2015 abridged formulary (partial list of covered drugs) · 2014-09-25 · h2986_pd_200...
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P.O. Box 21420 El Sobrante, CA 94820www.UHCAmedicare.org
University H
ealth Care Advantage2015 Abridged Form
ulary (Partial List of Covered Drugs)
2015 Abridged Formulary (Partial List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN
00015942, 5 This abridged formulary was updated on 08/08/2014. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact UHCA Member Services at 1-855-996-8422, or, for TTY users, 711, 7 days a week, 8:00 a.m. to 8:00 p.m., or visit www.UHCAmedicare.org.
H2986_PD_200 Accepted 2015
This abridged formulary was updated on 08/08/2014. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact UHCA Member Services at 1-855-996-8422, or, for TTY users, 711, 7 days a week, 8:00 a.m. to 8:00 p.m., or visit www.UHCAmedicare.org.
H2986_PD_200 Accepted 2015
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UNIVERSITY HEALTH CARE ADVANTAGE (HMO)
2015 ABRIDGED FORMULARY
(PARTIAL LIST OF COVERED DRUGS)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN
00015492, 5
This abridged formulary was updated on 08/08/2014. This is not a complete list of drugs covered by our
plan. For a complete listing or other questions, please contact University Health Care Advantage Member Services at 1-855-996-8422 or, for TTY users, Toll-free 711, Monday through Sunday from 8:00 a.m. to 8:00
p.m. (Pacific Standard Time), or visit www.UHCAmedicare.org.
University Health Care Advantage is an HMO plan with a Medicare contract. Enrollment in University Health
Care Advantage depends on contract renewal.
This information is available for free in other languages. Please contact Member Services at 1-855-996-8422 for additional information. TTY users should call 711. Hours are: 8:00 a.m. until 8:00 p.m., Pacific Standard
Time, 7 days a week. Member Services also has free language interpreter services available for non-English
speakers. Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro número de servicio al cliente 1-855-996-8422, 8:00 a.m. a 8:00 p.m., hora estándar del pacífico, siete días a la semana. Los usuarios de TTY deben
llamar al 711.
Thông tin này có sẵn miễn phí bằng các ngôn ngữ khác. Xin vui lòng gọi Dịch Vụ Hội Viên của chúng tôi tại số 1-855-996-8422, 8:00 sáng đến 8:00 chiều, giờ Chuẩn Thái Bình Dương, 7 ngày một tuần. Người dùng TTY gọi số 711.
8點至晚上8點之間致電我們的會員服務號碼 1-855-996-8422,時間為太平洋標準時間。TTY 使用者請撥打
711。
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Note to existing members: This formulary has changed since last year. Please review this document to
make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means University Health Care Advantage.
When it refers to “plan” or “our plan,” it means University Health Care Advantage (HMO).
This document includes a partial list of the drugs (formulary) for our plan which is current as of August 8, 2014. For a complete updated formulary, please contact us. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year.
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What is the University Health Care Advantage (HMO) Abridged Formulary?
A formulary is a list of covered drugs selected by University Health Care Advantage (HMO) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary
part of a quality treatment program. University Health Care Advantage (HMO) will generally cover the drugs
listed in our formulary as long as the drug is medically necessary, the prescription is filled at a University Health Care Advantage (HMO) network pharmacy, and other plan rules are followed. For more information
on how to fill your prescriptions, please review your Evidence of Coverage.
This document is a partial formulary and includes only some of the drugs covered by University Health Care
Advantage (HMO). For a complete listing of all prescription drugs covered by University Health Care Advantage (HMO), please visit our website or call us. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our
formulary, will not affect members who are currently taking the drug. It will remain available at the same
cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were
available when you chose our plan, except for cases in which you can save additional money or we can
ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective, or at the time the member requests a refill of
the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug
from the market, we will immediately remove the drug from our formulary and provide notice to members
who take the drug. The enclosed formulary is current as of August 8, 2014. To get updated information about the drugs covered by University Health Care Advantage (HMO), please contact us. Our contact
information appears on the front and back cover pages. In the event we make a non-maintenance change
to the formulary, we will post an errata sheet to our website and mail a letter to members. Members will
also receive notification via the normal member explanation of benefits process.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 15. The drugs in this formulary are grouped into categories depending on
the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category “Cardiovascular Agents.” If you know what your drug is used for,
H2986_PD_200 !==?JN?> ȕȓȔȘ Abridged FormularS 0age 4
look for the category name in the list that begins on page 15. Then look under the category name for
your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on
page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to
your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
University Health Care Advantage (HMO) covers both brand name drugs and generic drugs. A generic drug is
approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs
cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
Prior Authorization: University Health Care Advantage (HMO) requires you or your physician to get
prior authorization for certain drugs. This means that you will need to get approval from University
Health Care Advantage (HMO) before you fill your prescriptions. If you don’t get approval, University Health Care Advantage (HMO) may not cover the drug.
Quantity Limits: For certain drugs, University Health Care Advantage (HMO) limits the amount of
the drug that our plan will cover. For example, University Health Care Advantage (HMO) provides 30 pills per prescription for Ambien. This may be in addition to a standard one-month or three-month
supply.
Step Therapy: In some cases, University Health Care Advantage (HMO) requires you to first try
certain drugs to treat your medical condition before we will cover another drug for that condition.
For example, if Drug A and Drug B both treat your medical condition, University Health Care
Advantage (HMO) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on Formulary Page 15. You can also get more information about the restrictions applied to specific
covered drugs by visiting our Web site. We have posted on line documents that explain our prior
authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You can ask University Health Care Advantage (HMO) to make an exception to these restrictions or limits or
for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an
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exception to the University Health Care Advantage (HMO) formulary?” on page 5 (below) for information
about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member
Services and ask if your drug is covered. This document includes only a partial list of covered drugs, so University Health Care Advantage (HMO) may cover your drug. For more information, please contact us. Our
contact information, along with the date we last updated the formulary, appears on the front and back
cover pages.
If you learn that University Health Care Advantage (HMO) does not cover your drug, you have two options:
You can ask Member Services for a list of similar drugs that are covered by University Health Care
Advantage (HMO). When you receive the list, show it to your doctor and ask him or her to prescribe a
similar drug that is covered by our plan.
You can ask University Health Care Advantage (HMO) to make an exception and cover your drug. See
below for information about how to request an exception.
How do I request an exception to the University Health Care Advantage (HMO)’s
Formulary?
You can ask University Health Care Advantage (HMO) to make an exception to our coverage rules. There are
several types of exceptions that you can ask us to make.
You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered
at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the
specialty tier. If approved this would lower the amount you must pay for your drug.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
University Health Care Advantage (HMO) limits the amount of the drug that we will cover. If your
drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, University Health Care Advantage (HMO) will only approve your request for an exception if the
alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization
restrictions would not be as effective in treating your condition and/or would cause you to have adverse
medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you request a formulary, tiering or utilization restriction exception, you
should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request
an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by
waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
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What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need
a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will
cover the drug you take. While you talk to your doctor to determine the right course of action for you, we
may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover
a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network
pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of
the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with at least a 91 and may be up to a 98-day transition supply, consistent with dispensing
increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our
formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in
our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer
days) while you pursue a formulary exception.
In circumstances where a member is changing from one treatment setting to another, University Health
Care Advantage (HMO) will ensure a transition process for approving non-formulary Part D drugs. This
process shall also apply to formulary Part D drugs that require prior authorization or step-therapy. Examples of level of care changes include: members who are discharged from a hospital to a home;
members who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D
plan formulary; members who end a long-term care facility stay and return to the community; and, members who are discharged from psychiatric hospitals with medication regimens that are highly
individualized.
The pharmacy benefit manager for University Health Care Advantage (HMO) will provide pharmacies with access to representatives of the plan who have the ability to override pharmacy claims processing issues.
This access will allow pharmacies to obtain prescription claims overrides at the point-of-sale and ensure
that members receive reliable access to medications.
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For more information
For more detailed information about your University Health Care Advantage (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about University Health Care Advantage (HMO), please contact us. Our contact
information, along with the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-
MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit
http://www.medicare.gov.
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University Health Care Advantage (HMO)’s Formulary
The abridged formulary that begins page 15 provides coverage information about some of the drugs covered by University Health Care Advantage (HMO). If you have trouble finding your drug in the list, turn to
the Index that begins on Index Page I-1.
Remember: This is only a partial list of drugs covered by University Health Care Advantage (HMO). If your prescription is not in this partial formulary, please contact us. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., AVINZA) and
generic drugs are listed in lower-case italics (e.g., acetaminophen).
The information in the Requirements/Limits column tells you if University Health Care Advantage (HMO) has
any special requirements for coverage of your drug
The second column of the chart lists the drug tier. Every drug on the plan’s Drug List is in one of six cost-sharing tiers. The tables below provide an explanation of each tier.
Network Retail Pharmacy Drug Tier Copayment Levels
Tier Copay for up to a
one-month supply
Copay for up to a
three-month supply
Tier 1 (Preferred Generic) $2 $6
Tier 2 (NON-Preferred Generic) $15 $45
Tier 3 (Preferred Brand) $45 $135
Tier 4 (NON-Preferred Brand Name) $95 $285
Tier 5 (Specialty) 33% of cost 33% of cost
Tier 6 (Select Diabetic Drugs) $2 $6
Network Mail Order Drug Tier Copayment Levels
Tier Copay for up to a
one-month supply
Copay for up to a
three-month supply
Tier 1 (Preferred Generic) $2 $4
Tier 2 (NON-Preferred Generic) $15 $30
Tier 3 (Preferred Brand) $45 $90
Tier 4 (NON-Preferred Brand Name) $95 $190
Tier 5 (Specialty) 33% of cost 33% of cost
Tier 6 (Select Diabetic Drugs) $2 $4
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The following coverage abbreviations appear in the Requirements/Limits column:
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION DESCRIPTION EXPLANATION
Utilization Management Restrictions
PA Prior Authorization
Restriction
You (or your physician) are required to get prior
authorization from University Health Care Advantage (HMO) before you fill your prescription for this drug. Without prior
approval, University Health Care Advantage (HMO) may not
cover this drug.
PA BvD
Prior Authorization
Restriction
for
Part B vs Part D
Determination
This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior
authorization from University Health Care Advantage (HMO)
to determine whether this drug is covered under Medicare Part D before you fill your prescription for this drug.
Without prior approval, University Health Care Advantage
(HMO) may not cover this drug.
PA-HRM
Prior Authorization
Restriction
for High Risk Medications
This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare
beneficiaries 65 years or older. Members age 65 years or
older are required to get prior authorization from University
Health Care Advantage (HMO) before filling your prescription for this drug. Without prior approval,
University Health Care Advantage (HMO) may not cover this
drug.
PA NSO
Prior Authorization
Restriction
for New Starts Only
If you are a new member or if you have not taken this drug
previously, you (or your physician) are required to get prior
authorization from University Health Care Advantage (HMO)
before you fill your prescription for this drug. Without prior approval, University Health Care Advantage (HMO) may not
cover this drug.
QL Quantity Limit
Restriction
University Health Care Advantage (HMO) limits the amount
of this drug that is covered per prescription, or within a specific time frame.
ST Step Therapy
Restriction
Before University Health Care Advantage (HMO) will provide
coverage for this drug, you must first try another drug(s) to
treat your medical condition. This drug may only be covered if the other drug(s) does not work for you.
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OTHER COVERAGE ABBREVIATIONS
ABBREVIATION DESCRIPTION EXPLANATION
LA Limited Access Drug
This prescription may be available only at certain
pharmacies. For more information consult your Pharmacy Directory or call Member Services at number at 1-855-996-
8422, 8:00 a.m. to 8:00 p.m., Pacific Standard Time, 7 days a
week. TTY users call 711.
GC Gap Coverage We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for
more information about this coverage.
STRENGTH AND DOSAGE FORM ABBREVIATIONS
ABBREVIATION DESCRIPTION
adh. patch adhesive patch
aer br act aerosol, breath activated
aer pow aerosol, powder
aer pow ba aerosol powder, breath activated
aer refill aerosol refill
aer w/adap aerosol with adapter
ampul ampule
blkbaginj bulk bag injection
cap dr mp capsule, delayed release multiphasic
cap ds pk capsule, dose pack
cap er 12h capsule, 12 hour extended release
cap er 24h capsule, 24 hour extended release
cap er deg capsule, extended release degradable
cap er pel capsule, extended release pellets
cap mphase capsule, multiphasic
cap.sa 24h capsule, 24 hour sustained action
cap.sr 12h capsule, 12 hour sustained release
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ABBREVIATION DESCRIPTION
cap.sr 24h capsule, 24 hour sustained release
cap24h pct capsule, 24 hour controlled-onset pellets
cap24h pel capsule, 24 hour sustained release pellets
cap sprink capsule, sprinkle
cap sr pel capsule sustained release pellets
cap w/dev capsule with device
capsule dr capsule, delayed release
capsule er capsule, extended release
capsule sa capsule, sustained action
cmb cappad combination: capsule, pad
cmb ont fm combination: ointment, foam
cmb ont lt combination: ointment, lotion
cmb tabpad combination: tablet, pad
combo. pkg combination package
cpmp 12hr capsule, 12 hour multiphasic
cpmp 24hr capsule, 24 hour multiphasic
cpmp 30-70 capsule, multiphasic, 30%-70%
cpmp 50-50 capsule, multiphasic, 50%-50%
cream(g), cream(gm) cream (grams)
cream(ml) cream (milliliters)
cream/appl cream with applicator
cream, er (g) cream, extended release (grams)
cream pack cream, package
dehp fr bg di(2-ethylhexyl)phthalate free bag
dis needle disposable needle
disk w/dev disk with inhalation device
disp syrin disposable syringe
drops susp drops, suspension
drps hpvis drops, hyperviscous
emul adhes emulsion adhesive
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ABBREVIATION DESCRIPTION
emul packt emulsion packet
emulsn(g) emulsion (grams)
foam/appl. foam with applicator
froz.piggy frozen piggyback
g gram
gel/pf app gel with prefilled applicator
gel (gm) gel (grams)
gel (ml) gel (milliliters)
gel md pmp gel in metered dose pump
gel w/appl gel with applicator
gel w/pump gel with pump
gran pack granule pack
hfa aer ad hfa aerosol adapter
infus. Btl infusion bottle
insuln pen insulin pen
ip soln intraperitoneal solution
irrig soln irrigating solution
iv soln. intravenous solution
jel jelly
jelly/app jelly with applicator
jel/pf app jelly with pre-filled applicator
kit cl&crm kit: cleanser and cream
kt crm le kit: cream, lotion emollient
kt lotn ce kit: lotion, cream emollient
kt oint le kit: ointment, lotion emollient
lotion, er lotion, extended release
lozenge hd lozenge handle
m.ht patch medicated heated patch
ma buc tab mucoadhesive buccal tablet
mcg microgram
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ABBREVIATION DESCRIPTION
med. pad medicated pad
med. swab medicated swab
med. tape medicated tape
mg milligram
ml milliliter
muc er 12h mucoadhesive system, 12 hour extended release
ndl fr inj needle for injection
nl fm susp nail film suspension
oint. (g), oint.(gm) ointment (grams)
oral conc oral concentrate
oral susp oral suspension
paste (g) paste (grams)
patch td24 patch, 24 hour transdermal
patch td72 patch, 72 hour transdermal
patch tdsw patch, biweekly transdermal
patch tdwk patch, weekly transdermal
pca syring patient-controlled analgesic syringe
pca vial patient-controlled analgesic vial
pellet(ea) pellet (each)
pen ij kit pen injector kit
pen injctr pen injector
pggybk btl piggyback bottle
plast. Bag plastic bag
powd pack powder pack
sol md pmp solution with multi-dose pump
sol w/appl solution with applicator
sol/pf app solution with pre-filled applicator
sol-gel solution, gel-forming
soln recon solution, reconstituted
soln(gram) solution (grams)
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ABBREVIATION DESCRIPTION
spray susp spray, suspension
spray/pump spray with pump
stick(ea) stick (each)
supp.rect suppository, rectal
supp.vag suppository, vaginal
suppos. suppository
sus er 24h suspension, 24 hour extended release
sus er rec suspension, extended release reconstituted
sus mc rec suspension, microcapsule reconstituted
suspdr pkt suspension, delayed release packet
susp recon suspension, reconstituted
syringekit syringe kit
tab chew tablet, chewable
tab er 12h tablet, 12 hour extended release
tab er 24h tablet, 24 hour extended release
tab er prt tablet, extended release particles
tab er seq tablet, extended release sequels
tab disper tablet, dispersible
tab ds pk tablet, dose pack
tab er 24 tablet, 24 hour extended release
tab mphase tablet, multiphasic
tab part tablet, particles
tab rap dr tablet, rapid disintegrating delayed release
tab rapdis tablet, rapid disintegrating
tab subl tablet, sublingual
tab.sr 12h tablet, 12 hour sustained release
tab.sr 24h tablet, 24 hour sustained release
tabergr24hr tablet, 24 hour gradual extended release
tablet dr tablet, delayed release
tablet, er tablet, extended release
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ABBREVIATION DESCRIPTION
tablet eff tablet, effervescent
tablet sa tablet, sustained action
tablet sol tablet, soluble
tb er dspk tablet, extended release dose pack
tb mp dspk tablet, multiphasic dose pack
tb rd dspk tablet, rapid disintegrating dose pack
tbdspk 3mo tablet, 3-month dose pack
tbmp 12hr tablet, 12 hour multiphasic
tbmp 24hr tablet, 24 hour multiphasic
u Unit
vag ring vaginal ring
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
16
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Analgesics Analgesics, Miscellaneous
acetaminophen with codeine solution (Acetaminophen with
Codeine)
2 GC, QL: 2700 in 30 days
acetaminophen with codeine tablet: 300mg-
60mg
(Vopac) 2 GC, QL: 180 in 30 days
acetaminophen with codeine tablet: 300mg-
15mg, 300mg-30mg
(Vopac) 2 GC, QL: 360 in 30 days
AVINZA cpmp 24hr: 30mg, 45mg, 60mg,
75mg, 120mg
4 ST, QL: 30 in 30 days
AVINZA cpmp 24hr: 90mg 4 ST, QL: 60 in 30 days
butalb/acetaminophen/caffeine solution (Dolgic Lq) 2 GC, PA-HRM, QL: 2700
in 30 days
butalb/acetaminophen/caffeine tablet (Esgic) 2 GC, PA-HRM, QL: 180
in 30 days
CAPITAL W-CODEINE 4 QL: 2500 in 30 days
CONZIP 4 QL: 30 in 30 days
DILAUDID liquid 4 QL: 1200 in 30 days
DILAUDID tablet: 2mg, 4mg 4 QL: 180 in 30 days
DILAUDID tablet: 8mg 4 QL: 240 in 30 days
DURAGESIC patch td72: 12mcg/hr,
25mcg/hr, 50mcg/hr, 75mcg/hr
4 PA, QL: 10 in 30 days
DURAGESIC patch td72: 100mcg/hr 4 PA, QL: 20 in 30 days
ESGIC tablet 4 PA-HRM, QL: 180 in 30
days
EXALGO tab er 24h: 8mg, 12mg, 16mg 4 PA, QL: 30 in 30 days
EXALGO tab er 24h: 32mg 4 PA, QL: 60 in 30 days
fentanyl patch td72: 12mcg/hr, 25mcg/hr,
50mcg/hr, 75mcg/hr
(Duragesic) 2 GC, PA, QL: 10 in 30
days
fentanyl patch td72: 100mcg/hr (Duragesic) 2 GC, PA, QL: 20 in 30
days
HYCET 4 QL: 2700 in 30 days
hydrocodone/acetaminophen solution: 7.5-
325/15
(Hycet) 2 GC, QL: 2700 in 30 days
hydrocodone/acetaminophen tablet: 5mg-
325mg, 7.5-325mg, 10mg-325mg
(Norco) 2 GC, QL: 360 in 30 days
hydrocodone/acetaminophen tablet: 5mg-
300mg, 7.5-300mg, 10mg-300mg
(Norco) 2 GC, QL: 390 in 30 days
hydromorphone hcl liquid (Dilaudid) 2 GC, QL: 1200 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
17
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
hydromorphone hcl tablet: 2mg, 4mg (Dilaudid) 2 GC, QL: 180 in 30 days
hydromorphone hcl tablet: 8mg (Dilaudid) 2 GC, QL: 240 in 30 days
hydromorphone hcl tab er 24h (Exalgo) 2 GC, PA, QL: 30 in 30
days
KADIAN cap er pel: 10mg, 20mg, 30mg,
40mg, 50mg, 60mg, 70mg, 80mg
4 ST, QL: 60 in 30 days
KADIAN cap er pel: 200mg 5 ST, QL: 120 in 30 days
KADIAN cap er pel: 100mg, 130mg,
150mg
5 ST, QL: 60 in 30 days
LORTAB solution 4 QL: 2025 in 30 days
LORTAB tablet 4 QL: 360 in 30 days
morphine sulfate cpmp 24hr: 30mg, 45mg,
60mg, 75mg, 120mg
(Avinza) 2 GC, ST, QL: 30 in 30
days
morphine sulfate cap er pel: 10mg, 20mg,
30mg, 50mg, 60mg, 80mg; cpmp 24hr:
90mg
(Kadian) 2 GC, ST, QL: 60 in 30
days
morphine sulfate cap er pel: 100mg (Kadian) 5 ST, QL: 60 in 30 days
morphine sulfate cartridge: 2mg/ml, 4mg/
ml
(Morphine Sulfate) 2 GC
morphine sulfate tablet er: 30mg, 60mg,
100mg
(MS Contin) 2 GC, QL: 120 in 30 days
morphine sulfate tablet er: 15mg, 200mg (MS Contin) 2 GC, QL: 180 in 30 days
morphine sulfate solution: 100mg/5ml (MSIR) 2 GC, QL: 200 in 30 days
morphine sulfate solution: 20mg/5ml (MSIR) 2 GC, QL: 300 in 30 days
morphine sulfate solution: 10mg/5ml (MSIR) 2 GC, QL: 700 in 30 days
MORPHINE SULFATE 2 GC, QL: 180 in 30 days
MS CONTIN tablet er: 30mg, 60mg,
100mg
4 QL: 120 in 30 days
MS CONTIN tablet er: 15mg, 200mg 4 QL: 180 in 30 days
NORCO 4 QL: 360 in 30 days
OXECTA tablet orl: 7.5mg 4 QL: 360 in 30 days
OXECTA tablet orl: 5mg 4 QL: 540 in 30 days
oxycodone hcl capsule, oral conc, tablet (Dazidox) 2 GC, QL: 180 in 30 days
oxycodone hcl solution (Oxycodone HCl) 2 GC, QL: 1300 in 30 days
oxycodone hcl/acetaminophen tablet: 2.5-
325mg, 5mg-325mg, 7.5-325mg, 10mg-
325mg
(Alcet) 2 GC, QL: 360 in 30 days
oxycodone hcl/acetaminophen solution (Oxycodone HCl/
acetaminophen)
2 GC, QL: 1800 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
18
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
OXYCONTIN tab er 12h: 80mg 3 QL: 120 in 30 days
OXYCONTIN tab er 12h: 10mg, 15mg,
20mg, 30mg, 40mg, 60mg
3 QL: 60 in 30 days
PERCOCET 4 QL: 360 in 30 days
PRIMLEV 4 QL: 390 in 30 days
ROXICODONE 4 QL: 180 in 30 days
SUBSYS 5 PA, QL: 120 in 30 days
tramadol hcl tab er 24h: 200mg, 300mg (Ultram ER) 2 GC, QL: 30 in 30 days
tramadol hcl tab er 24h: 100mg (Ultram ER) 2 GC, QL: 90 in 30 days
tramadol hcl tablet (Ultram) 2 GC, QL: 240 in 30 days
TYLENOL-CODEINE NO.3 4 QL: 360 in 30 days
TYLENOL-CODEINE NO.4 4 QL: 180 in 30 days
ULTRAM ER tab er 24h: 200mg, 300mg 4 QL: 30 in 30 days
ULTRAM ER tab er 24h: 100mg 4 QL: 90 in 30 days
ULTRAM 4 QL: 240 in 30 days
XARTEMIS XR 4 QL: 360 in 30 days
XODOL 10-300 4 QL: 390 in 30 days
XODOL 5-300 4 QL: 390 in 30 days
XODOL 7.5-300 4 QL: 390 in 30 days
ZAMICET 4 QL: 2700 in 30 days
Nonsteroidal Anti-inflammatory Agents
CELEBREX 3 ST, QL: 60 in 30 days
diclofenac sodium gel (gram) (Solaraze) 5
diclofenac sodium drops, tab er 24h, tablet
dr
(Voltaren) 2 GC
EC-NAPROSYN 4
ibuprofen oral susp (Ibuprofen) 2 GC
ibuprofen tablet (Motrin) 1 GC
INDOCIN oral susp 4 PA-HRM
indomethacin capsule er (Indocin SR) 2 GC, PA-HRM, QL: 60 in
30 days
indomethacin capsule: 50mg (Indomethacin) 2 GC, PA-HRM, QL: 120
in 30 days
indomethacin capsule: 25mg (Indomethacin) 2 GC, PA-HRM, QL: 240
in 30 days
meloxicam tablet (Mobic) 1 GC
meloxicam oral susp (Mobic) 2 GC
MOBIC 4
nabumetone (Relafen) 2 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
19
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
NAPROSYN 4
naproxen tablet (Naprosyn) 1 GC
naproxen oral susp, tablet dr (Naprosyn) 2 GC
PENNSAID 4
SOLARAZE 5
VOLTAREN 3 (Topical Gel)
VOLTAREN-XR 4
Anesthetics Local Anesthetics
lidocaine hcl vial (Xylocaine) 2 GC, PA BvD (PA for
ESRD Only)
lidocaine hcl jel (ml), jel/pf app, solution:
2%, 40mg/ml
(Xylocaine) 2 GC
lidocaine oint. (g) (Lidocaine) 2 GC, PA BvD (PA for
ESRD Only)
lidocaine adh. patch (Lidoderm) 4 PA
LIDODERM 4 PA
XYLOCAINE solution, vial: 20mg/ml 4
Anti-addiction/substance Abuse Treatment Agents Anti-addiction/substance Abuse Treatment Agents
buprenorphine hcl (Subutex) 2 GC, PA, QL: 90 in 30
days
buprenorphine hcl/naloxone hcl (Suboxone) 2 GC, PA, QL: 90 in 30
days
CHANTIX tablet: 0.5mg, 1mg 3 QL: 168 in 84 days
CHANTIX tab ds pk 3 QL: 53 in 28 days
SUBOXONE film: 12mg-3mg 4 PA, QL: 60 in 30 days
SUBOXONE film: 2mg-0.5mg, 4mg-1mg,
8mg-2mg
4 PA, QL: 90 in 30 days
ZUBSOLV 3 PA, QL: 90 in 30 days
Antianxiety Agents Benzodiazepines
ALPRAZOLAM INTENSOL 4 QL: 180 in 30 days
alprazolam tab er 24h: 1mg, 2mg, 3mg (Xanax XR) 2 GC, QL: 60 in 30 days
alprazolam tab er 24h: 0.5mg; tab rapdis,
tablet
(Xanax) 2 GC, QL: 90 in 30 days
ATIVAN tablet 4 QL: 90 in 30 days
clonazepam tab rapdis: 2mg; tablet: 2mg (Klonopin) 2 GC, QL: 300 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
20
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
clonazepam tab rapdis: 0.125mg, 0.25mg,
0.5mg, 1mg; tablet: 0.5mg, 1mg
(Klonopin) 2 GC, QL: 90 in 30 days
KLONOPIN tablet: 2mg 4 QL: 300 in 30 days
KLONOPIN tablet: 0.5mg, 1mg 4 QL: 90 in 30 days
lorazepam tablet (Ativan) 2 GC, QL: 90 in 30 days
lorazepam oral conc (Lorazepam) 2 GC, QL: 150 in 30 days
XANAX XR tab er 24h: 1mg, 2mg, 3mg 4 QL: 60 in 30 days
XANAX XR tab er 24h: 0.5mg 4 QL: 90 in 30 days
XANAX 4 QL: 90 in 30 days
Antibacterials Aminoglycosides
gentamicin sulfate (Garamycin) 2 GC
neomycin sulfate (Neomycin Sulfate) 2 GC
TOBI 5 PA BvD
tobramycin in 0.225% nacl (Tobi) 5 PA BvD
Antibacterials, Miscellaneous
CLEOCIN HCL 4
CLEOCIN PALMITATE 4
clindamycin hcl (Cleocin HCl) 2 GC
clindamycin palmitate hcl (Cleocin Palmitate) 2 GC
MACRODANTIN capsule: 25mg, 100mg 4 PA-HRM, QL: 120 in 30
days (High Risk Med.
QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs)
nitrofurantoin macrocrystal (Macrodantin) 2 GC, PA-HRM, QL: 120
in 30 days (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs)
PRIMSOL 4
trimethoprim (Trimethoprim) 2 GC
VANCOCIN HCL 5
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
21
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
vancomycin hcl capsule (Vancocin HCl) 5
vancomycin hcl vial: 5g, 10g (Vancomycin HCl) 2 GC, PA BvD (PA for
ESRD Only)
XIFAXAN tablet: 200mg 5 PA, QL: 9 in 30 days
XIFAXAN tablet: 550mg 5 ST, QL: 60 in 30 days
Cephalosporins
cefadroxil (Cefadroxil) 2 GC
cefdinir (Omnicef) 2 GC
cefprozil (Cefzil) 2 GC
CEFTIN 4
cefuroxime axetil (Ceftin) 2 GC
cephalexin (Keflex) 1 GC
KEFLEX 4
SUPRAX 4
Macrolides
azithromycin (Zithromax) 2 GC
BIAXIN XL 4
BIAXIN 4
clarithromycin (Biaxin) 2 GC
ZITHROMAX TRI-PAK 4
ZITHROMAX 4
ZMAX 4
Miscellaneous B-lactam Antibiotics
CAYSTON 5 LA
INVANZ vial 4
Penicillins
amoxicillin (Amoxil) 1 GC
amoxicillin/potassium clav (Augmentin) 2 GC
ampicillin trihydrate (Ampicillin Trihydrate) 1 GC
AUGMENTIN susp recon: 125-31.25/ 4
dicloxacillin sodium (Dicloxacillin Sodium) 2 GC
MOXATAG 4
nafcillin sodium vial (Unipen) 2 GC
penicillin v potassium (Veetids 500) 2 GC
Quinolones
AVELOX ABC PACK 4
AVELOX 4
CIPRO tablet: 250mg, 500mg 4
ciprofloxacin hcl (Cipro) 1 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
22
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
LEVAQUIN solution, tablet: 250mg,
500mg, 750mg
4
levofloxacin tablet (Levaquin) 1 GC
levofloxacin solution, vial (Levaquin) 2 GC
moxifloxacin hcl (Avelox) 2 GC
Sulfonamides
AZULFIDINE 4
BACTRIM DS 4
BACTRIM 4
sulfamethoxazole/trimethoprim tablet (Septra) 1 GC
sulfamethoxazole/trimethoprim oral susp,
vial
(Sulfamethoxazole/
trimethoprim)
2 GC
sulfasalazine (Azulfidine) 2 GC
Tetracyclines
ADOXA capsule 4
doxycycline monohydrate (Adoxa) 2 GC
minocycline hcl (Dynacin) 2 GC
ORACEA 4
SOLODYN 5
VIBRAMYCIN susp recon 4
Anticancer Agents Anticancer Agents
AFINITOR DISPERZ 5 PA NSO, QL: 112 in 28
days
AFINITOR tablet: 2.5mg, 5mg, 7.5mg 5 PA NSO, QL: 28 in 28
days
AFINITOR tablet: 10mg 5 PA NSO, QL: 56 in 28
days
anastrozole (Arimidex) 2 GC
ARIMIDEX 4
AROMASIN 4
cyclophosphamide tablet (Cyclophosphamide) 2 GC, PA BvD, ST
CYCLOPHOSPHAMIDE 4 PA BvD, ST
DROXIA 3
ELIGARD syringe: 30mg 4 QL: 1 in 112 days
ELIGARD syringe: 7.5mg 4 QL: 1 in 28 days
ELIGARD syringe: 22.5mg 4 QL: 1 in 84 days
ELIGARD syringe: 45mg 5 QL: 1 in 168 days
exemestane (Aromasin) 2 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
23
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
FEMARA 4
GLEEVEC tablet: 400mg 5 PA NSO, QL: 60 in 30
days
GLEEVEC tablet: 100mg 5 PA NSO, QL: 90 in 30
days
HYDREA 4
hydroxyurea (Hydrea) 2 GC
IMBRUVICA 5 PA NSO, QL: 120 in 30
days
INLYTA tablet: 1mg 5 PA NSO, QL: 180 in 30
days
INLYTA tablet: 5mg 5 PA NSO, QL: 60 in 30
days
JAKAFI 5 PA NSO, QL: 60 in 30
days
letrozole (Femara) 2 GC
LEUKERAN 4
leuprolide acetate (Leuprolide Acetate) 2 GC
LUPRON DEPOT syringekit: 45mg 5 QL: 1 in 168 days
LUPRON DEPOT syringekit: 3.75mg 5 QL: 1 in 28 days
LUPRON DEPOT syringekit: 11.25mg,
22.5mg
5 QL: 1 in 84 days
LUPRON DEPOT-PED syringekit 5 QL: 1 in 112 days
LUPRON DEPOT-PED kit 5 QL: 1 in 28 days
LYSODREN 3
MEGACE ES 5
MEGACE 4
megestrol acetate (Megestrol Acetate) 2 GC
mercaptopurine (Purinethol) 2 GC
methotrexate sodium (Methotrexate Sodium) 2 GC, PA BvD, ST
methotrexate sodium/pf (Methotrexate Sodium/
PF)
2 GC, PA BvD
NEXAVAR 5 PA NSO, QL: 120 in 30
days
POMALYST 5 PA NSO, QL: 21 in 28
days
PURINETHOL 4
REVLIMID 5 LA, PA NSO, QL: 21 in
28 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
24
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
RHEUMATREX 4 PA BvD, ST
SOLTAMOX 4
SPRYCEL tablet: 50mg, 70mg, 80mg,
100mg, 140mg
5 PA NSO, QL: 30 in 30
days
SPRYCEL tablet: 20mg 5 PA NSO, QL: 60 in 30
days
SUTENT 5 PA NSO, QL: 30 in 30
days
tamoxifen citrate (Nolvadex) 2 GC
TARCEVA tablet: 25mg, 100mg 5 PA NSO, QL: 60 in 30
days
TARCEVA tablet: 150mg 5 PA NSO, QL: 90 in 30
days
TASIGNA 5 PA NSO, QL: 112 in 28
days
TREXALL 4 PA BvD, ST
TYKERB 5
VOTRIENT 5 PA NSO, QL: 120 in 30
days
XALKORI 5 PA NSO, QL: 60 in 30
days
XTANDI 5 PA NSO, QL: 120 in 30
days
ZYTIGA 5 PA NSO, QL: 120 in 30
days
Anticholinergic Agents Antimuscarinics/Antispasmodics
atropine sulfate syringe (Atropine Sulfate) 2 GC
propantheline bromide (Propantheline
Bromide)
2 GC
Anticonvulsants Anticonvulsants
carbamazepine (Tegretol) 2 GC
CARBATROL 4
DEPAKOTE ER 4
DEPAKOTE SPRINKLE 4
DEPAKOTE 4
DILANTIN capsule: 30mg 3
DILANTIN capsule: 100mg 4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
25
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
divalproex sodium (Depakote ER) 2 GC
EQUETRO 4
gabapentin (Neurontin) 2 GC
GRALISE tab er 24h: 300-600mg 4 ST, QL: 78 in 30 days
GRALISE tab er 24h: 300mg, 600mg 4 ST, QL: 90 in 30 days
KEPPRA XR 4
KEPPRA solution, tablet 4
LAMICTAL (BLUE) 4
LAMICTAL (GREEN) 4
LAMICTAL (ORANGE) 4
LAMICTAL ODT 4
LAMICTAL XR (BLUE) 4
LAMICTAL XR (GREEN) 4
LAMICTAL XR (ORANGE) 4
LAMICTAL XR 4
LAMICTAL tablet, tb chw dsp: 5mg,
25mg
4
lamotrigine tab er 24, tablet, tb chw dsp (Lamictal) 2 GC
levetiracetam (Keppra) 2 GC
LYRICA capsule 3 QL: 90 in 30 days
LYRICA solution 3 QL: 900 in 30 days
NEURONTIN 4
PHENYTEK 3
phenytoin sodium extended (Dilantin) 2 GC
QUDEXY XR 4
TEGRETOL XR tab er 12h: 100mg 3
TEGRETOL XR tab er 12h: 200mg,
400mg
4
TEGRETOL 4
TOPAMAX 4
topiramate cap sprink, tablet (Topamax) 2 GC
TROKENDI XR 4
Antidementia Agents Antidementia Agents
ARICEPT ODT 4 QL: 30 in 30 days
ARICEPT 4 QL: 30 in 30 days
donepezil hcl (Aricept) 2 GC, QL: 30 in 30 days
NAMENDA XR cap24 dspk 3 QL: 28 in 28 days
NAMENDA XR cap spr 24 3 QL: 30 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
26
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
NAMENDA 3 QL: 360 in 30 days
Antidepressants Antidepressants
amitriptyline hcl (Amitriptyline HCl) 2 GC, PA-HRM
bupropion hcl (Wellbutrin XL) 2 GC
CELEXA 4 QL: 30 in 30 days
citalopram hydrobromide tablet (Celexa) 1 GC, QL: 30 in 30 days
citalopram hydrobromide solution (Celexa) 2 GC
CYMBALTA capsule dr: 30mg 4 QL: 30 in 30 days
CYMBALTA capsule dr: 20mg, 60mg 4 QL: 60 in 30 days
duloxetine hcl capsule dr: 30mg (Cymbalta) 2 GC, QL: 30 in 30 days
duloxetine hcl capsule dr: 20mg, 60mg (Cymbalta) 2 GC, QL: 60 in 30 days
EFFEXOR XR 4
escitalopram oxalate (Lexapro) 2 GC
fluoxetine hcl capsule (Prozac) 1 GC
fluoxetine hcl capsule dr, solution, tablet (Rapiflux) 2 GC
FORFIVO XL 4
LEXAPRO tablet 4
LEXAPRO solution 4 QL: 697 in 30 days
paroxetine hcl (Paxil) 2 GC
PAXIL CR 4
PAXIL 4
PROZAC WEEKLY 4
PROZAC 4
SARAFEM 4
sertraline hcl tablet (Zoloft) 1 GC
sertraline hcl oral conc (Zoloft) 2 GC
trazodone hcl (Trazodone HCl) 1 GC
VENLAFAXINE HCL ER 3
venlafaxine hcl (Effexor XR) 2 GC
WELLBUTRIN SR 4
WELLBUTRIN XL 4
WELLBUTRIN 4
ZOLOFT 4
Antidiabetic Agents Antidiabetic Agents, Miscellaneous
ACTOS 4 QL: 30 in 30 days
BYDUREON 3 ST, QL: 4 in 28 days
FORTAMET tab er 24: 500mg 4 QL: 120 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
27
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
FORTAMET tab er 24: 1000mg 4 QL: 60 in 30 days
GLUCOPHAGE XR tab er 24h: 500mg 4 QL: 120 in 30 days
GLUCOPHAGE XR tab er 24h: 750mg 4 QL: 60 in 30 days
GLUCOPHAGE tablet: 500mg 4 QL: 120 in 30 days
GLUCOPHAGE tablet: 1000mg 4 QL: 60 in 30 days
GLUCOPHAGE tablet: 850mg 4 QL: 90 in 30 days
GLUMETZA tabergr24h: 500mg 4 QL: 120 in 30 days
GLUMETZA tabergr24h: 1000mg 4 QL: 60 in 30 days
INVOKANA tablet: 300mg 3 ST, QL: 30 in 30 days
INVOKANA tablet: 100mg 3 ST, QL: 60 in 30 days
JANUMET XR tbmp 24hr: 50mg-500mg,
100-1000mg
3 QL: 30 in 30 days
JANUMET XR tbmp 24hr: 50-1000mg 3 QL: 60 in 30 days
JANUMET 3 QL: 60 in 30 days
JANUVIA 3 QL: 30 in 30 days
metformin hcl tab er 24h: 500mg (Fortamet) 2 GC, QL: 120 in 30 days
metformin hcl tab er 24 (Fortamet) 2 GC, QL: 60 in 30 days
metformin hcl tab er 24h: 750mg (Fortamet) 2 GC, QL: 90 in 30 days
metformin hcl tablet: 500mg (Glucophage) 1 GC, QL: 120 in 30 days
metformin hcl tablet: 1000mg (Glucophage) 1 GC, QL: 60 in 30 days
metformin hcl tablet: 850mg (Glucophage) 1 GC, QL: 90 in 30 days
pioglitazone hcl (Actos) 2 GC, QL: 30 in 30 days
RIOMET 4 QL: 765 in 30 days
TRADJENTA 3 QL: 30 in 30 days
VICTOZA 3-PAK 4 PA, QL: 9 in 28 days
Insulins
HUMALOG insuln pen 6 QL: 30 in 28 days
HUMALOG vial 6 QL: 40 in 28 days
HUMULIN N KWIKPEN 6 QL: 30 in 28 days
HUMULIN N 6 QL: 40 in 28 days
LANTUS SOLOSTAR 6 QL: 30 in 28 days
LANTUS 6 QL: 40 in 28 days
NOVOLIN N vial 6 QL: 40 in 28 days
Sulfonylureas
AMARYL tablet: 1mg, 2mg 4 QL: 30 in 30 days
AMARYL tablet: 4mg 4 QL: 60 in 30 days
DIABETA tablet: 5mg 4 PA-HRM, QL: 120 in 30
days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
28
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
DIABETA tablet: 2.5mg 4 PA-HRM, QL: 240 in 30
days
DIABETA tablet: 1.25mg 4 PA-HRM, QL: 280 in 30
days
glimepiride tablet: 1mg, 2mg (Amaryl) 1 GC, QL: 30 in 30 days
glimepiride tablet: 4mg (Amaryl) 1 GC, QL: 60 in 30 days
glipizide tab er 24: 2.5mg, 5mg (Glucotrol XL) 2 GC, QL: 30 in 30 days
glipizide tab er 24: 10mg (Glucotrol XL) 2 GC, QL: 60 in 30 days
glipizide tablet: 10mg (Glucotrol) 1 GC, QL: 120 in 30 days
glipizide tablet: 5mg (Glucotrol) 1 GC, QL: 60 in 30 days
GLUCOTROL XL tab er 24: 2.5mg, 5mg 4 QL: 30 in 30 days
GLUCOTROL XL tab er 24: 10mg 4 QL: 60 in 30 days
GLUCOTROL tablet: 10mg 4 QL: 120 in 30 days
GLUCOTROL tablet: 5mg 4 QL: 30 in 30 days
glyburide tablet: 5mg (Micronase) 2 GC, PA-HRM, QL: 120
in 30 days
glyburide tablet: 2.5mg (Micronase) 2 GC, PA-HRM, QL: 240
in 30 days
glyburide tablet: 1.25mg (Micronase) 2 GC, PA-HRM, QL: 280
in 30 days
Antifungals Antifungals
clotrimazole (Mycelex) 2 GC
clotrimazole/betamethasone dip (Lotrisone) 2 GC
DIFLUCAN 4
econazole nitrate (Spectazole) 2 GC
EXTINA 4
fluconazole (Diflucan) 2 GC
ketoconazole (Kuric) 2 GC
KETODAN 4
LAMISIL 4
LOTRISONE 4
NIZORAL 4
nystatin (Nystatin) 2 GC
nystatin/triamcin (Mycogen II) 2 GC
terbinafine hcl (Lamisil) 2 GC
Antihistamines Antihistamines
CLARINEX 4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
29
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
cyproheptadine hcl (Cyproheptadine HCl) 2 GC, PA-HRM
desloratadine (Clarinex) 2 GC
levocetirizine dihydrochloride (Xyzal) 2 GC
XYZAL 4
Anti-infectives (Skin and Mucous Membrane) Anti-infectives (Skin and Mucous Membrane)
METROGEL-VAGINAL 4
metronidazole (Metrogel-vaginal) 2 GC
TERAZOL 3 4
TERAZOL 7 4
terconazole (Terazol 3) 2 GC
VANDAZOLE 4
Antimigraine Agents Antimigraine Agents
ALSUMA 4 QL: 4 in 28 days
AMERGE 4 QL: 18 in 28 days
IMITREX tablet 4 QL: 18 in 28 days
IMITREX cartridge, pen injctr, vial 4 QL: 4 in 28 days
MAXALT MLT 4 QL: 18 in 28 days
MAXALT 4 QL: 18 in 28 days
naratriptan hcl (Amerge) 2 GC, QL: 18 in 28 days
rizatriptan benzoate (Maxalt Mlt) 2 GC, QL: 18 in 28 days
sumatriptan succinate tablet (Imitrex) 2 GC, QL: 18 in 28 days
sumatriptan succinate pen injctr, vial (Imitrex) 2 GC, QL: 4 in 28 days
SUMAVEL DOSEPRO 4 QL: 4 in 28 days
Antimycobacterials Antimycobacterials
dapsone (Dapsone) 2 GC
ethambutol hcl (Myambutol) 2 GC
isoniazid tablet (Isoniazid) 1 GC
isoniazid solution, vial (Isoniazid) 2 GC
MYAMBUTOL 4
RIFADIN 4
rifampin (Rifadin) 2 GC
Antinausea Agents Antinausea Agents
meclizine hcl (Antivert) 2 GC
ondansetron hcl (Zofran) 2 GC, PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
30
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
ondansetron (Zofran Odt) 2 GC, PA BvD
PHENERGAN 4 PA-HRM
prochlorperazine maleate tablet (Compazine) 1 GC
prochlorperazine maleate supp.rect (Compazine) 2 GC
promethazine hcl ampul, supp.rect, tablet,
vial: 25mg/ml
(Promethazine HCl) 2 GC, PA-HRM
ZOFRAN ODT 5 PA BvD
ZOFRAN vial 4
ZOFRAN solution 4 PA BvD
ZOFRAN tablet 5 PA BvD
Antiparasite Agents Antiparasite Agents
ALBENZA 4
atovaquone/proguanil hcl (Malarone) 2 GC
FLAGYL ER 4
FLAGYL 4
hydroxychloroquine sulfate (Plaquenil) 2 GC
MALARONE 4
mefloquine hcl (Lariam) 2 GC
metronidazole (Flagyl) 2 GC
PLAQUENIL 4
Antiparkinsonian Agents Antiparkinsonian Agents
benztropine mesylate (Benztropine Mesylate) 2 GC, PA-HRM
carbidopa/levodopa (Sinemet 10-100) 2 GC
COGENTIN 4 PA-HRM
MIRAPEX ER 4
MIRAPEX 4
pramipexole di-hcl (Mirapex) 2 GC
REQUIP XL 4
REQUIP 4
ropinirole hcl (Requip) 2 GC
SINEMET 10-100 4
SINEMET 25-100 4
SINEMET 25-250 4
SINEMET CR 4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
31
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Antipsychotic Agents Antipsychotic Agents
ABILIFY DISCMELT tab rapdis: 15mg 3 QL: 60 in 30 days
ABILIFY DISCMELT tab rapdis: 10mg 3 QL: 90 in 30 days
ABILIFY MAINTENA 5 QL: 1 in 28 days
ABILIFY vial 3 QL: 161.2 in 28 days
ABILIFY tablet: 5mg, 10mg, 15mg, 20mg,
30mg
3 QL: 30 in 30 days
ABILIFY tablet: 2mg 3 QL: 60 in 30 days
ABILIFY solution 3 QL: 900 in 30 days
clozapine tablet: 200mg (Clozaril) 2 GC, QL: 135 in 30 days
clozapine tablet: 100mg (Clozaril) 2 GC, QL: 270 in 30 days
clozapine tablet: 25mg, 50mg (Clozaril) 2 GC, QL: 90 in 30 days
CLOZARIL tablet: 100mg 4 QL: 270 in 30 days
CLOZARIL tablet: 25mg 4 QL: 90 in 30 days
FAZACLO tab rapdis: 200mg 4 ST, QL: 120 in 30 days
FAZACLO tab rapdis: 150mg 4 ST, QL: 180 in 30 days
FAZACLO tab rapdis: 12.5mg, 25mg,
100mg
4 ST, QL: 90 in 30 days
GEODON capsule 4 QL: 60 in 30 days
haloperidol (Haloperidol) 2 GC
olanzapine tab rapdis: 20mg (Zyprexa Zydis) 2 GC, QL: 31 in 30 days
olanzapine tab rapdis: 5mg, 10mg, 15mg;
tablet, vial
(Zyprexa) 2 GC, QL: 30 in 30 days
quetiapine fumarate (Seroquel) 2 GC, QL: 90 in 30 days
RISPERDAL M-TAB tab rapdis: 3mg,
4mg
4 QL: 120 in 30 days
RISPERDAL M-TAB tab rapdis: 0.5mg,
1mg, 2mg
4 QL: 60 in 30 days
RISPERDAL solution 4 QL: 480 in 30 days
RISPERDAL tablet 4 QL: 60 in 30 days
risperidone tab rapdis: 3mg, 4mg (Risperdal M-tab) 2 GC, QL: 120 in 30 days
risperidone solution (Risperdal) 2 GC, QL: 480 in 30 days
risperidone tab rapdis: 0.25mg, 0.5mg,
1mg, 2mg; tablet
(Risperdal) 2 GC, QL: 60 in 30 days
SEROQUEL XR tab er 24h: 200mg 4 ST, QL: 30 in 30 days
SEROQUEL XR tab er 24h: 50mg,
150mg, 300mg, 400mg
4 ST, QL: 60 in 30 days
SEROQUEL 4 QL: 90 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
32
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
VERSACLOZ 5 ST, QL: 540 in 30 days
ziprasidone hcl (Geodon) 2 GC, QL: 60 in 30 days
ZYPREXA ZYDIS 4 QL: 30 in 30 days
ZYPREXA 4 QL: 30 in 30 days
Antivirals (Systemic) Antiretrovirals
ATRIPLA 5
EPZICOM 5
ISENTRESS powd pack, tab chew 3
ISENTRESS tablet 5
NORVIR 4
PREZISTA tablet: 75mg, 150mg 3
PREZISTA oral susp 4
PREZISTA tablet: 600mg, 800mg 5
REYATAZ 5
STRIBILD 5
TRUVADA 5
VIREAD 5
Antivirals, Miscellaneous
SYNAGIS 5
TAMIFLU 3
Hcv Antivirals
OLYSIO 5 PA, QL: 28 in 28 days
SOVALDI 5 PA, QL: 28 in 28 days
Interferons
PEGASYS PROCLICK 5 PA
PEGASYS 5 PA
PEGINTRON REDIPEN 5 PA
PEGINTRON 5 PA
SYLATRON 4-PACK 5 PA NSO, QL: 4 in 28
days
Nucleosides and Nucleotides
acyclovir (Zovirax) 2 GC
famciclovir (Famvir) 2 GC
FAMVIR 4
valacyclovir hcl (Valtrex) 2 GC
VALTREX 4
ZOVIRAX oral susp 4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
33
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Blood Products/modifiers/volume Expanders Anticoagulants
COUMADIN 4
enoxaparin sodium syringe: 40mg/0.4ml (Lovenox) 2 GC, QL: 13.6 in 30 days
enoxaparin sodium syringe: 30mg/0.3ml (Lovenox) 2 GC, QL: 18 in 30 days
enoxaparin sodium syringe: 60mg/0.6ml (Lovenox) 2 GC, QL: 20.4 in 30 days
enoxaparin sodium syringe: 80mg/0.8ml (Lovenox) 2 GC, QL: 27.2 in 30 days
enoxaparin sodium vial (Lovenox) 2 GC, QL: 36 in 30 days
enoxaparin sodium syringe: 120mg/.8ml (Lovenox) 5 QL: 27.2 in 30 days
enoxaparin sodium syringe: 150mg/ml (Lovenox) 5 QL: 34 in 30 days
enoxaparin sodium syringe: 100mg/ml (Lovenox) 5 QL: 36 in 30 days
LOVENOX syringe: 40mg/0.4ml 4 QL: 13.6 in 30 days
LOVENOX syringe: 30mg/0.3ml 4 QL: 18 in 30 days
LOVENOX syringe: 60mg/0.6ml 4 QL: 20.4 in 30 days
LOVENOX syringe: 80mg/0.8ml, 120mg/
.8ml
4 QL: 27.2 in 30 days
LOVENOX syringe: 150mg/ml 4 QL: 34 in 30 days
LOVENOX syringe: 100mg/ml; vial 4 QL: 36 in 30 days
warfarin sodium (Coumadin) 1 GC
XARELTO tablet: 10mg, 20mg 3 QL: 30 in 30 days
XARELTO tablet: 15mg 3 QL: 42 in 21 days
Blood Formation Modifiers
EPOGEN 3 PA, QL: 12 in 28 days
NEULASTA 5
NEUPOGEN 5
PROCRIT vial: 2000/ml, 3000/ml, 4000/
ml, 20000/2ml
3 PA, QL: 12 in 28 days
PROCRIT vial: 20000/ml 5 PA, QL: 12 in 28 days
PROCRIT vial: 40000/ml 5 PA, QL: 6 in 28 days
Hematologic Agents, Miscellaneous
AGRYLIN 4
anagrelide hcl (Agrylin) 2 GC
CYKLOKAPRON 4
LYSTEDA 4 QL: 30 in 30 days
tranexamic acid tablet (Lysteda) 2 GC, QL: 30 in 30 days
tranexamic acid vial (Tranexamic Acid) 2 GC
Platelet-aggregation Inhibitors
clopidogrel bisulfate (Plavix) 2 GC
EFFIENT 3 QL: 30 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
34
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
PLAVIX 4
Caloric Agents Caloric Agents
CLINIMIX E iv soln: 4.25% 4 PA BvD
CLINIMIX E iv soln: 5% 4 PA BvD
CLINISOL 4 PA BvD
dextrose 10 % in water (Dextrose 10 % in
Water)
2 GC, PA BvD
dextrose 5 % and 0.9 % nacl (Dextrose 5 % and 0.9
% NaCl)
2 GC
dextrose 5 % in water (Dextrose 5 % in
Water)
2 GC
dextrose 5 %-0.45 % nacl (Dextrose 5 %-0.45 %
NaCl)
2 GC
dextrose 5%-lactated ringers (Dextrose 5%-Lactated
Ringers)
2 GC
INTRALIPID emulsion: 20%, 30% 4 PA BvD
LIPOSYN III emulsion: 10%, 20% 4 PA BvD
PROSOL 4 PA BvD
TRAVASOL iv soln: 10% 4 PA BvD
TROPHAMINE iv soln: 10% 4 PA BvD
Cardiovascular Agents Alpha-adrenergic Agents
CARDURA XL 4
CARDURA 4
CATAPRES 4
clonidine hcl (Catapres) 1 GC
doxazosin mesylate (Cardura) 2 GC
guanfacine hcl (Tenex) 2 GC, PA-HRM
TENEX 4 PA-HRM
Angiotensin II Receptor Antagonists
AVAPRO 4 ST
COZAAR 4
DIOVAN HCT 4 ST
DIOVAN 3 ST
HYZAAR 4
irbesartan (Avapro) 2 GC
losartan potassium (Cozaar) 1 GC
losartan/hydrochlorothiazide (Hyzaar) 2 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
35
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
valsartan/hydrochlorothiazide (Diovan HCT) 2 GC
Angiotensin-Converting Enzyme Inhibitors
ALTACE 4
benazepril hcl (Lotensin) 1 GC
enalapril maleate (Vasotec) 1 GC
EPANED 4
lisinopril (Zestril) 1 GC
lisinopril/hydrochlorothiazide (Prinzide) 1 GC
LOTENSIN 4
PRINIVIL tablet: 5mg, 10mg, 20mg 4
ramipril (Altace) 2 GC
VASOTEC 4
ZESTORETIC 4
ZESTRIL 4
Antiarrhythmic Agents
amiodarone hcl tablet, vial (Cordarone) 2 GC
flecainide acetate (Tambocor) 2 GC
propafenone hcl (Rythmol) 2 GC
RYTHMOL SR 4
RYTHMOL 4
Beta-Adrenergic Blocking Agents
atenolol (Tenormin) 1 GC
BYSTOLIC 3
carvedilol (Coreg) 1 GC
COREG 4
INDERAL LA 4
INNOPRAN XL 4
LOPRESSOR 4
metoprolol succinate (Toprol XL) 2 GC
metoprolol tartrate tablet (Lopressor) 1 GC
metoprolol tartrate vial (Metoprolol Tartrate) 2 GC
propranolol hcl (Propranolol HCl) 2 GC
TENORMIN 4
TOPROL XL 4
Calcium-channel Blocking Agents
CALAN SR 4
CALAN 4
CARDIZEM CD 4
CARDIZEM LA 4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
36
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
CARDIZEM 4
DILACOR XR 4
diltiazem hcl tablet (Cardizem CD) 1 GC
diltiazem hcl cap er 12h, cap er 24h, cap er
deg, capsule er, tab er 24h, vial, vial port
(Cardizem CD) 2 GC
TIAZAC 4
verapamil hcl tablet (Calan) 1 GC
verapamil hcl cap24h pct, cap24h pel,
tablet er, vial
(Calan) 2 GC
VERELAN PM 4
VERELAN 4
Cardiovascular Agents, Miscellaneous
AUVI-Q 4
epinephrine ampul (Epinephrine) 2 GC
EPIPEN 2-PAK 3
EPIPEN JR 2-PAK 3
hydralazine hcl (Apresoline) 2 GC
Dihydropyridines
ADALAT CC 4
amlodipine besylate (Norvasc) 1 GC
amlodipine besylate/benazepril (Lotrel) 2 GC
LOTREL 4
nifedipine tab er 24, tablet er (Procardia XL) 2 GC
nifedipine capsule (Procardia) 2 GC, PA-HRM
NORVASC 4
PROCARDIA XL 4
PROCARDIA 4 PA-HRM
Diuretics
chlorthalidone (Chlorthalidone) 1 GC
DYAZIDE 4
furosemide solution, vial (Furosemide) 2 GC
furosemide tablet (Lasix) 1 GC
hydrochlorothiazide (Microzide) 1 GC
LASIX 4
MAXZIDE-25 MG 4
MAXZIDE 4
MICROZIDE 4
triamterene/hydrochlorothiazid (Maxzide) 2 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
37
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Dyslipidemics
ALTOPREV 4
atorvastatin calcium (Lipitor) 2 GC
CRESTOR 3
fenofibrate (Lofibra) 2 GC
FENOGLIDE 4
gemfibrozil (Lopid) 2 GC
LIPITOR 4
LIPOFEN 4
LOFIBRA tablet 4
LOPID 4
lovastatin (Mevacor) 1 GC
PRAVACHOL 4
pravastatin sodium (Pravachol) 1 GC
simvastatin (Zocor) 1 GC, QL: 30 in 30 days
ZOCOR 4 QL: 30 in 30 days
Renin-Angiotensin-Aldosterone System Inhibitors
ALDACTAZIDE 4
ALDACTONE 4
spironolact/hydrochlorothiazid (Aldactazide) 2 GC
spironolactone (Aldactone) 2 GC
Vasodilators
isosorbide mononitrate (Imdur) 2 GC
NITRO-BID 3
NITRO-DUR patch td24: 0.3mg/hr,
0.8mg/hr
4
NITRO-DUR patch td24: 0.1mg/hr,
0.2mg/hr, 0.4mg/hr, 0.6mg/hr
4 QL: 30 in 30 days
nitroglycerin patch td24: 0.1mg/hr, 0.2mg/
hr, 0.6mg/hr
(Nitro-dur) 2 GC, QL: 30 in 30 days
nitroglycerin patch td24: 0.4mg/hr (Nitro-dur) 2 GC, QL: 60 in 30 days
nitroglycerin spray, vial: 50mg/10ml (Nitromist) 2 GC
NITROLINGUAL 4
NITROMIST 4
NITROSTAT 3
Central Nervous System Agents Central Nervous System Agents
ADDERALL XR cap er 24h: 5mg, 10mg,
15mg
4 QL: 30 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
38
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
ADDERALL XR cap er 24h: 20mg, 25mg,
30mg
4 QL: 60 in 30 days
ADDERALL tablet: 20mg 4 QL: 60 in 30 days
CONCERTA tab er 24: 18mg, 27mg,
54mg
4 QL: 30 in 30 days
CONCERTA tab er 24: 36mg 4 QL: 60 in 30 days
dexmethylphenidate hcl cpbp 50-50 (Focalin XR) 2 GC, QL: 30 in 30 days
dexmethylphenidate hcl tablet (Focalin) 2 GC, QL: 60 in 30 days
dextroamphetamine/amphetamine cap er
24h: 5mg, 10mg, 15mg
(Adderall XR) 2 GC, QL: 30 in 30 days
dextroamphetamine/amphetamine cap er
24h: 20mg, 25mg, 30mg; tablet
(Adderall) 2 GC, QL: 60 in 30 days
FOCALIN XR 4 QL: 30 in 30 days
FOCALIN 4 QL: 60 in 30 days
lithium carbonate (Eskalith) 2 GC
LITHOBID 4
METADATE CD cpbp 30-70: 10mg,
20mg, 40mg, 50mg, 60mg
4 QL: 30 in 30 days
METADATE CD cpbp 30-70: 30mg 4 QL: 60 in 30 days
METADATE ER 4 QL: 90 in 30 days
METHYLIN tab chew: 10mg 4 QL: 180 in 30 days
METHYLIN tab chew: 2.5mg, 5mg 4 QL: 90 in 30 days
METHYLIN solution 4 QL: 900 in 30 days
methylphenidate hcl cpbp 30-70: 10mg,
20mg, 40mg, 50mg, 60mg; tab er 24:
18mg, 27mg, 54mg
(Concerta) 2 GC, QL: 30 in 30 days
methylphenidate hcl cpbp 30-70: 30mg; tab
er 24: 36mg
(Concerta) 2 GC, QL: 60 in 30 days
methylphenidate hcl solution (Methylin) 2 GC, QL: 900 in 30 days
methylphenidate hcl tablet, tablet er (Ritalin) 2 GC, QL: 90 in 30 days
QUILLIVANT XR 3 QL: 360 in 30 days
RITALIN LA cpbp 50-50: 10mg, 20mg,
40mg
4 QL: 30 in 30 days
RITALIN LA cpbp 50-50: 30mg 4 QL: 60 in 30 days
RITALIN 4 QL: 90 in 30 days
RITALIN-SR 4 QL: 90 in 30 days
VYVANSE 4 QL: 30 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
39
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Contraceptives Contraceptives
AMETHYST 4
ESTROSTEP FE 4
ethinyl estradiol/drospirenone (Yaz) 2 GC
levonorgestrel-ethin estradiol tablet (Nordette-28) 2 GC
levonorgestrel-ethin estradiol tbdspk 3mo (Seasonale) 2 GC, QL: 91 in 84 days
LO LOESTRIN FE 4
MINASTRIN 24 FE 4
MODICON 4
norethindrone-e.estradiol-iron (Loestrin Fe) 2 GC
norethindrone-ethinyl estrad tablet: 0.4-
0.035, 0.5-0.035, 1mg-35mcg, 7-9-5,
7daysx3, 10-11
(Modicon) 2 GC
norethindrone-ethinyl estrad tablet: 0.5-
0.035, 1mg-35mcg
(Modicon) 4
norgestimate-ethinyl estradiol (Ortho-cyclen) 2 GC
ORTHO TRI-CYCLEN LO 4
ORTHO TRI-CYCLEN 4
ORTHO-CYCLEN 4
ORTHO-NOVUM tablet: 1mg-35mcg,
7daysx3
4
OVCON-35 4
TRI-NORINYL 4
YASMIN 28 4
YAZ 4
Dental And Oral Agents Dental And Oral Agents
chlorhexidine gluconate (Peridex) 2 GC
triamcinolone acetonide (Kenalog In Orabase) 2 GC
Dermatological Agents Dermatological Agents, Other
ABSORICA 4
acyclovir (Zovirax) 2 GC, QL: 30 in 30 days
ALDARA 4 PA NSO, QL: 24 in 30
days
ammonium lactate (Lac-hydrin) 2 GC
AZELEX 4
calcipotriene (Dovonex) 2 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
40
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
CARAC 4
DOVONEX 4
EFUDEX 4
FINACEA 4
fluorouracil (Efudex) 2 GC
imiquimod (Aldara) 2 GC, PA NSO, QL: 24 in
30 days
isotretinoin (Accutane) 2 GC
LAC-HYDRIN 4
SORILUX 4
ZOVIRAX cream (g) 3 QL: 15 in 30 days
ZOVIRAX oint. (g) 4 QL: 30 in 30 days
ZYCLARA crm md pmp: 2.5% 4 PA NSO, QL: 15 in 28
days
ZYCLARA crm md pmp: 3.75% 4 PA NSO
Dermatological Antibacterials
ACANYA 4
BACTROBAN oint. (g) 4
CLEOCIN T 4
CLINDACIN P 4
clindamycin phos/benzoyl perox (Benzaclin) 2 GC
clindamycin phosphate (Cleocin T) 2 GC
METROCREAM 4
METROGEL 4
METROLOTION 4
metronidazole (Nydamax) 2 GC
mupirocin (Centany) 2 GC
NORITATE 4
SILVADENE 4
silver sulfadiazine (Silvadene) 2 GC
Dermatological Anti-inflammatory Agents
ANUSOL-HC 4
betamethasone dipropionate (Del-beta) 2 GC
CAPEX SHAMPOO 4
clobetasol propionate (Temovate) 2 GC
CLOBEX 4
DESONATE 4
desonide (Desowen) 2 GC
ELOCON 4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
41
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
fluocinolone acetonide (Derma-smoothe-fs) 2 GC
fluocinonide (Vanos) 2 GC
hydrocortisone cream (g), cream/appl,
enema, lotion, oint. (g)
(Hytone) 2 GC
KENALOG aerosol 4
mometasone furoate (Elocon) 2 GC
OLUX 4
SYNALAR cream (g) 4
TEMOVATE 4
triamcinolone acetonide cream (g), lotion,
oint. (g): 0.025%, 0.1%, 0.5%
(Triamcinolone
Acetonide)
2 GC
VANOS 5
Dermatological Retinoids
adapalene (Differin) 2 GC
ATRALIN 4 PA
DIFFERIN cream (g), gel (gram), lotion 4
RETIN-A 4 PA
tretinoin cream (g): 0.025%, 0.05%, 0.1%;
gel (gram): 0.01%, 0.025%
(Retin-A) 2 GC, PA
tretinoin cream (g): 0.025%; gel (gram):
0.025%
(Retin-A) 4 PA
Scabicides and Pediculicides
malathion (Ovide) 2 GC
OVIDE 4
permethrin (Elimite) 2 GC
Devices Devices
syring w-ndl,disp,insul,0.5ml (Syring W-
ndl,disp,insul,0.5ml)
2 GC
syringe & needle,insulin,1 ml (Syringe &
Needle,insulin,1 Ml)
2 GC
Enzyme Replacement/modifiers Enzyme Replacement/modifiers
CIMZIA 5 PA
CREON 3
KUVAN 5
LINZESS 3 QL: 30 in 30 days
LOTRONEX 5
PANCREAZE 4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
42
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
PERTZYE 4
PULMOZYME 5 PA BvD
ULTRESA 4
VIOKACE 4
ZENPEP 3
Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous
ASTEPRO 4 QL: 30 in 25 days
ATROVENT spray: 42mcg 4 QL: 15 in 10 days
ATROVENT spray: 21mcg 4 QL: 30 in 28 days
azelastine hcl spray/pump (Astelin) 2 GC, QL: 30 in 25 days
azelastine hcl drops (Optivar) 2 GC
cromolyn sodium (Cromolyn Sodium) 2 GC
ipratropium bromide spray: 42mcg (Atrovent) 2 GC, QL: 15 in 10 days
ipratropium bromide spray: 21mcg (Atrovent) 2 GC, QL: 30 in 28 days
OPTIVAR 4
PATADAY 3 ST
PATANASE 4 QL: 30.5 in 30 days
PATANOL 3 ST
Eye, Ear, Nose, Throat Anti-infectives Agents
CILOXAN 4
CIPRODEX 4
ciprofloxacin hcl drops (Ciloxan) 2 GC
CORTISPORIN solution 4
erythromycin base (Ilotycin) 2 GC
gentamicin sulfate (Garamycin) 2 GC
MAXITROL 4
neo/polymyx b sulf/dexameth (Maxitrol) 2 GC
neomycin/polymyxin b sulf/hc (Oticin HC) 2 GC
OCUFLOX 4
ofloxacin (Floxin) 2 GC
polymyxin b sulf/trimethoprim (Polytrim) 2 GC
POLYTRIM 4
TOBRADEX ST 3
TOBRADEX 4
tobramycin/dexamethasone (Tobradex) 2 GC
Eye, Ear, Nose, Throat Anti-inflammatory Agents
ACULAR LS 4
ACULAR 4
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pages of this document
43
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
FLONASE 4 QL: 16 in 30 days
flunisolide (Nasarel) 2 GC, QL: 50 in 25 days
fluticasone propionate (Flonase) 2 GC, QL: 16 in 30 days
ketorolac tromethamine (Acular) 2 GC
NASACORT AQ 4 QL: 16.5 in 30 days
NASONEX 4 QL: 34 in 28 days
OMNIPRED 4
PRED FORTE 4
PRED MILD 4
prednisolone acetate (Omnipred) 2 GC
RESTASIS 3 QL: 60 in 30 days
triamcinolone acetonide (Nasacort Aq) 2 GC, QL: 16.5 in 30 days
Gastrointestinal Agents Antiulcer Agents And Acid Suppressants
famotidine tablet (Pepcid) 1 GC (Rx Product Only)
famotidine tablet (Pepcid) 1 GC
famotidine oral susp (Pepcid) 2 GC (Rx Product Only)
lansoprazole (Prevacid) 2 GC (Rx Product Only)
NEXIUM 4 ST
omeprazole (Prilosec) 2 GC
pantoprazole sodium (Protonix) 2 GC
PEPCID 4 (Rx Product Only)
PREVACID 4 ST (Rx Product Only)
PRILOSEC capsule dr 4 (Rx Product Only)
PROTONIX IV 4
PROTONIX 4
ranitidine hcl capsule, syrup, vial (Taladine) 2 GC (Rx Product Only)
ranitidine hcl tablet (Zantac) 1 GC (Rx Product Only)
ranitidine hcl capsule, syrup, vial (Zantac) 2 GC
ZANTAC 4 (Rx Product Only)
ZANTAC 4
Gastrointestinal Agents, Other
ACTIGALL 4
BENTYL 4
dicyclomine hcl (Bentyl) 2 GC
diphenoxylate hcl/atropine (Lomotil) 2 GC
KRISTALOSE 4
lactulose solution: 10g/15ml (Lactulose) 2 GC
LOMOTIL 4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
44
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
metoclopramide hcl solution, vial (Metoclopramide HCl) 2 GC
metoclopramide hcl tablet (Reglan) 1 GC
METOZOLV ODT 4
REGLAN 4
URSO FORTE 4
URSO 4
ursodiol (Actigall) 2 GC
Laxatives
COLYTE with FLAVOR PACKETS 4
GOLYTELY 4
peg 3350/na sulf,bicarb,cl/kcl (Golytely) 2 GC
polyethylene glycol 3350 (Miralax) 2 GC
Phosphate Binders
calcium acetate (Phoslo) 2 GC
PHOSLO 4
PHOSLYRA 4
RENVELA 3
Genitourinary Agents Antispasmodics, Urinary
DETROL LA 4
DETROL 4
DITROPAN XL 4
GELNIQUE gel packet 4 QL: 30 in 30 days
oxybutynin chloride (Ditropan) 2 GC
tolterodine tartrate (Detrol LA) 2 GC
VESICARE 3
Genitourinary Agents, Miscellaneous
FLOMAX 4
tamsulosin hcl (Flomax) 2 GC
terazosin hcl (Hytrin) 1 GC
Heavy Metal Antagonists Heavy Metal Antagonists
CUPRIMINE 4
DEPEN 4
EXJADE tab disper: 125mg 4
EXJADE tab disper: 250mg, 500mg 5
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
45
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Hormonal Agents, Stimulant/replacement/modifying Androgens
ANDRODERM 3 PA, QL: 30 in 30 days
ANDROGEL gel md pmp: 20.25/1.25 3 PA, QL: 150 in 30 days
ANDROGEL gel md pmp: 1.25g(1%) 3 PA, QL: 300 in 30 days
AXIRON 4 PA, QL: 180 in 28 days
DEPO-TESTOSTERONE 4 PA
FORTESTA 4 PA, QL: 120 in 30 days
STRIANT 4 PA, QL: 60 in 30 days
TESTIM 4 PA, QL: 300 in 30 days
testosterone cypionate (Depo-testosterone) 2 GC, PA
VOGELXO 4 PA, QL: 300 in 30 days
Estrogens and Antiestrogens
ACTIVELLA 4 PA-HRM
ALORA 4 PA-HRM, QL: 8 in 28
days
CLIMARA 4 PA-HRM, QL: 4 in 28
days
COMBIPATCH 3 PA-HRM, QL: 8 in 28
days
DIVIGEL 4 PA-HRM, QL: 30 in 30
days
ESTRACE cream/appl 3
ESTRACE tablet 4 PA-HRM
estradiol patch tdwk (Climara) 2 GC, PA-HRM, QL: 4 in
28 days
estradiol tablet (Estrace) 2 GC, PA-HRM
estradiol/norethindrone acet (Activella) 2 GC, PA-HRM
ESTRASORB 4 PA-HRM, QL: 97.44 in
28 days
ESTRING 4 QL: 1 in 84 days
EVAMIST 4 PA-HRM, QL: 8.1 in 25
days
FEMHRT 4 PA-HRM
MENOSTAR 4 PA-HRM, QL: 4 in 28
days
MINIVELLE 4 PA-HRM, QL: 8 in 28
days
norethindrone ac-eth estradiol (Femhrt) 2 GC, PA-HRM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
46
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
PREMARIN cream/appl, vial 3
PREMARIN tablet 3 PA-HRM
PREMPHASE 3 PA-HRM
PREMPRO 3 PA-HRM
VAGIFEM 3 QL: 18 in 28 days
VIVELLE-DOT 3 PA-HRM, QL: 8 in 28
days
Glucocorticoids/mineralocorticoids
CORTEF 4 PA BvD
DEXAMETHASONE INTENSOL 4
dexamethasone tablet (Dexamethasone) 1 GC, PA BvD
dexamethasone elixir (Dexamethasone) 2 GC, PA BvD
DEXPAK tab ds pk: 1.5mg(51) 4
hydrocortisone (Cortef) 2 GC, PA BvD
MILLIPRED solution 4
ORAPRED ODT tab rapdis: 15mg, 30mg 4
ORAPRED 4 PA BvD
prednisolone sod phosphate (Orapred) 2 GC, PA BvD
PREDNISONE INTENSOL 3 PA BvD
prednisone tablet (Prednisone) 1 GC, PA BvD
prednisone solution (Prednisone) 2 GC, PA BvD
RAYOS 4 PA BvD
VERIPRED 20 4 PA BvD
Pituitary
DDAVP solution, tablet, vial 4
desmopressin acetate tablet, vial (DDAVP) 2 GC
desmopressin acetate spray/pump (Desmopressin Acetate) 2 GC, QL: 15 in 30 days
GENOTROPIN syringe: 0.2mg/0.25 4 PA
GENOTROPIN various dosage and/or
strengths are available
5 PA
HUMATROPE 5 PA
NORDITROPIN FLEXPRO 5 PA
NORDITROPIN NORDIFLEX 5 PA
NUTROPIN AQ NUSPIN 5 PA
OMNITROPE cartridge: 10mg/1.5ml 4 PA
OMNITROPE cartridge: 5mg/1.5ml; vial 5 PA
SAIZEN cartridge, vial: 5mg 5 PA
SEROSTIM 5 PA
STIMATE 4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
47
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
TEV-TROPIN 4 PA
ZORBTIVE 5 PA
Progestins
CRINONE gel/pf app: 4% 4
DEPO-PROVERA vial: 150mg/ml 4 QL: 1 in 84 days
DEPO-PROVERA vial: 400mg/ml 4 QL: 10 in 28 days
DEPO-SUBQ PROVERA 104 4 QL: 1 in 84 days
ENDOMETRIN 4
medroxyprogesterone acetate vial (Depo-provera) 2 GC, QL: 1 in 84 days
medroxyprogesterone acetate tablet (Provera) 2 GC
progesterone,micronized (Prometrium) 2 GC
PROMETRIUM 4
PROVERA 4
Thyroid and Antithyroid Agents
CYTOMEL 4
levothyroxine sodium vial: 100mcg (Levothyroxine
Sodium)
2 GC
levothyroxine sodium tablet (Levoxyl) 1 GC
LEVOXYL 4
liothyronine sodium (Cytomel) 2 GC
SYNTHROID 4
TIROSINT 4
UNITHROID 4
Immunological Agents Immunological Agents
ARAVA 4
ASTAGRAF XL 4 PA BvD
AZASAN 4 PA BvD
azathioprine (Imuran) 2 GC, PA BvD
CELLCEPT capsule 4 PA BvD
CELLCEPT susp recon, tablet 5 PA BvD
cyclosporine, modified (Neoral) 2 GC, PA BvD
ENBREL pen injctr 5 PA, QL: 3.92 in 28 days
ENBREL vial 5 PA, QL: 8 in 28 days
ENBREL syringe 5 PA, QL: 8.16 in 28 days
HUMIRA kit 5 PA, QL: 2 in 28 days
HUMIRA pen ij kit: 40mg/0.8ml 5 PA, QL: 6 in 28 days
(Starter Kit)
HUMIRA pen ij kit: 40mg/0.8ml 5 PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
48
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
IMURAN 4 PA BvD
leflunomide (Arava) 2 GC
mycophenolate mofetil (Cellcept) 2 GC, PA BvD
NEORAL 4 PA BvD
PROGRAF 4 PA BvD
tacrolimus (Hecoria) 2 GC, PA BvD
Vaccines
ADACEL TDAP vial 3
BOOSTRIX TDAP 3
ENGERIX-B ADULT 3 PA BvD
ENGERIX-B PEDIATRIC-
ADOLESCENT
3 PA BvD
HAVRIX vial 3 PA BvD
MENACTRA 3
MENVEO A-C-Y-W-135-DIP 3
RECOMBIVAX HB vial: 10mcg/ml,
40mcg/ml
3 PA BvD
TWINRIX vial 3
TYPHIM VI 3
VAQTA vial: 50unit/ml 3 PA BvD
ZOSTAVAX 3 QL: 1 in 365 days
Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents
APRISO 3
ASACOL HD 3 ST
balsalazide disodium (Colazal) 2 GC
CANASA 4
COLAZAL 4
DELZICOL 3 ST
GIAZO 4 ST
LIALDA 4 ST
PENTASA 4 ST
Irrigating Solutions Irrigating Solutions
sodium chloride irrig solution (Sodium Chloride Irrig
Solution)
2 GC
water for irrigation,sterile (Water for Irrigation,
Sterile)
2 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
49
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Metabolic Bone Disease Agents Metabolic Bone Disease Agents
ACTONEL tablet: 5mg, 30mg 3 QL: 30 in 30 days
ACTONEL tablet: 35mg 3 QL: 4 in 28 days
ACTONEL tablet: 150mg 4 QL: 1 in 28 days
alendronate sodium tablet: 35mg, 70mg (Fosamax) 1 GC, QL: 4 in 28 days
alendronate sodium tablet: 5mg, 10mg,
40mg
(Fosamax) 1 GC
alendronate sodium solution (Fosamax) 2 GC, QL: 300 in 28 days
ATELVIA 4 QL: 4 in 28 days
BINOSTO 4 QL: 4 in 28 days
BONIVA syringe 4 PA BvD, QL: 3 in 84
days (PA for ESRD
Only)
BONIVA tablet 4 QL: 1 in 28 days
calcitriol (Rocaltrol) 2 GC, PA BvD (PA for
ESRD Only)
FOSAMAX 4
ibandronate sodium tablet (Boniva) 2 GC, QL: 1 in 28 days
ibandronate sodium vial (Ibandronate Sodium) 2 GC, PA BvD, QL: 3 in
84 days (PA for ESRD
Only)
risedronate sodium (Actonel) 2 GC, QL: 1 in 28 days
ROCALTROL 4 PA BvD (PA for ESRD
Only)
Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
allopurinol (Zyloprim) 1 GC
AVODART 3
AVONEX ADMINISTRATION PACK 5 ST
AVONEX 5 ST
buspirone hcl (Buspar) 2 GC
COLCRYS 3
COPAXONE 5
ELMIRON 4
finasteride (Proscar) 2 GC
GLUCAGEN 3
GLUCAGON EMERGENCY KIT 4
hydroxyzine hcl (Hydroxyzine HCl) 2 GC, PA-HRM
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
50
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
hydroxyzine pamoate (Vistaril) 2 GC, PA-HRM
MESTINON 4
PROSCAR 4
pyridostigmine bromide (Mestinon) 2 GC
REBIF 5
SENSIPAR tablet: 30mg 3
SENSIPAR tablet: 60mg, 90mg 5
TECFIDERA capsule dr: 120mg 5 PA, QL: 14 in 30 days
TECFIDERA capsule dr: 120-240mg,
240mg
5 PA, QL: 60 in 30 days
ULORIC 3 ST, QL: 30 in 30 days
VISTARIL 4 PA-HRM
ZYLOPRIM 4
Ophthalmic Agents Antiglaucoma Agents
ALPHAGAN P drops: 0.1% 3
ALPHAGAN P drops: 0.15% 4
brimonidine tartrate (Alphagan P) 2 GC (drops: 0.15%,
0.20%)
COSOPT 4
dorzolamide hcl/timolol maleat (Cosopt) 2 GC
ISTALOL 4
latanoprost (Xalatan) 2 GC
LUMIGAN 3 QL: 2.5 in 25 days
timolol maleate (Timoptic) 2 GC
TIMOPTIC-XE 4
TRAVATAN Z 3 QL: 2.5 in 25 days
XALATAN 4 QL: 2.5 in 25 days
Replacement Preparations Replacement Preparations
0.9 % sodium chloride (0.9 % Sodium
Chloride)
2 GC
K-TAB ER 4
LACTATED RINGERS 4
potassium chloride in 0.9%nacl (Potassium Chloride In
0.9%NaCl)
2 GC
potassium chloride capsule er, piggyback:
10meq/0.1l, 10meq/50ml, 20meq/50ml; tab
er prt, tablet er, vial
(K-dur) 2 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
51
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
potassium chloride/d5-0.45nacl (Potassium Chloride/
d5-0.45NaCl)
2 GC
potassium chloride/d5-0.9%nacl (Potassium Chloride/
d5-0.9%NaCl)
2 GC
potassium citrate tablet er: 5meq, 10meq (Urocit-K) 2 GC
sodium chloride 0.45 % (Sodium Chloride 0.45
%)
2 GC
sodium chloride vial: 2.5meq/ml (Sodium Chloride) 2 GC
UROCIT-K 4
Respiratory Tract Agents Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS 3 QL: 60 in 30 days
ADVAIR HFA 3 QL: 12 in 28 days
FLOVENT DISKUS blst w/dev: 250mcg 3 QL: 120 in 30 days
FLOVENT DISKUS blst w/dev: 50mcg,
100mcg
3 QL: 60 in 30 days
FLOVENT HFA aer w/adap: 110mcg 3 QL: 12 in 28 days
FLOVENT HFA aer w/adap: 44mcg 3 QL: 21.2 in 28 days
FLOVENT HFA aer w/adap: 220mcg 3 QL: 24 in 28 days
QVAR 3 QL: 17.4 in 25 days
Antileukotrienes
ACCOLATE 4
montelukast sodium (Singulair) 2 GC
SINGULAIR 4
zafirlukast (Accolate) 2 GC
Bronchodilators
albuterol sulfate solution, vial-neb:
0.63mg/3ml, 1.25mg/3ml, 2.5mg/3ml
(Accuneb) 2 GC, PA BvD
albuterol sulfate syrup, tab er 12h, tablet (Albuterol Sulfate) 2 GC
ATROVENT HFA 3 QL: 25.8 in 28 days
COMBIVENT RESPIMAT 3 QL: 8 in 30 days
PROAIR HFA 3 QL: 17 in 25 days
PROVENTIL HFA 4 QL: 13.4 in 25 days
SPIRIVA 3 QL: 30 in 30 days
VENTOLIN HFA hfa aer ad: 90mcg 3 QL: 36 in 25 days
VOSPIRE ER 4
Respiratory Tract Agents, Other
DALIRESP 3 QL: 30 in 30 days
XOLAIR 5 PA, QL: 6 in 28 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
52
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Skeletal Muscle Relaxants Skeletal Muscle Relaxants
AMRIX 4 PA-HRM
baclofen (Baclofen) 2 GC
cyclobenzaprine hcl (Fexmid) 2 GC, PA-HRM
FEXMID 4 PA-HRM
methocarbamol (Robaxin) 2 GC, PA-HRM
Sleep Disorder Agents Sleep Disorder Agents
AMBIEN CR 4 PA-HRM, QL: 30 in 30
days (High Risk Med.
QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug)
AMBIEN 4 PA-HRM, QL: 30 in 30
days (High Risk Med.
QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug)
EDLUAR 4 PA-HRM, QL: 30 in 30
days (High Risk Med.
QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
53
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
INTERMEZZO 4 PA-HRM, QL: 30 in 30
days (High Risk Med.
QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug)
modafinil (Provigil) 2 GC, PA, QL: 60 in 30
days
NUVIGIL tablet: 150mg, 250mg 3 PA, QL: 30 in 30 days
NUVIGIL tablet: 50mg 3 PA, QL: 90 in 30 days
PROVIGIL 4 PA, QL: 60 in 30 days
zolpidem tartrate (Ambien) 2 GC, PA-HRM, QL: 30 in
30 days (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug)
ZOLPIMIST 4 PA-HRM, QL: 7.7 in 30
days (High Risk Med.
QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug)
Vasodilating Agents Vasodilating Agents
ADCIRCA 5 PA, QL: 60 in 30 days
CIALIS tablet: 2.5mg, 5mg 4 PA, QL: 30 in 30 days
LETAIRIS 5 PA, QL: 30 in 30 days
REVATIO vial 5 PA, QL: 37.5 in 1 day
REVATIO tablet 5 PA, QL: 90 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to the introduction
pages of this document
54
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
Drug Name Drug Tier Requirements/Limits
sildenafil citrate (Revatio) 2 GC, PA, QL: 90 in 30
days
Vitamins and Minerals Vitamins and Minerals
ped mv a,c,d3 #21 w-fluoride (Ped Mv A,c,d3 #21
W-fluoride)
2 GC
pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/
iron/fa)
3 (All Rx Prenatal
Vitamins Covered)
I-1
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
INDEX
0.9 % sodium chloride .......... 49
ABILIFY ............................... 30
ABILIFY DISCMELT .......... 30
ABILIFY MAINTENA ........ 30
ABSORICA .......................... 38
ACANYA ............................. 39
ACCOLATE ......................... 50
acetaminophen with codeine . 15
ACTIGALL........................... 42
ACTIVELLA ........................ 44
ACTONEL ............................ 48
ACTOS ................................. 25
ACULAR .............................. 41
ACULAR LS ........................ 41
acyclovir .......................... 31, 38
ADACEL TDAP ................... 47
ADALAT CC ........................ 35
adapalene .............................. 40
ADCIRCA............................. 52
ADDERALL ......................... 37
ADDERALL XR ............ 36, 37
ADOXA ................................ 21
ADVAIR DISKUS................ 50
ADVAIR HFA ...................... 50
AFINITOR ............................ 21
AFINITOR DISPERZ ........... 21
AGRYLIN............................. 32
ALBENZA ............................ 29
albuterol sulfate .................... 50
ALDACTAZIDE .................. 36
ALDACTONE ...................... 36
ALDARA .............................. 38
alendronate sodium ............... 48
allopurinol............................. 48
ALORA ................................. 44
ALPHAGAN P ..................... 49
alprazolam ............................ 18
ALPRAZOLAM INTENSOL18
ALSUMA .............................. 28
ALTACE ............................... 34
ALTOPREV .......................... 36
AMARYL ............................. 26
AMBIEN ............................... 51
AMBIEN CR ........................ 51
AMERGE .............................. 28
AMETHYST ......................... 38
amiodarone hcl ..................... 34
amitriptyline hcl .................... 25
amlodipine besylate .............. 35
amlodipine besylate/benazepril
........................................... 35
ammonium lactate ................. 38
amoxicillin............................. 20
amoxicillin/potassium clav.... 20
ampicillin trihydrate ............. 20
AMRIX ................................. 51
anagrelide hcl ....................... 32
anastrozole ............................ 21
ANDRODERM ..................... 44
ANDROGEL......................... 44
ANUSOL-HC ....................... 39
APRISO ................................ 47
ARAVA ................................ 46
ARICEPT .............................. 24
ARICEPT ODT ..................... 24
ARIMIDEX........................... 21
AROMASIN ......................... 21
ASACOL HD ........................ 47
ASTAGRAF XL ................... 46
ASTEPRO ............................. 41
ATELVIA ............................. 48
atenolol ................................. 34
ATIVAN ............................... 18
atorvastatin calcium.............. 36
atovaquone/proguanil hcl ..... 29
ATRALIN ............................. 40
ATRIPLA .............................. 31
atropine sulfate ..................... 23
ATROVENT ......................... 41
ATROVENT HFA ................ 50
AUGMENTIN ...................... 20
AUVI-Q ................................ 35
AVAPRO .............................. 33
AVELOX .............................. 20
AVELOX ABC PACK ......... 20
AVINZA ............................... 15
AVODART ........................... 48
AVONEX .............................. 48
AVONEX
ADMINISTRATION PACK
........................................... 48
AXIRON ............................... 44
AZASAN .............................. 46
azathioprine .......................... 46
azelastine hcl ......................... 41
AZELEX ............................... 38
azithromycin .......................... 20
AZULFIDINE ....................... 21
baclofen ................................. 51
BACTRIM ............................ 21
BACTRIM DS ...................... 21
BACTROBAN ...................... 39
balsalazide disodium ............. 47
benazepril hcl ........................ 34
BENTYL ............................... 42
benztropine mesylate ............. 29
betamethasone dipropionate . 39
BIAXIN................................. 20
BIAXIN XL .......................... 20
BINOSTO ............................. 48
BONIVA ............................... 48
BOOSTRIX TDAP ............... 47
brimonidine tartrate .............. 49
buprenorphine hcl ................. 18
buprenorphine hcl/naloxone hcl
........................................... 18
bupropion hcl ........................ 25
I-2
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
buspirone hcl ......................... 48
butalb/acetaminophen/caffeine
........................................... 15
BYDUREON ........................ 25
BYSTOLIC ........................... 34
CALAN ................................. 34
CALAN SR ........................... 34
calcipotriene ......................... 38
calcitriol ................................ 48
calcium acetate ..................... 43
CANASA .............................. 47
CAPEX SHAMPOO ............. 39
CAPITAL W-CODEINE ...... 15
CARAC ................................. 39
carbamazepine ...................... 23
CARBATROL ...................... 23
carbidopa/levodopa .............. 29
CARDIZEM .......................... 35
CARDIZEM CD ................... 34
CARDIZEM LA ................... 34
CARDURA ........................... 33
CARDURA XL ..................... 33
carvedilol .............................. 34
CATAPRES .......................... 33
CAYSTON ............................ 20
cefadroxil .............................. 20
cefdinir .................................. 20
cefprozil................................. 20
CEFTIN................................. 20
cefuroxime axetil ................... 20
CELEBREX .......................... 17
CELEXA ............................... 25
CELLCEPT ........................... 46
cephalexin ............................. 20
CHANTIX............................. 18
chlorhexidine gluconate ........ 38
chlorthalidone ....................... 35
CIALIS .................................. 52
CILOXAN............................. 41
CIMZIA ................................ 40
CIPRO ................................... 20
CIPRODEX........................... 41
ciprofloxacin hcl ............. 20, 41
citalopram hydrobromide ..... 25
CLARINEX .......................... 27
clarithromycin ....................... 20
CLEOCIN HCL .................... 19
CLEOCIN PALMITATE...... 19
CLEOCIN T .......................... 39
CLIMARA ............................ 44
CLINDACIN P ..................... 39
clindamycin hcl ..................... 19
clindamycin palmitate hcl ..... 19
clindamycin phos/benzoyl perox
........................................... 39
clindamycin phosphate.......... 39
CLINIMIX E ......................... 33
CLINISOL ............................ 33
clobetasol propionate............ 39
CLOBEX............................... 39
clonazepam ..................... 18, 19
clonidine hcl .......................... 33
clopidogrel bisulfate ............. 32
clotrimazole........................... 27
clotrimazole/betamethasone dip
........................................... 27
clozapine ............................... 30
CLOZARIL ........................... 30
COGENTIN .......................... 29
COLAZAL ............................ 47
COLCRYS ............................ 48
COLYTE with FLAVOR
PACKETS ......................... 43
COMBIPATCH .................... 44
COMBIVENT RESPIMAT .. 50
CONCERTA ......................... 37
CONZIP ................................ 15
COPAXONE ......................... 48
COREG ................................. 34
CORTEF ............................... 45
CORTISPORIN .................... 41
COSOPT ............................... 49
COUMADIN......................... 32
COZAAR .............................. 33
CREON ................................. 40
CRESTOR............................. 36
CRINONE ............................. 46
cromolyn sodium ................... 41
CUPRIMINE......................... 43
cyclobenzaprine hcl .............. 51
cyclophosphamide ................. 21
CYCLOPHOSPHAMIDE..... 21
cyclosporine, modified .......... 46
CYKLOKAPRON ................ 32
CYMBALTA ........................ 25
cyproheptadine hcl ................ 28
CYTOMEL ........................... 46
DALIRESP ........................... 50
dapsone ................................. 28
DDAVP ................................. 45
DELZICOL ........................... 47
DEPAKOTE ......................... 23
DEPAKOTE ER ................... 23
DEPAKOTE SPRINKLE ..... 23
DEPEN .................................. 43
DEPO-PROVERA ................ 46
DEPO-SUBQ PROVERA 104
........................................... 46
DEPO-TESTOSTERONE .... 44
desloratadine......................... 28
desmopressin acetate ............ 45
DESONATE ......................... 39
desonide ................................ 39
DETROL ............................... 43
DETROL LA ........................ 43
dexamethasone ...................... 45
DEXAMETHASONE
INTENSOL ....................... 45
dexmethylphenidate hcl ......... 37
DEXPAK .............................. 45
dextroamphetamine/
amphetamine ..................... 37
dextrose 10 % in water ......... 33
dextrose 5 % and 0.9 % nacl 33
dextrose 5 % in water ........... 33
dextrose 5 %-0.45 % nacl ..... 33
I-3
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
dextrose 5%-lactated ringers 33
DIABETA ....................... 26, 27
diclofenac sodium ................. 17
dicloxacillin sodium .............. 20
dicyclomine hcl ..................... 42
DIFFERIN............................. 40
DIFLUCAN .......................... 27
DILACOR XR ...................... 35
DILANTIN ........................... 23
DILAUDID ........................... 15
diltiazem hcl .......................... 35
DIOVAN ............................... 33
DIOVAN HCT ...................... 33
diphenoxylate hcl/atropine .... 42
DITROPAN XL .................... 43
divalproex sodium ................. 24
DIVIGEL .............................. 44
donepezil hcl ......................... 24
dorzolamide hcl/timolol maleat
........................................... 49
DOVONEX ........................... 39
doxazosin mesylate................ 33
doxycycline monohydrate ...... 21
DROXIA ............................... 21
duloxetine hcl ........................ 25
DURAGESIC ........................ 15
DYAZIDE ............................. 35
EC-NAPROSYN................... 17
econazole nitrate ................... 27
EDLUAR .............................. 51
EFFEXOR XR ...................... 25
EFFIENT............................... 32
EFUDEX ............................... 39
ELIGARD ............................. 21
ELMIRON ............................ 48
ELOCON .............................. 39
enalapril maleate .................. 34
ENBREL ............................... 46
ENDOMETRIN .................... 46
ENGERIX-B ADULT .......... 47
ENGERIX-B PEDIATRIC-
ADOLESCENT ................ 47
enoxaparin sodium ................ 32
EPANED ............................... 34
epinephrine ........................... 35
EPIPEN 2-PAK ..................... 35
EPIPEN JR 2-PAK ............... 35
EPOGEN ............................... 32
EPZICOM ............................. 31
EQUETRO ............................ 24
erythromycin base ................. 41
escitalopram oxalate ............. 25
ESGIC ................................... 15
ESTRACE ............................. 44
estradiol ................................ 44
estradiol/norethindrone acet . 44
ESTRASORB ....................... 44
ESTRING .............................. 44
ESTROSTEP FE ................... 38
ethambutol hcl ....................... 28
ethinyl estradiol/drospirenone
........................................... 38
EVAMIST ............................. 44
EXALGO .............................. 15
exemestane ............................ 21
EXJADE ............................... 43
EXTINA ................................ 27
famciclovir ............................ 31
famotidine ............................. 42
FAMVIR ............................... 31
FAZACLO ............................ 30
FEMARA .............................. 22
FEMHRT .............................. 44
fenofibrate ............................. 36
FENOGLIDE ........................ 36
fentanyl .................................. 15
FEXMID ............................... 51
FINACEA ............................. 39
finasteride ............................. 48
FLAGYL ............................... 29
FLAGYL ER ......................... 29
flecainide acetate .................. 34
FLOMAX .............................. 43
FLONASE............................. 42
FLOVENT DISKUS ............. 50
FLOVENT HFA ................... 50
fluconazole ............................ 27
flunisolide .............................. 42
fluocinolone acetonide .......... 40
fluocinonide........................... 40
fluorouracil ........................... 39
fluoxetine hcl ......................... 25
fluticasone propionate .......... 42
FOCALIN ............................. 37
FOCALIN XR ....................... 37
FORFIVO XL ....................... 25
FORTAMET ................... 25, 26
FORTESTA .......................... 44
FOSAMAX ........................... 48
furosemide ............................. 35
gabapentin............................. 24
GELNIQUE .......................... 43
gemfibrozil ............................ 36
GENOTROPIN ..................... 45
gentamicin sulfate ........... 19, 41
GEODON .............................. 30
GIAZO .................................. 47
GLEEVEC ............................ 22
glimepiride ............................ 27
glipizide ................................. 27
GLUCAGEN......................... 48
GLUCAGON EMERGENCY
KIT .................................... 48
GLUCOPHAGE ................... 26
GLUCOPHAGE XR ............. 26
GLUCOTROL ...................... 27
GLUCOTROL XL ................ 27
GLUMETZA......................... 26
glyburide ............................... 27
GOLYTELY ......................... 43
GRALISE .............................. 24
guanfacine hcl ....................... 33
haloperidol ............................ 30
HAVRIX ............................... 47
HUMALOG .......................... 26
HUMATROPE ...................... 45
I-4
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
HUMIRA .............................. 46
HUMULIN N ........................ 26
HUMULIN N KWIKPEN .... 26
HYCET ................................. 15
hydralazine hcl ...................... 35
HYDREA .............................. 22
hydrochlorothiazide .............. 35
hydrocodone/acetaminophen 15
hydrocortisone ................ 40, 45
hydromorphone hcl ......... 15, 16
hydroxychloroquine sulfate ... 29
hydroxyurea .......................... 22
hydroxyzine hcl ..................... 48
hydroxyzine pamoate ............ 49
HYZAAR .............................. 33
ibandronate sodium .............. 48
ibuprofen ............................... 17
IMBRUVICA ........................ 22
imiquimod ............................. 39
IMITREX .............................. 28
IMURAN .............................. 47
INDERAL LA ....................... 34
INDOCIN .............................. 17
indomethacin ......................... 17
INLYTA ................................ 22
INNOPRAN XL.................... 34
INTERMEZZO ..................... 52
INTRALIPID ........................ 33
INVANZ ............................... 20
INVOKANA ......................... 26
ipratropium bromide ............. 41
irbesartan .............................. 33
ISENTRESS .......................... 31
isoniazid ................................ 28
isosorbide mononitrate ......... 36
isotretinoin ............................ 39
ISTALOL .............................. 49
JAKAFI ................................. 22
JANUMET ............................ 26
JANUMET XR ..................... 26
JANUVIA ............................. 26
KADIAN ............................... 16
KEFLEX ............................... 20
KENALOG ........................... 40
KEPPRA ............................... 24
KEPPRA XR ......................... 24
ketoconazole .......................... 27
KETODAN ........................... 27
ketorolac tromethamine ........ 42
KLONOPIN .......................... 19
KRISTALOSE ...................... 42
K-TAB ER ............................ 49
KUVAN ................................ 40
LAC-HYDRIN ...................... 39
LACTATED RINGERS ....... 49
lactulose ................................ 42
LAMICTAL .......................... 24
LAMICTAL BLUE .............. 24
LAMICTAL GREEN............ 24
LAMICTAL ODT ................. 24
LAMICTAL ORANGE ........ 24
LAMICTAL XR ................... 24
LAMICTAL XR BLUE ........ 24
LAMICTAL XR GREEN ..... 24
LAMICTAL XR ORANGE .. 24
LAMISIL .............................. 27
lamotrigine ............................ 24
lansoprazole .......................... 42
LANTUS ............................... 26
LANTUS SOLOSTAR ......... 26
LASIX ................................... 35
latanoprost ............................ 49
leflunomide ............................ 47
LETAIRIS ............................. 52
letrozole................................. 22
LEUKERAN ......................... 22
leuprolide acetate.................. 22
LEVAQUIN .......................... 21
levetiracetam ......................... 24
levocetirizine dihydrochloride
........................................... 28
levofloxacin ........................... 21
levonorgestrel-ethin estradiol 38
levothyroxine sodium ............ 46
LEVOXYL ............................ 46
LEXAPRO ............................ 25
LIALDA ................................ 47
lidocaine ................................ 18
lidocaine hcl .......................... 18
LIDODERM ......................... 18
LINZESS............................... 40
liothyronine sodium .............. 46
LIPITOR ............................... 36
LIPOFEN .............................. 36
LIPOSYN III ......................... 33
lisinopril ................................ 34
lisinopril/hydrochlorothiazide
........................................... 34
lithium carbonate .................. 37
LITHOBID ............................ 37
LO LOESTRIN FE ............... 38
LOFIBRA ............................. 36
LOMOTIL............................. 42
LOPID ................................... 36
LOPRESSOR ........................ 34
lorazepam .............................. 19
LORTAB............................... 16
losartan potassium ................ 33
losartan/hydrochlorothiazide 33
LOTENSIN ........................... 34
LOTREL ............................... 35
LOTRISONE ........................ 27
LOTRONEX ......................... 40
lovastatin ............................... 36
LOVENOX ........................... 32
LUMIGAN ............................ 49
LUPRON DEPOT ................. 22
LUPRON DEPOT-PED ........ 22
LYRICA ................................ 24
LYSODREN ......................... 22
LYSTEDA ............................ 32
MACRODANTIN................. 19
MALARONE ........................ 29
malathion .............................. 40
MAXALT ............................. 28
MAXALT MLT .................... 28
I-5
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
MAXITROL ......................... 41
MAXZIDE ............................ 35
MAXZIDE-25 MG ............... 35
meclizine hcl.......................... 28
medroxyprogesterone acetate 46
mefloquine hcl ....................... 29
MEGACE .............................. 22
MEGACE ES ........................ 22
megestrol acetate .................. 22
meloxicam ............................. 17
MENACTRA ........................ 47
MENOSTAR......................... 44
MENVEO A-C-Y-W-135-DIP
........................................... 47
mercaptopurine ..................... 22
MESTINON .......................... 49
METADATE CD .................. 37
METADATE ER .................. 37
metformin hcl ........................ 26
methocarbamol ..................... 51
methotrexate sodium ............. 22
methotrexate sodium/pf ......... 22
METHYLIN .......................... 37
methylphenidate hcl .............. 37
metoclopramide hcl ............... 43
metoprolol succinate ............. 34
metoprolol tartrate ................ 34
METOZOLV ODT ............... 43
METROCREAM .................. 39
METROGEL ......................... 39
METROGEL-VAGINAL ..... 28
METROLOTION .................. 39
metronidazole ............ 28, 29, 39
MICROZIDE ........................ 35
MILLIPRED ......................... 45
MINASTRIN 24 FE .............. 38
MINIVELLE ......................... 44
minocycline hcl ..................... 21
MIRAPEX............................. 29
MIRAPEX ER ...................... 29
MOBIC ................................. 17
modafinil ............................... 52
MODICON ........................... 38
mometasone furoate .............. 40
montelukast sodium ............... 50
morphine sulfate.................... 16
MORPHINE SULFATE ....... 16
MOXATAG .......................... 20
moxifloxacin hcl .................... 21
MS CONTIN ......................... 16
mupirocin .............................. 39
MYAMBUTOL .................... 28
mycophenolate mofetil .......... 47
nabumetone ........................... 17
nafcillin sodium ..................... 20
NAMENDA .......................... 25
NAMENDA XR.................... 24
NAPROSYN ......................... 18
naproxen ............................... 18
naratriptan hcl ...................... 28
NASACORT AQ .................. 42
NASONEX ........................... 42
neo/polymyx b sulf/dexameth 41
neomycin sulfate.................... 19
neomycin/polymyxin b sulf/hc 41
NEORAL .............................. 47
NEULASTA ......................... 32
NEUPOGEN ......................... 32
NEURONTIN ....................... 24
NEXAVAR ........................... 22
NEXIUM............................... 42
nifedipine............................... 35
NITRO-BID .......................... 36
NITRO-DUR......................... 36
nitrofurantoin macrocrystal .. 19
nitroglycerin .......................... 36
NITROLINGUAL................. 36
NITROMIST ......................... 36
NITROSTAT ........................ 36
NIZORAL ............................. 27
NORCO................................. 16
NORDITROPIN FLEXPRO . 45
NORDITROPIN NORDIFLEX
........................................... 45
norethindrone ac-eth estradiol
........................................... 44
norethindrone-e.estradiol-iron
........................................... 38
norethindrone-ethinyl estrad 38
norgestimate-ethinyl estradiol
........................................... 38
NORITATE........................... 39
NORVASC ........................... 35
NORVIR ............................... 31
NOVOLIN N ........................ 26
NUTROPIN AQ NUSPIN .... 45
NUVIGIL .............................. 52
nystatin .................................. 27
nystatin/triamcin ................... 27
OCUFLOX ............................ 41
ofloxacin ................................ 41
olanzapine ............................. 30
OLUX ................................... 40
OLYSIO ................................ 31
omeprazole ............................ 42
OMNIPRED .......................... 42
OMNITROPE ....................... 45
ondansetron........................... 29
ondansetron hcl ..................... 28
OPTIVAR ............................. 41
ORACEA .............................. 21
ORAPRED ............................ 45
ORAPRED ODT ................... 45
ORTHO TRI-CYCLEN ........ 38
ORTHO TRI-CYCLEN LO .. 38
ORTHO-CYCLEN ............... 38
ORTHO-NOVUM ................ 38
OVCON-35 ........................... 38
OVIDE .................................. 40
OXECTA .............................. 16
oxybutynin chloride ............... 43
oxycodone hcl........................ 16
oxycodone hcl/acetaminophen
........................................... 16
OXYCONTIN ....................... 17
PANCREAZE ....................... 40
I-6
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
pantoprazole sodium ............. 42
paroxetine hcl........................ 25
PATADAY ........................... 41
PATANASE .......................... 41
PATANOL ............................ 41
PAXIL ................................... 25
PAXIL CR ............................ 25
ped mv a,c,d3 #21 w-fluoride 53
peg 3350/na sulf,bicarb,cl/kcl 43
PEGASYS ............................. 31
PEGASYS PROCLICK ........ 31
PEGINTRON ........................ 31
PEGINTRON REDIPEN ...... 31
penicillin v potassium ........... 20
PENNSAID ........................... 18
PENTASA............................. 47
PEPCID ................................. 42
PERCOCET .......................... 17
permethrin ............................. 40
PERTZYE ............................. 41
PHENERGAN ...................... 29
PHENYTEK ......................... 24
phenytoin sodium extended ... 24
PHOSLO ............................... 43
PHOSLYRA ......................... 43
pioglitazone hcl ..................... 26
PLAQUENIL ........................ 29
PLAVIX ................................ 33
pnv with ca,no.72/iron/fa ...... 53
polyethylene glycol 3350....... 43
polymyxin b sulf/trimethoprim
........................................... 41
POLYTRIM .......................... 41
POMALYST ......................... 22
potassium chloride ................ 49
potassium chloride in 0.9%nacl
........................................... 49
potassium chloride/d5-0.45nacl
........................................... 50
potassium chloride/d5-
0.9%nacl ........................... 50
potassium citrate ................... 50
pramipexole di-hcl ................ 29
PRAVACHOL ...................... 36
pravastatin sodium ................ 36
PRED FORTE ....................... 42
PRED MILD ......................... 42
prednisolone acetate ............. 42
prednisolone sod phosphate .. 45
prednisone ............................. 45
PREDNISONE INTENSOL . 45
PREMARIN .......................... 45
PREMPHASE ....................... 45
PREMPRO ............................ 45
PREVACID........................... 42
PREZISTA ............................ 31
PRILOSEC ............................ 42
PRIMLEV ............................. 17
PRIMSOL ............................. 19
PRINIVIL ............................. 34
PROAIR HFA ....................... 50
PROCARDIA ....................... 35
PROCARDIA XL ................. 35
prochlorperazine maleate ..... 29
PROCRIT .............................. 32
progesterone,micronized ....... 46
PROGRAF ............................ 47
promethazine hcl ................... 29
PROMETRIUM .................... 46
propafenone hcl .................... 34
propantheline bromide .......... 23
propranolol hcl ..................... 34
PROSCAR ............................ 49
PROSOL ............................... 33
PROTONIX .......................... 42
PROTONIX IV ..................... 42
PROVENTIL HFA ............... 50
PROVERA ............................ 46
PROVIGIL ............................ 52
PROZAC ............................... 25
PROZAC WEEKLY ............. 25
PULMOZYME ..................... 41
PURINETHOL ..................... 22
pyridostigmine bromide ........ 49
QUDEXY XR ....................... 24
quetiapine fumarate .............. 30
QUILLIVANT XR................ 37
QVAR ................................... 50
ramipril ................................. 34
ranitidine hcl ......................... 42
RAYOS ................................. 45
REBIF ................................... 49
RECOMBIVAX HB ............. 47
REGLAN .............................. 43
RENVELA ............................ 43
REQUIP ................................ 29
REQUIP XL .......................... 29
RESTASIS ............................ 42
RETIN-A............................... 40
REVATIO ............................. 52
REVLIMID ........................... 22
REYATAZ ............................ 31
RHEUMATREX ................... 23
RIFADIN .............................. 28
rifampin ................................. 28
RIOMET ............................... 26
risedronate sodium................ 48
RISPERDAL ......................... 30
RISPERDAL M-TAB ........... 30
risperidone ............................ 30
RITALIN............................... 37
RITALIN LA ........................ 37
RITALIN-SR ........................ 37
rizatriptan benzoate .............. 28
ROCALTROL....................... 48
ropinirole hcl ........................ 29
ROXICODONE .................... 17
RYTHMOL ........................... 34
RYTHMOL SR ..................... 34
SAIZEN ................................ 45
SARAFEM ............................ 25
SENSIPAR ............................ 49
SEROQUEL .......................... 30
SEROQUEL XR ................... 30
SEROSTIM ........................... 45
sertraline hcl ......................... 25
I-7
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
sildenafil citrate .................... 53
SILVADENE ........................ 39
silver sulfadiazine ................. 39
simvastatin ............................ 36
SINEMET 10-100 ................. 29
SINEMET 25-100 ................. 29
SINEMET 25-250 ................. 29
SINEMET CR ....................... 29
SINGULAIR ......................... 50
sodium chloride ..................... 50
sodium chloride 0.45 % ........ 50
sodium chloride irrig solution
........................................... 47
SOLARAZE .......................... 18
SOLODYN ........................... 21
SOLTAMOX ........................ 23
SORILUX ............................. 39
SOVALDI ............................. 31
SPIRIVA ............................... 50
spironolact/hydrochlorothiazid
........................................... 36
spironolactone....................... 36
SPRYCEL ............................. 23
STIMATE ............................. 45
STRIANT .............................. 44
STRIBILD............................. 31
SUBOXONE ......................... 18
SUBSYS ............................... 17
sulfamethoxazole/trimethoprim
........................................... 21
sulfasalazine .......................... 21
sumatriptan succinate ........... 28
SUMAVEL DOSEPRO ........ 28
SUPRAX ............................... 20
SUTENT ............................... 23
SYLATRON 4-PACK .......... 31
SYNAGIS ............................. 31
SYNALAR ............................ 40
SYNTHROID ....................... 46
syring w-ndl,disp,insul,0.5ml 40
syringe & needle,insulin,1 ml 40
tacrolimus ............................. 47
TAMIFLU ............................. 31
tamoxifen citrate ................... 23
tamsulosin hcl ....................... 43
TARCEVA ............................ 23
TASIGNA ............................. 23
TECFIDERA......................... 49
TEGRETOL .......................... 24
TEGRETOL XR ................... 24
TEMOVATE......................... 40
TENEX ................................. 33
TENORMIN ......................... 34
TERAZOL 3 ......................... 28
TERAZOL 7 ......................... 28
terazosin hcl .......................... 43
terbinafine hcl ....................... 27
terconazole ............................ 28
TESTIM ................................ 44
testosterone cypionate ........... 44
TEV-TROPIN ....................... 46
TIAZAC ................................ 35
timolol maleate...................... 49
TIMOPTIC-XE ..................... 49
TIROSINT ............................ 46
TOBI ..................................... 19
TOBRADEX ......................... 41
TOBRADEX ST ................... 41
tobramycin in 0.225% nacl ... 19
tobramycin/dexamethasone ... 41
tolterodine tartrate ................ 43
TOPAMAX ........................... 24
topiramate ............................. 24
TOPROL XL ......................... 34
TRADJENTA ....................... 26
tramadol hcl .......................... 17
tranexamic acid ..................... 32
TRAVASOL ......................... 33
TRAVATAN Z ..................... 49
trazodone hcl ......................... 25
tretinoin ................................. 40
TREXALL ............................ 23
triamcinolone acetonide. 38, 40,
42
triamterene/hydrochlorothiazid
........................................... 35
trimethoprim ......................... 19
TRI-NORINYL ..................... 38
TROKENDI XR.................... 24
TROPHAMINE .................... 33
TRUVADA ........................... 31
TWINRIX ............................. 47
TYKERB............................... 23
TYLENOL-CODEINE NO.3 17
TYLENOL-CODEINE NO.4 17
TYPHIM VI .......................... 47
ULORIC ................................ 49
ULTRAM .............................. 17
ULTRAM ER........................ 17
ULTRESA............................. 41
UNITHROID ........................ 46
UROCIT-K ........................... 50
URSO .................................... 43
URSO FORTE ...................... 43
ursodiol ................................. 43
VAGIFEM ............................ 45
valacyclovir hcl ..................... 31
valsartan/hydrochlorothiazide
........................................... 34
VALTREX ............................ 31
VANCOCIN HCL ................ 19
vancomycin hcl...................... 20
VANDAZOLE ...................... 28
VANOS ................................. 40
VAQTA................................. 47
VASOTEC ............................ 34
venlafaxine hcl ...................... 25
VENLAFAXINE HCL ER ... 25
VENTOLIN HFA ................. 50
verapamil hcl ........................ 35
VERELAN ............................ 35
VERELAN PM ..................... 35
VERIPRED 20 ...................... 45
VERSACLOZ ....................... 31
VESICARE ........................... 43
VIBRAMYCIN ..................... 21
I-8
University Health Care Advantage 2015 Medicare Preferred Drug List Effective: January 01, 2015
Formulary ID: 15492.000, Version: 5
VICTOZA 3-PAK ................. 26
VIOKACE............................. 41
VIREAD ............................... 31
VISTARIL ............................ 49
VIVELLE-DOT .................... 45
VOGELXO ........................... 44
VOLTAREN ......................... 18
VOLTAREN-XR .................. 18
VOSPIRE ER ........................ 50
VOTRIENT........................... 23
VYVANSE ........................... 37
warfarin sodium .................... 32
water for irrigation,sterile .... 47
WELLBUTRIN..................... 25
WELLBUTRIN SR ............... 25
WELLBUTRIN XL .............. 25
XALATAN ........................... 49
XALKORI............................. 23
XANAX ................................ 19
XANAX XR.......................... 19
XARELTO ............................ 32
XARTEMIS XR.................... 17
XIFAXAN............................. 20
XODOL 10-300 .................... 17
XODOL 5-300 ...................... 17
XODOL 7.5-300 ................... 17
XOLAIR ............................... 50
XTANDI ............................... 23
XYLOCAINE ....................... 18
XYZAL ................................. 28
YASMIN 28 .......................... 38
YAZ ...................................... 38
zafirlukast .............................. 50
ZAMICET ............................. 17
ZANTAC .............................. 42
ZENPEP ................................ 41
ZESTORETIC....................... 34
ZESTRIL............................... 34
ziprasidone hcl ...................... 31
ZITHROMAX....................... 20
ZITHROMAX TRI-PAK ...... 20
ZMAX ................................... 20
ZOCOR ................................. 36
ZOFRAN............................... 29
ZOFRAN ODT ..................... 29
ZOLOFT ............................... 25
zolpidem tartrate ................... 52
ZOLPIMIST .......................... 52
ZORBTIVE ........................... 46
ZOSTAVAX ......................... 47
ZOVIRAX....................... 31, 39
ZUBSOLV ............................ 18
ZYCLARA ............................ 39
ZYLOPRIM .......................... 49
ZYPREXA ............................ 31
ZYPREXA ZYDIS ............... 31
ZYTIGA ................................ 23
This abridged formulary was updated on 08/08/2014. This is not a complete list of drugs covered by
our plan. For a complete listing or other questions, please contact University Health Care Advantage Member Services at 1-855-996-8422 or, for TTY users, Toll-free 711, Monday through Sunday from
8:00 a.m. to 8:00 p.m. (Pacific Standard Time), or visit www.UHCAmedicare.org.
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