavert PA

Supprelin LA PA

Syprine PA

Tepezza PA

ThiolaThyrogen PA

Triptodur PA

Xuriden PA

Enzyme therapy

Adagen Aldurazyme PA Aralast NP PA Buphenyl Carbaglu Cerdelga PA Cerezyme PA Cholbam PA Cystagon Elaprase PA Elelyso PA Fabrazyme PA

Galafold PA

Givlaari PA Glassia PA Kanuma PA Lumizyme PA Mepsevii PA Myozyme PA Naglazyme PA

Onpattro PA Orfadin PA

Palynziq PA Prolastin-C PA

3PA – Prior authorization required • ST – Step therapy

4 OptumRx | optumrx.com



Revcovi PA Strensiq PA Sucraid Tegsedi PA Vimizim PA Vpriv PA Zavesca PA Zemaira PA

Gastrointestinal agents

Gattex PA

Ocaliva PA

Xermelo PA

Gene Therapy

Zolgensma PA

GROWTH HORMONE DEFICIENCY

Genotropin PA

Humatrope PA

Increlex PA

Norditropin PA

Nutropin AQ PA

Omnitrope PA

Saizen PA

Serostim PA

Zomacton PA

Zorbtive PA

Hematological agents

Adakveo PA Cablivi Doptelet PA

FibrygaMozobil PA

Mulpleta PA

Nplate PA

OxbrytaPanhematinPromacta PA

RiastapSoliris PA

Tavalisse PA

Thrombat IIIUltomiris PA

Hemophilia

AdvateAdynovateAfstylaAlphanateAlphanine SDAlprolixBebulinBenefixCeprotinCoagadexCorifactEloctateFeibaHelixate FSHemlibra Hemofil MHumate-PIdelvionIxinityJiviKoateKoate-DVIKogenate FSKovaltryMonoclate-PMononineNovoeightNovoseven RTNuwiq

ObizurProfilnineRebinyn RecombinateRixubisTrettenVonvendiWilateXyntha

Hepatitis B

Baraclude Epivir HBV Hepsera Tyzeka Vemlidy

Hepatitis C

CopegusDaklinza PA

Epclusa PA/ST.

Harvoni PA

Ledip-Sofosb PA

Mavyret PA

Olysio PA

Pegasys PA

Peg-Intron PA/ST

Rebetol RibavirinSofos/Velpat PA

Sovaldi PA

Technivie PA

Viekira PA

Vosevi PA/ST

Zepatier PA/ST

Hereditary angioedema

Berinert PA

Cinryze PA

Firazyr PA

Haegarda PA

Kalbitor PA

Ruconest PA

Takhzyro PA

Immune globulin

Asceniv PA Bivigam PA

Carimune NF PA

Cutaquig PA

Cuvitru PA

Cytogam PA

Flebogamma PA

Gamastan S/D PA

Gammagard PA

Gammaked PA

Gammaplex PA

Gamunex-C PA

Hizentra PA

Hyperrho S/DHyqvia PA

Micrhogam Octagam PA

Panzyga PA

Privigen PA

RhogamWinrho SDFXembify PA

Immunological agents

Actimmune PA

Arcalyst PA

Benlysta PA

Gamifant PA/ST

5

Ilaris PA/ST

Lemtrada PA

Palforzia PA

Infertility

Bravelle PA/ST

Cetrotide PA

Follistim AQ PA

Ganirelix PA

Gonal-F PA

HCG PA

Menopur PA

Novarel PA

OvidrelPregnyl PA

Inflammatory conditions

Actemra PA/ST

Cimzia PA/ST

Cosentyx PA

Dupixent PA

Enbrel PA

Entyvio PA

H.P.Acthar PA

Humira PA

Ilumya PA

Inflectra PA

Kevzara PA

Kineret PA/ST

Olumiant PA

Orencia PA/ST

Otezla PA

Remicade PA

Renflexis PA

RidauraRinvoqSiliq PA/ST

Simponi PA/ST

SkyriziStelara PA/ST

Taltz PA

Tremfya PA/ST

Xeljanz PA/ST

Metabolic bone disease

ReclastZometa

Mood Disorder

Spavato PA

Zulresso PA

Multiple sclerosis

Ampyra PA

Aubagio PA

Avonex PA

Betaseron PA

Copaxone PA

Extavia PA

Gilenya PA/ST

Mavenclad PA

Mayzent PA

Ocrevus PA

Plegridy PA

Rebif PA/ST

Tecfidera PA

Tysabri PA

Vumerity PA

Musculoskeletal agents

Botox Cosmet PA

Exondys 51 PA/ST

Spinraza PA

Xiaflex PA

Vyondys 53

Narcolepsy

Wakix PA

Xyrem PA

Neurological agents

Botox PA

Dysport PA

Myobloc PA

Xeomin PA

Neutropenia

Fulphila PA/ST

Granix PA

Leukine PA

Neulasta PA

Neupogen PA

Nivestym Trodelvy Udenyca PA

Zarxio PA

Ziextenzo

Oncology - injectable

AbraxaneAdcetris PA

AdriamycinAdrucilAlferon NAlimtaAliqopa PA

AlkeranArranonArzerra PA

AsparlasAvastin Ayvakit PA

Bavencio PA

Beleodaq PA

BelrapzoBendamustineBendeka PA

Besponsa PA

BicnuBleo 15KBleomycinBlincyto PA

Bortezomib PA Busulfex Brukinsa PA CarboplatinCampathCamptosarCisplatin Injectable CladribineClolarCosmegen CyclophosphamideCyramza PA

CytarabineDacogen PA Darzalex PA

DaunorubicinDepocytDocefrez DocetaxelDoxil DoxorubicinEligard PA/ST

EllenceElzonris PA

Empliciti PA

Enhertu PA

Erbitux PA

ErwinazeEtopophos Etoposide InjectableEvomela

PA – Prior authorization required • ST – Step therapy

FaslodexFludarabineFluorouracil InjectableFolotyn PA

FusilevGazyva PA

GemzarHalaven PA

Herceptin PA

Herzuma PA

HycamtinIdamycin PFS IfexIfosfamideImfinzi PA

ImlygicInfugemIntron A PA

Istodax OVR PA

Ixempra kit JelmytoJevtana PA

Kadcyla PA

Kanjinti PA

KepivanceKeytruda PA

Khapzory PA/ST

Koselugo PA

Kymriah PA

Kyprolis PA

Lartruvo PA

Leuprolide Injectable PA

LevoleucovorLibtayo PA

Lumoxiti PA

Lupron Depot PA

MarqiboMesnexMitomycin Injectable

MustargenMvasi PA

Mylotarg PA

NavelbineNipent Oforta Ogivri PA

Oncaspar Ontak Ontruzant PA

OnivydeOpdivo PA

Padcev PA

Pamidronate PemazyrePerjeta PA

PhotofrinPolivy PA

Portrazza PA

Poteligeo PA

Proleukin Provenge PA

Qinlock RetevmoRituxan PA

Romidepsin PA

Ruxience PA

Sarclisa PA

Sylatron PA

Sylvant PA

Synribo PA

TabrectaTaxotere Tazverik PA

Tecentriq PA

TemodarTepadinaTheracysThiotepaTice BCG

ToriselTotectTrazimera PA TreandaTrelstar mix PA/ST

Trisenox Truxima PA

TukysaUnituxin PA

ValstarVantas PA/ST

VectibixVelcade PA

VidazaVinblastine InjectableVyxeos PA

Xgeva PA

Yervoy PA

Yescarta PA

YondelisZaltrap PA

ZanosarZevalinZinecard Zirabev PA

Zoladex

Oncology - oral

Afinitor PA

Alecensa PA

AlkeranAlunbrig PA

Ayvakit PA

BalversaBosulif PA/ST

Braftovi PA

Brukinsa PA

Cabometyx PA

Calquence PA

Caprelsa PA

Cometriq PA

Copiktra PA

Cotellic PA

Daurismo PA

Erivedge PA

Erleada PA Etoposide CapsuleFarydak PA

Gilotrif PA

Gleevec PA

GleostineHycamtinIbrance PA

Iclusig PA

Idhifa PA

Imbruvica PA

Inlyta PA

InrebicIressa PA/ST

Jakafi PA

Kisqali PA

Koselugo PA

Lenvima PA

Lonsurf PA

Lorbrena PA

Lynparza PA

MatulaneMekinist PA

Mektovi PA

MesnexNerlynx PA

Nexavar PA

NilandronNinlaro PA

Nubeqa PA

Odomzo PA

Oforta PemazyrePiqray

6 OptumRx | optumrx.com



Pomalyst PA

Purixan RetevmoRevlimid PA

RozlytrekRubraca PA

Rydapt PA

Sarclisa PA

Sprycel PA/ST

Stivarga PA

Sutent PA

Tabloid Tabrecta Tafinlar PA

Tagrisso PA

Talzenna PA

Tarceva PA

Targretin PA

Tasigna PA

Tazverik PA

Temodar PA

Thalomid PA

Tibsovo PA

Turalio PA

TukysaTykerb PA

Venclexta PA

Verzenio PA

Vitrakvi PA/ST

Vizimpro PA

Votrient PA

Xalkori PA

Xeloda PA

Xospata PA

Xpovio PA

Xtandi PA/ST

Yonsa PA

Zejula PA

Zelboraf PA

Zolinza PA

Zydelig PA

Zykadia PA

Zytiga PA

Oncology - topical

Targretin Gel PA

Valchlor PA

Ophthalmic agents

BeovuBevacizumab Cystaran PA

DextenzaEyleaIluvienJetreaKeveyis PA

LucentisLuxturna PA MacugenOxervate PA

Ozurdex Retisert VisudyneYutiq

Opioid Antagonists

Sublocade

Osteoarthritis

Durolane PA

Euflexxa PA

Gel-one PA/ST

Gelsyn-3 PA

Genvisc 850 PA

Hyalgan PA/ST

Hymovis PA

Monovisc PA

Orthovisc PA

Sodium Hyalu PA

Supartz PA/ST

Synvisc PA

Trivisc PA

Visco-3 PA

Osteoporosis

Evenity PA

Forteo PA

Prolia PA

Teriparatide PA

Tymlos PA

Pain management

Prialt

Parkinson’s disease

Apokyn PA

Inbrija PA

Pulmonary fibrosis

Esbriet PA

Ofev PA

Pulmonary hypertension

Adcirca PA

Adempas PA

Flolan PA

Letairis PA

Opsumit PA

Orenitram PA

Remodulin PA

Revatio PA

Tracleer PA

Tyvaso PA

Uptravi PA

Veletri PA

Ventavis PA

7PA – Prior authorization required • ST – Step therapy

RSV

Synagis PA

Substance abuse treatment

Vivitrol

Transplant

Astagraf XLAtgamCellceptCellcept IVEnvarsus XRMyforticNeoralNulojix PA

PrografRapamuneSandimmuneZortress PA

About OptumRx

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. Our high-quality, integrated services deliver optimal member outcomes, superior savings and outstanding customer service. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.

To fill a prescription for a specialty medication on this list, please call 855-427-4682 or visit specialty.optumrx.com

This specialty pharmacy drug list may not be a complete list of all specialty medications; this list can change at any time without notice.

Non-specialty alternatives may be a recommended first-line therapy to treat your condition. Please consult your doctor.

© 2020 OptumRx, Inc ORX2700_200601 WF2546098_200601 75365A-062020


OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com/optumrx.


Over

Mail Service Saver Plus is a program that helps you better manage the medication you take on an ongoing basis. You can save both time and money by filling your prescriptions for maintenance medication through OptumRx® home delivery. Not only is home delivery safe and reliable, it also offers the following advantages:

Cost savings You may pay less for your medication with a three-month supply through OptumRx.

Convenience Get free standard shipping on medications delivered to your mailbox.

24/7 access and reminders Speak to a licensed pharmacist who can answer your questions any time, any day. You can even set up text reminders to help you remember to take or refill your medications.*

How Mail Service Saver Plus works

If you currently take maintenance medication on a regular basis, your pharmacy benefit plan requires you to use home delivery.

Your plan only covers a limited number of maintenance medication refills from a retail pharmacy. After the allowed fills, you must move to home delivery through OptumRx, or you will pay the entire cost for your medication at your retail pharmacy.

Discover the convenience of OptumRx Mail Service Saver Plus

OptumRx specializes in home delivery, clinical management and affordability of prescription medication and consumer health products. We are an Optum® company — a leading provider of integrated health services. Learn more at optum.com.

All Optum® trademarks and logos are owned by Optum, Inc. All other trademarks are the property of their respective owners.

© 2017 Optum, Inc. All rights reserved. ORX7321-MSSP_171013 49993-102017

optumrx.com

The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities.Free services are provided to help you communicate with us, such as letters in other languages or large print. You may ask to speak with an interpreter. To ask for help, please call the toll-free phone number listed on your ID card.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.

請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號碼。

* OptumRx provides this service at no cost. Standard message and data rates charged by your carrier may apply.

Whether you have a new prescription or need to transfer an existing prescription, it’s easy to get started with OptumRx home delivery.

Here’s how:

ePrescribe Your doctor can send an electronic prescription to OptumRx.

Online Register at optumrx.com.

Phone Just call the member phone number on your plan ID card to talk with a customer service representative right now. It’s helpful to have your plan ID card and medication bottle available. The representative can also contact your doctor directly if you need a new prescription.

Our new Hassle-Free Fill program allows you to receive automatic refills of the medication you take on a regular basis.

The Hassle-Free Fill program delivers convenience by providing automatic refills of eligible maintenance medication. When it is time to refill, OptumRx® Mail Service Pharmacy will automatically:

• Call to notify you that your medication will ship soon (unless you cancel it within three business days of the refill notice).

• Deliver your medication to the address you provided, with no standard delivery shipping charge.

• Bill your credit card for any copay, coinsurance or amount due.

We take care of everything — so you never have to worry about refills.

Learn more about Hassle-Free Fill

OptumRx® Hassle-Free FillSM Program

1. How do I enroll my eligible medication in the Hassle-Free Fill program?

You can enroll medication online, by mail or phone.

Online: Visit optumrx.com and select which medication you would like to enroll. Please note you must have a credit card on file, set up for automatic payment in order to enroll online.

Mail: Indicate on the refill order form in your next mail service package which medication you want in the program.

Phone: Call customer service at the toll-free phone number on the back of your plan ID card.

2. Now that my medication is part of the Hassle-Free Fill program, do I need to contact OptumRx for refills?

You do not need to contact OptumRx® to refill prescriptions in the Hassle-Free Fill program. Those medications will be refilled and delivered to you automatically. You may contact OptumRx if you have questions, want to speak to a pharmacist or change your credit card information we have on file.

3. If I fill a new medication through mail service, will I receive automatic refills?

No, refills for a new medication is not automatic. Visit optumrx.com to see if your new medication is eligible for the Hassle-Free Fill program. If it is eligible, you must select that medication to receive automatic refills. Or call OptumRx to learn if your new medication is eligible.

4. Do I receive all of my medication automatically, or can I choose the medication?

You choose which of your eligible medication you want to receive automatically through the program. Visit optumrx.com to learn which medication is eligible for the Hassle-Free Fill program, or call OptumRx.

5. Can I remove some, or all medication from the program?

Yes. If you no longer want your prescription refilled automatically log into optumrx.com and disenroll your medication from the program. You can also call OptumRx and provide the prescription number.

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an OptumTM company — a leading provider of integrated health services. Learn more at optum.com.

All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners.

© 2014 Optum, Inc. All rights reserved. A08628 ORX6843_140716

optumrx.com

6. How do I pay for my automatic refills? You are responsible for paying the copayment,

coinsurance or deductible for each of your refills. To make it easy, we will bill your credit card (on file) at the time of each refill and shipment. If there are changes to your credit card, please contact us.

7. Will I be told about upcoming refills? Yes. You’ll receive a phone message telling you that

your medication will soon be refilled and delivered.

8. When will I receive my refills? Approximately 10–20 days prior to your next fill

date, you will receive a phone call telling you that a refill will soon be shipped. You have three business days to confirm any changes or cancel the order.

9. What if I no longer need my automatic refill, or want to change the ship date?

You can cancel your automatic refill, or update the ship date, at optumrx.com. Or follow the prompts when you receive the phone call telling you that your order will soon be refilled.

10. What type of medication is eligible for the Hassle-Free Fill program?

A broad range of maintenance medication is eligible for the program. Including:

• Asthma/COPD

• Contraceptives

• Cholesterol/lipid lowering medication

• High blood pressure medication

• Oral diabetic medication

• Osteoporosis medication

11. Why is my medication not available through the Hassle-Free Fill program?

For safety reasons our clinical team has determined that a medication my be excluded from the Hassle-Free Fill program for one of the following reasons:

• Medication not indicated for chronic or long-term use (antibiotics, anti-infective)

• Drugs requiring frequent dose changes (chemotherapy, anticoagulants)

• Most controlled substances, due to potential abuse concerns

• Medication with legal restrictions or supply limits (State regulations)

• As needed medication

• Injectable drugs with supplies related to administration

• Specialty medication

• Topical and compounded products

12. What types or classes of drugs are excluded from the Hassle-Free Fill program?

Excluded drug classes are:

• Antipsychotics

• Cancer medication

• Compound

• Cough and cold medication

• Infections (bacterial/fungal/malaria)

• Medication with potential for abuse/overuse

• Needles/Syringes

• Specialty

• Topical skin conditions

• Tuberculosis medication

NRX001

New PrescriPtioN Mail-iN order ForMMember and physician information — please use black or blue ink. one form per member.

Member ID Number

(Additional coverage, if applicable) Secondary Member ID Number

Last Name First Name MI

Delivery Address Apt. #

City State ZIP

Phone Number with Area Code

Date of Birth (mm/dd/yyyy) Gender M F

Email

Physician Name

Physician Phone Number with Area Code

Health historyMedication Allergies: Aspirin Erythromycin Quinolones Others: None known Cephalosporins NSAIDs Sulfa Amoxil/Ampicillin Codeine Penicillin Tetracyclines

Health Conditions: Asthma Glaucoma High cholesterol Others: None known Cancer Heart condition Osteoporosis Arthritis Diabetes High blood pressure Thyroid Disease

Over-the-counter/herbal medications taken regularly:

Payment and shipping information — do not send cashStandard delivery is included at no charge. New prescriptions should arrive within about 10 business days from the date the completed order is received. Completed refill orders should arrive within about 7 business days. OptumRx will contact you if there will be an extended delay in delivering your medications.

For new prescription orders and maintenance refills, this credit card will be billed for copay/coinsurance and other such expenses related to prescription orders. By supplying my credit card number, I authorize OptumRx to maintain my credit card on file as payment method for any future charges. To modify payment selection, contact customer service at any time.

1

2

3

4

You may log on to optumrx.com to see if drug pricing information is available before enclosing payment. Once shipped, medications may not be returned for a refund or adjustment.

Mail this completed order form with your new prescription(s) to OptumRx, P.O. Box 2975, Mission, KS 66201. DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM.

ORX5633_140915

Ship overnight. Add $12.50 to order amount (subject to change).

Check enclosed. All checks must be signed and made payable to: OptumRx.

Charge to my credit card on file. Charge to my NEW credit card.

Signature: Date:

New Credit Card Number

Expiration Date (Month/Year) Visa, MasterCard, AMEX and Discover are accepted.

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 obtained on a walk-in basis by presenting the OptumRx ID card at the time of service. Members should review their benefit plan to determine coverage for vaccines.

Make your health a priority

Many vaccines can be obtained on a walk in basis. Show your OptumRx ID card before getting your flu shot or vaccine. Most OptumRx plans cover routine vaccines at 100% when you use network pharmacies.

See the pharmacy list on page 2.

For more information log in to optumrx.com or call the number on your OptumRx ID card.

OptumRx is a pharmacy care services company helping clients and more than 65 million members achieve better health outcomes and lower overall costs through innovative prescription drug benefit services. Learn more at optum.com/optumrx.


© 2019 Optum, Inc. All rights reserved. ORX72407_190726

optumrx.com

1 Sources: http://www.cdc.gov/flu/2 www.cdc.gov/flu/protect/keyfacts.htm#flu-vaccination3 There may be some instances where a particular location for 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.

Retail Pharmacies

This list represents the larger retail chain pharmacies in our network, but is not the full list. For a more complete list, you can log in to optumrx.com or call the number on your health plan or prescription ID card. 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• 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)• Meijer Pharmacies• Publix• Safeway Affiliated Pharmacies (Carrs, Pavilion’s,

Randalls, Safeway, Tom Thumb, Vons)• 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

Ask your employer or check your plan documents for your plan’s specific coverage details.

Not all vaccines on this list are available at all network pharmacies. Contact your local network pharmacy to confirm vaccine availability.

Routine vaccines4

Most of the following routine vaccines are available at pharmacies that participate in the Vaccine Immunization/Injection Network administered by OptumRx.

Age restrictions or limitations may apply. Check with your network pharmacy for specific age, flu shot and vaccine requirements.

Flu Shots Flu (Influenza)*

Afluria, Afluria Quad, Fluad, Fluarix Quad, Flublok, Flublok Quad, Flucelvax Quad, Flulaval Quad, FluMist Quad, Fluvirin, Fluzone HD, Fluzone ID Quad, Fluzone Quad, Fluzone Quad (pediatric dose)

Routine Adult VaccinesHepatitis A* (Adult and Pediatric)

Havrix, VaqtaHepatitis B* (Adult and Pediatric)

Engerix-B, Heplisav-B (adult only), Recombivax-HBHuman Papilloma Virus (HPV)* — Vaccine prevents HPV related cancers

Gardasil 9Measles, Mumps, Rubella*

MMR-IIMeningococcal* — Vaccine prevents meningitis Groups A, C, Y and W-135

Menactra, MenveoMeningococcal* — Vaccine prevents meningitis Group B

Bexsero, TrumenbaPneumococcal* — Vaccine prevents pneumonia

Prevnar13, Pneumovax 23Tdap* — Vaccine prevents tetanus, diptheria, pertussis

Adacel, BoostrixTetanus Diptheria* — TD

TenivacVaricella* — Vaccine prevents chicken pox

VarivaxZoster* — Vaccine prevents shingles

Shingrix, Zostavax*Vaccine type

Free Meter Program

Diabetes can harm your eyes, kidneys, nerves, heart and blood vessels. The impact can be long-term. Regular blood sugar testing can help you manage your diabetes and may lead to better glucose control.

Take advantage of this great offer

To help you monitor blood sugar levels, your pharmacy benefit plan offers a Free Meter Program. With this program, you may be able to get a blood sugar meter at no charge to you. You and your doctor can choose from various meters. For more details, call OptumRx customer service at the phone number on your ID card. Or contact the meter manufacturer Service Center.

How to get your free meter

The first step in every diabetes care plan is talking with your health care team. If you would like a new blood sugar meter, tell your doctor or diabetes educator. They will help you select the no-charge meter that’s right for you. Once you decide, it’s easy to place your order. Just call the manufacturer’s Service Center any time.

Your free meter choices are on the next pagePremium PDL Free Meter Program


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Don’t delay. Talk with your doctor about choosing the best brand-name meter for you. Then order your meter by calling the manufacturer’s Service Center.

Monitor Test Strips

OneTouch Verio® Meter OneTouch Verio® Test Strips

OneTouch Verio Flex® Meter OneTouch Verio® Test Strips

To order one of these OneTouch® meters call their Service Center at 1-866-355-9962 Order Code: 594PRX100 OneTouch.orderpoints.com

Your Pharmacy Benefits - LCS Faculty & Staff Website

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