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1 Your prescription drug program 2015

2 This information is also available in large print. Call TTY users should call toll-free

3 Table of Contents Your Prescription Drug Program... 1 Pharmacy Copayments... 1 Plan Exclusions... 2 Dispensing Limitations... 2 Coverage and Prior Authorization Review Process... 2 Temporary Supplies... 3 Generic Medications... 3 Step Therapy... 4 Step Therapy Medications... 4 Prior Authorization... 5 Prior Authorization Medications... 5 Quantity Limits... 7 Pharmacies for Prescriptions...15 Complaints, Grievances, and Fair Hearings...15 Pharmacy Benefit Questions...15 UPMC for You Prescription Drug Formulary...16 UPMC for You Over-the-Counter Formulary...30 Brand/Generic Reference Guide...33

4 Your Prescription Drug Program The UPMC for You Prescription Drug Formulary is a list of Food and Drug Administration (FDA) approved medications. This list has been developed by UPMC for You doctors and pharmacists. UPMC for You provides coverage (pays for) for medications on the formulary (drug list). The drugs on the formulary were selected because they are safe, work well, and cost less than other drugs that have the same level of effectiveness. For your convenience, there is a list of prescription medications and a list of over-the-counter (OTC) medications. These lists are in alphabetical order. The UPMC for You formulary includes the most commonly used drugs. It does not include every medication your doctor might prescribe. UPMC for You covers many other drugs besides the ones listed in the formulary. To find out if your medication is covered, ask your pharmacist or call UPMC for You Member Services. Your doctor should order medications for you from the formulary. A non-formulary medication is one that is not on the list of medications covered by UPMC for You. If your doctor writes you a prescription for a non-formulary medicine, he or she will need to contact Pharmacy Services at UPMC (8762) for a medical exception. You will not be able to get the medication until we authorize the exception. Some prescription medications have to be approved by UPMC for You. This is called prior authorization. The medication your provider is asking for is reviewed for medical necessity. This means we need to understand why the medication is needed to treat your specific condition. All requests for medications requiring a prior authorization are reviewed by the UPMC for You Pharmacy Department. Decisions to approve or deny will be made within 24 hours of the request. If the request is denied, you will receive a letter explaining why it was denied. The letter will also tell you how to file a grievance if you are not satisfied with the decision. For more information about how to file a grievance see Section 6 of your member handbook. You can get some over-the-counter medications when your doctor writes a prescription for them. Please refer to the UPMC for You Over-the-Counter formulary in this book for a listing of covered products. If you have any questions, call Member Services. Pharmacy Copayments Some members may need to pay a small amount to the pharmacist for their medications. This is called a copayment. The pharmacist will let you know if a copayment applies to you. If you need a medication and truly cannot pay the copayment amount at the time you pick up the prescription, the pharmacy will give you the prescribed medication and bill you for the copayment. You will still owe the pharmacy the copayment for that prescription and the pharmacy will require you to pay the copayment. Pharmacy copayments do not apply to pregnant women (including through the postpartum period), recipients under the age of 18, nursing facility residents, and those who reside in an Intermediate Care Facility for the Intellectually Disabled and Other Related Conditions (ICF/ID/ORC) and recipients eligible under the Breast and Cervical Cancer Prevention and Treatment coverage group and Titles IV-B Foster Care and IV-E Foster Care and Adoption Assistance. Pharmacy copayments also do not apply to emergency supplies and family planning supplies. Copayment Information If you have pharmacy benefits, brand-name prescription drugs and brand-name over-the-counter drugs are $3 for each new prescription or refill. If you have pharmacy benefits, generic prescription drugs and generic over-the-counter drugs are $1 for each new prescription or refill. Drugs, including immunizations, dispensed by a physician are excluded from copayments. You do not have to pay a copayment for certain drugs: anti-hypertensives (high blood pressure drugs), antineoplastics (cancer drugs), anti-diabetics (diabetes drugs), anti-convulsants (epilepsy drugs), cardiovascular preparations (heart disease drugs), anti-parkinson s agents (Parkinson s disease drugs), HIV/AIDS drugs, anti-glaucoma agents (glaucoma drugs), anti-psychotics If you have any questions, call UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free at

5 (drugs for psychosis), and anti-depressants (drugs for depression). If you have questions about copayments, please call Member Services. Plan Exclusions The following medications are not covered under the Medical Assistance Program: DESI drugs. DESI (Drug Efficacy Study Implementation) drugs are classified by the FDA as being safe but not effective since these drugs did not have the appropriate studies done to prove they are effective. Drugs from manufacturers not participating in the Medicaid Drug Rebate Program. Erectile dysfunction medications. Experimental/investigational medications. Drugs used for cosmetic purposes. Drugs used for fertility purposes. Weight loss drugs. Dispensing Limitations Prescriptions must be dispensed by a network pharmacy. Some network pharmacies can provide up to a 90-day supply of maintenance drug for one copayment. Please ask your pharmacist or call our Member Services representatives to see if your pharmacy participates in this program. A maintenance medication is one that you take on a regular basis for a chronic or long-term condition. Antibiotics, controlled substances, and specialty medications are limited to a maximum 30-day supply per copayment. Controlled substances are drugs with high abuse potential and have a schedule II-V classification according to the Drug Enforcement Agency (DEA) and Food and Drug Administration (FDA). Specialty drugs are high-cost medications used to treat complex diseases. These medications usually require specialized handling and close monitoring by a doctor. Please ask your pharmacist or call our Member Services representatives to determine which drugs can be filled for a 90-day supply. A medication may be refilled when 85% of the medication has been used. Authorizations for medications that are lost/misplaced, stolen, or destroyed/damaged must be reviewed by the UPMC for You Pharmacy Services Department. Coverage and Prior Authorization Review Process Your medication may require a review prior to coverage by UPMC for You. The types of review for coverage or exception include the following: Prior authorization (requires your medication be review for medical necessity) Step therapy (requires that you must try another medication first) Non-formulary (requires that you try formulary medications) Quantity limits (requires you to take the recommended amounts of the medication) If your medication requires a review, then your doctor or other health care provider must contact Pharmacy Services. Your doctor or health care provider can do the following: Fax a prior authorization request form to Pharmacy Services at Your doctor can find the form on the UPMC Health Plan website at Call UPMC (8762) for urgent requests. UPMC for You will respond to all requests for coverage or exception within 24 hours. You and your doctor will get a written notice of the decision. If the request is denied, the written notice will explain how to appeal the denial. If you have been receiving the medication and your request is denied, you can file a complaint, grievance, or request a fair hearing. If your request is hand delivered or postmarked within 10 days of the written notice of the If you have any questions, call UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free at

6 decision, you can get your medication while you wait for a decision about your appeal. Additional information on how to file an appeal can be found in your member handbook. Your medication may be approved for a certain time period. After that time, your doctor will need to make sure your medication is still covered for you. Temporary Supplies While UPMC for You is reviewing the request for an exception, the pharmacist may give you a 15-day supply of the medication if your prescription qualifies as an ongoing medication that you have been taking. If it is a new medication, the pharmacist will give you a 72- hour supply if you have an immediate need for it. If the pharmacist feels that taking the requested medication alone or along with other medications you are taking will hurt your health or safety, the prescribing provider will be contacted before giving you the medication. Generic Medications UPMC for You requires that generic medications be given to you when available. Generic drugs have the same active ingredients as their brand-name counterparts and are just as safe and effective. Doctors are encouraged to prescribe generic medications whenever clinically appropriate. If your doctor prescribes a drug by brand name, your pharmacist will give you a generic version of that drug. If your doctor thinks you need the brand-name version of the drug, your doctor will need to call Pharmacy Services at UPMC (8762). Representatives are available Monday through Friday from 8 a.m. to 5 p.m. If you have any questions, call UPMC for You Member Services at Representatives are available Monday, Tuesday, Thursday, and Friday from 7 a.m. to 7 p.m., Wednesday from 7 a.m. to 8 p.m., and Saturday from 8 a.m. to 3 p.m. TTY users should call toll-free at

7 Step Therapy Step therapy medications require that you try specific medications first. The step therapy medications are automatically covered if we have a record that the required medication has been tried first. If there is no record that the required medication has been tried, your doctor is required to consult with UPMC for You Pharmacy Services before your pharmacy plan will cover the step therapy medication. The drugs in the following table require step therapy: Step Therapy Medications Acitretin Alprazolam ODT Avandia Celebrex Clonazepam ODT Clozapine ODT Dificid Granisetron Irbesartan Irbesartan/HCTZ Januvia Juvisync Levalbuterol Olanzapine-fluoxetine Symlin Tradjenta Valsartan Valsartan/HCTZ 4

8 Prior Authorization Some medications listed on the UPMC for You formulary require additional information from your doctor. Your doctor is required to consult with UPMC for You Pharmacy Services the first time he or she prescribes these drugs for you and before your pharmacy plan will cover them. The drugs are as follows: Prior Authorization Medications 8-MOP Abilify (2 mg, 5 mg <12 years of age) Abilify Maintena Abstral Actemra Acthar Gel Actimmune Adagen Adcirca Adderall XR (<4 or >18 years of age) Adefovir Adempas Afinitor Aldurazyme Alferon N Amevive Amphetamine salts (<4 or >18 years of age) Ampyra Androgel Apokyn Aptiom Aralast Aranesp NP Arcalyst Aubagio Banzel Baraclude Benlysta Berinert Bivigam Bosulif Botox Buphenyl Buprenorphine Buprenorphine/naloxone tablets Capecitabine Caprelsa Carbaglu Cerezyme Chlorpromazine (<12 years of age) Cimzia Cinryze Clozapine (<12 years of age) Clozapine ODT (<12 years of age) Cometriq Cuprimine Cystadane Cystagon Cystaran Daliresp Danazol Demsar Depen Dexmethylphenidate (<4 or >18 years of age) Dextroamphetamine (<4 or >18 years of age) Dextroamphetamine SA (<4 or >18 years of age) Dibenzyline Donepezil Dysport Egrifta Elaprase Elelyso Elidel Eligard Enbrel Entyvio Epivir-HBV Epogen Erivedge Etoposide Euflexxa Evzio Exjade Eylea Fabrazyme Fanapt Fareston Fentanyl citrate lozenge Fentora Ferriprox Firazyr Firmagon Flolan/epoprostenol Fluphenazine (<12 years of age) Forteo Fulyzaq Fycompa Galantamine/ Galantamine ER Galzin Gammaked Gattex Gilenya Gilotrif Glassia Gleevec Gralise ER Granix Grastek Haloperidol (<12 years of age) Harvoni Hetlioz Horizant Humira Hycamtin Iclusig Ilaris Imbruvica Increlex Infergen Inlyta Intron-A Invega Sustenna Iressa Itraconazole IVIG (intravenous immune globulin) Jakafi Jetrea Juxtapid Kalbitor Kalydeco Kineret Korlym Krystexxa Kuvan Kynamro Lazanda Letairis Leukine Lidocaine patch Lotronex Loxapine (<12 years of age) Lucentis Lumizyme Lupaneta Pack Lupron Lupron Depot Lupron Depot-Ped Lyrica Lysodren Makena Mekinist Methylphenidate (<4 or >18 years of age) Methylphenidate ER (<4 or >18 years of age) Methylphenidate LA (<4 or >18 years of age) Methylphenidate SR (<4 or >18 years of age) 5

9 Modafnil Mozobil Myalept Myobloc Myozyme Naglazyme Namenda Neulasta Neupogen Nexavar Norditropin Northera Noxafil Nplate Nuedexta Nulojix Nuvigil Oforta Olanzapine (<12 years of age) Olysio Omontys Onfi Onmel Onsolis Opsumit Orap (<12 years of age) Orencia Orenitram Orfadin Otezla Otrexup Oxsorelen Panretin Peg-Intron Perphenazine (<12 years of age) Pomalyst Potiga Procrit Procysbi Prolastin Prolastin-C Prolia Promacta Protopic Provenge Pulmozyme Quetiapine Quetiapine (<12 years of age) Qutenza Ragwitek Rapamune Rasuvo Ravicti Relistor Remicade Remodulin Revlimid Riluzole Risperdal Consta Risperidone (<12 years of age) Rituxan Rivastigmine Sabril Samsca Sandostain LAR Depot Savella Serostim Signifor Sildenafil Simponi Sirturo Soliris Somatuline Depot Somavert Sovaldi Sprycel SQIG Stelara Stivarga Suboxone film Sucraid Supprelin LA Sutent Sylatron Sylvant Syprine Synagis Synarel Synvisc Syprine Tafinlar Tarceva Targretin Tasigna Tecfidera Temozolomide Testosterone Thalomid Thioridazine (<12 years of age) Thiothixene (<12 years of age) Tracleer Tranexamic acid Trelstar Tretinoin (age 35 and older) Trifluoperazine (<12 years of age) Tykerb Tysabri Tyvaso Tyzeka Valchlor Vantas Veletri Ventavis Viadur Vimizim Vivitrol Votrient VPRIV Vyvanse (<4 or >18 years of age) Xalkori Xeljanz Xenazine Xeomin Xgeva Xifaxan Xofigo Xolair Xtandi Xyrem Zavesca Zelboraf Zemaira Ziprasidone (<12 years of age) Zoladex Zoledronic acid Zolinza Zontivity Zorbtive Zortress Zubsolv Zydelig Zykadia Zytiga 6

10 Quantity Limits The UPMC for You Pharmacy and Therapeutics Committee has established quantity limits on certain drugs to encourage the appropriate use of these drugs. Quantity limits are drug-specific and limit the amount of certain drugs that can be dispensed in a specified period of time. These limits are based on the Food and Drug Administration s recommended dosing, clinical literature, and manufacturer s instructions. For some drugs, the dosing guidelines may recommend taking the drug one time a day in a larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and cover one larger dose per day. For example, a prescription for tramadol is limited to 240 tablets per month, a prescription for Prolia is limited to two vials per year, and a prescription for quetiapine is limited to three tablets per day. Your doctor is required to consult with UPMC for You Pharmacy Services if you require more than the quantity limit of your medication. The drugs in the following table have quantity limits: Medication Class Quantity Limits Allergic Rhinitis Medications Grastek Ragwitek 30 tablets per 30 days 30 tablets per 30 days Anticoagulant (blood thinner) Medications Effient Eliquis Enoxaparin, Fragmin, and Fondaparinux Pradaxa Xarelto Zontivity 30 tablets per month 2.5 mg: 60 tablets per 30 days 5 mg: 74 tablets per 30 days 2-month supply per year 60 capsules per 30 days 10 mg: 2-month supply per year 15 mg: 42 tablets per 30 days 20 mg: 30 tablets per 30 days Starter pack: 1 pack per year 30 tablets per 30 days Antiviral Medications famciclovir Relenza Synagis Tamiflu valacyclovir 125 mg: 21 tablets per month 250 mg: 70 tablets per month 500 mg: 21 tablets per month 1 kit per season 1 vial per month Maximum of 5 doses per season 10 capsules per season 6 mg/ml suspension: 120 ml per season 500 mg: 42 tablets per month 1000 mg: 21 tablets per month Asthma montelukast 30 tablets or oral packets per 30 days ADHD and Stimulant Medications Adderall XR amphetamine salt combo dexmethylphenidate dextroamphetamine dextroamphetamine SA 5 mg, 10 mg, 15 mg: 30 capsules per 30 days 20 mg, 25 mg, 30 mg: 60 capsules per 30 days 5 mg, 7.5 mg, 10 mg, 12.5 mg, 20 mg: 90 tablets per 30 days 15 mg, 30 mg: 60 tablets per 30 days 60 tablets per 30 days 120 tablets per 30 days 5 mg: 30 capsules per 30 days 10 mg, 15 mg: 120 capsules per 30 days = Prior Authorization Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 7

11 Medication Class methylphenidate methylphenidate ER methylphenidate ER methylphenidate SR modafinil Nuvigil Strattera Vyvanse Quantity Limits 2.5 mg, 5 mg, 10 mg, 20 mg: 30 tablets per 90 days 5 mg/5 ml solution: 1,800 ml per 30 days 10 mg/5 ml solution: 900 ml per 30 days 18 mg, 27 mg, 54 mg: 30 tablets per 30 days 36 mg: 60 tablets per 30 days 30 tablets per 30 days 90 capsules per 30 days 100 mg: 30 tablets per 30 days 200 mg: 60 tablets per 30 days 30 tablets per 30 days 10 mg, 40 mg, 60 mg, 80 mg, 100 mg: 30 tablets per month 18 mg: 60 tablets per month 25 mg: 90 tablets per month 30 capsules per 30 days Bronchodilators Proair HFA Ventolin HFA 2 inhalers per month 2 inhalers per month Contraceptive Agents Medroxyprogesterone injection Nuvaring Oral contraceptive tablets 1 vial/syringe per 90 days 1 ring per 28 days 28 tablets per 28 days 91 tablets per 90 days for extended cycle tablets Cystic Fibrosis Agents Kalydeco 60 tablets per month Dermatological Agents Regranex 3 tubes per year Diabetes Medications Symlin ST Victoza Insulin Lancets Test Strips 4 vials/pens per month 3 pens per month U-100: 5 vials per 30 days U-500: 1 vial per 30 days 3 boxes of pens/cartridges per 30 days 200 lancets per 30 days 150 test strips per month Fibromyalgia Medications Savella Savella titration pack 60 tablets per month 1 package per lifetime Gastrointestinal Medications Emend granisetron ST lansoprazole omeprazole OTC 40 mg: 1 tablet per month 80 mg: 4 tablets per month 125 mg: 2 tablets per month Tri-fold: 2 packs per month 1 vial per 30 days Tablets: 14 per month Suspension: 90 ml per month 30 capsules per month 60 tablets per month = Prior Authorization Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 8

12 Medication Class ondansetron pantoprazole Quantity Limits 4 mg, 8 mg: 90 tablets per month 24 mg: 7 tablets per month 60 tablets per month Hormone Replacement Therapy estradiol transdermal patches 4 patches per month Injectable & Biotech Medications Actemra Acthar gel Adcirca Adempas Amevive Ampyra Apokyn Arcalyst Aubagio Bethkis Botox Cayston Cimzia Cinryze Cystaran Dysport Egrifta Eligard Enbrel Firazyr Firmagon Forteo Fulyzaq Gattex Gilenya Harvoni Hetlioz Humira Ilaris Infergen Intravenous infusion 800 mg (40 ml) per 28 days Subcutaneous injection: 4 syringes per 28 days 3 vials per month 60 tablets per month 90 tablets per 30 days 2 treatment courses per year 60 tablets per month 30 syringes/cartridges per month 4 vials per month 30 tablets per 30 days 56 ampules per 56 days Four 100-unit vials per 84 days Two 200-unit vials per 84 days 84 vials per 56 days 2 vials/syringes per month 16 vials per month 4 bottles per 30 days Two vials per 84 days 60 vials per 30 days One 7.5 mg kit per 28 days One 22.5 mg kit per 84 days One 30 mg kit per 112 days One 45 mg kit per 168 days 25 mg: 8 vials per month 50 mg: 4 vials per month 3 syringes per 30 days Two 120 mg vials per lifetime One 80 mg vial per 28 days 1 pen per 28 days Maximum of 2 years of therapy per lifetime 60 tablets per 30 days 30 vials per 30 days 30 capsules per 30 days 30 tablets per 30 days 30 capsules per 30 days 2 syringes per month Crohn s Starter Pack: 1 pack per lifetime Psoriasis Starter Pack: 1 pack per lifetime 2 vials per 28 days 30 vials per month = Prior Authorization Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 9

13 Medication Class Jetrea Juxtapid Kineret Korlym Krystexxa Kynamro Letairis Lupron Lupron Depot Lupron Depot-Ped Lupaneta Pack Mozobil Myalept Myobloc Northera Nuedexta Olysio Opsumit Orencia Otezla Otrexup Peg-Intron Procysbi Prolia Promacta Provenge Pulmozyme Rasuvo Ravicti Rebetol solution Reclast Quantity Limits 2 injections per lifetime 5 mg and 10 mg: 30 capsules per 30 days 20 mg: 90 capsules per 30 days 30 syringes per month 120 tablets per 30 days 2 vials per 28 days 4 vials per 28 days 30 tablets per month 2 kits per 28 days One 3.75-mg kit per 28 days One 7.5-mg kit per 28 days One mg kit per 84 days One 22.5-mg kit per 84 days One 30-mg kit per 112 days One 45-mg kit per 168 days One 7.5-mg kit per 28 days One mg 1-month kit per 28 days One mg 3-month kit per 84 days One 15-mg kit per 28 days One 30-mg kit per 84 days One 1-month pack per 28 days One 3-month pack per 84 days 8 vials per 4 days 30 vials per 30 days Four 2,500-unit vials per 84 days Two 5,000-unit vials per 84 days One 10,000-unit vials per 84 days 100 mg: 540 capsules per lifetime 200 mg and 300 mg: 180 capsules per month 60 capsules per month 30 tablets per 30 days 30 tablets per 30 days 4 syringes per month 60 tablets per 30 days 1 starter pack per lifetime 1 package (4 auto-injectors) per 28 days 4 kits per month 900 capsules per 30 days 1 vial per 180 days 12.5 mg and 25 mg: 30 tablets per 30 days 50 mg and 75 mg: 60 tablets per 30 days 1 course per lifetime 30 ampules per month 1 package (4 auto-injectors) per 28 days 525 ml per month 900 ml per 30 days 1 infusion per year = Prior Authorization Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 10

14 Medication Class Ribasphere ribavirin Riluzole Quantity Limits 200 mg tablet/capsule: 180 tablets/capsules per 30 days 400 mg: 90 tablets per 30 days 600 mg: 60 tablets per 30 days 200 mg tablet/capsule: 180 tablets/capsules per 30 days 400 mg tablet: 90 tablets per 30 days 600 mg: 60 tablets per 30 days 60 tablets per month Rituxan 1 treatment course (two 1000 mg doses given on day 1 and 15) Samsca Sandostatin LAR Depot Signifor sildenafil Simponi Sivextro Somatuline Depot Somavert Sovaldi Stelara Supprelin LA Synarel Tecfidera TOBI TOBI Podhaler Tracleer tranexamic acid Trelstar Tysabri Vantas Xeljanz Xenazine Xeomin Xgeva Xofigo Xolair Zoladex 15 mg: 30 tablets per month 30 mg: 60 tablets per month 10 mg and 30 mg: 1 kit per 28 days 20 mg: 2 kits per 28 days 60 ampules per 30 days 90 tablets per 30 days 1,125 ml per 30 days (IV solution) 1 syringe/autoinjector per 28 days 6 tablets per 30 days 60 mg, 90 mg, and 120 mg: 1 syringe per 28 days 30 vials per 30 days 30 tablets per 30 days 1 vial/syringe per 12 weeks 1 implant per 365 days 5 bottles per 30 days 60 capsules per 30 days Starter pack: 1 pack per lifetime 56 vials per 56 days 224 capsules per 56 days 60 tablets per month 30 tablets per 28 days 3.75 mg: 1 vial every 28 days mg: 1 vial every 84 days 22.5 mg: 1 vial every 168 days 1 vial per 28 days 1 implant per 365 days 60 tablets per month 12.5 mg: 90 tablets per 30 days 25 mg: 60 tablets per 30 days 50 U vial: 8 vials per 84 days 100 U vial: 4 vials per 84 days 1 vial per 28 days 1 course per lifetime 6 vials per 28 days One 3.6-mg implant per 28 days One 10.8-mg implant per 84 days Migraine Medications naratriptan rizatriptan 9 tablets per month 9 tablets per month = Prior Authorization Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 11

15 Medication Class sumatriptan Quantity Limits Injection: 4 boxes per month Nasal spray: 6 bottles per month Tablets: 9 tablets per month Monthly Fill Limitations Benzodiazepines Narcotic analgesics 2 fills per month 4 fills per month Multiple Sclerosis Injectable Medications Avonex Copaxone 1 package (each containing 4 vials) per month 20 mg: 30 syringes per 30 days 40 mg: 12 syringes per 30 days Muscle Relaxants carisoprodol 120 tablets per year Narcolepsy Medication Xyrem 540 ml per month Non-steroidal Anti-inflammatory Medications (NSAIDs) Celebrex ST ketorolac 60 capsules per month 5-day supply Oral Antibiotic Medications azithromycin ciprofloxacin ER Dificid ST Xifaxan Zyvox 250 mg: 10 tablets per month 500 mg: 4 tablets per month 600 mg: 8 tablets per month 2 gr per 60 ml bottle: 1 bottle per month 500 mg: 3 tablets per prescription 1,000 mg: 14 tablets per prescription 20 tablets per 10 days 200 mg: 9 tablets per prescription 550 mg: 60 tablets per 30 days 56 tablets per year 1,650 ml per year Oral Antifungal Medications fluconazole itraconazole Noxafil Onmel terbinafine voriconazole 150 mg: 2 tablets per prescription 50 mg, 100 mg, 200 mg: 10 tablets per month 60 capsules per month 93 tablets per 30 days 30 tablets per 30 days 90 tablets per year 30 day supply for esophageal infections 100-day supply per year Oral Oncology Medications Afinitor Bosulif Caprelsa Cometriq Erivedge 30 tablets per 30 days 100 mg: 120 tablets per 30 days 500 mg: 30 tablets per 30 days 100 mg: 60 tablets per 30 days 300 mg: 30 tablets per 30 days 60 mg/day pack: 84 capsules per 28 days 100 mg/day pack: 56 capsules per 28 days 140 mg/day pack: 112 capsules per 28 days 30 tablets per 30 days = Prior Authorization Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 12

16 Medication Class Gilotrif Gleevec Iclusig Imbruvica Inlyta Iressa Jakafi Mekinist Nexavar Pomalyst Revlimid Sprycel Stivarga Sutent Tafinlar Tarceva Tasigna Thalomid Tykerb Votrient Xalkori Xtandi Zelboraf Zolinza Zydelig Zykadia Zytiga Quantity Limits 30 tablets per 30 days 100 mg: 90 tablets per 30 days 400 mg: 60 tablets per 30 days 15 mg: 60 tablets per 30 days 45 mg: 30 tablets per 30 days 120 capsules per 30 days 1 mg: 180 tablets per 30 days 5 mg: 120 tablets per 30 days 30 tablets per 30 days 60 tablets per 30 days 30 tablets per 30 days 120 tablets per 30 days 21 capsules per 28 days 30 tablets per 30 days 30 tablets per 30 days 84 tablets per 28 days 12.5 mg: 90 capsules per 30 days 25 mg, 37.5 mg, 50 mg: 30 capsules per 30 days 120 tablets per 30 days 100 mg and 150 mg: 30 tablets per 30 days 120 tablets per 30 days 50 mg and 100 mg: 30 tablets per 30 days 150 mg and 200 mg: 60 tablets per 30 days 180 tablets per 30 days 120 tablets per 30 days 60 capsules per 30 days 120 tablets per 30 days 240 tablets per 30 days 120 tablets per 30 days 60 tablets per 30 days 150 capsules per 30 days 120 tablets per 30 days Osteoarthritis of the Knee Injections Euflexxa Synvisc Twice-yearly injection course per knee Twice-yearly injection course per knee Pain Medications Combination drugs containing acetaminophen Combination drugs containing aspirin Abstral fentanyl citrate lozenge fentanyl transdermal patch Fentora Gralise 4 grams daily 4 grams daily 120 tablets per month 120 units per month 100 mcg: 30 patches per month 12 mcg, 25 mcg, 50 mcg, 75 mcg: 10 patches per month 120 tablets per month 300 mg: 30 tablets per 30 days 600 mg: 90 tablets per 30 days 1 starter pack per lifetime = Prior Authorization Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 13

17 Medication Class hydrocodone/ibuprofen Horizant Lazanda Lidoderm morphine sulfate sustained release Narcotic analgesics Onsolis oxymorphone ER oxycodone/ibuprofen Qutenza tramadol tramadol/acetaminophen Quantity Limits 50 tablets per 10 days 60 tablets per 30 days 120 doses per 30 days 3 patches per day 90 tablets per month 30-day supply 120 units per month 60 tablets per month 28 tablets per month 4 patches per 90 days 240 tablets per month 40 tablets per month Psychiatric Medications Abilify buprenorphine buprenorphine/naloxone tablets citalopram escitalopram Evzio Fanapt clozapine ODT ST Invega Sustenna olanzapine olanzapine-fluoxetine ST paroxetine CR quetiapine Risperdal Consta risperidone Suboxone film venlafaxine XR 1 tablet per day 2 orally disintegrating tablets per day Solution: 750 ml per 30 days 2 mg: 60 tablets per 30 days 8 mg: 60 tablets per 30 days 60 tablets per 30 days 10 mg and 20 mg: 45 tablets per 30 days 40 mg: 30 tablets per 30 days 10 mg: 1.5 tablets per day 5 mg, 20 mg: 1 tablet per day Solution: 20 ml per day 1 pack per 6 months 2 tablets per day Titration pack: 1 pack per year 12.5 mg: 1 tablet per day 25 mg: 3 tablets per day 100 mg: 9 tablets per day 150 mg: 6 tablets per day 200 mg: 4 tablets per day 1 syringe/kit per 28 days 15 mg, 20 mg: 2 tablets per day 2.5 mg, 5 mg, 7.5 mg, 10 mg: 1 tablet per day 1 capsule per day 1 tablet per day 3 tablets per day 2 kits per 28 days 60 tablets per 30 days Oral solution: 240 ml per 30 days 2/0.5 mg: 60 film strips per 30 days 8/2 mg: 60 film strips per 30 days 4 mg/1 mg: 60 film strips per 30 days 12 mg/3 mg: 30 film strips per 30 days 150 mg: 2 capsules per day 37.5 mg: 1 capsule per day 75 mg: 3 capsules per day = Prior Authorization Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. 14

18 Medication Class ziprasidone Zubsolv Quantity Limits 2 capsules per day 1.4 mg/0.36 mg: 60 tablets per 30 days 5.7 mg/1.4 mg: 60 tablets per 30 days Seizure Medications Aptiom Fycompa Levetiracetam ER Lyrica Onfi Potiga topiramate 200 mg, 400 mg, 800 mg: 30 tablets per 30 days 600 mg: 60 tablets per 30 days 30 tablets per 30 days 500 mg: 180 tablets per 30 days 750 mg: 120 tablets per 30 days 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg: 90 capsules per month 225 mg, 300 mg: 60 capsules per month 60 tablets per 30 days 480 ml per 30 days 50 mg: 270 tablets per 30 days 200 mg, 300 mg: 90 tablets per 30 days 400 mg: 60 tablets per 30 days 180 capsules per 30 days Stop Smoking Aids buproban nicotine gum nicotine lozenges nicotine patches Nicotrol inhaler Nicotrol nasal spray 12 weeks 12 weeks 12 weeks 12 weeks 24 weeks 12 weeks Smoking cessation products will be limited to 2 quit attempts per 365 day period = Prior Authorization Required These are the standard quantity limits we cover. Depending upon diagnosis and information provided by the doctor, higher quantities may be covered after medical review on a case-by-case basis. Pharmacies for Prescriptions UPMC for You has many participating pharmacies that can fill your prescription. You have pharmacy benefits coverage if the Department of Human Services has determined that you are eligible for this coverage. You can call UPMC for You Member Services to find a participating pharmacy close to you. You can also go online at to look up the addresses of the participating pharmacies closest to you. Complaints, Grievances, and Fair Hearings You have the right to appeal any denial made by UPMC for You and the right to file a complaint about the administration of the drug formulary, by using the complaints and grievances process described in the UPMC for You member handbook. To request this handbook, or for information on the complaint and grievance Process, call Member Services. You can also go online to to see a copy of this handbook. Pharmacy Benefit Questions If you have a question about your pharmacy benefit, please call UPMC for You Member Services. 15

19 UPMC for You Prescription Drug Formulary 8-MOP abacavir abacavir/lamivudine/ zidovudine ABILIFY ABILIFY MAINTENA ABSTRAL acarbose acebutolol acetazolamide acetic acid/aluminum acetate acetylcysteine acitretin ACTEMRA ACTHAR GEL ACTIMMUNE acyclovir ADAGEN ADCIRCA ADDERALL XR adefovir ADEMS ADVAIR AFINITOR albuterol ALDURAZYME alendronate ALFERON N alfuzosin ALIMTA ALKERAN allopurinol (2 mg, 5 mg), ST (<12 years of age),, (fills/ month) ST (<4 or >18 years of age), ALOMIDE alprazolam alprazolam ODT altavera amantadine amcinonide amethia amethia lo amethyst amiloride amiloride/ hydrochlorothiazide amino acids 15% solution amiodarone amitriptyline amlodipine amlodipine/benazepril amnesteem amoxicillin amoxicillin/clavulanate amphetamine salts ampicillin AMPYRA anagrelide anastrozole ANDROGEL APOKYN apri APRISO APTIOM APTIVUS ARALAST NP aranelle ARANESP (fills/month) ST, (fills/month) (<4 or >18 years of age), KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 16

20 UPMC for You Prescription Drug Formulary (continued) ARCALYST ASACOL ASACOL HD ASMANEX aspirin atenolol atenolol/chlorthalidone atorvastatin ATRAPRO HYDROGEL ATRIPLA atropine sulfate AUBAGIO AUVI-Q AVANDAMET AVANDARYL AVANDIA aviane AVODART AVONEX azathioprine azelastine azithromycin bacitracin baclofen balsalazide BANZEL benazepril benazepril/ hydrochlorothiazide BENLYSTA benzocaine/antipyrine benzonatate benzoyl peroxide (Gel, cleanser, and lotion ONLY) benztropine BERINERT ST betamethasone betaxolol BETHKIS BETOPTIC S bicalutamide bisoprolol bisoprolol/ hydrochlorothiazide BIVIGAM BOSULIF BOTOX BREO ELLIPTA bromocriptine brompheniramine/ pseudoephedrine budeprion XL budesonide EC budesonide RESPULES bumetanide BUPHENYL buprenorphine buprenorphine/naloxone tablets buproban bupropion bupropion SR bupropion XL butalbital/acetaminophen butalbital/acetaminophen/ caffeine butalbital/aspirin/caffeine calcipotriene calcitriol calcium acetate camila camrese KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 17

21 UPMC for You Prescription Drug Formulary (continued) CANASA capecitabine CAPRELSA captopril captopril/hydrochlorothiazide CARBAGLU carbamazepine carbamazepine ER carbamide peroxide carbidopa/levodopa carbidopa/levodopa/ entacapone carisoprodol carteolol carvedilol CAYSTON cefaclor cefadroxil cefdinir cefpodoxime CELEBREX cephalexin CEREZYME cetirizine OTC cevimeline chateal chlorhexidine chloroquine chlorpheniramine/ pseudoephedrine chlorpromazine chlorthalidone cholestyramine choline magnesium trisalicylate cilostazol ST, ST (<12 years of age) cimetidine CIMZIA CINRYZE ciprofloxacin ciprofloxacin ER citalopram claravis clarithromycin clindamycin clobetasol clomipramine clonazepam clonazepam ODT clonidine clopidogrel clotrimazole clotrimazole/betamethasone clozapine clozapine ODT codeine codeine/acetaminophen COLCRYS colestipol COMBIVENT COMBIVENT RESPIMAT COMBIVIR COMETRIQ COMPLERA COXONE cortisone acetate CREON CRIXIVAN cromolyn CUPRIMINE cyanocobalamin (fills/month) ST, (fills/month) ST (<12 years of age) ST, ST (<12 years of age), (fills/month), (fills/month) KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 18

22 UPMC for You Prescription Drug Formulary (continued) cyclobenzaprine cyclopentolate cyclophosphamide cyclosporine CYKLOKAPRON CYSTADANE CYSTAGON CYSTARAN DALIRESP danazol dantrolene DAPSONE dasetta daysee DELZICOL DEMSER DENAVIR DEPEN desipramine desmopressin desonide desoximetasone dexamethasone dexmethylphenidate dextroamphetamine dextroamphetamine SA diazepam diazepam rectal DIBENZYLINE diclofenac dicloxacillin dicyclomine DIFICID (<4 or >18 years of age), (<4 or >18 years of age), (<4 or >18 years of age), (fills/month) ST, diflorasone digoxin dihydroergotamine diltiazem diphenhydramine diphenoxylate/atropine dipyridamole disopyramide disulfiram DIURIL divalproex divalproex DR divalproex ER donepezil dorzolamide dorzolamide/timolol doxazosin doxycycline DULERA dyphylline-gg DYSPORT econazole EDURANT EFFIENT EGRIFTA ELAPRASE ELELYSO ELIDEL ELIGARD elinest ELIQUIS EMCYT EMEND emoquette EMTRIVA KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 19

23 UPMC for You Prescription Drug Formulary (continued) enalapril enalapril/hydrochlorothiazide ENBREL enoxaparin enpresse enskyce entacapone entecavir ENTYVIO epinastine epinephrine eplerenone EPOGEN epoprostenol EPZICOM ergocalciferol ergotamine ERIVEDGE erythromycin escitalopram estarylla estradiol estradiol transdermal estradiol/norethindrone estropipate ethosuximide etodolac etoposide EUFLEXXA EURAX EVZIO exemestane EXJADE EYLEA FABRAZYME falmina, famciclovir famotidine FANAPT FARESTON felbamate fenofibrate fenoprofen fentanyl citrate lozenge fentanyl patch FENTORA FERRIPROX fexofenadine OTC finasteride FIRAZYR FIRMAGON FLOLAN FLOVENT fluconazole flucytosine fludrocortisone flunisolide fluocinolone fluocinonide fluorometholone fluorouracil fluoxetine fluphenazine flurazepam flutamide fluticasone fluvoxamine folic acid fondaparinux, (fills/ month), (fills/month), (fills/ month) ST (<12 years of age) (fills/month) KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 20

24 UPMC for You Prescription Drug Formulary (continued) FORTEO fosinopril fosinopril/ hydrochlorothiazide FRAGMIN FULYZAQ furosemide FUZEON FYCOM gabapentin GABITRIL GABLOFEN galantamine galantamine er GALZIN GAMMAGARD GAMMAKED GAMUNEX GATTEX gemfibrozil gentamicin gianvi gidagia gildess gildess fe GILENYA GILOTRIF GLASSIA GLEEVEC glipizide ER GLUCAGON glyburide glycopyrrolate GRALISE ER granisetron GRANIX, ST, GRASTEK guaifenisin/codeine guaifensin/dextromethorphan guanabenz guanfacine haloperidol HARVONI heather HETLIOZ HORIZANT HUMALOG HUMIRA HUMULIN HYCAMTIN hydralazine hydrochlorothiazide hydrocodone/acetaminophen hydrocodone/homatropine hydrocodone/ibuprofen hydrocortisone hydroxychloroquine hydroxyurea hydroxyzine hylira HYPER-SAL ibandronate ibuprofen ICLUSIG ILARIS IMBRUVICA imipenem-cilastatin imipramine INCRELEX indapamide indomethacin INFERGEN (fills/month) ST (<12 years of age),, (fills/month) (fills/month), (fills/month) KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 21

25 UPMC for You Prescription Drug Formulary (continued) INLYTA INTELENCE INTRON-A introvale INVEGA SUSTENNA INVIRASE ipratropium irbesartan irbesartan/hctz IRESSA ISENTRESS ISENTRESS isoniazid ISOPTO HYOSCINE isosorbide dinitrate isosorbide mononitrate isradipine itraconazole IVIG (intravenous immune globulin) JAKAFI JANUMET JANUMET XR JANUVIA jencycla JENTADUETO JETREA JEVANTIQUE jolessa jolivette junel junel FE JUXTAPID KALBITOR KALETRA KALYDECO ST ST ST kariva ketoconazole ketoprofen ketorolac ketorolac tromethamine ketotifen KINERET KORLYM K-PHOS KRYSTEXXA KUVAN KYNAMRO labetalol lactulose lamivudine lamivudine lamivudine-zidovudine lamotrigine lansoprazole LANTUS latanoprost LAZANDA leena leflunomide lessina LETAIRIS letrozole LEUKERAN levalbuterol levetiracetam levetiracetam ER levobunolol levocetirizine levofloxacin levonest levora ST KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 22

26 UPMC for You Prescription Drug Formulary (continued) levothyroxine LEXIVA lidocaine lidocaine patch lidocaine/prilocaine LIFESCAN BLOOD GLUCOSE PRODUCTS (One Touch) liothyronine lisinopril lisinopril/hydrochlorothiazide lithium carbonate lomustine LOMUSTINE loperamide loratadine OTC loratadine/pseudoephedrine OTC lorazepam loryna losartan losartan-hydrochlorothiazide LOTRONEX lovastatin low-ogestrel loxapine LUCENTIS LUMIZYME LUNETA CK LUPRON LUPRON DEPOT LUPRON DEPOT-PED LYRICA LYSODREN lyza MAKENA malathion on test strips and lancets (fills/month) ST (<12 years of age) marlissa MATULANE meclizine medroxyprogesterone medroxyprogesterone injection mefloquine megestrol acetate MEKINIST meloxicam meperidine MEPHYTON MEPRON mercaptopurine mesalamine metformin metformin ER methadone methazolamide methenamine methimazole methocarbamol methotrexate methoxsalen methyldopa methylergonovine methylphenidate methylphenidate ER methylphenidate SR methylprednisolone metoclopramide metolazone metoprolol (fills/month) (<4 or >18 years of age), (<4 or >18 years of age), (<4 or >18 years of age), KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 23

27 UPMC for You Prescription Drug Formulary (continued) metronidazole mexiletine miconazole midodrine minocycline minoxidil mirtazapine misoprostol modafinil mometasone mononessa montelukast morphine sulfate morphine sulfate sustained release MOZOBIL MULTAQ multivitamin/fluoride/iron mupirocin MYALEPT mycophenolate MYOBLOC MYOZYME nadolol NAGLAZYME naltrexone NAMENDA naproxen naratriptan NASACORT OTC nateglinide NEBUSAL necon nefazodone neomycin sulfate (fills/month), (fills/month), neomycin/polymixin b/ bacitracin neomycin/polymixin B/ hydrocortisone NEULASTA NEUPOGEN nevirapine nevirapine ER NEXAVAR niacin nicotine gum, lozenges, patches NICOTROL inhaler NICOTROL nasal spray nifedipine nimodipine nisoldipine nitrofurantoin macrocrystals nitroglycerin nizatidine NIZORAL A-D nora-be NORDITROPIN norethindrone NORTHERA nortriptyline NORVIR NOXAFIL NPLATE NUEDEXTA NULOJIX NUVARING NUVIGIL nystatin nystatin/triamcinolone KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 24

28 UPMC for You Prescription Drug Formulary (continued) ocella ofloxacin OFORTA olanzapine olanzapine-fluoxetine OLSYIO omeprazole OTC OMONTYS ondansetron ONFI ONMEL ONSOLIS OPSUMIT ORAP ORENCIA ORENITRAM ORFADIN OTEZLA OTREXUP oxazepam OXSORALEN oxybutynin oxybutynin ER oxycodone oxycodone/acetaminophen oxycodone/aspirin oxycodone/ibuprofen oxymetazoline oxymorphone oxymorphone ER NRETIN pantoprazole paromomycin paroxetine ST (< 12 years of age), ST,, (fills/ month) ST (<12 years of age),, (fills/month) (fills/month), (fills/month), (fills/month), (fills/month) (fills/month), (fills/month) paroxetine CR peg 3350/electrolytes peg 3350/sodium bicarbonate/sodium chloride/potassium chloride PEG-INTRON penicillin VK pentoxifylline permethrin perphenazine phenazopyridine phenobarbital phenylephrine phenytoin philith pilocarpine pindolol pioglitazone pioglitazone/glimepiride pioglitazone/metformin piroxicam podofilox polymixin B/bacitracin POMALYST portia potassium bicarbonate/ citrate potassium chloride potassium citrate POTIGA PRADAXA pramipexole pramox pravastatin prazosin prednisolone ST (<12 years of age) KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 25

29 UPMC for You Prescription Drug Formulary (continued) prednisone PREMARIN PREMARIN CREAM PREMPHASE PREMPRO PREZISTA primaquine primidone PROAIR HFA probenecid procainamide prochlorperazine PROCRIT PROCYSBI progesterone PROLASTIN PROLASTIN-C PROLIA PROMACTA promethazine promethazine/codeine propafenone propranolol propranolol/ hydrochlorothiazide propylthiouracil PROTOPIC PROVENGE PULMOZYME pyrazinamide pyrethrins/piperonyl butoxide pyridostigmine quasense quetiapine quinapril (fills/month), ST (<12 years of age), quinapril/hydrochlorothiazide quinidine QUTENZA QVAR RAGWITEK raloxifene ramipril RANEXA ranitidine RAMUNE RASUVO RAVICTI REBETOL RECLAST REGRANEX RELENZA RELISTOR REMICADE REMODULIN RENAGEL RENVELA repaglinide RESCRIPTOR REVLIMID REYATAZ RIBASPHERE ribavirin RIDAURA rifampin riluzole rimantadine RISPERDAL CONSTA risperidone RITUXAN ST (<12 years of age), KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 26

30 UPMC for You Prescription Drug Formulary (continued) rivastigmine rizatriptan rizatriptan ODT ropinirole SABRIL salsalate SAMSCA SANDOSTATIN LAR DEPOT SANTYL SAVELLA selegiline selenium sulfide SELZENTRY SEREVENT DISKUS SEROSTIM sertraline SIGNIFOR sildenafil silver sulfadiazine SIMPONI simvastatin SIRTURO SIVEXTRO sodium fluoride sodium polystyrene sulfonate sodium sulfacetamide sulfur 10-5% SOLIRIS SOMATULINE DEPOT SOMAVERT sotalol SOVALDI SPIRIVA spironolactone, spironolactone/ hydrochlorothiazide sprintec SPRYCEL SQIG stavudine STELARA STIVARGA STRATTERA STRIBILD SUBOXONE FILM SUCRAID sucralfate sulfacetamide sulfacetamide-sulfur 10-5% lotion sulfamethoxazole/ trimethoprim sulfasalazine sulfisoxazole sulindac sumatriptan SUPPRELIN LA SUSTIVA SUTENT syeda SYLATRON SYLVANT SYMBICORT SYMLIN SYNAGIS SYNAREL SYNVISC SYPRINE tacrolimus TAFINLAR ST, KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 27

31 UPMC for You Prescription Drug Formulary (continued) TAMIFLU tamoxifen tamsulosin TARCEVA TARGRETIN TASIGNA TECFIDERA temazepam (fills/month) temozolomide terazosin terbinafine terbutaline terconazole testosterone injection tetracycline THALOMID theophylline thioguanine thioridazine ST (<12 years of age) thiothixene ST (<12 years of age) thyroid THYROLAR tiagabine ticlopidine timolol tinidazole TIVICAY tizanidine TOBI TOBI podhaler tobramycin tolnaftate tolterodine tolterodine ER topiramate torsemide TRACLEER TRADJENTA tramadol tramadol/acetaminophen trandolapril tranexamic acid trazodone TRELSTAR tretinoin trezix triamcinolone triamterene/ hydrochlorothiazide triazolam trifluoperazine trifluridine trihexyphenidyl trimethoprim trimipramine maleate trinessa tri-previfem tri-sprintec TRIUMEQ trivora trospium trospium ER TRUVADA trypsin/balsalm/castor oil TUDORZA TYBOST TYKERB TYSABRI TYVASO TYZEKA UROXATRAL ST (age 35 and older) (fills/month) ST (<12 years of age) KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 28

32 UPMC for You Prescription Drug Formulary (continued) ursodiol valacyclovir VALCYTE valproic acid valsartan valsartan/ hydrochlorothiazide vancomycin VANTAS VELETRI velivet venlafaxine venlafaxine ER capsule VENTAVIS VENTOLIN HFA verapamil vestura VIADUR VICTOZA VIDEX VIMIZIM VIRACEPT VIREAD vitamin A,D,C/fluoride/iron vitamin B complex,c/folic acid VIVITROL voriconazole VOTRIENT VPRIV VYVANSE warfarin wera ST ST, (<4 or >18 years of age), XALKORI XARELTO XELJANZ XENAZINE XEOMIN XGEVA XIFAXAN XOFIGO XOLAIR XTANDI XYREM zaleplon zarah ZAVESCA ZELBORAF ZEMAIRA ZETIA zidovudine ziprasidone ZOLADEX zoledronic acid ZOLINZA zolpidem zonisamide ZONTIVITY ZORBTIVE ZORTRESS zovia ZUBSOLV ZYDELIG ZYKADIA ZYTIGA ZYVOX ST (<12 years of age),, KEY = Prior Authorization Required Uppercase = brand name = Quantity Limits Lowercase = generic 29

33 UPMC for You Over-the-Counter Formulary The following is a list of some of the most commonly used over-the-counter (OTC) medications that are available in various dosage forms (e.g., tablets, liquids, ointments, creams, lotions) and strengths (e.g., adult, pediatric). Generic OTC medications are covered by UPMC for You with a prescription from your doctor. If a generic is not available, an OTC brand-name drug will be covered by UPMC for You. The brand names listed are for reference only. Category Generic Brand Name Example Acne benzoyl peroxide Panoxyl Analgesics acetaminophen and combinations Tylenol, Feverall, Q-Pap, Little Fevers aspirin and combinations Bayer, Ecotrin ibuprofen and combinations Advil, Motrin naproxen Aleve Anesthetics benzocaine Orajel, Anbesol dibucaine Nupercainal Antacids aluminum hydroxide Alternagel, Alu-cap, Alu-tab aluminum/magnesium Mylanta, Maalox Advanced, Gaviscon calcium carbonate Tums, Maalox calcium carbonate/magnesium hydroxide Mylanta Supreme, Rolaids cimetidine Tagamet famotidine Pepcid ranitidine Zantac nizatidine Axid omeprazole OTC Prilosec OTC lansoprazole Prevacid 24 hour Antibacterials bacitracin triple antibiotic providone-iodine Neosporin Betadine Antidiarrheals bismuth subsalicylate Kaopectate, Pepto-Bismol loperamide Imodium A-D Antiflatulents simethicone Gas-X, Phazyme, Mylicon Antihistamines chlorpheniramine Chlor-trimeton, Aller-chlor diphenhydramine Benadryl loratadine Claritin, Alavert cetirizine Zyrtec fexofenadine Allegra ketotifen Zaditor 30

34 UPMC for You Over-the-Counter Formulary (continued) Category Generic Brand Name Example Anti-inflammatory hydrocortisone Cortaid, Cortizone-10 Antinauseants bismuth subsalicylate Kaopectate, Pepto-Bismol dimenhydrinate Dramamine, Driminate meclizine Dramamine Less Drowsy, Bonine sugar/orthophosphoric acid Emetrol Cholesterol Agents niacin Slo-Niacin Cough/Cold Preparations guaifenesin guaifenesin/dextromethorphan Mucinex Robitussin DM, Mucinex-D Decongestants pseudoephedrine Sudafed phenylephrine Sudafed-PE Decongestant/ Antihistamine Combinations loratadine/pseudoephedrine cetirizine/pseuodephedrine Claritin-D, Alavert-D Zyrtec-D Dermatologic Baths colloidal oatmeal Aveeno Diabetes blood glucose monitors Lifescan monitors: One Touch Ultra Mini Meter, One Touch Ultra2 Meter, OneTouch Verio Sync Meter test strips lancets glucose tablets Lifescan test strips: One Touch Test Strips, One Touch Ultra Test Strips, One Touch Verio Test Strips One Touch Ultrasoft Lancets, One Touch Delica Lancets insulin Humulin R, Humulin N, Humulin 70/30 insulin syringes alcohol swabs BD Syringes BD Alcohol Swabs Fungicides clotrimazole Lotrimin AF miconazole Micatin, Zeasorb-AF tolnaftate Tinactin, Ting terbinafine Lamisil-AT salicylic acid Duofilm, Compound W 31