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Your Pharmacy Benefits

www.optumrx.com

2300 Main Street, Irvine, CA 92614

The information in this educational tool does not substitute for the medical advice, diagnosis or treatment of your physician. Always seek the help of your physician or qualified health provider for any questions you may have regarding your medical condition.

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

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

ORX2333_120629 ©2012 OptumRx, Inc.

Your Pharmacy Benefits

For a complete list of covered drugs or if you have questions:

Call the toll-free member phone number on your ID card.

Visit your plan’s member website listed on your ID card.• Locate a participating retail pharmacy by zip code.• Look up possible lower-cost medication alternatives.• Compare medication pricing and options.

Please read: This document contains information about the drugs covered under your pharmacy benefit plan.

Your 2018 Formulary

OptumRx 1

Effective January 1, 2018

Innoviant Select

2

Your Formulary

This Formulary outlines the most commonly prescribed medications from your plan’s complete pharmacy benefit coverage list, also known as a Prescription Drug List (PDL). A formulary identifies the drugs available for certain conditions and organizes them into cost levels, also known as tiers. An important part of the Formulary is giving you choices so you and your doctor can choose the best course of treatment for you.

Go to your plan’s member website for complete and up-to-date drug information

Since the Formulary may change, we encourage you to your plan’s member website, which should be listed on your ID card. This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers, possible lower-cost options and cost comparisons.

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Table of Contents

Drug tiers and cost . . . . . . . . . . . . . . . . . . . . 5

Programs and limits . . . . . . . . . . . . . . . . . . . 6

Drugs by category . . . . . . . . . . . . . . . . . . . . 9

Anti-InfectivesAntibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Antivirals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Cardiovascular/Heart DiseaseAnticoagulants. . . . . . . . . . . . . . . . . . . . . . . . 10High Blood Pressure . . . . . . . . . . . . . . . . . . . . 10High Cholesterol . . . . . . . . . . . . . . . . . . . . . . 10Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Pulmonary Arterial Hypertension . . . . . . . . . . 11

Central Nervous SystemAttention Deficit Disorder . . . . . . . . . . . . . . . 11Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . 11Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . 12Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Sedatives/Hypnotics . . . . . . . . . . . . . . . . . . . . 12Seizure Disorders . . . . . . . . . . . . . . . . . . . . . . 12

Dermatology . . . . . . . . . . . . . . . . . . . . . . . . 13

Diabetes/EndocrineBlood Glucose Monitoring . . . . . . . . . . . . . . . 13Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Non-Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . 15

EndocrineGrowth Hormone . . . . . . . . . . . . . . . . . . . . . 15Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Thyroid Hormone Replacement . . . . . . . . . . . 16

Eye ConditionsAllergies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

GastrointestinalAcid Suppression . . . . . . . . . . . . . . . . . . . . . . 16Nausea/Vomiting . . . . . . . . . . . . . . . . . . . . . . 17Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Inflammatory Conditions . . . . . . . . . . . . . . 17

Men’s HealthErectile Dysfunction . . . . . . . . . . . . . . . . . . . . 18Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Testosterone Therapy . . . . . . . . . . . . . . . . . . . 18

Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . 18

MusculoskeletalOsteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . 19 Other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Pain Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Overactive Bladder . . . . . . . . . . . . . . . . . . . 19

RespiratoryAsthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . 20Nasal Allergies . . . . . . . . . . . . . . . . . . . . . . . . 20Oral Allergies . . . . . . . . . . . . . . . . . . . . . . . . . 20

Transplant . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Vitamins/Electrolytes . . . . . . . . . . . . . . . . . 21

Women’s HealthBirth Control . . . . . . . . . . . . . . . . . . . . . . . . . 21Hormone Replacement . . . . . . . . . . . . . . . . . 22Vaginal Anti-Infectives . . . . . . . . . . . . . . . . . . 22

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

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At OptumRx, we want to help you better understand your medication options. Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked questions about the Formulary.

What is a Formulary?

This document is a list of commonly prescribed medications preferred by your plan sponsor for their safety, cost and effectiveness. Drugs are listed by common categories or class. They are placed into cost levels known as tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA).

Please note: Where differences are noted between this Formulary and your benefit plan documents, the benefit plan documents will rule. It is not intended to be a complete list of medications, and not all medications listed may be covered under your plan. Please look at your benefit plan documents provided by your employer or plan sponsor to see what medications are covered under your plan. You may also log on to your plan’s member website or call the toll-free member phone number on your ID card for more information.

How do I use my Formulary?

When choosing a medication, you and your doctor should consult the Formulary. It will help you and your doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is organized by common medical conditions. Medications are then listed alphabetically.

If your medication is not listed in this document, please visit your plan’s member website or call the toll-free member phone number on your ID card.

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What are tiers?

Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, which is determined by your employer or plan sponsor. This is how much you will pay when you fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.

Drug names shown in orange are preferred for their cost and effectiveness. If there is a symbol in the Drug Tier column, check your benefit plan documents to find out your specific pharmacy plan costs.

$ Drug Tier Includes Helpful Tips

Tier 1 Lowest Cost

Lower-cost, commonly used generic drugs. Some low-cost brands may be included.

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

Tier 2 Mid-range Cost

Many common brand-name drugs, called preferred brands.

Use Tier 2 drugs, instead of Tier 3, to help reduce your out-of-pocket costs.

Tier 3 Highest Cost

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

Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Please note: Some plans may have two or four tiers, while others may not have any. If you have a high deductible plan, the tier cost levels will apply once you hit your deductible. Refer to your enrollment and plan materials on your plan’s member website or call the toll-free member phone number on your ID card for more information about your benefit plan.

When does the Formulary change?

• Medications may move to a lower tier at any time. • Medications may move to a higher tier when its generic becomes available.• Medications may move to a higher tier or be excluded from coverage

on January 1 or July 1 of each year.

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

For the most up-to-date list, call customer service at the toll-free member phone number on your ID card.

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Programs and Limits

Some medications are noted with letters or symbols next to them. The letters and symbols refer to our pharmacy benefit programs and are provided to help you check which medications may have a program or limit. Your benefit plan determines how these medications may be covered for you.

AR Age Restrictions – Some restrictions may apply based on patient age.

PA Prior Authorization – Your doctor is required to provide additional information to determine coverage.

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

QL Quantity Limits – Amount of medication covered per copayment or in a specific time period.

SPSpecialty Medication – Medication is designated as a specialty pharmacy drug.

++ Coverage is determined by the consumer’s prescription drug benefit plan.

To learn more about a pharmacy program or to find out if it applies to you, please visit your plan’s member website or call the toll-free member phone number on your ID card.

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Why are some medications excluded from coverage?

Medications may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication. There may be other medication options available.

What if I don’t agree with a decision about an excluded medication?

You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling the toll-free member phone number on the back of your ID card.

Should I talk to my doctor about OTC medications?

An OTC medication may be the right treatment option for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than your out-of-pocket expense for prescription medications.

What is the difference between brand-name and generic medications?

Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. These types of medications are known as generic medications. Sometimes the same company that makes a brand-name medication also makes the generic version.

Is it a generic or brand-name drug?

The drug list shows brand-name drugs in bold type (for example, Clobex) and generic drugs in plain type (for example, clobetasol).

What if my doctor writes a brand-name prescription?

The next time your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option, but not always. Visit your plan’s member website to make sure.

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Are you taking a specialty medication?

Specialty medications treat rare or complex conditions and are typically higher cost medications. Please note, not all specialty medications are listed in the Formulary.

BriovaRx, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx and have your prescriptions delivered right to your home or office.

How do I get updated information about my pharmacy benefit?

Since the Formulary may change during your plan year, we encourage you to visit your plan’s member website or call the toll-free member phone number on the back of your ID card for more current information.

When you register on our website and open an account, you can use the website’s helpful tools and features to:

• Look up the price of drugs covered by your plan

• Find lower-cost options

• Refill and renew home delivery prescriptions

• View your order status and claims history

• View your benefits in real time

More informationIf you have additional questions please call customer service, 24 hours a day, 7 days a week using the toll-free member phone number on your ID card. Or visit your plan’s member website.

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Bold type = Brand-name drug [Plain type = Generic drug] Call customer service for pricing

AR Age Restrictions PA Prior Authorization ST Step TherapyQL Quantity Limits

SP Specialty Program++ Coverage is determined

by the consumer’s prescription benefit plan

Drug NameDrug Tier

Programs and Limits

Anti-Infectives: Antibiotics

Amoxicillin 1Amoxicillin/Clavulanate 1Azasite 3Azithromycin 1Bethkis 2 SPCefdinir 1Cefuroxime Tab 1Cephalexin 1Ciprodex Otic

Suspension2

Ciprofloxacin Tab 1Clarithromycin 1Clindamycin Cap 1Doryx MPC 3Doxycycline Hyclate Cap 1Doxycycline Hyclate Tab

(Immediate Release)1

Doxycycline Monohydrate Cap

1

Doxycycline Monohydrate Oral Suspension, Tab

1

Erythromycin 1Levofloxacin Tab 1Metronidazole Tab 1Minocycline Cap 1Nitrofurantoin

Macrocrystalline1

Nitrofurantoin Monohydrate Macrocrystalline

1

Ofloxacin Otic Solution 1Oracea 3Penicillin VK 1Solodyn 3Sulfamethoxazole-

Trimethoprim1

Drug NameDrug Tier

Programs and Limits

Sulfamethoxazole-Trimethoprim DS

1

Anti-Infectives: Antifungals

Fluconazole 1Nystatin Suspension 1Terbinafine Tab 1 QL

Anti-Infectives: Antivirals

Acyclovir Cap, Tab, Suspension

1

Entecavir 1 QL, SPEpclusa 2 PA, QL, SPFamciclovir Tab 1Harvoni 2 PA, QL, SPMavyret 2 PA, QL, SPOseltamivir 1 QLOdefsey 2 SPTamiflu 3 QLValacyclovir 1 QLZepatier 3 PA, QL, SP

Cancer

Akynzeo 3 QLAnastrozole Tab 1Cabometyx 2 PA, SPCapecitabine 1 PA, SPLetrozole 1Mercaptopurine 1 SPRevlimid 2 PA, SPSprycel 2 PA, SPTamoxifen Tab 1Zytiga 3 PA, SP

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Drug NameDrug Tier

Programs and Limits

Cardiovascular/Heart Disease: AnticoagulantsBrilinta 2Clopidogrel 1Effient 3Eliquis 3 QLEnoxaparin QL, SPPradaxa 2 QLSavaysa 3 QLWarfarin 1Xarelto 2 QLZontivity 3Cardiovascular/Heart Disease: High Blood PressureAmlodipine 1Amlodipine/Benazepril 1Amlodipine/Valsartan 1Atenolol 1Atenolol/Chlorthalidone 1Benazepril 1Benazepril/HCTZ 1Bisoprolol/HCTZ 1Bumetanide 1Bystolic 2Byvalson 2Cartia XT 1Carvedilol 1Chlorthalidone 1Clonidine Tab 1Diltiazem ER Cap 1Doxazosin 1Dutasteride 1Edarbi 3 STEdarbyclor 3 STEnalapril 1Furosemide 1Guanfacine Tab


Hydralazine 1Hydrochlorothiazide 1Irbesartan 1

Drug NameDrug Tier

Programs and Limits

Labetalol 1Lisinopril 1Lisinopril/HCTZ 1Losartan 1Losartan/HCTZ 1Metoprolol Succinate 1Metoprolol Tartrate 1Nadolol 1Nifedipine ER 1Olmesartan 1Olmesartan/HCTZ 1Prazosin 1Propranolol 1Propranolol ER 1Quinapril 1Ramipril 1Spironolactone 1Tekturna 2 STTekturna HCT 2 STTelmisartan 1Terazosin 1Torsemide Tab 1Triamterene/HCTZ 1Valsartan 1Valsartan/HCTZ 1Verapamil ER 1Cardiovascular/Heart Disease: High CholesterolAtorvastatin 1Choline Fenofibrate ER 1Crestor 3Fenofibrate 40 mg,

43 mg, 48 mg, 50 mg, 54 mg, 67 mg, 120 mg, 130 mg, 134 mg, 145 mg, 150 mg, 160 mg, 200 mg

1

Gemfibrozil 1Livalo 3 STLovastatin 1Niacin ER Tab 1Omega-3 Acid Cap

1 gm1

11





Drug NameDrug Tier

Programs and Limits

Praluent PA, QL, SPPravastatin 1Rosuvastatin 1Simvastatin 5 mg, 10

mg, 20 mg, 40 mg1

Simvastatin 80 mg 1 PAVascepa 2Vytorin 10-10 mg,

10-20 mg, 10-40 mg

3

Vytorin 10-80 mg 3 PAWelchol 2

Cardiovascular/Heart Disease: Other

Corlanor 3 PA, QLDigoxin 1Flecainide 1Isosorbide Mononitrate 1Isosorbide Mononitrate

ER1

Multaq 3Nitroglycerin SL Tab 1Ranexa 2 STSotalol 1Cardiovascular/Heart Disease: Pulmonary Arterial HypertensionAdcirca 3 PA, QL, SPAdempas 2 PA, QL, SPLetairis 2 PA, QL, SPOpsumit 2 PA, QL, SPOrenitram 3 PA, SPSildenafil Tab 20 mg 1 PA, QL, SPTracleer 2 PA, QL, SPCentral Nervous System: Attention Deficit DisorderAdderall XR Cap 3 QL, STAmphetamine-

Dextroamphetamine Tab

1 QL

Drug NameDrug Tier

Programs and Limits

Amphetamine-Dextroamphetamine SR 24Hr Cap

1 QL

Dexmethylphenidate ER Cap

1 QL

Guanfacine ER Tab 1Methylphenidate

ER Cap1 QL

Methylphenidate ER Tab 1 QLMethylphenidate SA

Osmotic ER Tab1 QL

Methylphenidate Tab 1 QLStrattera 3 QLVyvanse 2 QL

Central Nervous System: Depression

Amitriptyline 1Bupropion 1Bupropion ER 1 QLBupropion SR 1 QLBupropion XL 1 QLCitalopram 1Doxepin 1Duloxetine Cap 20 mg,

30 mg, 60 mg1 QL

Escitalopram Tab 1Fluoxetine Cap

(not PMDD)1

Forfivo XL 2 QLMirtazapine 1Nortriptyline 1Paroxetine Tab 1Pristiq 3 QLRexulti 3 QLRisperidone Tab 1 QLSertraline 1Trazodone 1Trintellix 3 QL, STVenlafaxine Tab 1Venlafaxine ER Cap 1Venlafaxine ER Tab 1Viibryd 3 QL

12





Drug NameDrug Tier

Programs and Limits

Central Nervous System: Migraine

Butalbital-Acetaminophen-Caffeine Cap, Tab 50-325-40 mg

1

Migranal 3 QLRelpax 3 QLRizatriptan Tab, ODT 1 QLSumatriptan Tab

and Spray1 QL

Sumavel Dose 3 QLCentral Nervous System: Multiple SclerosisAmpyra 2 PA, QL, SPAubagio 3 PA, QL, ST, SPAvonex Kit PA, QL, SPAvonex Pen Kit PA, QL, SPAvonex Prefill Kit PA, QL, SPBetaseron PA, QL, SPCopaxone 20 mg/mL

& 40 mg/mL PA, QL, SP

Gilenya* 3 PA, QL, ST, SPTecfidera 2 PA, QL, SP

Central Nervous System: Other

Alprazolam Tab 1 QLAripiprazole 1 QLBuspirone 1Diazepam Tab 1Hydroxyzine HCL 1Hydroxyzine Pamoate 1Latuda 3 QL, STLorazepam Tab 1 QLModafinil 1 PA, QLNamenda XR 2 QLNamzaric 2 QLOlanzapine Tab 1 QLPramipexole 1Quetiapine 1 QL

Drug NameDrug Tier

Programs and Limits

Risperidone Tab 1 QLRopinirole


Saphris 2 QLCentral Nervous System: Sedatives/HypnoticsEszopiclone Tab 1 QLSilenor 3 QLTemazepam 1 QLTriazolam Tab 1 QLXyrem 3 PA, QL, SPZaleplon 1 QLZolpidem 1 QLZolpidem ER 1 QLCentral Nervous System: Seizure DisordersClonazepam 1 QLDivalproex DR 1Divalproex ER 1Gabapentin 1Lamotrigine


Levetiracetam 1Lyrica Cap 2 QLOxcarbazepine 1Topiramate Tab 1Vimpat 3Zonisamide 1

* Tier 3 Preferred

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Drug NameDrug Tier

Programs and Limits

Dermatology

Absorica 3 PAAczone Gel 3Atralin 3 PAClaravis 1 PAClindamycin Gel,

Lotion, Solution1

Clindamycin/ Benzoyl Peroxide Gel 1-5%

1

Clindamycin/Benzoyl Peroxide Gel 1.2-5%

1

Clobetasol Cream, Ointment, Solution

1

Clobex 3Clotrimazole/

Betamethasone Cream, Lotion

1

Dupixent PA, QL, SPEconazole Cream 1Elidel 2 STEpiduo & Epiduo

Forte3

Eucrisa 2 STFluocinonide Cream,

0.1%1

Fluocinonide Cream, Gel, Ointment, Solution 0.05%

1

Hydrocortisone Cream, Ointment 2.5%

1

Lidocaine Topical Ointment, Solution

1

Ketoconazole Cream/Shampoo

1

Metrogel 3Metronidazole Gel

0.75%1

Mirvaso Gel 2Mupirocin Ointment 1Myorisan 1 PA

Drug NameDrug Tier

Programs and Limits

Nystatin Cream, Ointment, Powder

1

Onexton 3Oxsoralen-UL 2Permethrin Cream 5% 1Proctofoam HC 2Retin-A Micro gel

0.1%, 0.04%3 PA, ++

Soolantra 2Taclonex 3 QLTazorac 3 PA, ++Tretinoin Cream 1 PA, ++Tretinoin Microsphere

Gel1 PA, ++

Triamcinolone 1Vectical 3Zovirax Cream 2Zovirax Ointment 3Zyclara 3Diabetes/Endocrine Blood: Glucose MonitoringAccu-Chek Active

Glucose Control Liquid

2 ++

Accu-Chek Active Test Strips

2 QL, ++

Accu-Chek Aviva Connect Kit

2 ++

Accu-Chek Aviva Plus Control Liquid

2 ++

Accu-Chek Aviva Plus Kit

2 ++

Accu-Chek Aviva Plus Test Strips

2 QL, ++

Accu-Chek Compact Plus Control Liquid

2 ++

Accu-Chek Compact Plus Test Strips

2 QL, ++

Accu-Chek Compact Plus Kit

2 ++

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Drug NameDrug Tier

Programs and Limits

Accu-Chek FastClix Kit

2 ++

Accu-Chek FastClix Lancets

2 ++

Accu-Chek Guide Control Liquid

2 ++

Accu-Chek Guide Kit 2 ++Accu-Chek Guide Test

Strips2 QL, ++

Accu-Chek Multiclix Kit

2 ++

Accu-Chek Multiclix Lancets

2 ++

Accu-Chek Nano SmartView Kit

2 ++

Accu-Chek SmartView Control Liquid

2 ++

Accu-Chek SmartView Test Strips

2 QL, ++

Accu-Chek Soft Touch Lancets

2 ++

Accu-Chek Softclix Kit 2 ++Accu-Chek Softclix

Lancets2 ++

Bayer Contour Test Strips

3 QL, ST, ++

Dexcom G4 Platinum Kit

3 ++

Dexcom G4 Platinum Sensor Kit

3 ++

Dexcom G4 Platinum Transmitter Kit

3 ++

Dexcom G5 Kit 3 ++Dexcom G5 Sensor

Kit3 ++

Drug NameDrug Tier

Programs and Limits

Dexcom G5 Transmitter Kit

3 ++

Freestyle Test Strips 3 QL, ST, ++Insulin Pen Needle 2 ++Insulin Syringe/

Needle 2 ++

Novofine Pen Needle 2 ++Novofine Autocover

Pen Needle2 ++

Novotwist Pen Needle 2 ++

OneTouch Ultra 2 System

2 ++

OneTouch UltraMini System Kit

2 ++

OneTouch Ultra Test Strips

2 QL, ++

OneTouch Verio Flex System Kit

2 ++

OneTouch Verio IQ System Kit

2 ++

OneTouch Verio Sync System Kit

2 ++

OneTouch Verio System Kit

2 ++

OneTouch Verio Test Strips

2 QL, ++

Precision Test Strips 3 QL, ST, ++

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Drug NameDrug Tier

Programs and Limits

Diabetes/Endocrine: Insulin

Humalog Mix 50/50 Vial and KwikPen

2 ++

Humalog Mix 75-25 Vial and KwikPen

2 ++

Humalog U-100 Vial and KwikPen

2 ++

Humalog U-200 KwikPen

2 ++

Humulin 70-30 Vial and KwikPen

2 ++

Humulin N Vial and KwikPen

2 ++

Humulin R U-500 Vial and KwikPen

2 ++

Humulin R Vial 2 ++Lantus SoloStar 2 ++Lantus Vial 2 ++Levemir FlexTouch 2 ++Levemir Vial 2 ++Novolin 70/30 Vial 2 ++Novolin N Vial 2 ++Novolin R Vial 2 ++Novolog Flexpen 2 ++Novolog Mix 70/30

Vial and Flexpen2 ++

Novolog Penfill 2 ++Novolog Vial 2 ++Soliqua 2 QL, ST, ++Toujeo SoloStar 2 ++Tresiba 3 ++

Diabetes/Endocrine: Non-Insulin

Bydureon 2 QL, STByetta 2 QL, STFarxiga 3 STGlimepiride 1Glipizide 1Glipizide ER 1Glipizide XL 1

Drug NameDrug Tier

Programs and Limits

Glumetza 3 PAGlyburide 1Invokamet 2 STInvokamet XR 2 STInvokana 2 STJanumet 2 STJanumet XR 2 STJanuvia 2 STJardiance 2 STJentadueto 2 STJentadueto XR 2 STMetformin 1Metformin ER 1Pioglitazone 1Synjardy 2 STTradjenta 2 STTrulicity 2 QL, STVictoza 2 QL, ST

Endocrine: Growth Hormone

Norditropin PA, SP, ++Nutropin AQ PA, SP, ++Omnitrope PA, SP, ++

Endocrine: Other

Calcitriol Cap 1Clomiphene 1Dexamethasone Tab 1H.P. Acthar PA, SPHydrocortisone Tab 1Lupron Depot

3.75 mg, 11.25 mg PA, SP

Lupron Depot 7.5 mg, 22.5 mg, 30 mg, 45 mg

PA, SP

Methylprednisolone Tab 1Prednisone 1Prednisolone Solution

25 mg/5 ml1

Prednisolone Syrup, Solution 15 mg/5 ml

1

16





Drug NameDrug Tier

Programs and Limits

Endocrine: Thyroid Hormone Replacement Armour Thyroid 3Levothyroxine 1Liothyronine 1Methimazole 1Synthroid 3Tirosint 3

Eye Conditions: Allergies

Azelastine Ophthalmic Solution

1

Pataday 3Pazeo 2

Eye Conditions: Antibiotics

Besivance 3Ciprofloxacin

Ophthalmic Solution1

Erythromycin Ointment 1Moxeza 2Ofloxacin Ophthalmic

Solution1

Polymyxin B/Trimethoprim Solution

1

Tobramycin 1Tobramycin/

Dexamethasone1

Vigamox 3

Drug NameDrug Tier

Programs and Limits

Eye Conditions: Glaucoma

Alphagan P 2Azopt 2Betimol 3Combigan 2Cosopt PF 3Latanoprost 1 QLLumigan 2 QLSimbrinza 2Travatan Z 2 QL

Eye Conditions: Other

Ketorolac Ophthalmic Solution

1

Prednisolone Ophthalmic Suspension

1

Restasis 2 PARestasis Multidose 2 PAXiidra 2 PA

Gastrointestinal: Acid Suppression

Dexilant 2 QLEsomeprazole

Magnesium 40 mg (Rx only)

1 QL

Famotidine Tab 40 mg (Rx only)

1

Lansoprazole 30 mg (Rx only)

1 QL

Misoprostol 1Omeprazole (Rx only) 1 QLPantoprazole 1 QLRabeprazole 1 QLRanitidine Tab, Cap,

Syrup (Rx only)1

Sucralfate Tab 1

17





Drug NameDrug Tier

Programs and Limits

Gastrointestinal: Nausea/Vomiting

Metoclopramide 1Ondansetron ODT 1 QLOndansetron Tab 1Varubi 3 QL

Gastrointestinal: Other

Amitiza 2 QL, STApriso 2Canasa 2Creon 2Delzicol 3 STDicyclomine 1Dipentum 3Diphenoxylate/Atropine 1Gavilyte Solution 1Lialda 2 STLinzess 2 QL, STPentasa 3Prepopik 3Pylera 2Suprep Bowel Prep 3Uceris Foam 3Zenpep 2

HIV/AIDS

Atripla 2 SP Complera 2 SPDescovy 2 SPGenvoya 2 SPIsentress 2 SPNorvir 2 SPPrezcobix 2 SPPrezista 2 SPReyataz 2 SPStribild 2 SPTivicay 2 SPTriumeq 2 SPTruvada 2 SPViread 2 SP

Drug NameDrug Tier

Programs and Limits

InfertilityCetrotide PA, SP, ++Gonal-f PA, SP, ++Gonal-f RFF PA, SP, ++Ovidrel SP, ++

Inflammatory Conditions

Cimzia Kit PA, SPCosentyx* PA, SPDepen 2 SPEnbrel PA, SP, STHumira Kit PA, SPHumira Pen Kit PA, SPHumira Pen Kit

Crohns PA, SP

Humira Pen Kit Psoriasis

PA, SP

Hydroxychloroquine 1Leflunomide 1Methotrexate Tab 1Orencia SC PA, SP, STOtezla 2 PA, SPRasuvo 2 PA, QLRemicade PA, SPSimponi Aria PA, SPSimponi PA, SPStelara PA, SPXeljanz 3 PA, SP, ST

* Tier 3 Preferred

18





Drug NameDrug Tier

Programs and Limits

Men’s Health: Erectile Dysfunction

Cialis 2 QL, ++Levitra 3 QL, ++Stendra 3 QL, ++Viagra 2 QL, ++

Men’s Health: Prostate

Cialis 2.5 mg & 5 mg 2 QLDoxazosin 1Finasteride 5 mg 1Rapaflo 2Tamsulosin 1Terazosin 1

Men’s Health: Testosterone Therapy

Androderm 2 PAAndrogel 1.62% 2 PAAndrogel 1% 3 PA, STTestosterone Cypionate

IM Injection1 PA

Miscellaneous

Allopurinol 1Aranesp PA, SPArmodafinil 1 PA, QLAuryxia 3Benzonatate 1Botox 100, 200 unit

Injection (non-cosmetic)

PA, SP

Bunavail 3 QLCerdelga 3 PA, SPCheratussin 1Chlorhexidine 1Colcrys 2Contrave 2 PAEpinephrine

Auto-Injector (Authorized Generic of EpiPen made by Mylan)

2

EpiPen & EpiPen Jr 3 ST

Drug NameDrug Tier

Programs and Limits

Euflexxa PA, SPFosrenol 3Granix PA, SPGuaifenesin/Codeine

Syrup1

Hydrocodone/Chlorpheniramine Liquid

1

Hydrocodone Polistirex/Chlorpheniramine ER Suspension

1

Lidocaine Viscous Solution 2%

1

Makena PA, SPNarcan 2Neupogen PA, SPPhenazopyridine

(Rx only)1

Phentermine Tab 1 PAProcrit PA, SPPromethazine 1Promethazine DM Syrup 1Promethazine/Codeine

Syrup1

Renvela Tab 2Rezira 3Suboxone Film 2 QLSynvisc PA, SPSynvisc One PA, SPUloric 2 STVelphoro 3Zarxio PA, SPZubsolv 2 QLZurampic 3Zutripro 3

19





Drug NameDrug Tier

Programs and Limits

Musculoskeletal: Osteoporosis

Alendronate Tab 35 mg & 70 mg

1 QL

Binosto 3 QLForteo PA, SPTymlos PA, SP

Musculoskeletal: Other

Baclofen Tab 1Carisoprodol 350 mg 1Cyclobenzaprine Tab

5, 10 mg1

Lorzone 3Metaxalone 1Methocarbamol 1Tizanidine Cap 1Tizanidine Tab 1

Musculoskeletal: Pain Relief

Acetaminophen w/ Codeine

1 QL

Celecoxib 1 QLDiclofenac Gel 1 QLDiclofenac Tab 1Embeda 2 PA, QLEtodolac 1Flector patch 3 QLFentanyl Patch

25 mcg/hr, 50 mcg/hr, 75 mcg/hr, 100 mcg/hr

1 PA, QL

Fentanyl Patch 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr

1 PA, QL

Gralise 3 QL, ST

Drug NameDrug Tier

Programs and Limits

Hydrocodone/Acetaminophen 5, 7.5, 10/325 mg

1 QL

Hydromorphone Tab 1 QLHysingla ER 2 PA, QLIbuprofen Tab 400, 600,

800 mg (Rx only)1

Indomethacin Cap 1Ketorolac Tab 1 QLLidocaine Patch 5% 1Meloxicam 1Methadone Tab 1 PAMorphine Sulfate ER 1 PA, QLMorphine Sulfate Tab 1 PA, QLNabumetone 1Naproxen (Rx only) 1Oxycodone Tab 5,

10, 15, 30 mg (Immediate Release)

1 QL

Oxycodone w/ Acetaminophen

1 QL

Oxycontin 2 PA, QLTramadol Tab 50 mg 1Tramadol

w/ Acetaminophen 1

Zohydro ER 3 PA, QLZorvolex 3

Overactive Bladder

Myrbetriq 2Oxybutynin 1Oxybutynin ER 1Toviaz 3Vesicare 2

20





Drug NameDrug Tier

Programs and Limits

Respiratory: Asthma/COPD

Advair Diskus 2 QLAdvair HFA 2 QLAerospan 3 QLAlbuterol

Nebulizer Solution1 QL

Anoro Ellipta 2 QLArnuity Ellipta 2 QLBreo Ellipta 2 QLBudesonide Inhalation

Suspension1 QL

Combivent Respimat 2 QLDulera 3 QL, STFlovent Diskus 2 QLFlovent HFA 2 QLIncruse Ellipta 2 QLIpratropium/Albuterol

Nebulizer Solution1 QL

Montelukast 1Proair HFA, RespiClick 2 QLPulmicort Flexhaler 2 QLQvar 2 QLSerevent Diskus 2 QLSpiriva Handihaler 2 QLSpiriva Respimat 2 QLStiolto 2 QLSymbicort 2 QLVentolin HFA 2 QLXolair PA, SP

Drug NameDrug Tier

Programs and Limits

Respiratory: Nasal Allergies

Astepro 3 QLAzelastine Spray 1 QLDymista Spray 2 QLIpratropium Spray 1 QLMometasone 1 QLOmnaris 3 QLQNasl 3 QLZetonna 3 QL

Respiratory: Oral Allergies

Promethazine Tab 1

Transplant

Azathioprine Tab 1Mycophenolate Mofetil

250 mg Cap/ 500 mg Tab

1 SP

Mycophenolate Sodium 180 mg, 360 mg Tab

1 SP

Prograf Cap 3 SPTacrolimus Cap 1 SP

21





Drug NameDrug Tier

Programs and Limits

Vitamins/Electrolytes

Cyanocobalamine Injection

1 ++

Folic Acid 1 mg (Rx only)

1

Klor-Con 8 and 10 MEQ 1Klor-Con M10 and M20 1Ludent 1 ++Potassium Chloride ER

Tab, Cap1

Potassium Chloride Micro ER Tab

1

Vitamin D 50,000 units (Rx only)

1 ++

Women’s Health: Birth Control

Apri 1 ++Aviane 1 ++Azurette 1 ++Cryselle-28 1 ++Falmina 1 ++Generess Fe

Chewable3 ++

Gianvi 1 ++Gildess 1 ++Jolivette 1 ++Junel 1 ++Kariva 1 ++Levora 28 1 ++Lo Loestrin 3 ++Lomedia Fe 1 ++

Drug NameDrug Tier

Programs and Limits

Loryna 1 ++Low-Ogestrel 1 ++Lutera 1 ++Medroxyprogesterone

Acetate Injection1 QL, ++

Microgestin 1 ++Microgestin Fe 1 ++Mono-Linyah 1 ++Mononessa 1 ++Natazia 2 ++Necon 1 ++Nora-Be 1 ++Norgest/Ethi Estradio 1 ++Nortrel 1 ++Nuvaring 2 ++Ocella 1 ++Orsythia 1 ++Ortho Tri-Cyclen Lo 3 ++Previfem 1 ++Reclipsen 1 ++Sprintec 28 1 ++Tri-Linyah 1 ++Tri-Lo Sprintec 1 ++Tri-Previfem 1 ++Trinessa 1 ++Tri-Sprintec 1 ++Vestura 1 ++Viorele 1 ++Xulane 1 ++Zarah 1 ++

22





Drug NameDrug Tier

Programs and Limits

Women’s Health: Hormone Replacement

Climara Pro 2Divigel 3Duavee 2Elestrin Gel 3Estrace Vaginal Cream 3Estradiol Patch, Tab 1Estradiol/Norethindrone

Tab1

Medroxyprogesterone Acetate Tab

1

Minivelle 3Osphena 3Premarin Tab 2Premarin Vaginal

Cream2

Premphase 2Prempro 2Progesterone Cap 1Yuvafem 1

Women’s Health: Vaginal Anti-Infectives

Gynazole-1 Vaginal Cream

3

Metronidazole Vaginal Gel

1

Terconazole Vaginal Cream

1

Bold type = Brand-name drug [Plain type = Generic drug] 23

Index of Covered Drugs

A

Absorica . . . . . . . . . . 13Accu-Chek Active Glucose

Control Liquid . . . . . 13Accu-Chek Active

Test Strips . . . . . . . 13Accu-Chek Aviva

Connect Kit . . . . . . 13Accu-Chek Aviva

Plus Control Liquid . . 13Accu-Chek Aviva Plus Kit . 13Accu-Chek Aviva Plus

Test Strips . . . . . . . 13Accu-Chek Compact

Plus Control Liquid . . 13Accu-Chek Compact

Plus Kit . . . . . . . . . 13Accu-Chek Compact

Plus Test Strips. . . . . 13Accu-Chek FastClix Kit . . 14Accu-Chek FastClix Lancets . 14Accu-Chek Guide Control

Liquid. . . . . . . . . . 14Accu-Chek Guide Kit . . . 14Accu-Chek Guide Test Strips 14Accu-Chek Multiclix Kit . . 14Accu-Chek Multiclix Lancets 14Accu-Chek Nano

SmartView Kit . . . . . 14Accu-Chek SmartView

Control Liquid . . . . . 14Accu-Chek SmartView

Test Strips . . . . . . . 14Accu-Chek Softclix Kit. . . 14Accu-Chek Softclix Lancets . 14Accu-Chek Soft Touch

Lancets . . . . . . . . . 14Acetaminophen w/ Codeine 19Acyclovir Cap, Tab, Suspension. .9Aczone Gel. . . . . . . . . 13Adcirca . . . . . . . . . . . 11Adderall XR Cap . . . . . . 11Adempas. . . . . . . . . . 11Advair Diskus . . . . . . . 20Advair HFA . . . . . . . . 20Aerospan . . . . . . . . . 20Akynzeo . . . . . . . . . . . 9

Albuterol Nebulizer Solution . . 20Alendronate Tab . . . . . . 19Allopurinol . . . . . . . . . 18Alphagan P . . . . . . . . 16Alprazolam Tab . . . . . . . 12Amitiza. . . . . . . . . . . 17Amitriptyline . . . . . . . . 11Amlodipine . . . . . . . . . 10Amlodipine/Benazepril . . . 10Amlodipine/Valsartan . . . . 10Amoxicillin . . . . . . . . . . 9Amoxicillin/Clavulanate . . . . 9Amphetamine-

Dextroamphetamine SR 24Hr Cap . . . . . . 11

Amphetamine-Dextroamphetamine Tab . 11

Ampyra . . . . . . . . . . 12Anastrozole Tab . . . . . . . . 9Androderm . . . . . . . . 18Androgel. . . . . . . . . . 18Anoro Ellipta . . . . . . . 20Apri . . . . . . . . . . . . . 21Apriso . . . . . . . . . . . 17Aranesp . . . . . . . . . . 18Aripiprazole . . . . . . . . . 12Armodafinil . . . . . . . . . 18Armour Thyroid . . . . . . 16Arnuity Ellipta . . . . . . . 20Astepro . . . . . . . . . . 20Atenolol. . . . . . . . . . . 10Atenolol/Chlorthalidone. . . 10Atorvastatin . . . . . . . . 10Atralin . . . . . . . . . . . 13Atripla . . . . . . . . . . . 17Aubagio . . . . . . . . . . 12Auryxia . . . . . . . . . . 18Aviane . . . . . . . . . . . 21Avonex Kit. . . . . . . . . 12Avonex Pen Kit . . . . . . 12Avonex Prefill Kit . . . . . 12Azasite . . . . . . . . . . . . 9Azathioprine Tab . . . . . . 20Azelastine Ophthalmic

Solution . . . . . . . . . 16Azelastine Spray. . . . . . . 20Azithromycin . . . . . . . . . 9

Azopt . . . . . . . . . . . 16Azurette . . . . . . . . . . 21

B

Baclofen Tab . . . . . . . . 19Bayer Contour Test Strips . 14Benazepril. . . . . . . . . . 10Benazepril/HCTZ . . . . . . 10Benzonatate . . . . . . . . 18Besivance . . . . . . . . . 16Betaseron . . . . . . . . . 12Bethkis . . . . . . . . . . . . 9Betimol. . . . . . . . . . . 16Binosto. . . . . . . . . . . 19Bisoprolol/HCTZ . . . . . . . 10Botox. . . . . . . . . . . . 18Breo Ellipta . . . . . . . . 20Brilinta . . . . . . . . . . . 10Budesonide Inhalation

Suspension . . . . . . . 20Bumetanide . . . . . . . . . 10Bunavail . . . . . . . . . . 18Bupropion. . . . . . . . . . 11Bupropion ER . . . . . . . . 11Bupropion SR . . . . . . . . 11Bupropion XL . . . . . . . . 11Buspirone . . . . . . . . . . 12Butalbital-Acetaminophen-

Caffeine . . . . . . . . . 12Bydureon . . . . . . . . . 15Byetta . . . . . . . . . . . 15Bystolic. . . . . . . . . . . 10Byvalson . . . . . . . . . . 10

C

Cabometyx . . . . . . . . . . 9Calcitriol Cap . . . . . . . . 15Canasa . . . . . . . . . . . 17Capecitabine . . . . . . . . . 9Carisoprodol 350 mg . . . . 19Cartia XT . . . . . . . . . . 10Carvedilol . . . . . . . . . . 10Cefdinir . . . . . . . . . . . . 9Cefuroxime Tab . . . . . . . . 9Celecoxib . . . . . . . . . . 19Cephalexin . . . . . . . . . . 9



Cerdelga . . . . . . . . . . 18Cetrotide. . . . . . . . . . 17Cheratussin . . . . . . . . . 18Chlorhexidine . . . . . . . . 18Chlorthalidone . . . . . . . 10Choline Fenofibrate ER . . . 10Cialis . . . . . . . . . . . . 18Cimzia Kit . . . . . . . . . 17Ciprodex Otic Suspension . 9Ciprofloxacin Ophthalmic

Solution . . . . . . . . . 16Ciprofloxacin Tab . . . . . . . 9Citalopram . . . . . . . . . 11Claravis . . . . . . . . . . . 13Clarithromycin . . . . . . . . 9Climara Pro . . . . . . . . 22Clindamycin/Benzoyl Peroxide 13Clindamycin Cap . . . . . . . 9Clindamycin. . . . . . . . . 13Clobetasol Cream, Ointment,

Solution . . . . . . . . . 13Clobex . . . . . . . . . . . 13Clomiphene. . . . . . . . . 15Clonazepam . . . . . . . . 12Clonidine Tab . . . . . . . . 10Clopidogrel . . . . . . . . . 10Clotrimazole/Betamethasone. . 13Colcrys . . . . . . . . . . . 18Combigan . . . . . . . . . 16Combivent Respimat . . . 20Complera . . . . . . . . . 17Contrave . . . . . . . . . 18Copaxone . . . . . . . . . 12Corlanor . . . . . . . . . . 11Cosentyx. . . . . . . . . . 17Cosopt PF . . . . . . . . . 16Creon. . . . . . . . . . . . 17Crestor . . . . . . . . . . . 10Cryselle-28 . . . . . . . . . 21Cyanocobalamine Injection . 21Cyclobenzaprine Tab . . . . 19

D

Delzicol . . . . . . . . . . 17Depen . . . . . . . . . . . 17Descovy . . . . . . . . . . 17Dexamethasone Tab . . . . 15

Dexcom G4 Platinum Kit . 14Dexcom G4 Platinum

Sensor Kit . . . . . . . 14 Dexcom G4 Platinum

Transmitter Kit. . . . . 14Dexcom G5 Kit. . . . . . . 14Dexcom G5 Sensor Kit . . 14Dexcom G5 Transmitter Kit 14Dexilant . . . . . . . . . . 16Dexmethylphenidate ER Cap . . 11Diazepam Tab . . . . . . . . 12Diclofenac Gel . . . . . . . 19Diclofenac Tab . . . . . . . 19Dicyclomine . . . . . . . . . 17Digoxin . . . . . . . . . . . 11Diltiazem ER Cap . . . . . . 10Dipentum . . . . . . . . . 17Diphenoxylate/Atropine . . . 17Divalproex DR . . . . . . . . 12Divalproex ER . . . . . . . . 12Divigel . . . . . . . . . . . 22Doryx MPC. . . . . . . . . . 9Doxazosin . . . . . . . . . . 10Doxazosin . . . . . . . . . . 18Doxepin . . . . . . . . . . . 11Doxycycline Hyclate . . . . . . 9Doxycycline Monohydrate Cap. .9Doxycycline Monohydrate

Oral Suspension . . . . . . 9Duavee. . . . . . . . . . . 22Dulera . . . . . . . . . . . 20Duloxetine Cap . . . . . . . 11Dupixent . . . . . . . . . . 13Dutasteride . . . . . . . . . 10Dymista Spray . . . . . . . 20

E

Econazole Cream . . . . . . 13Edarbi . . . . . . . . . . . 10Edarbyclor . . . . . . . . . 10Effient . . . . . . . . . . . 10Elestrin Gel . . . . . . . . 22Elidel . . . . . . . . . . . . 13Eliquis . . . . . . . . . . . 10Embeda . . . . . . . . . . 19Enalapril. . . . . . . . . . . 10

Enbrel . . . . . . . . . . . 17Enoxaparin . . . . . . . . . 10Entecavir . . . . . . . . . . . 9Epclusa. . . . . . . . . . . . 9Epiduo & Epiduo Forte . . 13Epinephrine Auto-Injector. . 18EpiPen & EpiPen Jr . . . . 18Erythromycin . . . . . . . . . 9Erythromycin Ointment . . . 16Escitalopram Tab . . . . . . 11Esomeprazole Magnesium . 16Estrace Vaginal Cream . . 22Estradiol/Norethindrone Tab . 22Estradiol Patch, Tab . . . . . 22Eszopiclone Tab . . . . . . . 12Etodolac . . . . . . . . . . 19Eucrisa . . . . . . . . . . . 13Euflexxa . . . . . . . . . . 18

F

Falmina . . . . . . . . . . . 21Famciclovir Tab . . . . . . . . 9Famotidine TabFarxiga . . . . . . . . . . . 15Fenofibrate . . . . . . . . . 10Fentanyl Patch . . . . . . . 19Finasteride . . . . . . . . . 18Flecainide . . . . . . . . . . 11Flector patch. . . . . . . . 19Flovent Diskus. . . . . . . 20Flovent HFA . . . . . . . . 20Fluconazole . . . . . . . . . . 9Fluocinonide Cream. . . . . 13Fluoxetine Cap . . . . . . . 11Folic Acid . . . . . . . . . . 21Forfivo XL . . . . . . . . . 11Forteo . . . . . . . . . . . 19Fosrenol . . . . . . . . . . 18Freestyle Test Strips . . . . 14Furosemide . . . . . . . . . 10

G

Gabapentin . . . . . . . . . 12Gavilyte Solution . . . . . . 17



Gemfibrozil . . . . . . . . . 10Generess Fe Chewable . . 21Genvoya . . . . . . . . . . 17Gianvi . . . . . . . . . . . . 21Gildess . . . . . . . . . . . 21Gilenya. . . . . . . . . . . 12Glimepiride . . . . . . . . . 15Glipizide . . . . . . . . . . 15Glipizide ER . . . . . . . . . 15Glipizide XL . . . . . . . . . 15Glumetza . . . . . . . . . 15Glyburide . . . . . . . . . . 15Gonal-f . . . . . . . . . . . 17Gonal-f RFF . . . . . . . . 17Gralise . . . . . . . . . . . 19Granix . . . . . . . . . . . 18Guaifenesin/Codeine Syrup . 18Guanfacine ER Tab . . . . . 11Guanfacine Tab . . . . . . . 10Gynazole-1 Vaginal Cream . 22

H

Harvoni . . . . . . . . . . . 9H.P. Acthar . . . . . . . . . 15Humalog Mix 50/50

Vial and KwikPen . . . 15Humalog Mix 75-25

Vial and KwikPen . . . 15Humalog U-100 Vial

and KwikPen. . . . . . 15Humalog U-200 KwikPen . 15Humira Kit . . . . . . . . . 17Humira Pen Kit . . . . . . 17Humira Pen Kit Crohns . . 17Humira Pen Kit Psoriasis . 17Humulin 70-30 Vial

and KwikPen. . . . . . 15Humulin N Vial

and KwikPen. . . . . . 15Humulin R U-500 Vial and

KwikPen . . . . . . . . 15Humulin R Vial. . . . . . . 15Hydralazine . . . . . . . . . 10Hydrochlorothiazide. . . . . 10Hydrocodone/Acetaminophen 19Hydrocodone/

Chlorpheniramine Liquid . . 18

Hydrocodone Polistirex/Chlorpheniramine ER Suspension . . . . . . . 18

Hydrocortisone . . . . . . . 13Hydrocortisone Tab . . . . . 15Hydromorphone Tab . . . . 19Hydroxychloroquine . . . . . 17Hydroxyzine HCL . . . . . . 12Hydroxyzine Pamoate . . . . 12Hysingla ER . . . . . . . . . 19

I

Ibuprofen . . . . . . . . . . 19Incruse Ellipta . . . . . . . 20Indomethacin Cap . . . . . 19Insulin Pen Needle . . . . 14Insulin Syringe/Needle . . 14Invokamet . . . . . . . . . 15Invokamet XR . . . . . . . 15Invokana. . . . . . . . . . 15Ipratropium/Albuterol

Nebulizer Solution. . . . 20Ipratropium Spray . . . . . . 20Irbesartan . . . . . . . . . . 10Isentress . . . . . . . . . . 17Isosorbide Mononitrate . . . 11Isosorbide Mononitrate ER . 11

J

Janumet . . . . . . . . . . 15Janumet XR . . . . . . . . 15Januvia. . . . . . . . . . . 15Jardiance. . . . . . . . . . 15Jentadueto. . . . . . . . . 15Jentadueto XR. . . . . . . 15Jolivette . . . . . . . . . . . 21Junel . . . . . . . . . . . . 21

K

Kariva . . . . . . . . . . . . 21Ketoconazole

Cream/Shampoo . . . . 13Ketorolac

Ophthalmic Solution. . . 16

Ketorolac Tab . . . . . . . . 19Klor-Con 8 and 10 MEQ. . . 21Klor-Con M10 and M20. . . 21

L

Labetalol . . . . . . . . . . 10Lamotrigine . . . . . . . . . 12Lansoprazole 30 mg. . . . . 16Lantus SoloStar . . . . . . 15Lantus Vial . . . . . . . . . 15Latanoprost . . . . . . . . . 16Latuda . . . . . . . . . . . 12Leflunomide. . . . . . . . . 17Letairis . . . . . . . . . . . 11Letrozole . . . . . . . . . . . 9Levemir FlexTouch. . . . . 15Levemir Vial . . . . . . . . 15Levetiracetam . . . . . . . . 12Levitra . . . . . . . . . . . 18Levofloxacin Tab. . . . . . . . 9Levora 28 . . . . . . . . . . 21Levothyroxine . . . . . . . . 16Lialda. . . . . . . . . . . . 17Lidocaine Patch 5% . . . . . 19Lidocaine Topical Ointment,

Solution . . . . . . . . . 13Lidocaine Viscous

Solution 2%. . . . . . . 18Linzess . . . . . . . . . . . 17Liothyronine . . . . . . . . 16Lisinopril . . . . . . . . . . 10Lisinopril/HCTZ . . . . . . . 10Livalo. . . . . . . . . . . . 10Lo Loestrin . . . . . . . . . 21Lomedia Fe . . . . . . . . . 21Lorazepam Tab . . . . . . . 12Loryna . . . . . . . . . . . 21Lorzone . . . . . . . . . . 19Losartan. . . . . . . . . . . 10Losartan/HCTZ . . . . . . . 10Lovastatin . . . . . . . . . 10Low-Ogestrel . . . . . . . . 21Ludent . . . . . . . . . . . 21Lumigan . . . . . . . . . . 16Lupron Depot . . . . . . . 15



Lutera . . . . . . . . . . . . 21Lyrica Cap . . . . . . . . . 12

M

Makena . . . . . . . . . . 18Mavyret . . . . . . . . . . . . 9Medroxyprogesterone

Acetate Injection . . . . 21Medroxyprogesterone

Acetate Tab . . . . . . . 22Meloxicam . . . . . . . . . 19Mercaptopurine . . . . . . . . 9Metaxalone . . . . . . . . . 19Metformin . . . . . . . . . 15Metformin ER . . . . . . . . 15Methadone Tab . . . . . . . 19Methimazole . . . . . . . . 16Methocarbamol . . . . . . . 19Methotrexate Tab . . . . . . 17Methylphenidate ER Cap . . 11Methylphenidate ER Tab. . . 11Methylphenidate SA

Osmotic ER Tab . . . . . 11Methylphenidate Tab . . . . 11Methylprednisolone Tab . . . 15Metoclopramide . . . . . . 17Metoprolol Succinate . . . . 10Metoprolol Tartrate . . . . . 10Metrogel . . . . . . . . . . 13Metronidazole Gel 0.75%. . 13Metronidazole Tab . . . . . . 9Metronidazole Vaginal Gel . 22Microgestin . . . . . . . . . 21Microgestin Fe . . . . . . . 21Migranal . . . . . . . . . . 12Minivelle . . . . . . . . . . 22Minocycline Cap . . . . . . . 9Mirtazapine . . . . . . . . . 11Mirvaso Gel . . . . . . . . 13Misoprostol . . . . . . . . . 16Modafinil . . . . . . . . . . 12Mometasone . . . . . . . . 20Mono-Linyah . . . . . . . . 21Mononessa . . . . . . . . . 21Montelukast . . . . . . . . 20Morphine Sulfate ER . . . . 19

Morphine Sulfate Tab . . . . 19Moxeza . . . . . . . . . . 16Multaq . . . . . . . . . . . 11Mupirocin Ointment . . . . 13Mycophenolate

Mofetil 250 mg Cap/ 500 mg Tab . . . . . . . 20

Mycophenolate Sodium 180 mg, 360 mg Tab . . . . . . . 20

Myorisan . . . . . . . . . . 13Myrbetriq . . . . . . . . . 19

N

Nabumetone . . . . . . . . 19Nadolol . . . . . . . . . . . 10Namenda XR. . . . . . . . 12Namzaric . . . . . . . . . . 12Naproxen . . . . . . . . . . 19Narcan . . . . . . . . . . . 18Natazia. . . . . . . . . . . 21Necon. . . . . . . . . . . . 21Neupogen . . . . . . . . . 18Niacin ER Tab . . . . . . . . 10Nifedipine ER . . . . . . . . 10Nitrofurantoin Macrocrystalline .9Nitrofurantoin Monohydrate

Macrocrystalline . . . . . . 9Nitroglycerin SL Tab . . . . . 11Nora-Be . . . . . . . . . . . 21Norditropin . . . . . . . . 15Norgest/Ethi Estradio . . . . 21Nortrel . . . . . . . . . . . 21Nortriptyline. . . . . . . . . 11Norvir . . . . . . . . . . . 17Novofine Autocover

Pen Needle. . . . . . . 14Novofine Pen Needle . . . 14Novolin 70/30 Vial. . . . . 15Novolin N Vial . . . . . . . 15Novolin R Vial . . . . . . . 15Novolog Flexpen . . . . . 15Novolog Mix 70/30

Vial and Flexpen. . . . 15Novolog Penfill . . . . . . 15Novolog Vial. . . . . . . . 15Novotwist Pen Needle . . 14

Nutropin AQ. . . . . . . . 15Nuvaring. . . . . . . . . . 21Nystatin Cream,

Ointment, Powder. . . . 13Nystatin Suspension. . . . . . 9

O

Ocella . . . . . . . . . . . . 21Odefsey . . . . . . . . . . . 9Ofloxacin Ophthalmic Solution 16Ofloxacin Otic Solution . . . . 9Olanzapine Tab . . . . . . . 12Olmesartan . . . . . . . . . 10Olmesartan/HCTZ . . . . . . 10Omega-3 Acid Cap . . . . . 10Omeprazole . . . . . . . . . 16Omnaris . . . . . . . . . . 20Omnitrope . . . . . . . . . 15Ondansetron ODT. . . . . . 17Ondansetron Tab . . . . . . 17OneTouch Ultra 2 System . 14OneTouch UltraMini

System Kit . . . . . . . 14OneTouch Ultra Test Strips . 14OneTouch Verio

Flex System Kit . . . . 14OneTouch Verio IQ

System Kit . . . . . . . 14OneTouch Verio

Sync System Kit . . . . 14OneTouch Verio System Kit . 14OneTouch Verio Test Strips . 14Onexton . . . . . . . . . . 13Opsumit . . . . . . . . . . 11Oracea . . . . . . . . . . . . 9Orencia SC . . . . . . . . . 17Orenitram . . . . . . . . . 11Orsythia . . . . . . . . . . . 21Ortho Tri-Cyclen Lo . . . . 21Oseltamivir . . . . . . . . . . 9Osphena . . . . . . . . . . 22Otezla . . . . . . . . . . . 17Ovidrel . . . . . . . . . . . 17Oxcarbazepine . . . . . . . 12Oxsoralen-UL . . . . . . . 13Oxybutynin . . . . . . . . . 19Oxybutynin ER . . . . . . . 19



Oxycodone Tab . . . . . . . 19Oxycodone w/Acetaminophen 19Oxycontin . . . . . . . . . 19

P

Pantoprazole . . . . . . . . 16Paroxetine Tab . . . . . . . 11Pataday . . . . . . . . . . 16Pazeo. . . . . . . . . . . . 16Penicillin VK. . . . . . . . . . 9Pentasa . . . . . . . . . . 17Permethrin Cream 5% . . . 13Phenazopyridine . . . . . . 18Phentermine Tab . . . . . . 18Pioglitazone. . . . . . . . . 15Polymyxin B/Trimethoprim

Solution . . . . . . . . . 16Potassium Chloride ER . . . 21Potassium Chloride

Micro ER Tab . . . . . . 21Pradaxa . . . . . . . . . . 10Praluent . . . . . . . . . . 11Pramipexole . . . . . . . . . 12Pravastatin . . . . . . . . . 11Prazosin . . . . . . . . . . . 10Precision Test Strips . . . . 14Prednisolone Ophthalmic

Suspension . . . . . . . 16Prednisolone Solution . . . . 15Prednisolone Syrup . . . . . 15Prednisone . . . . . . . . . 15Premarin Tab. . . . . . . . 22Premarin Vaginal Cream . 22Premphase . . . . . . . . . 22Prempro . . . . . . . . . . 22Prepopik . . . . . . . . . . 17Previfem . . . . . . . . . . 21Prezcobix . . . . . . . . . 17Prezista . . . . . . . . . . 17Pristiq . . . . . . . . . . . 11Proair HFA, RespiClick. . . 20Procrit . . . . . . . . . . . 18Proctofoam HC . . . . . . 13Progesterone Cap . . . . . . 22Prograf Cap . . . . . . . . 20Promethazine . . . . . . . . 18Promethazine/Codeine Syrup 18

Promethazine DM Syrup . . 18Promethazine Tab . . . . . . 20Propranolol . . . . . . . . . 10Propranolol ER . . . . . . . 10Pulmicort Flexhaler . . . . 20Pylera . . . . . . . . . . . 17

Q

QNasl. . . . . . . . . . . . 20Quetiapine . . . . . . . . . 12Quinapril . . . . . . . . . . 10Qvar . . . . . . . . . . . . 20

R

Rabeprazole. . . . . . . . . 16Ramipril . . . . . . . . . . . 10Ranexa . . . . . . . . . . . 11Ranitidine . . . . . . . . . . 16Rapaflo. . . . . . . . . . . 18Rasuvo . . . . . . . . . . . 17Reclipsen . . . . . . . . . . 21Relpax . . . . . . . . . . . 12Remicade . . . . . . . . . 17Renvela Tab . . . . . . . . 18Restasis . . . . . . . . . . 16Restasis Multidose . . . . 16Retin-A Micro gel . . . . . 13Revlimid . . . . . . . . . . . 9Rexulti . . . . . . . . . . . 11Reyataz . . . . . . . . . . 17Rezira . . . . . . . . . . . 18Risperidone Tab . . . . . 11, 12Rizatriptan Tab, ODT . . . . 12Ropinirole . . . . . . . . . . 12Rosuvastatin . . . . . . . . 11

S

Saphris . . . . . . . . . . . 12Savaysa . . . . . . . . . . 10Serevent Diskus . . . . . . 20Sertraline . . . . . . . . . . 11Sildenafil Tab 20 mg. . . . . 11Silenor . . . . . . . . . . . 12Simbrinza . . . . . . . . . 16Simponi . . . . . . . . . . 17

Simponi Aria. . . . . . . . 17Simvastatin . . . . . . . . . 11Soliqua. . . . . . . . . . . 15Solodyn . . . . . . . . . . . 9Soolantra . . . . . . . . . 13Sotalol . . . . . . . . . . . 11Spiriva Handihaler . . . . 20Spiriva Respimat . . . . . 20Spironolactone . . . . . . . 10Sprintec 28 . . . . . . . . . 21Sprycel . . . . . . . . . . . . 9Stelara . . . . . . . . . . . 17Stendra . . . . . . . . . . 18Stiolto . . . . . . . . . . . 20Strattera . . . . . . . . . . 11Stribild . . . . . . . . . . . 17Suboxone Film. . . . . . . 18Sucralfate Tab . . . . . . . . 16Sulfamethoxazole-Trimethoprim .9Sulfamethoxazole-Trimethoprim

DS. . . . . . . . . . . . . 9Sumatriptan Tab and Spray . 12Sumavel Dose . . . . . . . 12Suprep Bowel Prep . . . . 17Symbicort . . . . . . . . . 20Synjardy . . . . . . . . . . 15Synthroid . . . . . . . . . 16Synvisc . . . . . . . . . . . 18Synvisc One . . . . . . . . 18

T

Taclonex . . . . . . . . . . 13Tacrolimus Cap . . . . . . . 20Tamiflu . . . . . . . . . . . . 9Tamoxifen Tab. . . . . . . . . 9Tamsulosin . . . . . . . . . 18Tazorac. . . . . . . . . . . 13Tecfidera . . . . . . . . . . 12Tekturna . . . . . . . . . . 10Tekturna HCT . . . . . . . . 10Telmisartan . . . . . . . . . 10Temazepam . . . . . . . . . 12Terazosin . . . . . . . . 10, 18Terbinafine Tab . . . . . . . . 9Terconazole Vaginal Cream . 22Testosterone Cypionate IM

Injection. . . . . . . . . 18



Tirosint. . . . . . . . . . . 16Tivicay . . . . . . . . . . . 17Tizanidine Cap . . . . . . . 19Tizanidine Tab. . . . . . . . 19Tobramycin . . . . . . . . . 16Tobramycin/Dexamethasone. 16Topiramate Tab . . . . . . . 12Torsemide Tab. . . . . . . . 10Toujeo SoloStar . . . . . . 15Toviaz . . . . . . . . . . . 19Tracleer . . . . . . . . . . 11Tradjenta. . . . . . . . . . 15Tramadol Tab 50 mg . . . . 19Tramadol w/ Acetaminophen . 19Travatan Z . . . . . . . . . 16Trazodone. . . . . . . . . . 11Tresiba . . . . . . . . . . . 15Tretinoin Cream . . . . . . . 13Tretinoin Microsphere Gel . . 13Triamcinolone . . . . . . . . 13Triamterene/HCTZ . . . . . . 10Triazolam Tab . . . . . . . . 12Tri-Linyah . . . . . . . . . . 21Tri-Lo Sprintec. . . . . . . . 21Trinessa . . . . . . . . . . . 21Trintellix . . . . . . . . . . 11Tri-Previfem . . . . . . . . . 21Tri-Sprintec . . . . . . . . . 21Triumeq . . . . . . . . . . 17Trulicity . . . . . . . . . . 15Truvada . . . . . . . . . . 17Tymlos . . . . . . . . . . . 19

U

Uceris Foam . . . . . . . . 17Uloric. . . . . . . . . . . . 18

V

Valacyclovir . . . . . . . . . . 9Valsartan . . . . . . . . . . 10Valsartan/HCTZ . . . . . . . 10Varubi . . . . . . . . . . . 17Vascepa . . . . . . . . . . 11Vectical. . . . . . . . . . . 13Velphoro . . . . . . . . . . 18

Venlafaxine ER Cap . . . . . 11Venlafaxine ER Tab . . . . . 11Venlafaxine Tab . . . . . . . 11Ventolin HFA . . . . . . . 20Verapamil ER . . . . . . . . 10Vesicare . . . . . . . . . . 19Vestura . . . . . . . . . . . 21Viagra . . . . . . . . . . . 18Victoza . . . . . . . . . . . 15Vigamox . . . . . . . . . . 16Viibryd . . . . . . . . . . . 11Vimpat . . . . . . . . . . . 12Viorele . . . . . . . . . . . 21Viread . . . . . . . . . . . 17Vitamin DVytorin . . . . . . . . . . . 11Vyvanse . . . . . . . . . . 11

W

Warfarin . . . . . . . . . . 10Welchol . . . . . . . . . . 11

X

Xarelto . . . . . . . . . . . 10Xeljanz . . . . . . . . . . . 17Xiidra. . . . . . . . . . . . 16Xolair. . . . . . . . . . . . 20Xulane . . . . . . . . . . . 21Xyrem . . . . . . . . . . . 12

Y

Yuvafem . . . . . . . . . . 22

Z

Zaleplon. . . . . . . . . . . 12Zarah . . . . . . . . . . . . 21Zarxio . . . . . . . . . . . 18Zenpep . . . . . . . . . . 17Zepatier . . . . . . . . . . . 9Zetonna . . . . . . . . . . 20Zohydro ER . . . . . . . . 19Zolpidem . . . . . . . . . . 12Zolpidem ER. . . . . . . . . 12Zonisamide . . . . . . . . . 12

Zontivity . . . . . . . . . . 10Zorvolex . . . . . . . . . . 19Zovirax Cream . . . . . . . 13Zovirax Ointment . . . . . 13Zubsolv . . . . . . . . . . 18Zurampic . . . . . . . . . . 18Zutripro . . . . . . . . . . 18Zyclara . . . . . . . . . . . 13Zytiga . . . . . . . . . . . . 9

29

“My Medications” worksheet

Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every drug you take and you should have a list as well.

Name of Medicine and Strength

Drug Tier

I Take This Medicine For

Directions Doctor

Example: Lisinopril, 20 mg Tier 1 High blood pressure One tablet daily Dr. Johnson

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All Optum® trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. © 2016 Optum, Inc. All rights reserved. ORX284511_161212

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

We provide assistance free of charge to people with disabilities or whose primary language is not English. To request a document in another format such as large print or to get language assistance such as a qualified interpreter, please call the number located on the back of your prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can send a complaint to:

OptumRx Civil Rights Coordinator 11000 Optum Circle Eden Prairie, MN 55344 Phone: 1-800-562-6223, TTY 711 Fax: 855-351-5495 Email: [email protected]

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

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue,

SW Room 509F, HHH Building Washington, D.C. 20201 This information is available in other formats like large print. To ask for another format, please call the telephone number listed on your health plan ID card.

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

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su

disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.

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

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نفلت هرامش اب افطل .دشاب یم امش رایتخا رد ناگیار روط هب ینابز دادما تامدخ ،تسا (Farsi) یسراف امش نابز رگا :هجوت.ديريگب سامت هدش دیق امش یياسانش تراک یور هک یناگیار

ध्यान दें: यदि आप हिंदी (Hindi) बोलते है, आपको भाषा सहायता सेबाए,ं नि:शुल्क उपलब्ध हैं। कृपया अपने पहचान पत्र पर सूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करें।

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej.

ចំណាប់អារម្មណ៍ៈ បើសិនអ្នកនិយាយភាសាខ្មែរ(Khmer)សេវាជំនួយភាសាដោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។ សូមទូរស័ព្ទទៅលេខឥតគិតថ្លៃ ដែលមាននៅលើអត្ដសញ្ញាណប័ណ្ណរបស់អ្នក។

PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identification card mo.

DÍÍ BAA’ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti’go, saad bee áka›anída›awo›ígíí, t’áá jíík’eh, bee ná’ahóót’i’. T’áá shǫǫdí ninaaltsoos nitł’izí bee nééhozinígíí bine’dę́ę́› t’áá jíík’ehgo béésh bee hane’í biká’ígíí bee hodíilnih.

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

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

©2018 OptumRx, Inc. ORX6700D-INV_180101 68256-092017 Innoviant Select

Core and select quantity limits on medications

Your pharmacy benefit plan’s quantity limits program protects you and can help you get the best results from your medication therapy. Along with supporting safe and appropriate dosing, quantity limits can also keep prescription drug costs lower for you and your benefit plan sponsor.

Determining quantity limits

Quantity limits are meant to minimize the risk of over-dosing and unwanted drug interactions. Quantity limit rules are based on:

• Food and Drug Administration (FDA) approved indications

• Manufacturer’s package labeling instructions

• Well-accepted or published clinical recommendations

Establishing guidelines for use

Our review committee of independent doctors and pharmacists meets regularly to review medications and consider how they should be covered by pharmacy benefit plans. They also recommend quantity limit guidelines.

Core and Select Non-Specialty Quantity LimitTHERAPY CLASS MEDICATION NAME LIMITAnti-infectivesAntibiotics SIVEXTRO (tedizolid) Soln 6 vials/30 days

SIVEXTRO (tedizolid) Tabs 6 tabs/30 daysZYVOX (linezolid) 28 tabs/30 daysZYVOX (linezolid) Suspension 6 bottles (900 mL)/28 days

Antifungals LAMISIL (terbinafine) 250 mg 84 days supply/180 daysAntivirals, Herpetic SITAVIG (acyclovir) 50 mg 2 tabs/30 days

VALTREX (valacyclovir) 4 tabs/dayAntivirals, Influenza RELENZA (zanamivir) 40 inh/365 days

TAMIFLU (oseltamivir) 30 mg 40 caps/365 daysTAMIFLU (oseltamivir) 45 mg, 75 mg 20 caps/365 daysTAMIFLU (oseltamivir) Suspension 360 mL/365 days

CardiologyAnticoagulants ELIQUIS (apixiban) 2 tabs/day

ELIQUIS (apixiban) 5 mg 3 tabs/dayPRADAXA (dabigatran) 2 caps/daySAVAYSA (edoxaban) 1 tab/dayXARELTO (rivaroxaban) 1 tab/dayXARELTO (rivaroxaban) 15 mg 2 tabs/dayXARELTO (rivaroxaban) Starter Pack 1 pack/30 days

Heart Failure CORLANOR (ivabradine) 2 tabs/dayENTRESTO (sacubitril/valsartan) 2 tabs/day

Platelet Inhibitors YOSPRALA (aspirin-omeprazole) 1 tab/dayCentral Nervous SystemADHD Agents ADDERALL (amphetamine/

dextroamphetamine)3 tabs/day

ADDERALL XR (amphetamine/dextroamphetamine mixed salts)

1 cap/day

ADZENYS XR-ODT (amphetamine) 1 tab/dayAPTENSIO XR (methylphenidate) 1 cap/dayCONCERTA (methylphenidate) 36 mg 2 tabs/dayCONCERTA (methylphenidate) 1 tab/dayCOTEMPLA XR-ODT (methylphenidate) 8.6 mg

6 tabs/day

COTEMPLA XR-ODT (methylphenidate) 17.3 mg

3 tabs/day

COTEMPLA XR-ODT (methylphenidate) 25.9 mg

2 tabs/day

2 OptumRx | optumrx.com

THERAPY CLASS MEDICATION NAME LIMITADHD Agents (cont.) DAYTRANA (methylphenidate

transdermal)1 patch/day

DESOXYN (methamphetamine) 5 tabs/dayDEXEDRINE (dextroamphetamine) 5 mg 3 caps/dayDEXEDRINE (dextroamphetamine) 15 mg 4 caps/dayDEXEDRINE (dextroamphetamine) 10 mg 6 caps/dayDYANAVEL XR (amphetamine) 8 mL/dayEVEKEO (amphetamine) 6 tabs/dayFOCALIN (dexmethylphenidate) 2 tabs/dayFOCALIN XR (dexmethylphenidate) 20 mg 2 caps/dayFOCALIN XR (dexmethylphenidate) 1 cap/dayMETADATE CD (methylphenidate) 1 cap/dayMETADATE ER (methylphenidate) 20 mg 3 tabs/dayMETHYLIN (methylphenidate) 3 tabs/dayMETHYLIN 10 mg/5 mL (methylphenidate) Soln

30 mL/day

METHYLIN 5 mg/5 mL (methylphenidate) Soln

60 mL/day

METHYLIN CHEW TAB (methylphenidate) 3 tabs/dayMETHYLIN CHEW TAB (methylphenidate) 10 mg

6 tabs/day

METHYLPHENIDATE ER 10 mg 2 tabs/dayMYDAYIS (amphetamine/dextroamphetamine)

1 cap/day

PROCENTRA (dextroamphetamine) Sol 60 mL/dayQUILLICHEW ER (methylphenidate) 30 mg

2 tabs/day

QUILLICHEW ER (methylphenidate) 1 tab/dayQUILLIVANT XR (methylphenidate) 12 mL/dayRITALIN (methylphenidate) 3 tabs/dayRITALIN LA (methylphenidate) 1 cap/dayRITALIN SR (methylphenidate) 20 mg 3 tabs/daySTRATTERA (atomoxetine) 1 cap/daySTRATTERA (atomoxetine) 10 mg, 40 mg 2 caps/dayVYVANSE (lisdexamfetamine) 1 cap/dayVYVANSE CHEW TAB (lisdexamfetamine) 1 tab/dayZENZEDI (dextroamphetamine) 10 mg 6 tabs/dayZENZEDI (dextroamphetamine) 3 tabs/dayZENZEDI (dextroamphetamine) 30 mg 2 tabs/day

3

THERAPY CLASS MEDICATION NAME LIMITAlzheimers Agents NAMENDA XR (memantine hcl) caps 1 cap/day

NAMENDA XR TITRATION PACK (memantine hcl) caps

1 cap/day

NAMZARIC (memantine hcl) caps 1 cap/ dayNAMZARIC TITRATION PACK (memantine hcl)

2 packs/365 days

Analgesics (non-opioid) CELEBREX (celecoxib) 2 caps/dayDUEXIS (naproxen/esomeprazole) 3 tabs/dayFLECTOR (diclofenac epolamine) 2 patches/day up to 15 daysKetorolac (ketorolac) 20 tabs or 5 days supply/30

daysQUTENZA (capsaicin) 4 patches/3 monthsSPRIX (ketorolac) 5 bottles or 5 days supply/30

daysVIMOVO (naproxen/esomeprazole) 2 tabs/dayVOLTAREN (diclofenac) Gel 10 tubes/month

Analgesics (opioid) ABSTRAL (fentanyl citrate) 4 tabs/dayacetaminophen/codeine soln 120-12 mg/5 mL

136 mL/day up to 7 days for treatment naive, 166.5 mL/day for treatment experienced

acetaminophen/codeine tab 300-15 13 tabs/day up to 7 days for treatment naïve, 13 tabs/day for treatment experienced

ACTIQ (fentanyl citrate) 4 lozenges/dayARYMO ER (morphine sulfate) 3 tabs/dayAVINZA (morphine ext-release) 1 cap/dayAVINZA (morphine ext-release) 120 mg 2 caps/dayBELBUCA (buprenorphine) film 2 films/dayBUNAVAIL (buprenorphrine/naloxone) 2.1-0.3 mg

6 films/day

BUNAVAIL (buprenorphrine/naloxone) 6.3-1 mg

2 films/day

BUNAVAIL (buprenorphrine/naloxone) 4.2-0.7 mg

3 films/day

BUTRANS (buprenorphine) 4 patches/28 daysCAPITAL/codeine susp 120-12mg /5 mL 136 mL/day up to 7 days for

treatment naive, 166.5 mL/day for treatment experienced

codeine tab 15 mg 21 tabs/day up to 7 days for treatment naïve, 40 tabs/day for treatment experienced


5

THERAPY CLASS MEDICATION NAME LIMITAnalgesics (opioid) (cont.)



CONZIP (tramadol SR) 1 cap/dayDEMEROL (meperidine) tab 100 mg 4 tabs/day up to 7 days for

treatment naïve, 9 tabs/day for treatment experienced

DEMEROL (meperidine) tab 50 mg 9 tabs/day up to 7 days for treatment naïve, 18 tabs/day for treatment experienced

DILAUDID (hydromorphone) liq 1 mg/mL 12.25 mL/day up to 7 days for treatment naive, 22.5 mL/day for treatment experienced

DILAUDID (hydromorphone) tab 2 mg 6 tabs/day up to 7 days for treatment naïve, 11 tabs/day for treatment experienced



DURAGESIC (fentanyl transdermal) 15 patches/30 daysDURAGESIC (fentanyl transdermal) 75 mcg/hr, 100 mcg/hr

30 patches/30 days

EMBEDA (morphine/naltrexone) 2 caps/dayEXALGO (hydromorphone) 2 tabs/dayFENTORA (fentanyl citrate) 4 tabs/dayHYCET (hydrocodone/acetaminophen) sol 7.5-325 mg/15 mL

98 mL/day up to 7 days for treatment naive, 180 mL/day for treatment experienced

hydromorphone supp 3 mg 4 supps/day up to 7 days for treatment naïve, 7 supps/day for treatment experienced

HYSINGLA ER (hydrocodone bitartrate) 1 tab/dayKADIAN (morphine ext-release) 2 caps/dayLAZANDA (fentanyl citrate) 1 bottle/day


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

73.5 mL/day up to 7 days for treatment naïve, 135 mL/day for treatment experienced

meperidine/promethazine cap 50-25 mg 9 caps/day up to 7 days for treatment naïve, 18 caps/day for treatment experienced

mepridine sol 50 mg/5 mL 49 mL/day up to 7 days for treatment naïve, 90 mL/day for treatment experienced

MORPHABOND ER (morphine ext-release) 2 tabs/daymorphine sol 10 mg/5 mL 24.5 mL/day up to 7 days for

treatment naïve, 45 mL/day for treatment experienced

morphine sol 20 mg/5 mL 12.25 mL/day up to 7 days for treatment naïve, 22.5 mL/day for treatment experienced

morphine sol 20 mg/mL 2.4 mL/day up to 7 days for treatment naïve, 4.5 mL/day for treatment experienced

morphine supp 10 mg 4 supps/day up to 7 days for treatment naïve, 9 supps/day for treatment experienced




morphine tab 15 mg 3 tabs/day up to 7 days for treatment naïve, 6 tabs/day for treatment experienced

morphine tab 30 mg 1 tab/day up to 7 days for treatment naïve, 3 tabs/day for treatment experienced

MS CONTIN (morphine ext-release) 3 tabs/dayNORCO (hydrocodone/acetaminophen) tab 10-325 mg

4 tabs/day up to 7 days for treatment naïve, 9 tabs/day for treatment experienced


7


NORCO (hydrocodone/acetaminophen) tab 5-325 mg


NORCO (hydrocodone/acetaminophen) tab 7.5-325 mg


NUCYNTA (tapentadol) tab 100 mg 1 tab/day up to 7 days for treatment naïve, 2 tabs/day for treatment experienced

NUCYNTA (tapentadol) tab 50 mg 2 tabs/day up to 7 days for treatment naïve, 4 tabs/day for treatment experienced

NUCYNTA (tapentadol) tab 75 mg 1 tab/day up to 7 days for treatment naïve, 3 tabs/day for treatment experienced

NUCYNTA ER (tapentadol) 2 tabs/dayOPANA (oxymorphone) tab 10 mg 1 tab/day up to 7 days for


OPANA (oxymorphone) tab 5 mg 3 tabs/day up to 7 days for treatment naïve, 6 tabs/day for treatment experienced

OPANA ER (oxymorphone ext-release) 4 tabs/dayOXAYDO (oxycodone) tab 5 mg 6 tabs/day up to 7 days for


OXAYDO (oxycodone) tab 7.5 mg 4 tabs/day up to 7 days for treatment naïve, 8 tabs/day for treatment experienced

oxycodone/aspirin tab 6 tabs/day up to 7 days for treatment naïve, 12 tabs/day for treatment experienced

oxycodone/ibuprofen tab 5-400 mg 6 tabs/day up to 7 days for treatment naïve, 8 tabs/day for treatment experienced

oxycodone cap 5 mg 6 caps/day up to 7 days for treatment naïve, 12 caps/day for treatment experienced

oxycodone conc 20 mg/mL 1.6 mL/day up to 7 days for treatment naïve, 3 mL/day for treatment experienced


oxycodone sol 5 mg/5 mL 32.6 mL/day up to 7 days for treatment naïve, 60 mL/day for treatment experienced

oxycodone tab 10 mg 3 tabs/day up to 7 days for treatment naïve, 6 tabs/day for treatment experienced

oxycodone tab 20 mg 1 tab/day up to 7 days for treatment naïve, 3 tabs/day for treatment experienced

oxycodone/acetaminophen sol 5-325 mg/5 mL


OXYCONTIN (oxycodone ext-release) 4 tabs/daypentazocine/naloxone tab 50-0.5 mg 5 tabs/day up to 7 days for


PERCOCET (oxycodone/acetaminophen) tab 10-325 mg


PERCOCET (oxycodone/acetaminophen) tab 2.5-325 mg


PERCOCET (oxycodone/acetaminophen) tab 5-325 mg


PERCOCET (oxycodone/acetaminophen) tab 7.5-325 mg


PRIMLEV (oxycodone/acetaminophen) tab 10-300 mg


PRIMLEV (oxycodone/acetaminophen) tab 5-300 mg


PRIMLEV (oxycodone/acetaminophen) tab 7.5-300 mg


REPREXAIN (hydrocodone/ibuprofen) tab 10-200 mg



9


REPREXAIN (hydrocodone/ibuprofen) tab 5-200 mg


ROXICODONE (oxycodone) tab 15 mg 2 tabs/day up to 7 days for treatment naïve, 4 tabs/day for treatment experienced

ROXICODONE (oxycodone) tab 30 mg 1 tab/day up to 7 days for treatment naïve, 2 tabs/day for treatment experienced

ROXICODONE (oxycodone) tab 5 mg 6 tabs/day up to 7 days for treatment naïve, 12 tabs/day for treatment experienced

SUBOXONE (buprenorphrine/naloxone) 8-2 mg

3 tabs or films/day


2 films/day


6 films/day

SUBOXONE (buprenorphrine/naloxone) 2-0.5 mg

12 tabs or films/day

SUBSYS (fentanyl) 16 sprays/daySUBUTEX (buprenorphrine) 8 mg 3 tabs/daySUBUTEX (buprenorphrine) 2 mg 12 tabs/daySYNALGOS-DC (aspirin/caffeine/dihydrocodeine) cap

11 caps/day up to 7 days for treatment naïve, 11 caps/day for treatment experienced

TREZIX (acetaminophen/caffeine/dihydrocodeine) cap

12 caps/day up to 7 days for treatment naïve, 12 caps/day for treatment experienced

TYLENOL (acetaminophen)/codeine #3 10 tabs/day up to 7 days for treatment naïve, 13 tabs/day for treatment experienced

TYLENOL (acetaminophen)/codeine #4 5 tabs/day up to 7 days for treatment naïve, 10 tabs/day for treatment experienced

ULTRAM ER (tramadol ext-release) 1 tab/dayVERDROCET (hydrocodone/acetaminophen) tab 2.5-325 mg



VICODIN (hydrocodone/acetaminophen) tab 5-300 mg


VICODIN ES (hydrocodone/acetaminophen) tab 7.5-300 mg


VICODIN HP (hydrocodone/acetaminophen) tab 10-300 mg


VICOPROFEN (hydrocodone/ibuprofen) tab 7.5-200 mg


XTAMPZA ER (oxycodone) 4 caps/dayZAMICET (hydrocodone/acetaminophen) sol 10-325 mg/15 mL


ZOHYDRO ER (hydrocodone) 2 caps/dayZOHYDRO ER (hydrocodone) 50 mg 4 caps/dayZUBSOLV (buprenorphine/naloxone) SL Tab 0.7-0.18 MG

3 tabs/day

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

3 tabs/day

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

2 tabs/day


1 tab/day


6 tabs/day

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

12 tabs/day

Anticonvulsants DIASTAT GEL (diazepam) 2 boxes/fillGRALISE (gabapentin) 300 mg 6 tabs/dayGRALISE (gabapentin) 600 mg 3 tabs/dayGRALISE (gabapentin) Pack 1 kit/fill (78 tabs per fill)HORIZANT (gabapentin enacarbil) 2 tabs/dayLYRICA (pregabalin) 300 mg 2 caps/dayLYRICA (pregabalin) caps 3 caps/dayLYRICA (pregabalin) Soln 900 mL/30 days

Antidepressants APLENZIN (bupropion) 1 tab/dayCYMBALTA (duloxetine) 2 caps/day


11

THERAPY CLASS MEDICATION NAME LIMITAntidepressants (cont.) CYMBALTA (duloxetine) 30 mg 3 caps/day

desvenlafaxine fumarate 1 tab/dayEMSAM (selegiline) 1 patch/dayFETZIMA (levomilnacipran) 1 cap/dayFETZIMA (levomilnacipran) Pack 1 pack (28 caps)/yearFORFIVO XL (bupropion) 450 mg 1 tab/dayIRENKA (duloxetine) 2 caps/dayKHEDEZLA (desvenlafaxine ER) 1 tab/dayKHEDEZLA (desvenlafaxine ER) 100 mg 4 tabs/dayLUVOX CR (fluvoxamine) 2 caps/dayOLEPTRO (trazodone) 1 tab/dayPEXEVA (paroxetine) 1 tab/dayPEXEVA (paroxetine) 30 mg 2 tabs/dayPRISTIQ (desvenlafaxine) 1 tab/dayPRISTIQ (desvenlafaxine) 100 mg 4 tabs/dayPROZAC WEEKLY (fluoxetine) 4 caps/28 daysTRINTELLIX (vortioxetine) 1 tab/dayVIIBRYD (vilazodone) 1 tab/dayVIIBRYD (vilazodone) Kit 1 kit (30 tabs)/ fillWELLBUTRIN SR (bupropion) 3 tabs/dayWELLBUTRIN XL (bupropion) 1 tab/dayWELLBUTRIN XL (bupropion) 150 mg 3 tabs/day

Antipsychotics ABILIFY (aripiprazole) tabs 1 tab/dayABILIFY DISCMELT (aripiprazole) 2 tabs/dayABILIFY SOLN (aripiprazole) 1 mg/mL 25 mL/dayCLOZARIL (clozapine) 100 mg 9 tabs/dayCLOZARIL (clozapine) 200 mg 4 tabs/dayCLOZARIL (clozapine) 25 mg 9 tabs/dayCLOZARIL (clozapine) 50 mg 6 tabs/dayFANAPT (iloperidone) 2 tabs/dayFANAPT PAK (iloperidone) 1 pack/180 daysFAZACLO (clozapine) 100 mg 9 tabs/dayFAZACLO (clozapine) 12.5 mg 3 tabs/dayFAZACLO (clozapine) 150 mg 6 tabs/dayFAZACLO (clozapine) 200 mg 4 tabs/dayFAZACLO (clozapine) 25 mg 9 tabs/dayGEODON (ziprasidone) 2 caps/dayINVEGA (paliperidone) 1 tab/dayINVEGA (paliperidone) 6 mg 2 tabs/day

THERAPY CLASS MEDICATION NAME LIMITAntipsychotics (cont.) LATUDA (lurasidone) 20 mg, 40 mg,

60mg, 120 mg1 tab/day

LATUDA (lurasidone) 80 mg 2 tabs/dayREXULTI (brexpiprazole) 1 tab/dayRISPERDAL (risperidone) 2 tabs/dayRISPERDAL M (risperidone) 2 tabs/dayRISPERDAL SOLN (risperidone) 8 mL/daySAPHRIS (asenapine) 2 tabs/daySEROQUEL (quetiapine) 300 mg, 400 mg 2 tabs/daySEROQUEL (quetiapine) 25 mg, 50 mg, 100 mg, 200 mg

3 tabs/day

SEROQUEL XR (quetiapine) 2 tabs/daySEROQUEL XR (quetiapine) 200 mg 3 tabs/daySYMBYAX (olanzapine/fluoxetine) 1 cap/daySYMBYAX (olanzapine/fluoxetine) 3-25 mg

3 caps/day

SYMBYAX (olanzapine/fluoxetine) 6-25 mg

3 caps/day

VERSACLOZ (clozapine) 18 mL/dayVRAYLAR (cariprazine) 1 cap/dayVRAYLAR (cariprazine) pack 2 packs/365 daysZYPREXA (olanzapine) 1 tab/dayZYPREXA ZYDIS (olanzapine) 1 tab/day

Benzodiazepines ALPRAZOLAM INTENSOL (alprazolam) 10 mL/dayALPRAZOLAM ODT (alprazolam) 4 tabs/dayALPRAZOLAM ODT (alprazolam) 2 mg 5 tabs/dayATIVAN (lorazepam) 3 tabs/dayATIVAN (lorazepam) 2 mg 5 tabs/dayCHLORDIAZEP (chlordiazepoxide) 10 mg 30 caps/dayCHLORDIAZEP (chlordiazepoxide) 25 mg 12 caps/dayCHLORDIAZEP (chlordiazepoxide) 5 mg 4 caps/dayCLONAZEP ODT (clonazepam) 3 tabs/dayCLONAZEP ODT (clonazepam) 2 mg 10 tabs/dayKLONOPIN (clonazepam) 3 tabs/dayLORAZEPAM INTENSOL (lorazepam) 5 mL/dayOXAZEPAM (oxazepam) 4 caps/dayTRANXENE T (clorazepate) 15 mg 6 tabs/dayTRANXENE T (clorazepate) 3.75 mg 24 tabs/day


13

THERAPY CLASS MEDICATION NAME LIMITBenzodiazepines (cont.) TRANXENE T (clorazepate) 7.5 mg 12 tabs/day

XANAX (alprazolam) 4 tabs/dayXANAX (alprazolam) 2 mg 5 tabs/dayXANAX XR (alprazolam) 1 tab/dayXANAX XR (alprazolam) 2 mg 5 tabs/dayXANAX XR (alprazolam) 3 mg 3 tabs/day

Fibromyalgia SAVELLA (milnacipran) 2 tabs/daySAVELLA (milnacipran) Pack 1 pack (55 tabs)/year

Hypoactive Sexual Desire Disorder

ADDYI (flibanserin) 1 tab/day

Migraine ALSUMA (sumatriptan) 5 packages (10 syringes)/30 days

AMERGE (naratriptan) 9 tabs/30 daysAXERT (almotriptan) 12 tabs/30 daysFROVA (frovatriptan) 9 tabs/30 daysIMITREX (sumatriptan) 9 tabs/30 daysIMITREX (sumatriptan) AUTO-INJECTOR 4 mg/0.5 mL & 6 mg/0.5 mL

5 kits (10 units)/30 days

IMITREX (sumatriptan) CARTRIDGE 4 mg/0.5 mL & 6 mg/0.5 mL


IMITREX (sumatriptan) Nasal 12 spray unit devices/30 daysIMITREX (sumatriptan) SYRINGE 4 mg/0.5 mL & 6 mg/0.5 mL


MAXALT (rizatriptan) 18 tabs/30 daysMAXALT-MLT (rizatriptan) 18 tabs/30 daysMIGRANAL (dihydroergotamine) 1 package (8 vials)/30 daysONZETRA XSAIL (sumatriptan) 1 kit (8 doses)/30 daysRELPAX (eletriptan) 12 tabs/30 daysSUMAVEL DOSEPRO (sumatriptan) 12 prefilled syringes/30 daysTREXIMET (sumatriptan/naproxen) 9 tabs/30 daysZECUITY (sumatriptan) 4 systems (1 carton)/30 daysZEMBRACE SYMTOUCH (sumatriptan) 4 cartons (16 doses)/30 daysZOMIG (zolmitriptan) 9 tabs/30 daysZOMIG (zolmitriptan) 2.5 mg 12 tabs/30 daysZOMIG (zolmitriptan) Nasal 2 packages (12 spray units)

/30 daysZOMIG ZMT (zolmitriptan) 9 tabs/30 daysZOMIG ZMT (zolmitriptan) 2.5 mg 12 tabs/30 days

Miscellaneous RILUTEK (riluzole) 2 tabs/dayParkinson’s XADAGO (safinamide) 1 tab/day

THERAPY CLASS MEDICATION NAME LIMITSedative Hypnotics AMBIEN (zolpidem) 1 tab/day

AMBIEN CR (zolpidem) 1 tab/dayBELSOMRA (suvorexant) 1 tab/dayDORAL (quazepam) 1 tab/dayEDLUAR (zolpidem) 1 tab/dayESTAZOLAM (estazolam) 1 tab/dayFLURAZEPAM (flurazepam) 1 cap/dayHALCION (triazolam) 2 tabs/dayINTERMEZZO (zolpidem) 1 tab/dayLUNESTA (eszopiclone) 1 tab/dayRESTORIL (temazepam) 1 cap/dayROZEREM (ramelteon) 1 tab/daySILENOR (doxepin) 1 tab/daySONATA (zaleplon) 10 mg 2 cap/daySONATA (zaleplon) 5 mg 1 cap/dayZOLPIMIST (zolpidem) 1 bottle (7.7 g)/30 days

Stimulants NUVIGIL (armodafinil) 1 tab/dayNUVIGIL (armodafinil) 50 mg 2 tabs/dayPROVIGIL (modafinil) 1 tab/day

DermatologyAnti-Inflammatory SOLARAZE (diclofenac) GEL 300 gm/30 daysMiscellaneous ENSTILAR (calcipotriene/betamethasone

dipropionate)420 g/28 days

TACLONEX (calcipotriene/betamethasone) 400 g/30 daysTACLONEX SCALP (calcipotriene/betamethasone)

120 g/30 days

Endocrinology & MetabolismAndrogens, Anabolic OXANDRIN (oxandrolone) 10 mg 2 tabs/daySteroids OXANDRIN (oxandrolone) 2.5 mg 8 tabs/dayAntidiabetic Agents ADLYXIN (lixisenatide) 2 pens (6 mL)/28 days

ADLYXIN (lixisenatide) Starter Pack 2 starter kits (12 mL)/365 daysBYDUREON (exenatide) 4 vials/pen-inj/28 daysBYETTA (exenatide) 1 syringe/30 daysSOLIQUA (insulin glargine/lixisenatide) 6 pens (18 mL)/30 daysTANZEUM (albiglutide) 4 pen-inj/28 daysTRULICITY (dulaglutide) 4 pen-inj/28 daysVICTOZA (liraglutide) 3 pen-inj/ 30 daysXULTOPHY (insulin degludec/liraglutide) 5 pens (15 mL)/30 days


15

THERAPY CLASS MEDICATION NAME LIMITOsteoporosis ACTONEL (risedronate) tab 150 mg 1 tab/28 days

ACTONEL (risedronate) tab 35 mg 4 tabs/28 daysATELVIA (risedronate) 4 tabs/28 daysBINOSTO (alendronate) 4 tabs/28 daysBONIVA (ibandronate) 1 tab/28 daysBONIVA (ibandronate) inj 1 syringe/90 daysFORTICAL (calcitonin) 1 bottle (3.7mL)/30 daysFOSAMAX (alendronate) 35 mg & 70 mg 4 tabs/28 daysFOSAMAX PLUS D (alendronate/cholecalciferol)

4 tabs/28 days

MIACALCIN (calcitonin) 1 bottle (3.7mL)/30 daysGastroenterologyAntiemetics AKYNZEO (netupitant-palonosetron) 2 caps/30 days

ANZEMET (dolasetron) 2 tabs/30 daysCESAMET (nabilone) 20 tabs/fill or 3 max daysDICLEGIS (doxylamine-pyridoxine) 4 tabs/dayEMEND (aprepitant) caps 125 mg 2 caps/30 daysEMEND (aprepitant) 125 mg/80 mg 2 packs (6 caps)/30 daysEMEND (aprepitant) 40 mg 1 cap/30 daysEMEND (aprepitant) 80 mg 4 caps/30 daysEMEND (aprepitant) Susp 125 mg 3 packets/30 daysGRANISOL (granisetron) 1 bottole (30 mL)/30 daysKYTRIL (granisetron) 4 tabs/30 daysMARINOL (dronabinol) 2 caps/daySANCUSO (granisetron) 2 patches/30 daysSUSTOL (ganisetron) 3 syringes/30 daysSYNDROS (dronabinol) 4 mL/dayVARUBI (rolapitant) 4 tabs/30 daysZOFRAN (ondansetron) 120 mL/30 daysZOFRAN (ondansetron) 24 mg 2 tabs/30 daysZOFRAN ODT (ondansetron) 4 mg, 8 mg 15 tabs/30 daysZUPLENZ (ondansetron) 10 films/30 days

Constipation AMITIZA (lubiprostone) 2 caps/dayLINZESS (linaclotide) 1 cap/day

Diarrhea FULYZAQ (crofelemer) 2 tabs/dayMYTESI (crofelemer) 2 tabs/day

Irritable Bowel Syndrome VIBERZI (eluxadoline) 2 tabs/day

THERAPY CLASS MEDICATION NAME LIMITOpioid-induced Constipation

MOVANTIK (naloxegol) 1 tab/day

RELISTOR (methylnaltrexone) 1 syringe/dayRELISTOR (methylnaltrexone) Kit 1 vial/dayRELISTOR (methylnaltrexone) tab 3 tabs/dayTRULANCE (plecanatide) 1 tab/day

Proton Pump Inhibitors ACIPHEX (rabeprazole) 1 tab/dayACIPHEX SPRINKLE (rabeprazole) SPR 1 cap/dayDEXILANT (dexlansoprazole) 1 cap/dayesomeprazole strontium 1 cap/dayNEXIUM (esomeprazole) Caps 1 cap/dayNEXIUM (esomeprazole) Packs 1 packet/dayPREVACID (lansoprazole) 1 cap/dayPREVACID (lansoprazole) Solutab 1 tab/dayPRILOSEC (omeprazole) 1 cap/dayPRILOSEC PACKETS (omeprazole) 2 packets/dayPROTONIX (pantoprazole) packets 1 packet/dayPROTONIX (pantoprazole) tab 1 tab/dayZEGERID (omeprazole) caps 2 caps/dayZEGERID (omeprazole) packets 2 packets/day

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

ORALAIR (mixed grass pollens allergen) 300 IR

1 tab/day

ORALAIR ADULT SAMPLE KIT (mixed grass pollens allergen) Kit

1 kit/year

ORALAIR ADULT STARTER PACK (mixed grass pollens allergen)

1 pack/year

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

2 packs/year

ORALAIR CHILDREN/ADOLESCENTS (mixed grass pollens allergen) Sample Kit,

2 kits/year

RAGWITEK (short ragweed pollen allergen)

1 tab/day

MiscellaneousDiabetic Supplies Glucose Test Strips 300/30 daysMethotrexate Auto-Injectors

OTREXUP (methotrexate) 4 auto-injectors/28 days

RASUVO (methotrexate) 4 auto-injectors/28 days


THERAPY CLASS MEDICATION NAME LIMITMovement Disorder Agents

INGREZZA (valbenazine tosylate) 2 caps/day

Smoking Cessation Products

CHANTIX (varenicline) 180 days supply/year

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

Obstetrics & GynecologyContraceptives AMETHIA (levonorg-eth est) 1/91 days

AMETHIA LO (levonorg-eth est) 1/91 daysASHLYNA (levonorg-eth est) 1/91 daysCAMRESE (levonorg-eth est) 1/91 daysCAMRESE LO (levonorg-eth est) 1/91 daysDAYSEE (levonorg-eth est) 1/91 daysDEPO/DEPO-SUBQ PROVERA (medroxyprogesterone)

1/90 days

INTROVALE (levonorg-eth est) 1/91 daysJOLESSA (levonorg-eth est) 1/91 daysLOSEASONIQUE (ethinyl estradiol/levonorgestrel)

1/91 days

QUARTETTE (levonorg-eth est) 1/91 daysQUASENSE (levonorg-eth est) 1/91 daysSEASONIQUE (ethinyl estradiol/levonorgestrel)

1/91 days

SETLAKIN (levonorg-eth est) 1/91 daysHormone Replacement CRINONE (progesterone) 15 applicators/30 days

ESTRING (estradiol) 1 package/90 daysFEMRING (estradiol acetate) 1 package/90 days

Miscellaneous BRISDELLE (paroxetine) 1 cap/dayOphthalmologyAnti-inflammatory BROMDAY (bromfenac) 4 bottles/year

BROMSITE (bromfenac) 4 bottles/yearILEVRO (nepafenac) 0.3% 2 bottles/30 daysLOTEMAX (loteprednol) gel, oint 4 bottles/yearNEVANAC (nepafenac) 0.1% 2 bottles/30 daysPROLENSA (bromfenac sodium) 4 bottles/year

17

THERAPY CLASS MEDICATION NAME LIMITProstaglandins LUMIGAN (bimatoprost) 1 bottle (2.5 mL)/25 days

RESCULA (unoprostone) 1 bottle (5 mL)/25 daysTRAVATAN (travoprost) 1 bottle (2.5 mL)/25 daysTRAVATAN Z (travoprost) 1 bottle (2.5 mL)/25 daysXALATAN (latanoprost) 1 bottle (2.5 mL)/25 daysZIOPTAN (tafluprost) 1 container/day

RespiratoryAllergy (intranasal) ASTELIN 2 bottles (60 mL)/30 days

ASTEPRO (azelastine) 2 bottles (60 mL)/30 daysBECONASE AQ (beclomethasone) 1 inhaler (25 g)/25 daysDYMISTA (fluticasone/azelastine) 1 inhaler (23 g)/30 daysFLUNISOLIDE (flunisolide) 1 bottle (25 mL)/30 daysNASONEX (mometasone) 2 inhalers/30 daysOMNARIS (ciclesonide) 1 inhaler (12.5 g)/30 daysPATANASE (olopatadine) 1 bottle (30.5 g)/30 daysQNASL (beclomethasone) 1 inhaler (8.7 g)/30 daysQNASL CHILDRENS (beclomethasone) 1 inhaler (4.9 g)/30 daysRHINOCORT AQUA (budesonide) 2 bottles/30 daysVERAMYST (fluticasone furoate) 1 bottle (10 g)/30 daysZETONNA (ciclesonide nasal) 1 inhaler (6.1 g)/30 days

Asthma/COPD (inhaled) ADVAIR DISKUS (fluticasone/salmeterol) 1 diskus (60 doses)/30 daysADVAIR HFA (fluticasone/salmeterol) 1 inhaler/30 daysAEROSPAN (flunisolide) 2 inhalers (8.9 g each)/30 daysAIRDUO RESPICLICK (fluticasone/salmeterol)

1 inhaler/30 days

ALVESCO (ciclesonide) 2 inhalers (6.1 g each)/30 daysANORO ELLIPTA (umeclidinium-vilanterol) 1 package (60 blisters)/30 daysARCAPTA (indacaterol) 4 caps/dayARMONAIR RESPICLICK (fluticacone) 1 inhaler/30 daysARNUITY ELLIPTA (fluticasone furoate) 1 inhaler/30 daysASMANEX HFA (mometasone) 1 inhaler/30 daysASMANEX TWISTHALER (mometasone) 1 inhaler/30 daysATROVENT HFA (ipratropium) 2 inhalers (12.9 g each)/30

daysBREO ELLIPTA (fluticasone furoate-vilanterol)

1 package (60 blisters)/30 days

BEVESPI AEROSPHERE (glycopyrrolate-formoterol)

1 inhaler/30 days


THERAPY CLASS MEDICATION NAME LIMITAsthma/COPD (inhaled) (cont.)

COMBIVENT RESPIMAT (ipratropium/albuterol)

2 inhalers (4 g each)/30 days

DULERA (mometasone/formoterol) 1 inhaler/30 daysFLOVENT (fluticasone) 110 mcg, 220 mcg 2 inhalers (12 g each)/30 daysFLOVENT (fluticasone) 44 mcg 2 inhalers/30 daysFLOVENT DISKUS (fluticasone) 250 mcg 240 blisters/30 daysFLOVENT DISKUS (fluticasone) 50 mcg, 100 mcg

60 blisters/30 days

FORADIL (formoterol) 1 package (60 doses)/30 daysINCRUSE ELLIPTA (umeclidnium) 1 inhaler/30 daysPROAIR HFA (albuterol) 2 inhalers/30 daysPROAIR RESPICLICK (albuterol) 2 inhalers/30 daysPROVENTIL HFA (albuterol) 2 inhalers/30 daysPULMICORT FLEXHALER (budesonide) 2 packages/30 daysQVAR (beclomethasone) 40 mcg 2 inhalers/30 daysQVAR (beclomethasone) 80 mcg 3 inhalers/30 daysSEEBRI NEOHALER (glycopyrolate) 2 caps/daySEREVENT DISKUS (salmeterol) 50 mcg 1 package (60 doses)/30 daysSPIRIVA HANDIHALER (tiotropium) 1 package (30 caps)/30 daysSPIRIVA RESPIMAT (tiotropium) 1 inhaler/30 daysSTIOLTO RESPIMAT (tiotropium br-olodaterol)

1 inhaler/30 days

STRIVERDI RESPIMAT (olodaterol) 1 inhaler/30 daysSYMBICORT (budesonide/formoterol) 1 inhaler/30 daysTUDORZA (aclidinium bromide) 1 pouch (60 doses)/30 daysUTIBRON NEOHALER (indacaterol maleate-glycopyrrolate)

2 caps/day

VENTOLIN HFA (albuterol) 2 inhalers/30 daysXOPENEX HFA (levalbuterol) 2 inhalers (15 g)/30 days

Asthma/COPD (nebulized) ACCUNEB (albuterol) 5 packages (125 vials or 375 mL)/30 days

Albuterol (albuterol) 2.5 mg/3 mL (0.083%)

180 vials (540 mL)/30 days

Albuterol (albuterol) 5 mg/mL (0.5%) 150 mL/30 daysATROVENT (ipratropium) 125 vials (312.5 mL)/30 daysBROVANA (arformoterol) 60 vials (120 mL)/30 daysDUONEB (ipratropium/albuterol) 180 vials (540 mL)/30 daysPERFOROMIST (formoterol) 60 vials (120 mL)/30 daysPROVENTIL (albuterol) 2.5 mg/3mL (0.083%)

180 vials (540 mL)/30 days

19

THERAPY CLASS MEDICATION NAME LIMITAsthma/COPD (nebulized) PULMICORT RESPULES (budesonide) 2 packages (120 mL)/30 days

XOPENEX (levalbuterol) 180 vials (540 mL)/30 daysXOPENEX (levalbuterol) 1.25 mg/0.5 mL 90 vials (45 mL)/30 daysXOPENEX (levalbuterol) 1.25 mg/3 mL 90 vials (270 mL)/30 days

UrologyErectile Dysfunction CAVERJECT (alprostadil) 6 units/30 days

CIALIS (tadalafil) 10 mg 6 tabs/30 daysCIALIS (tadalafil) 2.5 mg 1 tab/dayCIALIS (tadalafil) 20 mg 6 tabs/30 daysCIALIS (tadalafil) 5 mg 1 tab/dayEDEX (alprostadil) 6 units/30 daysLEVITRA (vardenafil) 6 tabs/30 daysMUSE (alprostadil) 6 units/30 daysSTAXYN (vardenafil) 6 tabs/30 daysSTENDRA (avanafil) 6 tabs/30 daysVIAGRA (sildenafil) 6 tabs/30 days

Overactive Bladder Antispasmodics

OXYTROL (oxybutynin) 8 patches/28 days


Core and Select Specialty Quantity LimitTHERAPY CLASS MEDICATION NAME LIMITAnti-InfectivesAntiretrovirals, Hepatitis B BARACLUDE (entecavir) 1 tab/day

BARACLUDE (entecavir) Soln 630 mL/30 daysAntiretrovirals, HIV FUZEON (enfuvirtide) 60 vials or 1 kit/30 daysCardiologyAnticoagulants, LMWH ARIXTRA (fondaparinux) 35 days supply/180 days

FRAGMIN (dalteparin) 35 days supply/180 daysLOVENOX (enoxaparin) 35 days supply/180 days

Antilipemic JUXTAPID (lomitapide) 1 tab/dayKYNAMRO (mipomersen) 4 syringes/28 daysPRALUENT (alirocumab) 2 syringes/28 daysREPATHA (evolocumab) 3 syringes/28 daysREPATHA PUSH (evolocumab) 1 cartridge/28 days

Pulmonary Arterial Hypertension

ADCIRCA (tadalafil) 2 tabs/day

ADEMPAS (riociguat) 3 tabs/dayLETAIRIS (ambrisentan) 1 tab/dayOPSUMIT (macitentan) 1 tab/dayREVATIO (sildenafil) Susp 2 bottles/30 daysREVATIO (sildenafil) Tabs 3 tabs/dayTRACLEER (bosentan) 2 tabs/dayTYVASO (treprostinil) 1 ampule/dayUPTRAVI (selexipag) 2 tabs/dayUPTRAVI (selexipag) Pack 2 packs/yearVENTAVIS (iloprost) 9 ampules/day

Central Nervous SystemDepressant XYREM (sodium oxybate) 3 bottles (540 mL)/30 daysParkinson’s APOKYN (apomorphine) 30 cartridges/30 daysSleep Disorder HETLIOZ (tasimelteon) 1 cap/dayDermatologyAtopic Dermatitis DUPIXENT (dupilumab) 4 syringes (8mL)/28 daysElectrolyte & Renal AgentsDiuretics KEVEYIS (dichlorphenamide) 4 tabs/dayEndocrinology & MetabolismGonadotropins ELIGARD (leuprolide) 22.5 mg (3-month) 1 injection/84 days

ELIGARD (leuprolide) 30 mg (4-month) 1 injection/112 daysELIGARD (leuprolide) 45 mg (6-month) 1 injection/168 daysELIGARD (leuprolide) 7.5 mg (1-month) 1 injection/28 days

21

THERAPY CLASS MEDICATION NAME LIMITGonadotropins (cont.) FIRMAGON (degarelix) 120 mg 2 vials/year

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

1 pack/84 days

LUPANETA PACK (leuprolide) 3.75 mg (1 mon)

1 pack/28 days

SUPPRELIN LA (histrelin acetate) 1 kit/365 daysTRELSTAR (triptorelin) 22.5 mg (6-month) 1 injection/168 daysTRELSTAR DEPOT (triptorelin) 3.75 mg (1-month)

1 injection/28 days

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

1 injection/84 days

VANTAS (histrelin) 1 implant/yearZOLADEX (goserelin) 10.8 mg 1 injection/84 daysZOLADEX (goserelin) 3.6 mg 1 injection/28 days

Growth Hormones and Related Therapy

EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)/day

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)/dayHormone Modifiers NATPARA (parathyroid hormone) 2 cartridges/28 daysMiscellaneous KORLYM (mifepristone) 4 tabs/dayOsteoporosis PROLIA (denosumab) 2 syringes/yearSomatostatins SIGNIFOR (pasireotide) 2 ampules/day

SIGNIFOR LAR (pasireotide) 1 vial/28 daysVasopressin Antagonist SAMSCA (tolvaptan) 30 days supply/60 daysEnzyme-RelatedCystine-depleting Agents CYSTARAN (cysteamine) 4 bottles/28 daysEnzyme Replacement XURIDEN (uridine triacetate) 4 packets/dayGastroenterologyDiarrhea XERMELO (telotristat ethyl) 3 tabs/dayHepatic Agents OCALIVA (obeticholic acid) 1 tab/dayImmunologyHematopoietic Agents MOZOBIL (plerixafor) 8 vials (9.6 mL)/transplantHepatitis C Agents DAKLINZA (daclatasvir dihydrochloride) 1 tab/day

EPCLUSA (sofosbuvir-velpatasvir) 1 tab/dayHARVONI (ledipasvir-sofosbuvir) 1 tab/dayMAVYRET (glecaprevir-pibrentasvir) 3 tabs/dayOLYSIO (simeprevir) 1 cap/daySOVALDI (sofosbuvir) 1 tab/dayTECHNIVIE (ombitasvir-paritaprevir-ritonavir)

2 tabs/day


THERAPY CLASS MEDICATION NAME LIMITHepatitis C Agents (cont.)

VIEKIRA PAK (dasabuvir-ombitasvir-paritaprevir-ritonavir)

4 tabs/day

VIEKIRA XR (dasabuvir-ombitasvir-paritaprevir-ritonavir)

3 tabs/day

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

Interleukins ILARIS (canakinumab) 2 vials/4 weeksMultiple Sclerosis AMPYRA (dalfampridine) 2 tabs/day

AUBAGIO (teriflunomide) 1 tab/dayAVONEX (interferon beta-1a) 1 kit (4 syringes)/28 daysBETASERON (interferon beta-1b) 1 package/28 daysCOPAXONE (glatiramer) SOSY 20 mg/ml 1 kit/30 daysCOPAXONE (glatiramer) SOSY 40 mg/ml 1 kit/28 days EXTAVIA (interferon beta-1b) 1 package/28 daysGILENYA (fingolimod) 1 cap/dayGLATOPA (glatiramer) SOSY 20 mg/ml 1 kit/30 daysOCREVUS (ocrelizumab) Soln 40mL (4 vials)/365 daysPLEGRIDY (peginterferon beta) 2 pens/syringes/28 daysPLEGRIDY (peginterferon beta) Starter Pack

1 starter pack/30 days

REBIF (interferon beta-1a) 12 syringes/28 daysREBIF (interferon beta-1a) Starter Pack 1 starter pack/yearTECFIDERA (dimethyl fumarate) 2 caps/dayTECFIDERA (dimethyl fumarate) Starter Pack

1 starter pack/year

TYSABRI (natalizumab) 1 injection/28 daysMovement Disorder Agents

AUSTEDO (deutetrabenazine) 4 tabs/day

OncologyKinase and Molecular Target Inhibitors

AFINITOR (everolimus) 1 tab/day

ALECENSA (alectinib) 8 caps/dayALUNBRIG (brigatinib) 6 tabs/dayCAPRELSA (vandetanib) 100 mg 2 tabs/dayCOTELLIC (cobimetnib) 63 tabs/28 daysFARYDAK (panobinostat) 6 caps/21 daysGILOTRIF (afatinib) 1 tab/dayICLUSIG (ponatinib) 15 mg 2 tabs/dayJAKAFI (ruxolitinib) 10 mg 2 tabs/dayNINLARO (ixazomib) 3 caps/28 days

23

Quantity Limits effective as of January 1, 2018.

PLEASE NOTE: This drug list is subject to periodic updates and may not be all inclusive. Drugs affected included both brand and generic where applicable and includes all strengths unless otherwise specifically noted. If a targeted drug has a new strength, it will automatically be added to the list.



© 2018 Optum, Inc. All rights reserved. ORX0801E-180101 68515-092017

optumrx.com

THERAPY CLASS MEDICATION NAME LIMITKinase and Molecular Target Inhibitors (cont.)

PORTRAZZA (necitumumab) Soln 2 vials/21 days

RYDAPT (midostaurin) 8 tabs/dayTAGRISSO (osimertinib) 1 tab/dayTARCEVA (erlotinib) 100 mg, 150 mg 1 tab/dayTARCEVA (erlotinib) 25 mg 3 tabs/dayZEJULA (niraparib tosylate) caps 3 caps/day

Miscellaneous KISQALI (ribociclib) Tabs 63 tabs/28 daysKISQALI FEMARA DOSE (ribociclib succinate-letrozole) Pack

91 tabs/28 days

LONSURF (trifluridine-tipiracil) 15-6.14 MG

100 tabs/28 days

LONSURF (trifluridine-tipiracil) 20-8.19 MG

80 tabs/28 days

RUBRACA (rucaparib camsylate) 4 tabs/dayRespiratoryAsthma/COPD NUCALA (mepolizumab) 1 vial/28 daysCystic Fibrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabs/day

TOBI PODHALER (tobramycin) 1 package (224 tabs)/56 days

Select Step Therapy

Most medical conditions have multiple medication options. Although their clinical effectiveness may be similar, prices can vary widely. With the Step Therapy program, you get the treatment you need, usually at a lower cost.

Here’s how it works:

With this program, you need to try a Step 1 medication first, before a Step 2 medication may be covered. When you bring a prescription to the pharmacy, our system will automatically screen the medication for step therapy requirements. If your prior pharmacy claims show you have tried a Step 1 medication in the recent past, the Step 2 medication may be processed. If not, the pharmacist will contact your doctor for further explanation.

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

You get a prescription

Try a Step 1 medication first

Before a Step 2 medication is covered

Step Therapy Program

OptumRx | optumrx.com

Step Therapy Medications

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

Condition Step 1 Step 2

Anti-infectives

Oral Brand Tetracyclines

Any one of the following generics: doxycycline

AND any one of the following preferred brands:Doryx MPC

Acticlate, Adoxa, Doryx, Monodox, Targadox

Otic Agents ofloxacin Cetraxal, Ciprofloxacin

Cardiovascular

Beta Blockers carvedilol Coreg CR

Calcium Channel Blockers

Any one of the following generics: amlodipine, perindopril

Prestalia

Renin-Angiotensin System Agents

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

Edarbi, Edarbyclor, Tekturna, Tekturna HCT

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

Altoprev, Flolipid, Lipitor, Livalo, Nikita, Zypitamag

Bold type = Brand-name drug Plain type = Generic drug

3


Fibric Acid Derivatives

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

AND any one of the following preferred brands: Lipofen

Fenoglide, Fibricor, Lofibra, Triglide

Antianginals Any one of the following generics or preferred brands: acebutolol, amlodipine, amlodipine-benazepril, amlodipine-telmisartan, amlodipine-valsartan, atenolol, bextaxolol, bisoprolol, carvedilol, diltiazem, diltiazem ER, felodipine ER, isosorbide dinitrate ER, isosorbide mononitrate ER, isradipine, metoprolol, metoprolol ER, nadolol, nicardipine, nifedipine, nisoldipine SR, nitroglycerin ER, pindolol, propranolol, propranolol SR, timolol, trandolapril-verapamil, verapamil, verapamil ER

Bystolic, Dilatrate SR, Inderal XL, Innopran XL

Ranexa

Central Nervous System

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

Adderall XR#, Adzenys XR ODT#, Aptensio XR#, Concerta#, Cotempla XR-ODT#, Daytrana#, Desoxyn#, Dyanavel XR#, Evekeo#, Focalin XR#, Kapvay, Metadate CD#, Methylin# solution, Methylin Chew#, Mydayis#, Procentra#, Quillichew ER#, Quillivant#, Ritalin LA#, Zenzedi#

Anticonvulsants* topiramate Trokendi XR


Step Therapy Medications Continued




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

Trintellix#

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

Fetzima#

bupropion XL Alpenzin#

Antipsychotics* Any two of the following generics or preferred brands: aripiprazole, olanzapine, quetiapine, risperidone

Saphris, Seroquel XR

Fanapt#, Latuda#, Vraylar#

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

Belsomra#

Any one of the following generics: zolpidem, zolpidem CR

Edluar#, Zolpimist#

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

Treximet#, Zecuity#

Any two of the following generics: rizatriptan, sumatriptan, zolmitriptan

Onzetra Xsail#

Neurologic Agents

gabapentin Gralise#

Any one of the following generics or preferred brands:

amitriptyline, cyclobenzaprine, duloxetine

Lyrica

Savella#



5


Non-Narcotic Analgesics

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

Cambia, Tivorbex

Opioid Antagonists

Narcan Nasal Spray Evzio

Parkinson’s Disease

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

Rytary

Both of the following generics: rasagiline, selegiline

Xadago#

Women’s Health Any one of the following generics: esterified estrogens-methyltestosterone, estradiol, estradiol-norethindrone, estropipate, paroxetine, fluoxetine

Brisdelle#

Dermatology

Rosacea Soolantra Finacea

Mirvaso Rhofade

Skin Cancer Agents

Any one of the following generics: fluorouracil, imiquimod

diclofenac gel 3%#, Picato, Solaraze#, Tolak

Topical Acne Treatments

Any one of the following preferred brands: Epiduo/Epiduo Forte, Onexton

Acanya, Aktipak, Benzaclin, Benzamycin, Duac, Veltin, Ziana






Topical Immuno-modulators

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

Elidel, Eucrisa

Endocrinology

Basal Insulin All of the following preferred brands: Lantus, Levemir, and Toujeo

Basaglar

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

Actoplus Met XR

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

Avandia, Cycloset

Blood Glucose Meters and Strips

Both of the following preferred brands: Accu-Check, Onetouch

Abbott#, Acon#, At Last#, Bayer#, Embrace#, EPS#, Fora Care#, Glucocard#, Gmate#, Liberty#, Neutek#, Quintet#, Relion#, Reveal#, Supreme#, True Metrix#, Truetest#, Truetrack#, Ultima#, Unistrip#



7


DPP4 Inhibitors Any one of the following generics: metformin, metformin ER, glipizide-metformin, glyburide-metformin, pioglitazone-metformin

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

Any one of the following preferred brands: Janumet†, Janumet XR†, Januvia†

AND any one of the following preferred brands: Jentadueto†, Jentadueto XR†, Tradjenta†

alogliptin, alogliptin-metformin, alogliptin-pioglitazone, Kazano, Kombiglyze XR, Nesina, Onglyza, Oseni

GLP-1 Agonist Combinations

Any one of the following preferred brands: Bydureon†, Byetta†, Trulicity†, Victoza†, Lantus, Levemir, or Toujeo

Xultophy#

Any one of the following: Adlyxin†, Bydureon†, Byetta†, Tanzeum†, Trulicity†, Victoza†, Basaglar†, Lantus, Levemir, Tresiba or Toujeo

Soliqua#

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

Invokamet, Invokamet XR, Invokana, Jardiance, Synjardy, Synjardy XR

Any one of the following preferred brands: Invokamet†, Invokana†, Invokamet XR†

AND any one of the following preferred brands: Jardiance†, Synjardy†, Synjardy XR†

Farxiga, Glyxambi, Xigduo XR






Short-Acting Insulin

Any one of the following preferred brands: Humalog, Novolog

Apidra

Gastroenterology

Constipation Agents

Any one of the following generics: lactulose, polyethylene glycol

Amitiza#, Linzess#

Any one of the following generics: lactulose, polyethylene glycol

AND both of the following brands: Amitiza#, Linzess#

Trulance#

Gastroprotective Agents

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

Duexis#

Irritable Bowel Syndrome

Apriso Asacol HD, Delzicol, mesalamine DR

Opioid-Induced Constipation

Amitiza† Movantik#

Pancreatic Enzymes

Both of the following preferred brands: Creon, Zenpep

Pancreaze, Pertzye, Ultresa, Viokace

Proton Pump Inhibitors

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

Aciphex#, esomeprazole strontium#, First-Lansoprazole, First-Omeprazole, Prevacid#, Prilosec#, Protonix#, Zegerid#

Any one of the following preferred brands: Omeclamox-Pak, Pylera

Prevpac




Miscellaneous

Antigout Agents Colcrys Mitigare, colchicine

allopurinol Uloric, Zurampic

Ophthalmology

Ophthalmic Antihistamines

Any one of the following generics or preferred brands: azelastine, olopatadine Pataday

Bepreve, Lastacaft

Ophthalmic Antiinflammatory Agents

Bromsite Prolensa#

Respiratory

Epinephrine Auto Injectors*

Any one of the following generics: generic Epipen (manufactured by Mylan), generic Epipen-Jr (manufactured by Mylan)

Adrenaclick, Auvi-Q, Epipen, Epipen-Jr, epinephrine

Inhaled Corticosteroids

Any two of the following preferred brands: Arnuity Ellipta, Flovent, Pulmicort Flexhaler, QVAR

Alvesco#, Armonair Respiclick#, Asmanex#

Inhaled Cystic Fibrosis Agents

Bethkis Kitabis, Tobi, Tobi Podhaler#, to-bramycin nebulizer solution

Leukotriene Modifiers

Any one of the following generics: montelukast, zafirlukast

zileuton ER, Zyflo, Zyflo CR



9




Long-Acting Bronchodilators

Any two of the following preferred brands: Advair, Breo Ellipta, Serevent, Symbicort

Arcapta#, Striverdi Respimat#

Both of the following preferred brands: Incruse Ellipta, Spiriva

Seebri Neohaler#, Tudorza Pressair#

Long-Acting Bronchodilator Combinations

Any two of the following generics or preferred brands: fluticasone-salmeterol, Advair, Breo Ellipta, Symbicort

Airduo Respiclick#, Dulera#

Any one of the following preferred brands: Advair, Breo Ellipta, Serevent, Symbicort

AND any one of the following preferred brands: Spiriva

Bevespi Aerosphere#, Utibron Neohaler#

Short-Acting Beta Agonist Inhalers

Any one of the following preferred brands: Ventolin HFA

AND any one of the following preferred brands: ProAir HFA, ProAir Respiclick

levalbuterol HFA#, Proventil HFA#, Xopenex HFA#

Urology

BPH Agents Any two of the following generics or preferred brands: alfuzosin, doxazosin, tamsulosin, terazosin

Rapaflo

Cardura XL


Step therapy requirements are effective as of January 1, 2018. The list of step therapy medications is subject to change without notice. Step therapy requirements may vary by benefit plan. Additional clinical programs, including quantity limits and prior authorization, may exist for the above medications which may affect your prescription drug coverage.

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

# Quantity limits may also apply. Please refer to the Select Quantity Limits document.

* Applies to new starts only


Headline

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

Using your ID card

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

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

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

Retail pharmacy network


Retail pharmacy network

Finding a network pharmacy

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

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

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

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

AA S Medication Solutions

AADP

Accesshealth

Accesshealth Plus

Albertsons

American Drug Stores

American Pharmacy Network Solutions

Amerita

Aurora Pharmacy

BBalls Four B Corp

Bi Lo

Bimart Corporation

Biorx

Brookshire Bros

Brookshire Grocery Company

CCardinal Health Managed Care Servic

Carrs Quality Center

Central Dakota Pharmacys

Cigna Medical Group Pharmacy

City Market

Complete Claims Processing

Costco Pharmacies

Curators Of The University Of Mo

CVS Pharmacy

DDallas Metrocare Services

Dillon Stores

Discount Drug Mart

Doctors Choice Pharmacies

EE Medrx Solutions

Eaton Apothecary

Epic Pharmacy Network

FF & F Pharmacies

Fairview Health Services

Fairview Pharmacy Services

Family Care Pharmacy Network

Ff Acquisition

Food City-K-Va-T Food Stores

Food Lion

Fred Meyer

Freds Pharmacy

Freds Stores Of Tennessee

Fruth Pharmacy

Frys Food And Drug Stores

GGerimed Network

Giant Eagle

Global

Good Neighbor Phcy Provider

HHannaford Bros Co

Harris Teeter

Harvard Vanguard Medical Associates

Heb Grocery Company

Horton And Converse Pharmacy

Humana Pharmacy Inc Pharmacy

Hy-Vee

IIHC Health Services

Ingles Markets Pharmacy

Innovatix Network

Innovatix Specialty Network

Inserra Supermarkets

Insty Meds

KK Mart Pharmacy

King Soopers Pharmacy Co

Kinney Drugs

Kleins Family Markets

Klingensmiths Drug Store

Kohlls Pharmacy And Homecare

KS Management Services

LLeader Drug Stores

Leader Puerto Rico

LML Enterprises

Longs Drug Stores California

MM K Stores

Major Value Third Party Network

Marianos Pharmacies

Marshfield Clinic Pharmacy

Maxor National Phcy Srvs Corp

Mayo Clinic Pharmacy

Mds Rx

Medicap Pharmacies

Medicine Shoppe International

Meijer

Mha Long Term Care Network

Myrx

NNai Saturn Eastern

Navarro Discount Pharmacies

NCPRX

Neighborcare Pharmacy Services

Northeast Phcy Svce Corp

Northwest Health Ventures

OOmnicare Inc Ncs Healthcare

Oncology Pharmacy Services

PPacmed Clinics

Patient First Corporation

Pharmerica

Physicians Pharmaceutical Corp

Physicians Pharmaceutical Corp

Planned Parenthood Of The Pacific S

Poc Network Technologies

Ppok Rxselect Phcy Network

Price Chopper House Calls Pharma

Procare Pharmacy

Progressive Pharmacies

Provider Services Of America

Publix Super Markets

QQCP Networx

Quality Food Centers

Quick Chek Corporation

RRaleys Drug Center

Ralphs Pharmacy

Randalls Food And Drug

Recept Healthcare Services

Red Cross Pharmacy

Redners Markets

Rite Aid Corporation

Ronetco Supermarkets

Roundys Pharmacies

SS R S

Safeway

Saker Shoprites

Sav Mor Drug Stores

Save Mart Supermarkets

Schnuck Markets

Seip Drug

Shaws Supermarket

Shopko Stores Operating Co

Shoprite Financial Services

Shoprite Supermarkets

Smiths Food And Drug Center

Stop And Shop Pharmacy

Supervalu Pharmacies

Swift Rx Llc

TTarget Corporation

Tempest Med

The Bartell Drug Company

The Kroger Co

Third Party Station

Third Party Station Cp

Third Party Station Pr

Thrifty Drug Stores

Tom Thumb Pharmacies

Tops Markets

UUcsd Medical Center Phcy

United Drugs

United Drugs Rural Network

United Pharmacy Tx

University Of Utah Pharmacies

VValley Wholesale Drug Co

Vantage Rx Dispensing Services

Village Supermarkets

Vons Companies

WWalgreens Drug Store

Walmart Stores

Wegman Food Market

Weis Pharmacies

Welgo

Winn Dixie Pharmacy

ZZallie Supermarkets



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

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

optumrx.com

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

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

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

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

How Mail Service Saver works

If you are currently taking maintenance medication on a regular basis, your pharmacy benefit plan strongly encourages you to use home delivery.

Your health plan covers only a limited number of maintenance medication refills from a retail pharmacy (call Customer Service at the member phone number on the back of your health plan ID card for the number of fills covered by your specific plan). After the allowed fills, you must move to home delivery through OptumRx or you will pay an increased cost at your retail pharmacy.

Discover the convenience of OptumRx® Mail Service Saver

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

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

©2015 Optum, Inc. All rights reserved. ORX7321-MSS_150608 49994-082015

optumrx.com

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

Here is how:

By online registration:Visit optumrx.com, register and follow the simple step-by-step instructions. You can manage your medication online, including filling new prescriptions and transferring other prescriptions to home delivery. You can also set up text message reminders to help manage your medication schedule. Be sure to have your health plan ID card and medication bottles on hand.

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

By mail:Ask your doctor for a new prescription for up to a three-month supply, plus refills for up to one year. Then go to optumrx.com and download the new prescription order form. Mail it to the address provided on the bottom of the form.

By fax / ePrescribe:Ask your doctor to call 1-800-791-7658 for instructions on how to fax your prescription directly to OptumR. Or your doctor can send an electronic prescription to OptumRx.

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

NRX001

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

Member ID Number

(Additional coverage, if applicable) Secondary Member ID Number

Last Name First Name MI

Delivery Address Apt. #

City State ZIP

Phone Number with Area Code

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

Email

Physician Name

Physician Phone Number with Area Code

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

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

Over-the-counter/herbal medications taken regularly:

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

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

1

2

3

4

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

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

ORX5633_140915

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

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

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

Signature: Date:

New Credit Card Number

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

Specialty medications can be important to maintaining or improving your health — and your quality of life. BriovaRx®, the OptumRx® specialty pharmacy, provides the resources and personalized, condition-specific support you need to help you better manage your condition.

What is a specialty medication?

We define an injectable, oral or inhaled medication as a specialty medication if it:

• May require ongoing clinical oversight and additional education for best management

• Has unique storage or shipping requirements

• May not be available at retail pharmacies

BriovaRx: A specialty pharmacy to meet your needs

BriovaRx offers support to help you manage your condition. Take advantage of personalized patient support from knowledgeable pharmacists and nurses who specialize in your condition at no additional cost to you. In addition, you’ll receive:

• Access to your medications at the lowest cost

• 24/7 access to pharmacists

• Support through clinical and adherence programs

• Any medication-related supplies at no additional cost

• Proactive refill reminders

• Timely delivery and shipping in confidential packaging

Welcome to your specialty pharmacy

Specialty medication resources

Customer service Call 1-855-4BRIOVA (1-855-427-4682)

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

Getting started: Transfer your prescriptions

Enroll in the specialty pharmacy program with BriovaRx.

If you haven’t done so yet, call BriovaRx at 1-855-4BRIOVA (1-855-427-4682) to get started.

Access to a pharmacist 24/7.

Our specialty pharmacists and patient care coordinators are available 24/7 and will take care of everything for you, including:

• Transferring your prescription to BriovaRx

• Helping you find affordable access to your medication and manage any side effects

• Explaining how the specialty pharmacy works

Personalized support.

Once you start getting your specialty medications through BriovaRx, you’ll also experience personalized, one-on-one support from pharmacists and nurses. They’re there for you any time you have questions about your medication, side effects and more.

Working with your pharmacist or nurse

Continued conversations.

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

• Any side effects

• Trouble remembering to take your medication

Monitor your health.

If you need help with anything else from weight loss to back pain and even smoking cessation, your specialty pharmacist or nurse can help you locate wellness coaching and disease management programs to help you stay on track with your health.

Follow your care plan.

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

Staying on track with your treatment

Quick and easy refills.

We make it easy for you to remember to take your medication with a reminder phone call a few days prior to the time when you need to refill your prescription. You can even sign up for text message reminders online or by phone.

Overnight delivery.

With your specialty pharmacy, shipping your medication is quick, easy and safe. Refrigerated medications will be delivered overnight directly to your home or office, in a temperature-controlled package. Others will be shipped within one to three days. Supplies will also be provided at no extra cost.

Save more time and money.

If you’re looking to save money on your medications, finding lower-cost alternatives and transferring your non-specialty prescriptions through the mail can help.


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

© 2017 Optum, Inc. All rights reserved. 65614-052017

optumrx.com

Rx guide for specialty medications

Guiding your health journey under your pharmacy benefitWe understand the challenge of living with and managing a complex health condition. That’s where BriovaRx comes in, to assist you every step of the way.

Headline


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

Specialty pharmacy drug list

January 1, 2018

Characteristics of specialty medications

“Specialty” medications are defined as high-cost oral or injectable medications used to treat rare and complex conditions. These are highly complex medications, typically biology-based, that structurally mimic compounds found within the body. Medications must have at least one of the following characteristics in order to be classified as a specialty medication by BriovaRx:

High cost• Typically priced at more than $1,000 per 30-day supply.

High complexity• Biotechnology products†

• Medications that treat ultra rare conditions

• Medications that are included in a specialty therapeutic drug class strategy

High-touch medications that require:• Temperature control or other special handling and shipping requirements

(e.g., refrigerated or frozen shipping)

• Ongoing management by a pharmacist and/or physician specializing in treating the condition

• Focused, in-depth education including how to administer injections, adhere to the treatment protocol, and manage side effects

† Protein or protein-based molecular entities



Adult incontinence

Solesta

Ammonia detoxicants

Ravicti PA

Anemia

Aranesp PA Epogen PA, ST Mircera PA Procrit PA

Anticoagulation

Arixtra Enoxaparin Fondaparinux Fragmin Lovenox

Anti-Gout agent

Krystexxa PA

Antihyperlipidemic

Juxtapid PA Kynamro PA Praluent PA, ST Repatha PA, ST

Anti-infective

Daraprim PA

Asthma

Cinqair PA

Fasenra PA

Nucala PA

Xolair PA

Birth control

Nexplanon

Cardiovascular

Northera PA

Central nervous system agents

Austedo PA

Brineura PA

Hetlioz PA

Radicava PA

Sabril PA

Tetrabenazin PA

Vigabatrin PA

Xenazine PA

Cystic fibrosis

BethkisCayston PA

Kalydeco PA

Kitabis Pak ST

Orkambi PA

Pulmozyme PA

Tobi ST

Tobramycin ST

Diagnostic

Acthrel

Duchenne muscular dystrophy

Emflaza PA

Endocrine

Cuprimine PA

Egrifta PA

Firmagon PA

Hydroxy Capr PA

Korlym PA

Kuvan PA

Lupaneta PA

Makena PA

Myalept PA

Natpara PA

NityrOctreotide PA

ParsabivProcysbi PA

SamscaSandostatin PA

Signifor PA

Somatuline PA

Somavert PA

Supprelin LA PA

Syprine PA

ThiolaThyrogen PA

Triptodur PA

Vantas PA, ST

Xuriden PA

Enzyme therapy

Adagen Aldurazyme PA Aralast NP PA Buphenyl

Carbaglu Cerdelga PA Cerezyme PA Cholbam PA Cystagon Elaprase PA Elelyso PA Fabrazyme PA Glassia PA Kanuma PA Lumizyme PA Naglazyme PA Orfadin Phenylbutyra Prolastin-C PA Sodium Pheny Strensiq PA Sucraid Vimizim PA Vpriv PA Zavesca PA Zemaira PA

Gastrointestinal agents

Gattex PA

Ocaliva PA

Xermelo PA

GROWTH HORMONE DEFICIENCY

Genotropin PA, ST

Humatrope PA, ST

Increlex PA, ST

Norditropin PA, ST

Nutropin AQ PA, ST

Omnitrope PA, ST

3PA – Prior authorization required • ST – Step therapy




Saizen PA, ST

Serostim PA, ST

Zomacton PA, ST

Zorbtive PA, ST

Hematological agents

Mozobil PA

Nplate PA

PanhematinPromacta PA

RiastapSoliris PA

Thrombat III

Hemophilia

AdvateAdynovateAfstylaAlphanateAlphanine SDAlprolixBebulinBenefixCeprotinCoagadexCorifactEloctateFeibaHelixate FSHemlibra Hemofil MHumate-PIdelvionIxinityKoateKoate-DVIKogenate FSKovaltry

Monoclate-PMononineNovoeightNovoseven RTNuwiqObizurProfilnineRebinyn RecombinateRixubisTrettenVonvendiWilateXyntha

Hepatitis B

Adefov Dipiv Baraclude Entecavir Epivir HBV Hepsera Lamivudine Vemlidy

Hepatitis C

CopegusDaklinza PA

Epclusa PA. ST

Harvoni PA

Mavyret PA

ModeribaOlysio PA

Pegasys PA, ST

Pegintron PA, ST

RebetolRibapakRibasphereRibavirin

Sovaldi PA

Technivie PA

Viekira PA

Vosevi PA, ST

Zepatier PA, ST

Hereditary angioedema

Berinert PA

Cinryze PA

Firazyr PA

Haegarda PA

Kalbitor PA

Ruconest PA

HIV

ABACAV/LAMIVAbacavirAptivusAtriplaCombivirCompleraCrixivanDescovyDidanosineEdurantEmtrivaEpivirEpzicomEvotazFosamprenaviFuzeonGenvoyaIntelenceInviraseIsentressKaletraLamivud/zidoLamivudine

LexivaLopin/ritonNevirapineNorvirOdefseyPrezcobixPrezistaRescriptorRetrovirReyatazSelzentryStavudineStribildSustivaTivicayTriumeqTrizivirTruvadaTybostVidexViraceptViramuneVireadZeritZiagenZidovudine

Immune globulin

AtgamBivigam PA

Carimune NF PA

Cuvitru PA

Cytogam PA

Flebogamma PA

Gamastan S/D PA

Gammagard PA

Gammaked PA

Gammaplex PA

5

Gamunex-C PA

Hizentra PA

Hyperrab S/DHyperrho S/DHyqvia PA

Imogam RabieMicrhogam Octagam PA

Privigen PA

Immunological agents

ActimmuneArcalyst PA

Benlysta PA

Ilaris PA

Lemtrada PA

Infertility

Bravelle PA, ST

Cetrotide PA

Chor Gonadot PA

Follistim AQ PA

Ganirelix AC PA

Gonal-F PA

Menopur PA

Novarel PA

OvidrelPregnyl PA

Inflammatory conditions

Actemra PA, ST

Cimzia PA, ST

Cosentyx PA

Dupixent PA

Enbrel PA

Entyvio PA

Humira PA

Inflectra PA

Kevzara PA

Kineret PA, ST

Orencia PA, ST

Otezla PA

Remicade PA

Renflexis PA

Siliq PA, ST

Simponi PA, ST

Stelara PA, ST

Taltz PA

Tremfya PA, ST

Xeljanz PA, ST

Metabolic bone disease

ReclastZoledronicZometa

Multiple sclerosis

Ampyra PA

Aubagio PA

Avonex PA

Betaseron PA

Copaxone PA

Extavia PA

Gilenya PA, ST

Glatiramer PA

Glatopa PA

Ocrevus PA

Plegridy PA

Rebif PA, ST

Tecfidera PA

Tysabri PA

Zinbryta PA

Musculoskeletal agents

Exondys 51 PA, ST

Spinraza PA

Xiaflex PA

Narcolepsy

Xyrem PA

Neurological agents

Botox PA

Dysport PA

Myobloc PA

Xeomin PA

Neutropenia

Granix PA

H.P. Acthar PA

Leukine PA

Neulasta PA

Neupogen PA

Zarxio PA

Oncology - injectable

AbraxaneAdcetris PA

AdriamycinAdrucilAlferon NAlimtaAliqopa PA

AlkeranArranonArzerra PA

AvastinAzacitidineBavencio PA

Beleodaq PA

BendekaBesponsa PA

BicnuBleo 15kBleomycinBlincyto PA

Bortezomib PA BusulfanBusulfexCampathCamptosarCarboplatinCisplatinCladribineClofarabineClolarCosmegenCyclophosphCyramza PA

CytarabineDacarbazineDacogen PA

Darzalex PA

DaunorubicinDecitabine PA

DexrazoxaneDocetaxelDoxilDoxorubicinEligard PA

EllenceEmpliciti PA

EpirubicinErbitux PA

ErwinazeEtopophosEtoposideEvomelaFaslodexFE PyrophospFloxuridineFludarabineFluorouracil InjectableFolotyn PA

Fusilev

PA – Prior authorization required • ST – Step therapy

Gazyva PA

GemcitabineGemzarHalaven PA

Herceptin PA

HycamtinIdarubicinIfexIfosfamideImfinzi PA

ImlygicIntron A PA

IrinotecanIstodax OVR PA

Ixempra kitJevtana PA

Kadcyla PA

KepivanceKeytruda PA

Kymriah PA

Kyprolis PA

Lartruvo PA

L-AsparagineLeuprolide PA

LevoleucovorLipodox 50Lupron Depot PA

MarqiboMelphalanMesnaMesnexMitomycinMitoxantron PA

MustargenMylotarg PA

NavelbineNipentOncasparOnivyde

Opdivo PA

OxaliplatinPaclitaxelPamidronatePerjeta PA

PhotofrinPortrazza PA

ProleukinRituxan PA

Sod PyrophosSylatron PA

Sylvant PA

Synribo PA

TaxotereTecentriq PA

Temodar PA

TeniposideTepadinaTheracysThiotepaTice BCGToposarTopotecanToriselTotectTreandaTrelstar mixTrisenoxUnituxin PA

ValstarVectibixVelcade PA

VidazaVinblastineVincasar PFSVincristineVinorelbineVyxeos PA

Xgeva PA

Yervoy PA

Yescarta PA

YondelisZaltrap PA

ZanosarZevalinZinecardZoladex

Oncology - oral

Afinitor PA

Alecensa PA

Alunbrig PA

Bexarotene PA

Bosulif PA, ST

Cabometyx PA

Calquence PA Capecitabine PA

Caprelsa PA

Cometriq PA

Cotellic PA

Erivedge PA

EtoposideFarydak PA

Gilotrif PA

Gleevec PA

GleostineHycamtinIbrance PA

Iclusig PA

Idhifa PA

Imatinib Mes PA

Imbruvica PA

Inlyta PA

Iressa PA, ST

Jakafi PA

Kisqali PA

Lenvima PA

Lonsurf PA

Lynparza PA

MatulaneMekinist PA

MercaptopurineMesnexNerlynx PA

Nexavar PA

NilandronNilutamideNinlaro PA

Odomzo PA

Pomalyst PA

PurixanRevlimid PA

Rubraca PA

Rydapt PA

Sprycel PA, ST

Stivarga PA

Sutent PA

Tafinlar PA

Tagrisso PA

Tarceva PA

Targretin PA

Tasigna PA

Temodar PA

Temozolomide PA

Thalomid PA

TretinoinTykerb PA

Venclexta PA

Verzenio PA

Votrient PA

Xalkori PA

Xeloda PA

Xtandi PA

Zejula PA

Zelboraf PA

Zolinza PA

Zydelig PA

Zykadia PA

Zytiga PA




Oncology - topical

Valchlor PA

Ophthalmic agents

Cystaran PA

EyleaIluvienJetreaKeveyis PA

LucentisMacugenVisudyne

Osteoarthritis

Durolane PA

Euflexxa PA, ST

Gel-one PA, ST

Gelsyn-3 PA

Genvisc 850 PA, ST

Hyalgan PA, ST

Hymovis PA

Monovisc PA

Orthovisc PA

Supartz PA, ST

Synvisc PA

Visco-3 PA, ST

Osteoporosis

Forteo PA

Prolia PA

Tymlos PA

Pain management

Prialt

Parkinson’s disease

Apokyn PA

Pulmonary fibrosis

Esbriet PA

Ofev PA

Pulmonary hypertension

Adcirca PA

Adempas PA

Epoprostenol PA

Flolan PA

Letairis PA

Opsumit PA

Orenitram PA

Remodulin PA

Revatio PA

Sildenafil PA

Tracleer PA

Tyvaso PA

Uptravi PA

Veletri PA

Ventavis PA

RSV

Ribavirin inhalSynagis PA

Virazole

Substance abuse treatment

Vivitrol PA

Transplant

Astagraf XLCellceptCellcept IVCyclosporineEnvarsus XRGengrafMycophenolatMycophenolicMyforticNeoralNulojix PA

PrografRapamuneSandimmuneSirolimusTacrolimusZortress PA

7PA – Prior authorization required • ST – Step therapy

About OptumRx

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

To fill a prescription for a specialty medication on this list, please call 1-855-4BRIOVA (855-427-4682) or visit optumrx.com.

This specialty pharmacy drug list may not be a complete representation of all available specialty medications; this list is subject to change at any time without prior notice.

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


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

© 2018 OptumRx, Inc. ORX2700_180101


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

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

Smart Fill program

Smart fill has two program strategies

Split fill 90-day fill

Eligible classes Oral oncology HIV, MS, RA, Transplant

Member stability Unstable on medication Stable on medication

Clinical benefits Adjust to medication Adherence

Program outcome Avoid waste Member convenience

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

Copays 1/2 copay 3x copay

Manage drug waste, adherence and costs

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



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

© 2016 Optum, Inc. All rights reserved. ORX9673_160711

[email protected] | optum.com/optumrx

Reduce costsBy being more proactive, split fill may save you up to 50 percent in costs associated with drug waste. Shorter fills also means smaller, prorated copays for members. Split fill is available to clients who use BriovaRx as their exclusive specialty pharmacy.

Split fill program strategy

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

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

• More frequent conversations with the member

• Early identification of adverse events

• Timely clinical intervention

• Adherence monitoring

90-day fill program strategy

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

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

• Enhanced member convenience

• Adherence monitoring

• Improved member satisfaction

Make your health a priority

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

See the pharmacy list on page 2.

Get your flu shot and other routine vaccines

Flu shotsThe flu affects millions of people each year and can lead to serious illness, or even death. The flu can be a contagious illness caused by influenza viruses that infect the lungs, throat and nose. According to the Centers for Disease Control and Prevention (CDC), one of the best ways to prevent the flu is by getting vaccinated each year.1 The CDC recommends a yearly flu vaccine for everyone 6 months of age and older as the first and most important step in protecting against this serious disease.2

Routine vaccinesYou can also keep yourself and your family members healthy with routine vaccines that prevent illnesses like tetanus, pneumonia and shingles. Routine vaccines are available on most plans, and can help you and your family maintain better overall health.

Easy access to flu shots and other vaccinesOptumRx contracts with a variety of national pharmacy chains to provide members with easy access to flu shots and other routine vaccines. Plus, members get the highest level of benefit coverage (100% for many plans) for vaccines obtained from contracted pharmacies that participate in the Vaccine Immunization/Injection Network administered by OptumRx.3

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

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

is not participating in the national OptumRx Vaccine Immunization/Injection Network.4 Not all vaccines on this list are available at all participating pharmacies. Members should

contact their participating pharmacy of choice to confirm vaccine availability.All trademarks are the property of their respective owners.M54390-A 1/16 ©2016 Optum, Inc. All rights reserved.

Routine vaccines4

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

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

Flu Shots & Nasal Mists

Flu (Influenza)

Afluria Fluzone HD Fluarix Quad

Fluarix Fluzone ID Flulaval Quad

Flulaval Fluzone PED Fluzone Quad

Fluvirin Flucelvax Flublok

Fluzone Flumist Quad

Routine Adult Vaccines

Hepatitis A (Adult and Pediatric)

Havrix Vaqta

Hepatitis B (Adult and Pediatric)

Engerix-B Recombivax-HB

Human Papilloma Virus (HPV) – Vaccine prevents cervical cancer

Cervarix Gardasil Gardasil 9

Measles, Mumps, Rubella - MMR-II

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

Menactra Menomune Menveo

Meningococcal - Vaccine prevents meningitis Group B

Bexsero Trumenba

Pneumococcal – Vaccine prevents pneumonia

Prevnar13

Pneumovax 23

Tdap – Vaccine prevents tetanus, diptheria, pertussis

Adacel Boostrix

Tetanus Diptheria - TD

Tenivac

Tetanus toxoid

Varicella – Vaccine prevents chicken pox

Varivax

Zoster – Vaccine prevents shingles

Zostavax

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

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

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

Retail PharmaciesThis list represents the larger retail chain pharmacies in our network, but is not the full list. For a more complete list, you can log in to www.optumrx.com or call the number on your health plan or prescription ID card. Pharmacists administer the vaccines at these locations.

The Great Atlantic & Pacific Tea Company (A&P, FoodBasics, The Food Emporium, Pathmark, Superfresh, Waldbaums)

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

Albertsons CVS Pharmacy Four B Corporation (Hen House,

Price Chopper) H-E-B Pharmacy Hy-Vee Pharmacy Kmart Pharmacy K-VA-T Food Stores, Inc. (Food City) Marsh Drugs LLC Meijer Pharmacies Publix Roundy’s (Pick’n Save, Copps,

Rainbow, Metro Market, Mariano’s) Safeway Affiliated Pharmacies

(Carrs, Pavilion’s, Randalls, Safeway, Tom Thumb, Vons)

Shopko Stores SUPERVALU Affiliated Pharmacies

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

Thrifty White Pharmacy Tops Markets Walgreens Pharmacy (Duane Reade) Wegmans

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